Living evidence and adaptive policy: perfect partners?

BACKGROUND

While there has been widespread global acceptance of the importance of evidence-informed policy, many opportunities to inform health policy with research are missed, often because of a mismatch between when and where reliable evidence is needed, and when and where it is available. 'Living evidence' is an approach where systematic evidence syntheses (e.g. living reviews, living guidelines, living policy briefs, etc.) are continually updated to incorporate new relevant evidence as it becomes available. Living evidence approaches have the potential to overcome a major barrier to evidence-informed policy, making up-to-date systematic summaries of policy-relevant research available at any time that policy-makers need them. These approaches are likely to be particularly beneficial given increasing calls for policy that is responsive, and rapidly adaptive to changes in the policy context. We describe the opportunities presented by living evidence for evidence-informed policy-making and highlight areas for further exploration.

DISCUSSION

There are several elements of living approaches to evidence synthesis that might support increased and improved use of evidence to inform policy. Reviews are explicitly prioritised to be 'living' by partnerships between policy-makers and researchers based on relevance to decision-making, as well as uncertainty of existing evidence, and likelihood that new evidence will arise. The ongoing nature of the work means evidence synthesis teams can be dynamic and engage with policy-makers in a variety of ways over time; and synthesis topics, questions and methods can be adapted as policy interests or contextual factors shift. Policy-makers can sign-up to be notified when relevant new evidence is found, and can be confident that living syntheses are up-to-date and contain all research whenever they access them. The always up-to-date nature of living evidence syntheses means producers can rapidly demonstrate availability of relevant, reliable evidence when it is needed, addressing a frequently cited barrier to evidence-informed policymaking.

CONCLUSIONS

While there are challenges to be overcome, living evidence provides opportunities to enable policy-makers to access up-to-date evidence whenever they need it and also enable researchers to respond to the issues of the day with up-to-date research; and update policy-makers on changes in the evidence base as they arise. It also provides an opportunity to build flexible partnerships between researchers and policy-makers to ensure that evidence syntheses reflect the changing needs of policy-makers.

Development of a radiographic technique for porcine head ballistic research

INTRODUCTION

The porcine model shows structural features comparable to that of humans and are routinely used within research, due to the ethical, legal, and practical use of post-mortem human samples. Methods for obtaining high quality and comparable reference data using standardised acquisition protocols are essential.

METHODS

The decapitated heads of three adult white sows were subjected to radiographic imaging before and after cranial trauma (9 mm, Heckler and Koch MP5). Digital radiographs were generated using a Siemens MULTIX TOP system with an Agfa digital detector, with foam blocks and sandbags as ancillary equipment. An iterative approach was adopted by the authors to generate reproducible radiographic views from two perpendicular angles. Specimens were kept at 5 °C and wrapped in polythene bags to reduce the impact of putrefaction.

RESULTS

Standardised head radiography technique was developed for superior-inferior and lateral views demonstrating porcine anatomy. Key parameters included: automatic exposure control for tube current (∼4 mAs), tube voltage of 73 kVp, 100 cm source to image receptor distance, and an anti-scatter grid. Slight variances in specimen morphology, developmental status, and soft tissue changes did not affect imaging outcomes.

CONCLUSION

The technique and positioning proposed in this study allows for the acquisition of high quality and reproducible radiographic images for comparable ballistic research datasets. Specimen positioning and centring of the primary beam may be applied across porcine breeds, although individual radiographic parameters may differ according to equipment specifications and specimen size.

IMPLICATIONS FOR PRACTICE

Development of a reproducible radiographic technique of porcine heads in forensic and veterinary research.

HIV treatment-as-prevention and its effect on incidence of HIV among cisgender gay, bisexual, and other men who have sex with men in Australia: a 10-year longitudinal cohort study

BACKGROUND

Although HIV treatment-as-prevention reduces individual-level HIV transmission, population-level effects are unclear. We aimed to investigate whether treatment-as-prevention could achieve population-level reductions in HIV incidence among gay, bisexual, and other men who have sex with men (GBM) in Australia's most populous states, New South Wales and Victoria.

METHODS

TAIPAN was a longitudinal cohort study using routine health record data extracted from 69 health services that provide HIV diagnosis and care to GBM in New South Wales and Victoria, Australia. Data from Jan 1, 2010, to Dec 31, 2019, were linked within and between services and over time. TAIPAN collected data from all cisgender GBM who attended participating services, resided in New South Wales or Victoria, and were 16 years or older. Two cohorts were established: one included HIV-positive patients, and the other included HIV-negative patients. Population prevalence of viral suppression (plasma HIV viral load <200 RNA copies per μL) was calculated by combining direct measures of viral load among the HIV-positive cohort with estimates for undiagnosed GBM. The primary outcome of HIV incidence was measured directly via repeat testing in the HIV-negative cohort. Poisson regression analyses with generalised estimating equations assessed temporal associations between population prevalence of viral suppression and HIV incidence among the subsample of HIV-negative GBM with multiple instances of HIV testing.

FINDINGS

At baseline, the final sample (n=101 772) included 90 304 HIV-negative and 11 468 HIV-positive GBM. 59 234 patients in the HIV-negative cohort had two or more instances of HIV testing and were included in the primary analysis. Over the study period, population prevalence of viral suppression increased from 69·27% (95% CI 66·41-71·96) to 88·31% (86·37-90·35), while HIV incidence decreased from 0·64 per 100 person-years (95% CI 0·55-0·76) to 0·22 per 100 person-years (0·17-0·28). Adjusting for sociodemographic characteristics and HIV pre-exposure prophylaxis (PrEP) use, treatment-as-prevention achieved significant population-level reductions in HIV incidence among GBM: a 1% increase in population prevalence of viral suppression corresponded with a 6% decrease in HIV incidence (incidence rate ratio [IRR] 0·94, 95% CI 0·93-0·96; p<0·0001). PrEP was introduced in 2016 with 17·60% uptake among GBM that year, which increased to 36·38% in 2019. The relationship between population prevalence of viral suppression and HIV incidence was observed before the availability of PrEP (IRR 0·98, 95% CI 0·96-0·99; p<0·0001) and was even stronger after the introduction of PrEP (0·80, 0·70-0·93; p=0·0030).

INTERPRETATION

Our results suggest that further investment in HIV treatment, especially alongside PrEP, can improve public health by reducing HIV incidence among GBM.

FUNDING

National Health and Medical Research Council of Australia.

Can retrospectively fusing SPECT to CT images reduce radiation doses in myocardial perfusion imaging?

INTRODUCTION

To establish if the CT dataset acquired during the stress element of myocardial perfusion imaging can be fused to the subsequent rest scan to reduce radiation doses from these procedures.

METHODS

86 rest scans were processed and evaluated using a self-designed project specific tool. Recording processing time, the time between the two data sets selected for fusion and assessing radiographic reports to ensure produced images were of diagnostic quality.

RESULTS

70% of fused scans were acquired 6-7 days apart; the mean (SD) processing time was calculated as 2.03 (0.36) minutes. The Pearson's correlation between these two variables was determined to be 0.22, showing a slight positive correlation although not statistically significant. 100% of the images produced were of diagnostic quality.

CONCLUSION

Rest scans can be fused to a previously acquired CT, careful consideration should be given when positioning the patient and to the time interval between acquiring the two data sets, departmental guidelines can assist with this. Staff training may also be beneficial to ensure staff can assess if data sets are fusible prior to completing a scan.

IMPLICATIONS FOR PRACTICE

This data provides evidence that retrospective fusion can reduce patient radiation doses in myocardial perfusion imaging without compromising diagnostic outcomes. Dose optimisation is an essential part of the ionising radiation (medical exposure) regulations therefore retrospective fusion should be considered in practice to ensure departmental compliance, although it is noteworthy this study is solely based in a single centred one camera department.

Short Communication: Identification of equine corticotropin-like intermediate lobe peptide (CLIP) binding to an adrenocortipcotrophic hormone (ACTH) assay capture antibody

A chemiluminescent immunoassay is commonly employed to measure adrenocorticotrophic hormone (ACTH) concentrations to assist pituitary pars intermedia dysfunction diagnosis. In a previous study, seasonally-dependent assay cross-reactivity to endogenous equine corticotropin-like intermediate lobe peptide (CLIP, ACTH 18-39) was suspected. The present study aimed to demonstrate binding of endogenous equine CLIP to the capture antibody of the ACTH chemiluminescent immunoassay. Liquid chromatography - mass spectrometry (LCMS) methods were optimised to identify selected ions from synthetic human ACTH, α-melanocyte stimulating hormone (α-MSH, ACTH 1-17) and CLIP. Synthetic ACTH and CLIP bound to the capture antibody of the chemiluminescent ACTH assay, but α-MSH did not. Equine endogenous CLIP was detected by LCMS in pony plasma taken in the autumn and could be eluted from the capture antibody of the ACTH chemiluminescent immunoassay. Further research is required to enable quantification of CLIP. Equine CLIP may alter measured ACTH concentrations in vivo.

Care for adults with COVID ‐19: living guidelines from the National COVID ‐19 Clinical Evidence Taskforce

Introduction

The Australian National COVID‐19 Clinical Evidence Taskforce was established in March 2020 to maintain up‐to‐date recommendations for the treatment of people with coronavirus disease 2019 (COVID‐19). The original guideline (April 2020) has been continuously updated and expanded from nine to 176 recommendations, facilitated by the rapid identification, appraisal, and analysis of clinical trial findings and subsequent review by expert panels.

Main recommendations

In this article, we describe the recommendations for treating non‐pregnant adults with COVID‐19, as current on 1 August 2022 (version 61.0). The Taskforce has made specific recommendations for adults with severe/critical or mild disease, including definitions of disease severity, recommendations for therapy, COVID‐19 prophylaxis, respiratory support, and supportive care.

Changes in management as a result of the guideline

The Taskforce currently recommends eight drug treatments for people with COVID‐19 who do not require supplemental oxygen (inhaled corticosteroids, casirivimab/imdevimab, molnupiravir, nirmatrelvir/ritonavir, regdanvimab, remdesivir, sotrovimab, tixagevimab/cilgavimab) and six for those who require supplemental oxygen (systemic corticosteroids, remdesivir, tocilizumab, sarilumab, baricitinib, casirivimab/imdevimab). Based on evidence of their achieving no or only limited benefit, ten drug treatments or treatment combinations are not recommended; an additional 42 drug treatments should only be used in the context of randomised trials. Additional recommendations include support for the use of continuous positive airway pressure, prone positioning, and endotracheal intubation in patients whose condition is deteriorating, and prophylactic anticoagulation for preventing venous thromboembolism. The latest updates and full recommendations are available at www.covid19evidence.net.au.

The National COVID-19 Clinical Evidence Taskforce: pregnancy and perinatal guidelines

INTRODUCTION

Pregnant women are at higher risk of severe illness from coronavirus disease 2019 (COVID-19) than non-pregnant women of a similar age. Early in the COVID-19 pandemic, it was clear that evidenced-based guidance was needed, and that it would need to be updated rapidly. The National COVID-19 Clinical Evidence Taskforce provided a resource to guide care for people with COVID-19, including during pregnancy. Care for pregnant and breastfeeding women and their babies was included as a priority when the Taskforce was set up, with a Pregnancy and Perinatal Care Panel convened to guide clinical practice.

MAIN RECOMMENDATIONS

As of May 2022, the Taskforce has made seven specific recommendations on care for pregnant women and those who have recently given birth. This includes supporting usual practices for the mode of birth, umbilical cord clamping, skin-to-skin contact, breastfeeding, rooming-in, and using antenatal corticosteroids and magnesium sulfate as clinically indicated. There are 11 recommendations for COVID-19-specific treatments, including conditional recommendations for using remdesivir, tocilizumab and sotrovimab. Finally, there are recommendations not to use several disease-modifying treatments for the treatment of COVID-19, including hydroxychloroquine and ivermectin. The recommendations are continually updated to reflect new evidence, and the most up-to-date guidance is available online (https://covid19evidence.net.au).

CHANGES IN MANAGEMENT RESULTING FROM THE GUIDELINES

The National COVID-19 Clinical Evidence Taskforce has been a critical component of the infrastructure to support Australian maternity care providers during the COVID-19 pandemic. The Taskforce has shown that a rapid living guidelines approach is feasible and acceptable.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Delivering evidence-based interventions for type 1 diabetes in the virtual world - A review of UK practice during the SARS-CoV-2 pandemic

AIMS

This review considers the impact of the SARS-CoV-2 pandemic on access to interventions for those living with type 1 diabetes and discusses the solutions which have been considered and actioned to ensure ongoing access care.

METHODS

We performed a focussed review of the published literature, and the guidelines for changes that have been effected during the pandemic. We also drew from expert recommendations and information about local practice changes for areas where formal data have not been published.

RESULTS

Evidence based interventions which support the achievement of improved glucose levels and/or reduction in hypoglycaemia include group structured education to support self-management, insulin pump therapy and continuous glucose monitoring. The SARS-CoV-2 pandemic had impacted the ability of diabetes services to deliver these intervention. Multiple adaptations have been put in place - transition to online delivery of education and care, and usage of diabetes technology.

CONCLUSIONS

Although various adaptations have been made during the pandemic that have positively influenced uptake of services, there are many areas of delivery that need immediate improvement in the UK. We recommend a proactive approach in recognising the digital divide and inequity in distribution of these changes and we recommend introducing measures to reduce them.

The Australian living guidelines for the clinical care of people with COVID-19: What worked, what didn't and why, a mixed methods process evaluation

Introduction

The Australian National COVID-19 Clinical Evidence Taskforce is producing living, evidence-based, national guidelines for treatment of people with COVID-19 which are updated each week. To continually improve the process and outputs of the Taskforce, and inform future living guideline development, we undertook a concurrent process evaluation examining Taskforce activities and experience of team members and stakeholders during the first 5 months of the project.

Methods

The mixed-methods process evaluation consisted of activity and progress audits, an online survey of all Taskforce participants; and semi-structured interviews with key contributors. Data were collected through five, prospective 4-weekly timepoints (beginning first week of May 2020) and three, fortnightly retrospective timepoints (March 23, April 6 and 20). We collected and analysed quantitative and qualitative data.

Results

An updated version of the guidelines was successfully published every week during the process evaluation. The Taskforce formed in March 2020, with a nominal start date of March 23. The first version of the guideline was published two weeks later and included 10 recommendations. By August 24, in the final round of the process evaluation, the team of 11 staff, working with seven guideline panels and over 200 health decision-makers, had developed 66 recommendations addressing 58 topics. The Taskforce website had received over 200,000 page views. Satisfaction with the work of the Taskforce remained very high (>90% extremely or somewhat satisfied) throughout. Several key strengths, challenges and methods questions for the work of the Taskforce were identified.

Conclusions

In just over 5 months of activity, the National COVID-19 Clinical Evidence Taskforce published 20 weekly updates to the evidence-based national treatment guidelines for COVID-19. This process evaluation identified several factors that enabled this achievement (e.g. an extant skill base in evidence review and convening), along with challenges that needed to be overcome (e.g. managing workloads, structure and governance) and methods questions (pace of updating, and thresholds for inclusion of evidence) which may be useful considerations for other living guidelines projects. An impact evaluation is also being conducted separately to examine awareness, acceptance and use of the guidelines.

Care of older people and people requiring palliative care with COVID-19: guidance from the Australian National COVID-19 Clinical Evidence Taskforce

Introduction

Older people living with frailty and/or cognitive impairment who have coronavirus disease 2019 (COVID‐19) experience higher rates of critical illness. There are also people who become critically ill with COVID‐19 for whom a decision is made to take a palliative approach to their care. The need for clinical guidance in these two populations resulted in the formation of the Care of Older People and Palliative Care Panel of the National COVID‐19 Clinical Evidence Taskforce in June 2020. This specialist panel consists of nursing, medical, pharmacy and allied health experts in geriatrics and palliative care from across Australia.

Main recommendations

The panel was tasked with developing two clinical flow charts for the management of people with COVID‐19 who are i) older and living with frailty and/or cognitive impairment, and ii) receiving palliative care for COVID‐19 or other underlying illnesses. The flow charts focus on goals of care, communication, medication management, escalation of care, active disease‐directed care, and managing symptoms such as delirium, anxiety, agitation, breathlessness or cough. The Taskforce also developed living guideline recommendations for the care of adults with COVID‐19, including a commentary to discuss special considerations when caring for older people and those requiring palliative care.

Changes in management as result of the guideline

The practice points in the flow charts emphasise quality clinical care, with a focus on addressing the most important challenges when caring for older individuals and people with COVID‐19 requiring palliative care. The adult recommendations contain additional considerations for the care of older people and those requiring palliative care.

Radiography of human dry bones: A reflective account with recommendations for practice

INTRODUCTION

This study presents the reflective account of a large-scale radiographic survey of medieval and post-medieval long bones from St Albans, United Kingdom. As a practicing diagnostic radiographer and archaeologist, the author sought to apply experiential learning to generate recommendations for archaeological and forensic radiography practice. The purpose of the imaging was to identify Harris lines for biological stress, however this reflective piece concerns the adaptation of clinical radiographic technique for human dry bones.

METHODS

Imaging took place over five sessions in early 2021 with the assistance of an osteoarchaeologist. Radiography followed standard clinical views (anterior-posterior and medio-lateral) of femora, humeri, radii and tibiae using a digital radiography system. A workplace diary was used to record challenges, solutions and musings related to radiographic technique. The Rolfe, Freshwater and Jasper reflective model was applied to collate and present findings.

RESULTS

A total of 502 radiographs of 426 long bones (92 individuals) were acquired. A multidisciplinary team was found to be essential for correct identification of anatomy, laterality and orientation of remains during the survey. Anterior-posterior views were easiest to achieve, with medio-lateral imaging requiring considerably more effort. Radiolucent sponge supports were necessary, although fragmented remains were often impossible to position accurately. Hands-on experience of human bones improved the author's knowledge and confidence with osteology.

CONCLUSION

Although limited to selective long bones of archaeological context and personal experience, the findings of this study have direct applications for forensic radiography practice. This includes use of a multidisciplinary team, robust workflow with integrated failsafe checks, consistent imaging approach and the application of radiolucent sponge supports.

IMPLICATIONS FOR PRACTICE

Recommendations within this study may contribute towards a comprehensive guide for radiographic technique for human dry bones.

Feasibility of using his bundle pacing with boston scientific generators

Introduction

His bundle pacing (HBP) aims to deliver physiological activation of the ventricles via the native His-Purkinje conduction system. A challenge of HBP is the limited market of implantation tools, pacing leads and specifically designed pacing algorithms.

Purpose

Over the last three years both Medtronic (MDT) and Boston Scientific (BSC) generators have been used for HBP in a large tertiary centre. We examined whether there was any difference between lead parameters and battery longevity depending on the type of manufacturer used.

Methods

Patients implanted with a MDT Select Secure model 3830 lead were included in this retrospective study. Data collected included HBP thresholds (analysed at 1ms pulse width) at implant and at the most recent device check, HBP percentages and battery longevity (months). Battery longevity were calculated by adding duration of follow up and estimated battery life at last follow up.

Results

A total of 31 patients were included for data analysis (58% male and mean age 72 years). 18 patients had MDT generators of which 3 were PPMs, 5 were CRT-Ps and 10 were CRT-Ds. 13 patients had BSC generators of which 5 were PPMs, 5 were CRT-Ps and 3 were CRT-Ds. Mean follow up of the cohort was 12.7±9.02 months.

Mean HBP percentages were 77±37% and 72.2±42.1% for MDT and BSC, respectively (p=0.430). Mean HBP threshold (Volts) at implant was significantly lower with BSC vs MDT (0.85±0.58 vs 1.84±1.06, p=0.01), and similar after follow up (1.01±0.91 vs 1.32±0.73, p=NS). There were no statistically significant differences between mean HBP threshold at implant compared to follow up for both manufacturers.

Interestingly, mean battery longevity for BSC vs MDT generators was significantly higher (136±29.3 vs 90.5±29.1, p&lt;0.001). Longevity was also compared for PPM/CRT-P and CRT-D separately. For PPM/CRT-P, BSC generators had significantly higher longevity as compared to MDT (141.6±33.1 vs 91.6±34.5, p=0.009). This difference was not observed for CRT-Ds between the 2 manufacturers (p=0.068).

Conclusion

Our results suggest HBP with MDT Select Secure 3830 lead is feasible with BSC generators. There is potentially greater battery longevity with BSC compared to MDT generators. Further studies are needed with greater numbers and longer follow up to confirm this finding.

Funding Acknowledgement

Type of funding sources: None.

32 Congenital Arteriovenous Malformation of The Breast Associated with Giant Hairy Naevus: A Case Report

Introduction

An arteriovenous malformation (AVM) is defined as an abnormal connection between arteries and veins, bypassing the capillary system. AVM of the breast is a rare clinical entity, with limited evidence to guide management. We present the case of a congenital AVM of the breast in an otherwise healthy woman, with an interesting presenting complaint.

Case Description

A 38-year-old female presented with a ‘buzzing’ sensation and mastalgia in her left breast. Examination revealed a visible pulsatile linear abnormality with a bruit on auscultation. Duplex ultrasonography demonstrated mixing of the arterial and venous flow, consistent with an AVM. Operative management entailed ultrasound guided identification, ligation and excision of all aneurysmal segments. Histopathologic evaluation demonstrated an AVM with no malignant features. At one year postoperatively, the patient reported complete symptom resolution. Literature review identified nine case reports, including two cases of congenital breast AVM, both treated surgically. Seven cases of iatrogenic AVM were identified, with diagnosis based on duplex ultrasonography and management by surgical ligation in all except one, which resolved spontaneously.

Conclusions

ongenital AVM of the breast is a rare clinical entity. Diagnosis can be established using duplex ultrasonography, while CT and MRI may be useful for preoperative planning. Endovascular management alone is associated with high recurrence rates and surgical excision is the favoured approach where technically feasible without major aesthetic or functional compromise.

A New Method for Estimating the Incidence of Infectious Diseases

Ambitious World Health Organization targets for disease elimination require monitoring of epidemics using routine health data in settings of decreasing and low incidence. We evaluated 2 methods commonly applied to routine testing results to estimate incidence rates that assume a uniform probability of infection between consecutive negative and positive tests based on 1) the midpoint of this interval and 2) a randomly selected point in this interval. We compared these with an approximation of the Poisson binomial distribution, which assigns partial incidence to time periods based on the uniform probability of occurrence in these intervals. We assessed bias, variance, and convergence of estimates using simulations of Weibull-distributed failure times with systematically varied baseline incidence and varying trend. We considered results for quarterly, half-yearly, and yearly incidence estimation frequencies. We applied the methods to assess human immunodeficiency virus (HIV) incidence in HIV-negative patients from the Treatment With Antiretrovirals and Their Impact on Positive and Negative Men (TAIPAN) Study, an Australian study of HIV incidence in men who have sex with men, between 2012 and 2018. The Poisson binomial method had reduced bias and variance at low levels of incidence and for increased estimation frequency, with increased consistency of estimation. Application of methods to real-world assessment of HIV incidence found decreased variance in Poisson binomial model estimates, with observed incidence declining to levels where simulation results had indicated bias in midpoint and random-point methods.

The use of ondansetron for the treatment of nausea in dogs with vestibular syndrome

Background

Vestibular syndrome is often accompanied by nausea. Drugs currently approved for its treatment have been developed to stop vomiting but not nausea. The efficacy of 5-HT₃ receptor antagonists to reduce nausea has been described for chemotherapy, but not for nausea secondary to vestibular disorders.

Methods

Sixteen dogs with vestibular syndrome-associated nausea were included in the open-label, multicentre study. The intensity of nausea-like behaviour was analysed before ondansetron administration (0.5 mg/kg i.v.) and 2 h afterwards, using a validated 5-point-scale. The occurrence and frequency of salivation, lip licking, restlessness, vocalisation, lethargy, and vomiting were assessed.

Results

All dogs initially showed signs of nausea, whereas only 31% showed vomitus. The intensity of nausea was significantly reduced in all dogs (p ≤ 0.0001) 2 h after ondansetron administration, including the clinical signs of nausea analysed in 11 dogs (salivation [p = 0.0078], lip licking [p = 0.0078], restlessness [p = 0.0039], and lethargy [p = 0.0078]) except for vocalisation (p > 0.9999).

Conclusions

The results provide preliminary evidence of the potential benefit of ondansetron in the treatment of nausea, which was present in all examined dogs. Vomiting was only observed in 5 dogs indicating that nausea can occur separately and should not be perceived only as a preceding stimulation of the vomiting centre.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12917-021-02931-9.

Machine learning reduced workload with minimal risk of missing studies: development and evaluation of a randomized controlled trial classifier for Cochrane Reviews

OBJECTIVES

This study developed, calibrated, and evaluated a machine learning classifier designed to reduce study identification workload in Cochrane for producing systematic reviews.

METHODS

A machine learning classifier for retrieving randomized controlled trials (RCTs) was developed (the "Cochrane RCT Classifier"), with the algorithm trained using a data set of title-abstract records from Embase, manually labeled by the Cochrane Crowd. The classifier was then calibrated using a further data set of similar records manually labeled by the Clinical Hedges team, aiming for 99% recall. Finally, the recall of the calibrated classifier was evaluated using records of RCTs included in Cochrane Reviews that had abstracts of sufficient length to allow machine classification.

RESULTS

The Cochrane RCT Classifier was trained using 280,620 records (20,454 of which reported RCTs). A classification threshold was set using 49,025 calibration records (1,587 of which reported RCTs), and our bootstrap validation found the classifier had recall of 0.99 (95% confidence interval 0.98-0.99) and precision of 0.08 (95% confidence interval 0.06-0.12) in this data set. The final, calibrated RCT classifier correctly retrieved 43,783 (99.5%) of 44,007 RCTs included in Cochrane Reviews but missed 224 (0.5%). Older records were more likely to be missed than those more recently published.

CONCLUSIONS

The Cochrane RCT Classifier can reduce manual study identification workload for Cochrane Reviews, with a very low and acceptable risk of missing eligible RCTs. This classifier now forms part of the Evidence Pipeline, an integrated workflow deployed within Cochrane to help improve the efficiency of the study identification processes that support systematic review production.

The effect of myxomatous mitral valve disease severity on packed cell volume in dogs

OBJECTIVES

The aim of this study was to examine whether associations between disease severity and packed cell volume exist in dogs with myxomatous mitral valve disease.

MATERIALS AND METHODS

Data were selected from 289 dogs that had been examined at a research clinic (2004-2017) on multiple occasions (n=1465). American College of Veterinary Internal Medicine stage and echocardiographic measurements were entered in separate multivariable linear mixed effects models with packed cell volume as the dependent variable. Age, breed, sex, weight and blood urea nitrogen concentrations were additionally tested in these analyses to control for patient characteristics.

RESULTS

Packed cell volume (% whole blood) in stages B1 and B2 (B1: 42.62 ±0.27, P=0.001; B2: 41.77± 0.42, P < 0.001) was lower than stage A (44.57 ±0.53). In stage C, packed cell volume was greater than both preclinical stages (C: 43.84 ±0.46). When the administration of loop diuretics was included in statistical models, packed cell volume was inversely related to normalised left ventricular internal diameters (β: -2.37; 95% confidence intervals: -3.49, -1.25; P < 0.001).

CLINICAL SIGNIFICANCE

Dogs with myxomatous mitral valve disease may develop reductions in packed cell volume as their disease progresses. Although this finding was statistically significant at a population level, it should be noted that the differences described are relatively small. This, along with other causes of variation in packed cell volume, means that changes would be challenging to appreciate within individual patients. Plasma volume depletion following diuretic administration may explain why findings differed in stage C.

The views of health guideline developers on the use of automation in health evidence synthesis

BACKGROUND

The increasingly rapid rate of evidence publication has made it difficult for evidence synthesis-systematic reviews and health guidelines-to be continually kept up to date. One proposed solution for this is the use of automation in health evidence synthesis. Guideline developers are key gatekeepers in the acceptance and use of evidence, and therefore, their opinions on the potential use of automation are crucial.

METHODS

The objective of this study was to analyze the attitudes of guideline developers towards the use of automation in health evidence synthesis. The Diffusion of Innovations framework was chosen as an initial analytical framework because it encapsulates some of the core issues which are thought to affect the adoption of new innovations in practice. This well-established theory posits five dimensions which affect the adoption of novel technologies: Relative Advantage, Compatibility, Complexity, Trialability, and Observability. Eighteen interviews were conducted with individuals who were currently working, or had previously worked, in guideline development. After transcription, a multiphase mixed deductive and grounded approach was used to analyze the data. First, transcripts were coded with a deductive approach using Rogers' Diffusion of Innovation as the top-level themes. Second, sub-themes within the framework were identified using a grounded approach.

RESULTS

Participants were consistently most concerned with the extent to which an innovation is in line with current values and practices (i.e., Compatibility in the Diffusion of Innovations framework). Participants were also concerned with Relative Advantage and Observability, which were discussed in approximately equal amounts. For the latter, participants expressed a desire for transparency in the methodology of automation software. Participants were noticeably less interested in Complexity and Trialability, which were discussed infrequently. These results were reasonably consistent across all participants.

CONCLUSIONS

If machine learning and other automation technologies are to be used more widely and to their full potential in systematic reviews and guideline development, it is crucial to ensure new technologies are in line with current values and practice. It will also be important to maximize the transparency of the methods of these technologies to address the concerns of guideline developers.

Clinical care of pregnant and postpartum women with COVID-19: Living recommendations from the National COVID-19 Clinical Evidence Taskforce

To date, 18 living recommendations for the clinical care of pregnant and postpartum women with COVID-19 have been issued by the National COVID-19 Clinical Evidence Taskforce. This includes recommendations on mode of birth, delayed umbilical cord clamping, skin-to-skin contact, breastfeeding, rooming-in, antenatal corticosteroids, angiotensin-converting enzyme inhibitors, disease-modifying treatments (including dexamethasone, remdesivir and hydroxychloroquine), venous thromboembolism prophylaxis and advanced respiratory support interventions (prone positioning and extracorporeal membrane oxygenation). Through continuous evidence surveillance, these living recommendations are updated in near real-time to ensure clinicians in Australia have reliable, evidence-based guidelines for clinical decision-making. Please visit https://covid19evidence.net.au/ for the latest recommendation updates.

Investigation of the transforming growth factor-beta 1 signalling pathway as a possible link between hyperphosphataemia and renal fibrosis in feline chronic kidney disease

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Chronic kidney disease (CKD) is associated with development of hyperphosphataemia.

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Severity of renal fibrosis has been correlated with degree of hyperphosphataemia.

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Transforming growth factor-β1 (TGF-β1) is a major pro-fibrotic mediator in CKD.

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A phosphate restricted diet did not affect urinary active TGF-β1 excretion in cats.

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Increased extracellular phosphate had no pro-fibrotic effect on feline renal cells.

Chronic kidney disease (CKD) is common in geriatric cats, and is characterised in the majority of cases by tubulointerstitial inflammation and fibrosis. Hyperphosphataemia is a frequent complication of CKD and is independently associated with severity of renal fibrosis and disease progression. Transforming growth factor-beta 1 (TGF-β1) signalling is thought to be a convergent pathway which mediates the progression of renal fibrosis in CKD. The aims of this study were to explore the interaction between increased extracellular phosphate and the TGF-β1 signalling pathway by investigating: (a) the effect of a commercially available, phosphate-restricted, diet on urinary TGF-β1 excretion in cats with CKD; and (b) the role of increased extracellular phosphate in regulating proliferation, apoptosis, and expression of genes related to TGF-β1 signalling and extracellular matrix (ECM) production in feline proximal tubular epithelial cells (FPTEC) and cortical fibroblasts from cats with azotaemic CKD (CKD-FCF).

The dietary intervention study revealed no effect of dietary phosphate restriction on urinary active TGF-β1 excretion after 4–8 weeks (P = 0.98), despite significantly decreasing serum phosphate (P < 0.001). There was no effect of increased growth media phosphate concentration (from 0.95 mM to 2 mM and 3.5 mM) on proliferation (P = 0.99) and apoptotic activity in FPTEC (P = 0.22), or expression of genes related to ECM production and the TGF-β1 signalling pathway in FPTEC and CKD-FCF (P > 0.05). These findings suggest the beneficial effects of dietary phosphate restriction on progression of feline CKD may not occur through modulation of renal TGF-β1 production, and do not support a direct pro-fibrotic effect of increased extracellular phosphate on feline renal cells.

The new age of renal biomarkers: does SDMA solve all of our problems?

Within clinical small animal practice, diagnosis of both chronic kidney disease and acute kidney injury is common. To assess renal function, measurement of glomerular filtration rate is considered the gold standard. Currently, routine tests of kidney function include surrogate markers of glomerular filtration rate such as serum creatinine, and urea, each with their own limitations, whilst urine protein to creatinine ratio gives an indication of glomerular and tubular handling of protein, and urine specific gravity information about urine concentrating ability by the kidney. These parameters are used together with historical and physical examination data to give a diagnosis of kidney disease following which creatinine, proteinuria and blood pressure are used to stage chronic kidney disease and, together with urine output, grade acute kidney injury according to the International Renal Interest Society. However, there has been much concern that creatinine is insensitive when used to indicate early decline in renal function and this has highlighted the need for additional methods of diagnosing and monitoring these patients, with the potential to allow earlier therapeutic intervention. Symmetric dimethylarginine is a novel biomarker, which has been shown to perform as a surrogate marker of glomerular filtration rate in small animals. This article will review current research on symmetric dimethylarginine and the ways in which it may be utilised in small animal practice; current research supports the use of symmetric dimethylarginine as a screening test for detection of early chronic kidney disease according to International Renal Interest Society guidelines, but further research is required in to the usefulness of symmetric dimethylarginine as a tool for monitoring disease and the effect of non-renal influences.

Weekly updates of national living evidence-based guidelines: methods for the Australian living guidelines for care of people with COVID-19

Background and Objectives

The Australian National COVID-19 Clinical Evidence Taskforce is a consortium of 31 Australian health professional organisations developing living, evidence-based guidelines for care of people with COVID-19, which are updated weekly. This article describes the methods used to develop and maintain the guidelines.

Methods

The guidelines use the GRADE methods and are designed to meet Australian NHMRC standards. Each week, new evidence is reviewed, current recommendations are revised, and new recommendations made. These are published in MAGIC and disseminated through traditional and social media. Relevant new questions to be addressed are continually sought from stakeholders and practitioners. For prioritized questions, the evidence is actively monitored and updated. Evidence surveillance combines horizon scans and targeted searches. An evidence team appraises and synthesizes evidence and prepares evidence-to-decision frameworks to inform development of recommendations. A guidelines leadership group oversees the development of recommendations by multidisciplinary guidelines panels and is advised by a consumer panel.

Results

: The Taskforce formed in March 2020, and the first recommendations were published 2 weeks later. The guidelines have been revised and republished on a weekly basis for 24 weeks, and as of October 2020, contain over 90 treatment recommendations, suggesting that living methods are feasible in this context.

Conclusions

The Australian guidelines for care of people with COVID-19 provide an example of the feasibility of living guidelines and an opportunity to test and improve living evidence methods.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Histiocytic sarcoma in miniature schnauzers: 30 cases

OBJECTIVES

To summarise the clinical presentation and outcomes in a series of miniature schnauzers diagnosed with histiocytic sarcoma.

MATERIALS AND METHODS

Retrospective review of medical records of miniature schnauzers diagnosed with histiocytic sarcoma between 2008 and 2019 at two referral centres in the UK. Signalment, clinical signs at initial presentation, imaging results and clinico- and histopathological findings, treatment type and outcome were recorded. Progression-free survival and overall survival time were calculated.

RESULTS

Thirty dogs were included. Twenty-four of 29 dogs undergoing imaging of the thorax had lung and/or mediastinal involvement. The median overall survival time for dogs that were not euthanased within 3 days of diagnosis was 117 days (range 10 to 790). Three dogs underwent surgery; 13 received treatment with lomustine as a sole therapy - with partial responses documented on imaging in five of six dogs and 11 of 13 showing clinical improvement.

CLINICAL SIGNIFICANCE

Histiocytic sarcoma should be considered as a differential diagnosis for miniature schnauzers with pulmonary masses. Although responses to treatment were common, they were usually short-lived because of the aggressive nature of the disease.

What are the characteristics of the best type 1 diabetes patient education programmes (from diagnosis to long-term care), do they improve outcomes and what is required to make them more effective?

The last 20 years have witnessed a marked change in approaches to the management of type 1 diabetes in the UK. This is exemplified by National Institute of Health and Care Excellence (NICE) guidance which acknowledges that reaching and maintaining target glucose depends on people with type 1 diabetes effectively implementing flexible intensive insulin therapy. The guidance emphasizes that successful self-management requires the acquisition of complex skills and is best achieved by participation in high-quality structured education. Controlled trials and other research have shown that programmes teaching self-management can lower glucose levels while reducing hypoglycaemia, improve psychological outcomes and are highly cost-effective. An important principle of successful programmes is therapeutic education in which learning becomes a partnership between the professional and the person with diabetes who learns to fit diabetes into his/her everyday life. Other recommended elements of programmes include a written curriculum, group teaching by a professional multidisciplinary team and quality assurance. Yet many participants struggle post-course to implement and maintain skills, and overall HbA_1c levels, particularly in the UK, remain far from target. Recent studies have identified the barriers to sustained effective self-management and concluded that even high-quality programmes generally lack critical components. These include incorporating evidence from behaviour change research, exploiting the promise of new technologies in reducing the burden of self-management, and providing structured professional support once people have completed the training. Studies are currently underway to evaluate structured training courses which have added these elements and examine whether they can lower glucose to levels closer to target without impairing quality of life.

Feasibility and acceptability of living systematic reviews: results from a mixed-methods evaluation

BACKGROUND

Living systematic reviews (LSRs) offer an approach to keeping high-quality evidence synthesis continually up to date, so the most recent, relevant and reliable evidence can be used to inform policy and practice, resulting in improved quality of care and patient health outcomes. However, they require modifications to authoring and editorial processes and pose technical and publishing challenges. Several teams within Cochrane and the international Living Evidence Network have been piloting living systematic reviews.

METHODS

We conducted a mixed-methods evaluation with participants involved in six LSRs (three Cochrane and three non-Cochrane). Up to three semi-structured interviews were conducted with 27 participants involved with one or more of the pilot LSRs. Interviews explored participants' experiences contributing to the LSR, barriers and facilitators to their conduct and opportunities for future development. Pilot team members also completed monthly surveys capturing time for key tasks and the number of citations screened for each review.

RESULTS

Across the pilot LSRs, search frequency was monthly to three-monthly, with some using tools such as machine learning and Cochrane Crowd to screen searches. Varied approaches were used to communicate updates to readers. The number of citations screened varied widely between the reviews, from three to 300 citations per month. The amount of time spent per month by the author team on each review also varied from 5 min to 32 h. Participants were enthusiastic to be involved in the LSR pilot. They highlighted the importance of a motivated and well-organised team; the value of technology enablers to improve workflow efficiencies; the need to establish reliable and efficient processes to sustain living reviews; and the potential for saving time and effort in the long run. Participants highlighted challenges with the current publication processes, managing ongoing workload and the lack of resources to support LSRs in the long term.

CONCLUSIONS

Findings to date support feasibility and acceptability of LSR production. There are challenges that need to be addressed for living systematic reviews to be sustainable and have maximum value. The findings from this study will be used in discussions with the Cochrane community, key decision makers and people more broadly concerned with LSRs to identify and develop priorities for scale-up.

Working with Insulin, Carbohydrates, Ketones and Exercise to Manage Diabetes (WICKED): evaluation of a self-management course for young people with Type 1 diabetes

AIMS

To evaluate a 5-day self-management education course for young people with Type 1 diabetes and assess its effects on knowledge, self-efficacy, beliefs, distress, self-management behaviours and HbA_1c .

METHODS

This is an evaluation of a structured education course. Young people (aged 16-24 years) with Type 1 diabetes were recruited from three diabetes centres. In the first centre, participants completed self-report measures of knowledge, self-efficacy, positive and negative outcome expectancies, and hypoglycaemic worries at baseline (n=47) and the end of the course (n=42). In two additional centres, participants completed these and other measures assessing self-management behaviours, cognitive adaptation to diabetes and diabetes distress at baseline (n=32), the end of the course (n=27) and 3-month follow-up (n = 27). HbA_1c levels were recorded at baseline (n=79), 6 months (n=77) and 12 months (n=65).

RESULTS

There were statistically significant increases in self-report knowledge, self-efficacy, positive outcome expectancies and self-management behaviours, and a statistically significant decrease in negative outcome expectances, between baseline and the end of the course. There were also statistically significant increases in self-report knowledge, self-efficacy, self-management behaviours and cognitive adaptation to diabetes between baseline and 3-month follow-up. Compared with baseline, HbA_1c levels decreased by a mean (sd) of 5.44 (19.93) mmol/mol (0.48%) at 6 months (P=0.019), and by 5.98 (23.32) mmol/mol (0.54%) at 12 months (P =0.043).

DISCUSSION

The results indicate the potential benefits of a self-management course designed to address the developmental needs and challenges faced by young people with Type 1 diabetes. Further studies with larger numbers and appropriate controls are required to confirm these initial findings.

Characterisation of Crandell-Rees Feline Kidney (CRFK) cells as mesenchymal in phenotype

The Crandell-Rees Feline Kidney Cell (CRFK) is an immortalised cell line derived from the feline kidney that is utilised for the growth of certain vaccinal viruses. Confusion exists as to whether CRFK are epithelial or mesenchymal in phenotype. The aim of this study was to characterise CRFK cells via immunofluorescence, enzyme cytochemistry, western blotting, RT-qPCR for S100A4 and comparison to primary feline proximal tubular epithelial cells (FPTEC) and feline cortical fibroblasts (FCF). CRFK cells were of fusiform morphology and appeared similar to FCF. CRFK expressed the mesenchymal intermediate filament (IF) protein vimentin together with two cell adhesion molecules associated with feline fibroblasts (CD29 and CD44), and lacked expression of the epithelial IF cytokeratin, myogenic IF desmin and endothelial marker von Willebrand factor (vWF). In addition, CRFK did not demonstrate brush border enzyme activity typical of FPTEC. S100A4 gene expression, implicated in both neoplastic transformation and epithelial to mesenchymal transition, was highly upregulated in CRFK in comparison to the primary feline renal cells. CRFK appear phenotypically similar to fibroblasts, rather than tubular epithelial cells, and may have undergone neoplastic transformation or epithelial-to-mesenchymal transition after extensive passaging. This finding may have potential implications for future research utilising this cell line.

A Retrospective Study of Multi-agent Chemotherapy including either Cyclophosphamide or Lomustine as Initial Therapy for Canine High-grade T-cell Lymphoma (2011-2017)

Multi-agent chemotherapy (vincristine, epirubicin and prednisolone) including either cyclophosphamide (CEOP) or lomustine (LEOP) was given as first-line chemotherapy to treatment-naïve canine lymphoma patients with measurable, high grade T-cell lymphoma (HGTCL). All patients responded to either CEOP or LEOP. Toxicity was typical of multi-agent chemotherapy protocols and 25% of dogs receiving lomustine exhibited mild-to-moderate ALT elevation and 29% grade 3 or 4 neutropenia. Median progression-free survival (100 versus 269 days) and overall survival (155 versus 327 days) were significantly higher in patients receiving LEOP compared to CEOP. Overall survival was improved for patients receiving LEOP compared to those receiving CEOP followed by lomustine-based rescue therapy. The results of this retrospective study support further evaluation of lomustine as part of first-line, multi-agent therapy for patients with HGTCL.

Urinary peptidome analyses for the diagnosis of chronic kidney disease in dogs

Chronic kidney disease (CKD) is clinically important in canine medicine. Current diagnostic tools lack sensitivity for detection of subclinical CKD. The aim of the present study was to evaluate urinary peptidome analysis for diagnosis of CKD in dogs. Capillary electrophoresis coupled to mass spectrometry analysis demonstrated presence of approximately 5400 peptides in dog urine. Comparison of urinary peptide abundance of dogs with and without CKD led to the identification of 133 differentially excreted peptides (adjusted P for each peptide <0.05). Sequence information was obtained for 35 of these peptides. This 35 peptide subset and the total group of 133 peptides were used to construct two predictive models of CKD which were subsequently validated by researchers masked to results in an independent cohort of 20 dogs. Both models diagnosed CKD with an area under the receiver operating characteristic (ROC) curve of 0.88 (95% confidence intervals [CI], 0.72-1.0). Most differentially excreted peptides represented fragments of collagen I, indicating possible association with fibrotic processes in CKD (similar to the equivalent human urinary peptide CKD model, CKD273). This first study of the urinary peptidome in dogs identified peptides that were associated with presence of CKD. Future studies are needed to validate the utility of this model for diagnosis and prediction of progression of canine CKD in a clinical setting.

A multicentre, UK, retrospective, observational study to assess the effectiveness of insulin glargine 300 units/ml in treating people with Type 1 diabetes mellitus in routine clinical practice (SPARTA)

AIM

To conduct an open-label study to provide UK real-world evidence regarding the use of insulin glargine 300 units/ml (U300) in people with Type 1 diabetes mellitus.

METHODS

People with Type 1 diabetes who had been prescribed U300 ≥6 months before data collection and had HbA_1c levels recorded within 3 months prior to U300 (baseline) were included. The primary endpoint was change in HbA_1c from baseline to month 6 after U300 initiation. Other endpoints included number of documented hypoglycaemic and diabetic ketoacidosis episodes, and change in daily basal insulin dose.

RESULTS

A total of 298 people with Type 1 diabetes were included [mean age 42.1 years, mean HbA_1c 79 mmol/mol (9.4%)]. After U300 initiation, the mean reduction in HbA_1c from baseline to month 6 was -4 mmol/mol (-0.4%; P<0.001; n=188). The total daily basal insulin dose at 6 months was 1.3 units higher than at the time of U300 initiation (P<0.001; n=275) but was not significantly different from the prior basal insulin dose. There was no clinically significant difference in weight between baseline and month 6 [mean difference +0.7 kg, 95% CI -0.1, 1.5; P=0.084; n=115). During the 6 months before and after U300 initiation, severe hypoglycaemic episodes were documented for 6/298 and 4/298 participants. Diabetic ketoacidosis episodes requiring Accident and Emergency department visits or hospitalization were documented for 4/298 and 6/298 participants, before and after U300 initiation, respectively.

CONCLUSIONS

In people with Type 1 diabetes, a change in basal insulin to U300 was associated with clinically and statistically significant HbA_1c improvements, without significant changes in basal insulin dose and weight. Documented severe hypoglycaemia episodes and diabetic ketoacidosis requiring Accident and Emergency department visits or hospitalization were low and similar before and after U300 initiation.

Facilitating Web-Based Collaboration in Evidence Synthesis (TaskExchange): Development and Analysis

BACKGROUND

The conduct and publication of scientific research are increasingly open and collaborative. There is growing interest in Web-based platforms that can effectively enable global, multidisciplinary scientific teams and foster networks of scientists in areas of shared research interest. Designed to facilitate Web-based collaboration in research evidence synthesis, TaskExchange highlights the potential of these kinds of platforms.

OBJECTIVE

This paper describes the development, growth, and future of TaskExchange, a Web-based platform facilitating collaboration in research evidence synthesis.

METHODS

The original purpose of TaskExchange was to create a platform that connected people who needed help with their Cochrane systematic reviews (rigorous syntheses of health research) with people who had the time and expertise to help. The scope of TaskExchange has now been expanded to include other evidence synthesis tasks, including guideline development. The development of TaskExchange was initially undertaken in 5 agile development phases with substantial user engagement. In each phase, software was iteratively deployed as it was developed and tested, enabling close cycles of development and refinement.

RESULTS

TaskExchange enables users to browse and search tasks and members by keyword or nested filters, post and respond to tasks, sign up to notification emails, and acknowledge the work of TaskExchange members. The pilot platform has been open access since August 2016, has over 2300 members, and has hosted more than 630 tasks, covering a wide range of research synthesis-related tasks. Response rates are consistently over 75%, and user feedback has been positive.

CONCLUSIONS

TaskExchange demonstrates the potential for new technologies to support Web-based collaboration in health research. Development of a relatively simple platform for peer-to-peer exchange has provided opportunities for systematic reviewers to get their reviews completed more quickly and provides an effective pathway for people to join the global health evidence community.