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1.  Time to Update and Quantitative Changes in the Results of Cochrane Pregnancy and Childbirth Reviews 
PLoS ONE  2010;5(7):e11553.
The recommended interval between updates for systematic reviews included in The Cochrane Library is 2 years. However, it is unclear whether this interval is always appropriate. Whereas excessive updating wastes time and resources, insufficient updating allows out-of-date or incomplete evidence to guide clinical decision-making. We set out to determine, for Cochrane pregnancy and childbirth reviews, the frequency of updates, factors associated with updating, and whether updating frequency was appropriate.
Methodology/Principal Findings
Cochrane pregnancy and childbirth reviews published in Issue 3, 2007 of the Cochrane Database of Systematic Reviews were retrieved, and data were collected from their original and updated versions. Quantitative changes were determined for one of the primary outcomes (mortality, or the outcome of greatest clinical significance). Potential factors associated with time to update were assessed using the Cox proportional hazard model. Among the 101 reviews in our final sample, the median time before the first update was 3.3 years (95% CI 2.7–3.8). Only 32.7% had been updated within the recommended interval of 2 years. In 75.3% (76/101), a median of 3 new trials with a median of 576 additional participants were included in the updated versions. There were quantitative changes in 71% of the reviews that included new trials (54/76): the median change in effect size was 18.2%, and the median change in 95% CI width was 30.8%. Statistical significance changed in 18.5% (10/54) of these reviews, but conclusions were revised in only 3.7% (2/54). A shorter time to update was associated with the same original review team at updating.
Most reviews were updated less frequently than recommended by Cochrane policy, but few updates had revised conclusions. Prescribed time to update should be reconsidered to support improved decision-making while making efficient use of limited resources.
PMCID: PMC2903478  PMID: 20644625
2.  Updated recommendations: an assessment of NICE clinical guidelines 
Updating is important to ensure clinical guideline (CG) recommendations remain valid. However, little research has been undertaken in this field. We assessed CGs produced by the National Institute for Health and Care Excellence (NICE) to identify and describe updated recommendations and to investigate potential factors associated with updating. Also, we evaluated the reporting and presentation of recommendation changes.
We performed a descriptive analysis of original and updated CGs and recommendations, and an assessment of presentation formats and methods for recording information. We conducted a case-control study, defining cases as original recommendations that were updated (‘new-replaced’ recommendations), and controls as original recommendations that were considered to remain valid (‘not changed’ recommendations). We performed a comparison of main characteristics between cases and controls, and we planned a multiple regression analysis to identify potential predictive factors for updating.
We included nine updated CGs (1,306 recommendations) and their corresponding original versions (1,106 recommendations). Updated CGs included 812 (62%) recommendations ‘not reviewed’, 368 (28.1%) ‘new’ recommendations, 104 (7.9%) ‘amended’ recommendations, and 25 (1.9%) recommendations reviewed but unchanged. The presentation formats used to indicate the changes in recommendations varied widely across CGs. Changes in ‘amended’, ‘deleted’, and ‘new-replaced’ recommendations (n = 296) were reported infrequently, mostly in appendices. These changes were recorded in 167 (56.4%) recommendations; and were explained in 81 (27.4%) recommendations. We retrieved a total of 7.1% (n = 78) case recommendations (‘new-replaced’) and 2.4% (n = 27) control recommendations (‘not changed’) in original CGs. The updates were mainly from ‘Fertility CG’, about ‘gynaecology, pregnancy and birth’ topic, and ‘treatment’ or ‘prevention’ purposes. We did not perform the multiple regression analysis as originally planned due to the small sample of recommendations retrieved.
Our study is the first to describe and assess updated CGs and recommendations from a national guideline program. Our results highlight the pressing need to standardise the reporting and presentation of updated recommendations and the research gap about the optimal way to present updates to guideline users. Furthermore, there is a need to investigate updating predictive factors.
PMCID: PMC4067507  PMID: 24919856
Clinical practice guidelines; Information dissemination; Evidence-based medicine; Knowledge translation; Methods; Updating
3.  Updating Systematic Reviews: An International Survey 
PLoS ONE  2010;5(4):e9914.
Systematic reviews (SRs) should be up to date to maintain their importance in informing healthcare policy and practice. However, little guidance is available about when and how to update SRs. Moreover, the updating policies and practices of organizations that commission or produce SRs are unclear.
Methodology/Principal Findings
The objective was to describe the updating practices and policies of agencies that sponsor or conduct SRs. An Internet-based survey was administered to a purposive non-random sample of 195 healthcare organizations within the international SR community. Survey results were analyzed using descriptive statistics. The completed response rate was 58% (n = 114) from across 26 countries with 70% (75/107) of participants identified as producers of SRs. Among responders, 79% (84/107) characterized the importance of updating as high or very-high and 57% (60/106) of organizations reported to have a formal policy for updating. However, only 29% (35/106) of organizations made reference to a written policy document. Several groups (62/105; 59%) reported updating practices as irregular, and over half (53/103) of organizational respondents estimated that more than 50% of their respective SRs were likely out of date. Authors of the original SR (42/106; 40%) were most often deemed responsible for ensuring SRs were current. Barriers to updating included resource constraints, reviewer motivation, lack of academic credit, and limited publishing formats. Most respondents (70/100; 70%) indicated that they supported centralization of updating efforts across institutions or agencies. Furthermore, 84% (83/99) of respondents indicated they favoured the development of a central registry of SRs, analogous to efforts within the clinical trials community.
Most organizations that sponsor and/or carry out SRs consider updating important. Despite this recognition, updating practices are not regular, and many organizations lack a formal written policy for updating SRs. This research marks the first baseline data available on updating from an organizational perspective.
PMCID: PMC2848577  PMID: 20376338
4.  Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks 
Updating clinical practice guidelines (CPGs) is a crucial process for maintaining the validity of recommendations. Methodological handbooks should provide guidance on both developing and updating CPGs. However, little is known about the updating guidance provided by these handbooks.
We conducted a systematic review to identify and describe the updating guidance provided by CPG methodological handbooks and included handbooks that provide updating guidance for CPGs. We searched in the Guidelines International Network library, US National Guidelines Clearinghouse and MEDLINE (PubMed) from 1966 to September 2013. Two authors independently selected the handbooks and extracted the data. We used descriptive statistics to analyze the extracted data and conducted a narrative synthesis.
We included 35 handbooks. Most handbooks (97.1%) focus mainly on developing CPGs, including variable degrees of information about updating. Guidance on identifying new evidence and the methodology of assessing the need for an update is described in 11 (31.4%) and eight handbooks (22.8%), respectively. The period of time between two updates is described in 25 handbooks (71.4%), two to three years being the most frequent (40.0%). The majority of handbooks do not provide guidance for the literature search, evidence selection, assessment, synthesis, and external review of the updating process.
Guidance for updating CPGs is poorly described in methodological handbooks. This guidance should be more rigorous and explicit. This could lead to a more optimal updating process, and, ultimately to valid trustworthy guidelines.
PMCID: PMC3904688  PMID: 24383701
Clinical practice guidelines; Evidence-based medicine; Handbooks; Methodology; Systematic review
5.  Studying the potential impact of automated document classification on scheduling a systematic review update 
Systematic Reviews (SRs) are an essential part of evidence-based medicine, providing support for clinical practice and policy on a wide range of medical topics. However, producing SRs is resource-intensive, and progress in the research they review leads to SRs becoming outdated, requiring updates. Although the question of how and when to update SRs has been studied, the best method for determining when to update is still unclear, necessitating further research.
In this work we study the potential impact of a machine learning-based automated system for providing alerts when new publications become available within an SR topic. Some of these new publications are especially important, as they report findings that are more likely to initiate a review update. To this end, we have designed a classification algorithm to identify articles that are likely to be included in an SR update, along with an annotation scheme designed to identify the most important publications in a topic area. Using an SR database containing over 70,000 articles, we annotated articles from 9 topics that had received an update during the study period. The algorithm was then evaluated in terms of the overall correct and incorrect alert rate for publications meeting the topic inclusion criteria, as well as in terms of its ability to identify important, update-motivating publications in a topic area.
Our initial approach, based on our previous work in topic-specific SR publication classification, identifies over 70% of the most important new publications, while maintaining a low overall alert rate.
We performed an initial analysis of the opportunities and challenges in aiding the SR update planning process with an informatics-based machine learning approach. Alerts could be a useful tool in the planning, scheduling, and allocation of resources for SR updates, providing an improvement in timeliness and coverage for the large number of medical topics needing SRs. While the performance of this initial method is not perfect, it could be a useful supplement to current approaches to scheduling an SR update. Approaches specifically targeting the types of important publications identified by this work are likely to improve results.
PMCID: PMC3420236  PMID: 22515596
6.  Strategies for monitoring and updating clinical practice guidelines: a systematic review 
Scientific knowledge is in constant change. The flow of new information requires a frequent re-evaluation of the available research results. Clinical practice guidelines (CPGs) are not exempted from this phenomenon and need to be kept updated to maintain the validity of their recommendations. The objective of our review is to systematically identify, describe and assess strategies for monitoring and updating CPGs.
Study design and setting
We conducted a systematic review of studies evaluating one or more methods of updating (with or without monitoring) CPGs or recommendations. We searched MEDLINE (PubMed) and The Cochrane Methodology Register (The Cochrane Library) from 1966 to June 2012. Additionally, we hand-searched reference lists of the included studies and the Guidelines International Network book of abstracts. If necessary, we contacted study authors to obtain additional information.
We included a total of eight studies. Four evaluated if CPGs were out of date, three updated CPGs, and one continuously monitored and updated CPGs. The most detailed reported phase of the process was the identification of new evidence. As opposed to studies updating guidelines, studies evaluating if CPGs were out of date applied restricted searches. Only one study compared a restricted versus an exhaustive search suggesting that a restricted search is sufficient to assess recommendations’ Validity. One study analyzed the survival time of CPGs and suggested that these should be reassessed every three years.
There is limited evidence about the optimal strategies for monitoring and updating clinical practice guidelines. A restricted search is likely to be sufficient to monitor new evidence and assess the need to update, however, more information is needed about the timing and type of search. Only the exhaustive search strategy has been assessed for the update of CPGs. The development and evaluation of more efficient strategies is needed to improve the timeliness and reduce the burden of maintaining the validity of CPGs.
PMCID: PMC3520818  PMID: 23164220
Clinical practice guidelines; Diffusion of innovation; Evidence-based medicine; Information storage and retrieval; Methodology; Updating; Implementation science; Dissemination and implementation; Knowledge translation
7.  Many family physicians will not manually update PDA software: an observational study 
Informatics in primary care  2009;17(4):225-230.
In a prospective study to explore connections between clinical information delivery and information retrieval, 41 Canadian family physicians searched an Electronic Knowledge Resource as needed for practice. Research software, called the Information Assessment Method prompted family physicians to report on the situational relevance, perceived cognitive impact, and application of their retrieved information hits. Both the Information Assessment Method and the Electronic Knowledge Resource needed periodic updating to properly address our research questions.
To determine the frequency of software updates when manual or semi-automatic approaches are used by family physicians.
Each family physician received a handheld computer (PDA) that ran the Windows Mobile 6 operating system. For technical reasons, the Information Assessment Method and the Electronic Knowledge Resource were accessed offline on PDA. To update the Electronic Knowledge Resource and the Information Assessment Method, family physicians were asked to synchronize their PDA to their PC. Updating the Information Assessment Method was a manual process, whereas updating the Electronic Knowledge Resource was semi-automatic.
We found: (1) about 25% of family physicians never or rarely updated PDA software on their own (2) a large number of software updates were never installed, and (3) the semi-automatic method was associated with a small increase in the proportion of installed software updates (58.9% versus 48.6% for the manual method).
When a wireless Internet connection is not used to update PDA software, sociotechnical issues complicate mobile data collection and data transfer.
PMCID: PMC2878612  PMID: 20359400 CAMSID: cams799
Computers handheld; software; family practice
8.  The updating of clinical practice guidelines: insights from an international survey 
Clinical practice guidelines (CPGs) have become increasingly popular, and the methodology to develop guidelines has evolved enormously. However, little attention has been given to the updating process, in contrast to the appraisal of the available literature. We conducted an international survey to identify current practices in CPG updating and explored the need to standardize and improve the methods.
We developed a questionnaire (28 items) based on a review of the existing literature about guideline updating and expert comments. We carried out the survey between March and July 2009, and it was sent by email to 106 institutions: 69 members of the Guidelines International Network who declared that they developed CPGs; 30 institutions included in the U.S. National Guideline Clearinghouse database that published more than 20 CPGs; and 7 institutions selected by an expert committee.
Forty-four institutions answered the questionnaire (42% response rate). In the final analysis, 39 completed questionnaires were included. Thirty-six institutions (92%) reported that they update their guidelines. Thirty-one institutions (86%) have a formal procedure for updating their guidelines, and 19 (53%) have a formal procedure for deciding when a guideline becomes out of date. Institutions describe the process as moderately rigorous (36%) or acknowledge that it could certainly be more rigorous (36%). Twenty-two institutions (61%) alert guideline users on their website when a guideline is older than three to five years or when there is a risk of being outdated. Twenty-five institutions (64%) support the concept of "living guidelines," which are continuously monitored and updated. Eighteen institutions (46%) have plans to design a protocol to improve their guideline-updating process, and 21 (54%) are willing to share resources with other organizations.
Our study is the first to describe the process of updating CPGs among prominent guideline institutions across the world, providing a comprehensive picture of guideline updating. There is an urgent need to develop rigorous international standards for this process and to minimize duplication of effort internationally.
PMCID: PMC3191352  PMID: 21914177
9.  A surveillance system to assess the need for updating systematic reviews 
Systematic Reviews  2013;2:104.
Systematic reviews (SRs) can become outdated as new evidence emerges over time. Organizations that produce SRs need a surveillance method to determine when reviews are likely to require updating. This report describes the development and initial results of a surveillance system to assess SRs produced by the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program.
Twenty-four SRs were assessed using existing methods that incorporate limited literature searches, expert opinion, and quantitative methods for the presence of signals triggering the need for updating. The system was designed to begin surveillance six months after the release of the original review, and thenceforth every six months for any review not classified as being a high priority for updating. The outcome of each round of surveillance was a classification of the SR as being low, medium or high priority for updating.
Twenty-four SRs underwent surveillance at least once, and ten underwent surveillance a second time during the 18 months of the program. Two SRs were classified as high, five as medium, and 17 as low priority for updating. The time lapse between the searches conducted for the original reports and the updated searches (search time lapse - STL) ranged from 11 months to 62 months: The STL for the high priority reports were 29 months and 54 months; those for medium priority reports ranged from 19 to 62 months; and those for low priority reports ranged from 11 to 33 months. Neither the STL nor the number of new relevant articles was perfectly associated with a signal for updating. Challenges of implementing the surveillance system included determining what constituted the actual conclusions of an SR that required assessing; and sometimes poor response rates of experts.
In this system of regular surveillance of 24 systematic reviews on a variety of clinical interventions produced by a leading organization, about 70% of reviews were determined to have a low priority for updating. Evidence suggests that the time period for surveillance is yearly rather than the six months used in this project.
PMCID: PMC3874670  PMID: 24225065
Systematic review; Updating; Surveillance
10.  Adaptive Decoding for Brain-Machine Interfaces through Bayesian Parameter Updates 
Neural Computation  2011;23(12):3162-3204.
Brain machine interfaces (BMIs) transform activity of neurons recorded in motor areas of the brain into movements of external actuators. Representation of movements by neuronal populations varies over time, during both voluntary limb movements and movements controlled through BMIs, due to motor learning, neuronal plasticity, and instability in recordings. To assure accurate BMI performance over long time spans, BMI decoders must adapt to these changes. We propose the Bayesian regression self-training method for updating the parameters of an unscented Kalman filter decoder. This novel paradigm uses the decoder’s output to periodically update the decoder’s neuronal tuning model in a Bayesian linear regression. We use two previously-known statistical formulations of Bayesian linear regression: (1) a joint formulation which allows fast and exact inference, and (2) a factorized formulation which allows the addition and temporary omission of neurons from updates, but requires approximate variational inference. To evaluate these methods, we performed off-line reconstructions and closed-loop experiments with Rhesus monkeys implanted cortically with micro-wire electrodes. Off-line reconstructions used data recorded in areas M1, S1, PMd, SMA, and PP of 3 monkeys while they controlled a cursor using a hand-held joystick. The Bayesian regression self-training updates significantly improved the accuracy of offline reconstructions compared to the same decoder without updates. We performed 11 sessions of real-time, closed-loop experiments with a monkey implanted in areas M1 and S1. These sessions spanned 29 days. The monkey controlled the cursor using the decoder with and without updates. The updates maintained control accuracy and did not require information about monkey hand movements, assumptions about desired movements, or knowledge of the intended movement goals as training signals. These results indicate that Bayesian regression self-training can maintain BMI control accuracy over long time periods, making clinical neuroprosthetics more viable.
PMCID: PMC3335277  PMID: 21919788
brain machine interface; decoding; adaptive filtering
11.  Adaptation of Clinical Prediction Models for Application in Local Settings 
Medical Decision Making  2012;32(3):E1-E10.
Background. When planning to use a validated prediction model in new patients, adequate performance is not guaranteed. For example, changes in clinical practice over time or a different case mix than the original validation population may result in inaccurate risk predictions. Objective. To demonstrate how clinical information can direct updating a prediction model and development of a strategy for handling missing predictor values in clinical practice. Methods. A previously derived and validated prediction model for postoperative nausea and vomiting was updated using a data set of 1847 patients. The update consisted of 1) changing the definition of an existing predictor, 2) reestimating the regression coefficient of a predictor, and 3) adding a new predictor to the model. The updated model was then validated in a new series of 3822 patients. Furthermore, several imputation models were considered to handle real-time missing values, so that possible missing predictor values could be anticipated during actual model use. Results. Differences in clinical practice between our local population and the original derivation population guided the update strategy of the prediction model. The predictive accuracy of the updated model was better (c statistic, 0.68; calibration slope, 1.0) than the original model (c statistic, 0.62; calibration slope, 0.57). Inclusion of logistical variables in the imputation models, besides observed patient characteristics, contributed to a strategy to deal with missing predictor values at the time of risk calculation. Conclusions. Extensive knowledge of local, clinical processes provides crucial information to guide the process of adapting a prediction model to new clinical practices.
PMCID: PMC3426927  PMID: 22427369
clinical prediction rules; methodology; decision rules; provider decision making; statistical methods
12.  Update in Women’s Health 
The aim of this clinical update is to summarize articles and guidelines published in the last year with the potential to change current clinical practice as it relates to women’s health.
We used two independent search strategies to identify articles relevant to women’s health published between March 1, 2007 and February 29, 2008. First, we reviewed the Cochrane Database of Systematic Reviews and journal indices from the ACP Journal Club, Annals of Internal Medicine, Archives of Internal Medicine, British Medical Journal, Circulation, Diabetes, JAMA, JGIM, Journal of Women’s Health, Lancet, NEJM, Obstetrics and Gynecology, and Women’s Health Journal Watch. Second, we performed a MEDLINE search using the medical subject heading term “sex factors.” The authors, who all have clinical and/or research experience in the area of women’s health, reviewed all article titles, abstracts, and, when indicated, full publications. We excluded articles related to obstetrical aspects of women’s health focusing on those relevant to general internists. We had two acceptance criteria, scientific rigor and potential to impact women’s health. We also identified new and/or updated women’s health guidelines released during the same time period.
We identified over 250 publications with potential relevance to women’s health. Forty-six articles were selected for presentation as part of the Clinical Update, and nine were selected for a more detailed discussion in this paper. Evidence-based women’s health guidelines are listed in Table 1. Table 1Important Women’s Health Guidelines in 2007–2008: New or UpdatedTopicIssuing organizationUpdated recommendations and commentsMammography screening in women 40–4917ACPIndividualized risk assessment and informed decision making should be used to guide decisions about mammography screening in this age group.To aid in the risk assessment, a discussion of the risk factors, which if present in a woman in her 40s increases her risk to above that of an average 50-year-old woman, is provided in the guidelines. In addition, available risk prediction models, such as the NIH Web site calculator ( can also be used to estimate quantitative breast cancer risk. This model was updated in 2008 with race-specific data for calculating risk in African-American women.18The harms and benefits of mammography should be discussed and incorporated along with a woman’s preferences and breast cancer risk profile into the decision on when to begin screening. If a woman decides to forgo mammography, the decision should be readdressed every 1 to 2 years.STD screening guidelines19USPSTF and CDCRoutine screening for this infection is now recommended for ALL sexually active women age 24 and under, based on the recent high prevalence estimates for chlamydiaIt is not recommended for women (pregnant or nonpregnant) age 25 and older, unless they are at increased risk for infection.STD treatment guidelines20CDCFlouroquinolones are NO longer recommended for treatment of N. gonorrhea, due to increasing resistance (as high as 15% of isolates in 2006).For uncomplicated infections, treatment of gonorrhea should be initiated with ceftriaxone 125 mg IM or cefixime 400 mg PO and co-treatment for chlamydia infection (unless ruled out with testing). Recent estimates demonstrate that almost 50% of persons with gonorrhea have concomitant chlamydia infection21.STD = sexually transmitted disease, NIH = National Institutes of Health, ACP = American College of Physicians, USPSTF = United States Prevention Services Task Force, CDC = Centers for Disease Control
PMCID: PMC2686759  PMID: 19259751
women’s health; osteoporosis; preconception counseling; HPV vaccine; obesity; cardiovascular disease
13.  Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults 
In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and/or gaps in the previous guidelines.
Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta2-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.
The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.
The present clinical practice guideline is the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.
PMCID: PMC3373283  PMID: 22536582
Asthma; Clinical practice guideline; Management
14.  BOADICEA breast cancer risk prediction model: updates to cancer incidences, tumour pathology and web interface 
British Journal of Cancer  2013;110(2):535-545.
The Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) is a risk prediction model that is used to compute probabilities of carrying mutations in the high-risk breast and ovarian cancer susceptibility genes BRCA1 and BRCA2, and to estimate the future risks of developing breast or ovarian cancer. In this paper, we describe updates to the BOADICEA model that extend its capabilities, make it easier to use in a clinical setting and yield more accurate predictions.
We describe: (1) updates to the statistical model to include cancer incidences from multiple populations; (2) updates to the distributions of tumour pathology characteristics using new data on BRCA1 and BRCA2 mutation carriers and women with breast cancer from the general population; (3) improvements to the computational efficiency of the algorithm so that risk calculations now run substantially faster; and (4) updates to the model's web interface to accommodate these new features and to make it easier to use in a clinical setting.
We present results derived using the updated model, and demonstrate that the changes have a significant impact on risk predictions.
All updates have been implemented in a new version of the BOADICEA web interface that is now available for general use:
PMCID: PMC3899766  PMID: 24346285
breast cancer; risk prediction; BOADICEA; BRCA1; BRCA2; incidence; update; tumour; user interface; CIMBA; BCAC
15.  Motivating authors to update systematic reviews: practical strategies from a behavioural science perspective 
Systematic reviews are used by clinicians, policy makers and consumers of health care, and should provide up-to-date evidence for clinical decision making. Motivating systematic review authors to update reviews is a challenge, and despite resources such as methodologists and statisticians, many reviews are not updated in a timely manner. Conflicting clinical responsibilities, lack of funding or other essential resources, and waning interest in the review topic are potential barriers to updating. Illustrations of survey questions to elicit updating attitudes and beliefs, and conditions that make updating easier or more difficult within the framework of the Theory of Planned Behaviour, are presented. These surveys may be used to tailor interventions to assist authors with difficulties and may ultimately increase the rate of updates in the published literature.
PMCID: PMC4410721  PMID: 18237350
systematic reviews; theory of planned behaviour
16.  Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer 
To update the American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAP) guideline recommendations for human epidermal growth factor receptor 2 (HER2) testing in breast cancer to improve the accuracy of HER2 testing and its utility as a predictive marker in invasive breast cancer.
ASCO/CAP convened an Update Committee that included coauthors of the 2007 guideline to conduct a systematic literature review and update recommendations for optimal HER2 testing.
The Update Committee identified criteria and areas requiring clarification to improve the accuracy of HER2 testing by immunohistochemistry (IHC) or in situ hybridization (ISH). The guideline was reviewed and approved by both organizations.
The Update Committee recommends that HER2 status (HER2 negative or positive) be determined in all patients with invasive (early stage or recurrence) breast cancer on the basis of one or more HER2 test results (negative, equivocal, or positive). Testing criteria define HER2-positive status when (on observing within an area of tumor that amounts to >10% of contiguous and homogeneous tumor cells) there is evidence of protein overexpression (IHC) or gene amplification (HER2 copy number or HER2/CEP17 ratio by ISH based on counting at least 20 cells within the area). If results are equivocal (revised criteria), reflex testing should be performed using an alternative assay (IHC or ISH). Repeat testing should be considered if results seem discordant with other histopathologic findings. Laboratories should demonstrate high concordance with a validated HER2 test on a sufficiently large and representative set of specimens. Testing must be performed in a laboratory accredited by CAP or another accrediting entity. The Update Committee urges providers and health systems to cooperate to ensure the highest quality testing.
PMCID: PMC4086638  PMID: 24099077
17.  The Movement Disorder Society Evidence-Based Medicine Review Update: Treatments for the Non-Motor Symptoms of Parkinson's Disease 
The Movement Disorder Society (MDS) Task Force on Evidence-Based Medicine (EBM) Review of Treatments for Parkinson's Disease (PD) was first published in 2002 and was updated in 2005 to cover clinical trial data up to January 2004 with the focus on motor symptoms of PD. In this revised version the MDS task force decided it was necessary to extend the review to non-motor symptoms. The objective of this work was to update previous EBM reviews on treatments for PD with a focus on non-motor symptoms. Level-I (randomized controlled trial, RCT) reports of pharmacological and nonpharmacological interventions for the non-motor symptoms of PD, published as full articles in English between January 2002 and December 2010 were reviewed. Criteria for inclusion and ranking followed the original program outline and adhered to EBM methodology. For efficacy conclusions, treatments were designated: efficacious, likely efficacious, unlikely efficacious, non-efficacious, or insufficient evidence. Safety data were catalogued and reviewed. Based on the combined efficacy and safety assessment, Implications for clinical practice were determined using the following designations: clinically useful, possibly useful, investigational, unlikely useful, and not useful. Fifty-four new studies qualified for efficacy review while several other studies covered safety issues. Updated and new efficacy conclusions were made for all indications. The treatments that are efficacious for the management of the different non-motor symptoms are as follows: pramipexole for the treatment of depressive symptoms, clozapine for the treatment of psychosis, rivastigmine for the treatment of dementia, and botulinum toxin A (BTX-A) and BTX-B as well as glycopyrrolate for the treatment of sialorrhea. The practical implications for these treatments, except for glycopyrrolate, are that they are clinically useful. Since there is insufficient evidence of glycopyrrolate for the treatment of sialorrhea exceeding 1 week, the practice implication is that it is possibly useful. The treatments that are likely efficacious for the management of the different non-motor symptoms are as follows: the tricyclic antidepressants nortriptyline and desipramine for the treatment of depression or depressive symptoms and macrogol for the treatment of constipation. The practice implications for these treatments are possibly useful. For most of the other interventions there is insufficient evidence to make adequate conclusions on their efficacy. This includes the tricyclic antidepressant amitriptyline, all selective serotonin reuptake inhibitors (SSRIs) reviewed (paroxetine, citalopram, sertraline, and fluoxetine), the newer antidepressants atomoxetine and nefazodone, pergolide, Ω-3 fatty acids as well as repetitive transcranial magnetic stimulation (rTMS) for the treatment of depression or depressive symptoms; methylphenidate and modafinil for the treatment of fatigue; amantadine for the treatment of pathological gambling; donepezil, galantamine, and memantine for the treatment of dementia; quetiapine for the treatment of psychosis; fludrocortisone and domperidone for the treatment of orthostatic hypotension; sildenafil for the treatment of erectile dysfunction, ipratropium bromide spray for the treatment of sialorrhea; levodopa/carbidopa controlled release (CR), pergolide, eszopiclone, melatonin 3 to 5 mg and melatonin 50 mg for the treatment of insomnia and modafinil for the treatment of excessive daytime sleepiness. Due to safety issues the practice implication is that pergolide and nefazodone are not useful for the above-mentioned indications. Due to safety issues, olanzapine remains not useful for the treatment of psychosis. As none of the studies exceeded a duration of 6 months, the recommendations given are for the short-term management of the different non-motor symptoms. There were no RCTs that met inclusion criteria for the treatment of anxiety disorders, apathy, medication-related impulse control disorders and related behaviors other than pathological gambling, rapid eye movement (REM) sleep behavior disorder (RBD), sweating, or urinary dysfunction. Therefore, there is insufficient evidence for the treatment of these indications. This EBM review of interventions for the non-motor symptoms of PD updates the field, but, because several RCTs are ongoing, a continual updating process is needed. Several interventions and indications still lack good quality evidence, and these gaps offer an opportunity for ongoing research.
PMCID: PMC4020145  PMID: 22021174
Parkinson's disease; evidence-based medicine; dopamine agonists; tricyclic antidepressants; selective serotonin reuptake inhibitors (SSRIs); omega-3 fatty-acids; transcranial magnetic stimulation
18.  Comparison of international guideline programs to evaluate and update the Dutch program for clinical guideline development in physical therapy 
Clinical guidelines are considered important instruments to improve quality in health care. Since 1998 the Royal Dutch Society for Physical Therapy (KNGF) produced evidence-based clinical guidelines, based on a standardized program. New developments in the field of guideline research raised the need to evaluate and update the KNGF guideline program.
Purpose of this study is to compare different guideline development programs and review the KNGF guideline program for physical therapy in the Netherlands, in order to update the program.
Six international guideline development programs were selected, and the 23 criteria of the AGREE Instrument were used to evaluate the guideline programs. Information about the programs was retrieved from published handbooks of the organizations. Also, the Dutch program for guideline development in physical therapy was evaluated using the AGREE criteria. Further comparison the six guideline programs was carried out using the following elements of the guideline development processes: Structure and organization; Preparation and initiation; Development; Validation; Dissemination and implementation; Evaluation and update.
Compliance with the AGREE criteria of the guideline programs was high. Four programs addressed 22 AGREE criteria, and two programs addressed 20 AGREE criteria. The previous Dutch program for guideline development in physical therapy lacked in compliance with the AGREE criteria, meeting only 13 criteria.
Further comparison showed that all guideline programs perform systematic literature searches to identify the available evidence. Recommendations are formulated and graded, based on evidence and other relevant factors. It is not clear how decisions in the development process are made. In particular, the process of translating evidence into practice recommendations can be improved.
As a result of international developments and consensus, the described processes for developing clinical practice guidelines have much in common. The AGREE criteria are common basis for the development of guidelines, although it is not clear how final decisions are made. Detailed comparison of the different guideline programs was used for updating the Dutch program. As a result the updated KNGF program complied with 22 AGREE criteria. International discussion is continuing and will be used for further improvement of the program.
PMCID: PMC2228296  PMID: 18036215
19.  2011 Focused Update of 2009 American Society of Clinical Oncology Clinical Practice Guideline Update on Chemotherapy for Stage IV Non–Small-Cell Lung Cancer 
Journal of Clinical Oncology  2011;29(28):3825-3831.
An American Society of Clinical Oncology (ASCO) focused update updates a single recommendation (or subset of recommendations) in advance of a regularly scheduled guideline update. This document updates one recommendation of the ASCO Guideline Update on Chemotherapy for Stage IV Non–Small-Cell Lung Cancer (NSCLC) regarding switch maintenance chemotherapy.
Clinical Context
Recent results from phase III clinical trials have demonstrated that in patients with stage IV NSCLC who have received four cycles of first-line chemotherapy and whose disease has not progressed, an immediate switch to alternative, single-agent chemotherapy can extend progression-free survival and, in some cases, overall survival. Because of limitations in the data, delayed treatment with a second-line agent after disease progression is also acceptable.
Recent Data
Seven randomized controlled trials of carboxyaminoimidazole, docetaxel, erlotinib, gefitinib, gemcitabine, and pemetrexed have evaluated outcomes in patients who received an immediate, non–cross resistant alternative therapy (switch maintenance) after first-line therapy.
In patients with stage IV NSCLC, first-line cytotoxic chemotherapy should be stopped at disease progression or after four cycles in patients whose disease is stable but not responding to treatment. Two-drug cytotoxic combinations should be administered for no more than six cycles. For those with stable disease or response after four cycles, immediate treatment with an alternative, single-agent chemotherapy such as pemetrexed in patients with nonsquamous histology, docetaxel in unselected patients, or erlotinib in unselected patients may be considered. Limitations of this data are such that a break from cytotoxic chemotherapy after a fixed course is also acceptable, with initiation of second-line chemotherapy at disease progression.
PMCID: PMC3675703  PMID: 21900105
20.  Reassessing Google Flu Trends Data for Detection of Seasonal and Pandemic Influenza: A Comparative Epidemiological Study at Three Geographic Scales 
PLoS Computational Biology  2013;9(10):e1003256.
The goal of influenza-like illness (ILI) surveillance is to determine the timing, location and magnitude of outbreaks by monitoring the frequency and progression of clinical case incidence. Advances in computational and information technology have allowed for automated collection of higher volumes of electronic data and more timely analyses than previously possible. Novel surveillance systems, including those based on internet search query data like Google Flu Trends (GFT), are being used as surrogates for clinically-based reporting of influenza-like-illness (ILI). We investigated the reliability of GFT during the last decade (2003 to 2013), and compared weekly public health surveillance with search query data to characterize the timing and intensity of seasonal and pandemic influenza at the national (United States), regional (Mid-Atlantic) and local (New York City) levels. We identified substantial flaws in the original and updated GFT models at all three geographic scales, including completely missing the first wave of the 2009 influenza A/H1N1 pandemic, and greatly overestimating the intensity of the A/H3N2 epidemic during the 2012/2013 season. These results were obtained for both the original (2008) and the updated (2009) GFT algorithms. The performance of both models was problematic, perhaps because of changes in internet search behavior and differences in the seasonality, geographical heterogeneity and age-distribution of the epidemics between the periods of GFT model-fitting and prospective use. We conclude that GFT data may not provide reliable surveillance for seasonal or pandemic influenza and should be interpreted with caution until the algorithm can be improved and evaluated. Current internet search query data are no substitute for timely local clinical and laboratory surveillance, or national surveillance based on local data collection. New generation surveillance systems such as GFT should incorporate the use of near-real time electronic health data and computational methods for continued model-fitting and ongoing evaluation and improvement.
Author Summary
In November 2008, Google Flu Trends was launched as an open tool for influenza surveillance in the United States. Engineered as a system for early detection and daily monitoring of the intensity of seasonal influenza epidemics, Google Flu Trends uses internet search data and a proprietary algorithm to provide a surrogate measure of influenza-like illness in the population. During its first season of operation, the novel A/H1N1-pdm influenza virus emerged, heterogeneously causing sporadic outbreaks in the spring and summer of 2009 across many parts of the United States. During the autumn 2009 pandemic wave, Google updated their model with a new algorithm and case definition; the updated model has run prospectively since. Our study asks whether Google Flu Trends provides accurate detection and monitoring of influenza at the national, regional and local geographic scales. Reliable local surveillance is important to reduce uncertainty and improve situational awareness during seasonal epidemics and pandemics. We found substantial flaws with the original and updated Google Flu Trends models, including missing the emergence of the 2009 pandemic and overestimating the 2012/2013 influenza season epidemic. Our work supports the development of local near-real time computerized syndromic surveillance systems, and collaborative regional, national and international networks.
PMCID: PMC3798275  PMID: 24146603
21.  A Novel Dynamic Update Framework for Epileptic Seizure Prediction 
BioMed Research International  2014;2014:957427.
Epileptic seizure prediction is a difficult problem in clinical applications, and it has the potential to significantly improve the patients' daily lives whose seizures cannot be controlled by either drugs or surgery. However, most current studies of epileptic seizure prediction focus on high sensitivity and low false-positive rate only and lack the flexibility for a variety of epileptic seizures and patients' physical conditions. Therefore, a novel dynamic update framework for epileptic seizure prediction is proposed in this paper. In this framework, two basic sample pools are constructed and updated dynamically. Furthermore, the prediction model can be updated to be the most appropriate one for the prediction of seizures' arrival. Mahalanobis distance is introduced in this part to solve the problem of side information, measuring the distance between two data sets. In addition, a multichannel feature extraction method based on Hilbert-Huang transform and extreme learning machine is utilized to extract the features of a patient's preseizure state against the normal state. At last, a dynamic update epileptic seizure prediction system is built up. Simulations on Freiburg database show that the proposed system has a better performance than the one without update. The research of this paper is significantly helpful for clinical applications, especially for the exploitation of online portable devices.
PMCID: PMC4090468  PMID: 25050381
22.  The predictive value of current haemoglobin levels for incident tuberculosis and/or mortality during long-term antiretroviral therapy in South Africa: a cohort study 
BMC Medicine  2015;13:70.
Low haemoglobin concentrations may be predictive of incident tuberculosis (TB) and death in HIV-infected patients receiving antiretroviral therapy (ART), but data are limited and inconsistent. We examined these relationships retrospectively in a long-term South African ART cohort with multiple time-updated haemoglobin measurements.
Prospectively collected clinical data on patients receiving ART for up to 8 years in a community-based cohort were analysed. Time-updated haemoglobin concentrations, CD4 counts and HIV viral loads were recorded, and TB diagnoses and deaths from all causes were ascertained. Anaemia severity was classified using World Health Organization criteria. TB incidence and mortality rates were calculated and Poisson regression models were used to identify independent predictors of incident TB and mortality, respectively.
During a median follow-up of 5.0 years (IQR, 2.5-5.8) of 1,521 patients, 476 cases of incident TB and 192 deaths occurred during 6,459 person-years (PYs) of follow-up. TB incidence rates were strongly associated with time-updated anaemia severity; those without anaemia had a rate of 4.4 (95%CI, 3.8-5.1) cases/100 PYs compared to 10.0 (95%CI, 8.3-12.1), 26.6 (95%CI, 22.5-31.7) and 87.8 (95%CI, 57.0-138.2) cases/100 PYs in those with mild, moderate and severe anaemia, respectively. Similarly, mortality rates in those with no anaemia or mild, moderate and severe time-updated anaemia were 1.1 (95%CI, 0.8-1.5), 3.5 (95%CI, 2.7-4.8), 11.8 (95%CI, 9.5-14.8) and 28.2 (95%CI, 16.5-51.5) cases/100 PYs, respectively. Moderate and severe anaemia (time-updated) during ART were the strongest independent predictors for incident TB (adjusted IRR = 3.8 [95%CI, 3.0-4.8] and 8.2 [95%CI, 5.3-12.7], respectively) and for mortality (adjusted IRR = 6.0 [95%CI, 3.9-9.2] and adjusted IRR = 8.0 [95%CI, 3.9-16.4], respectively).
Increasing severity of anaemia was associated with exceptionally high rates of both incident TB and mortality during long-term ART. Patients receiving ART who have moderate or severe anaemia should be prioritized for TB screening using microbiological assays and may require adjunctive clinical interventions.
PMCID: PMC4411796  PMID: 25889688
HIV; AIDS; Tuberculosis; Africa; Anaemia; Antiretroviral; Mortality
23.  Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine 
Critical care medicine  2009;37(2):666-688.
The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote “best practices” and to improve patient outcomes.
2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock.
Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001–2006).
The Pubmed/MEDLINE literature database (1966–2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus.
The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%–3% in previously healthy, and 7%– 10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained.
The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill ≤2 secs, and 2) subsequent intensive care unit hemodynamic support directed to goals of central venous oxygen saturation >70% and cardiac index 3.3–6.0 L/min/m2.
PMCID: PMC4447433  PMID: 19325359
guidelines; sepsis; severe sepsis
24.  German-austrian recommendations for HIV1-therapy in pregnancy and in HIV1-exposed newborn - update 2008 
German-Austrian recommendations for HIV1-therapy in pregnancy - Update 2008 Bernd Buchholz (University Medical Centre Mannheim, Pediatric Clinic), Matthias Beichert (Mannheim, Gynecology and Obstetrics Practice), Ulrich Marcus (Robert Koch Institute, Berlin), Thomas Grubert, Andrea Gingelmaier (Gynecology Clinic of the Ludwig Maximilians University of Munich), Dr. med. Annette Haberl (HIV-Department, J. W. Goethe-University Hospital, Frankfurt), Dr. med. Brigitte Schmied (Otto-Wagner Spital, Wien).
In Germany during the last years about 200-250 HIV1-infected pregnant women delivered a baby each year, a number that is currently increasing. To determine the HIV-status early in pregnancy voluntary HIV-testing of all pregnant women is recommended in Germany and Austria as part of prenatal care. In those cases, where HIV1-infection was known during pregnancy, since 1995 the rate of vertical transmission of HIV1 was reduced to 1-2%.
This low transmission rate has been achieved by the combination of anti-retroviral therapy of pregnant women, caesarean section scheduled before onset of labour, anti-retroviral post exposition prophylaxis in the newborn and refraining from breast-feeding by the HIV1-infected mother. To keep pace with new results in research, approval of new anti-retroviral drugs and changes in the general treatment recommendations for HIV1-infected adults, in 1998, 2001, 2003 and 2005 an interdisciplinary consensus meeting was held. Gynaecologists, infectious disease specialists, paediatricians, pharmacologists, virologists and members of the German AIDS Hilfe (NGO) were participating in this conference to update the prevention strategies. A fifth update became necessary in 2008. The updating process was started in January 2008 and was terminated in September 2008. The guidelines provide new recommendations on the indication and the starting point for HIV-therapy in pregnancies without complications, drugs and drug combinations to be used preferably in these pregnancies and updated information on adverse effects of anti-retroviral drugs. Also the procedures for different scenarios and risk constellations in pregnancy have been specified again.
With these current guidelines in Germany and Austria the low rate of vertical HIV1-transmission should be further maintained.
PMCID: PMC3352287  PMID: 19948442
Pregnancy; HIV-therapy; HIV-status; HIV-testing; anti-retroviral drugs; recommendations
25.  Strategies to assess the validity of recommendations: a study protocol 
Clinical practice guidelines (CPGs) become quickly outdated and require a periodic reassessment of evidence research to maintain their validity. However, there is little research about this topic. Our project will provide evidence for some of the most pressing questions in this field: 1) what is the average time for recommendations to become out of date?; 2) what is the comparative performance of two restricted search strategies to evaluate the need to update recommendations?; and 3) what is the feasibility of a more regular monitoring and updating strategy compared to usual practice?. In this protocol we will focus on questions one and two.
The CPG Development Programme of the Spanish Ministry of Health developed 14 CPGs between 2008 and 2009. We will stratify guidelines by topic and by publication year, and include one CPG by strata.
We will develop a strategy to assess the validity of CPG recommendations, which includes a baseline survey of clinical experts, an update of the original exhaustive literature searches, the identification of key references (reference that trigger a potential recommendation update), and the assessment of the potential changes in each recommendation.
We will run two alternative search strategies to efficiently identify important new evidence: 1) PLUS search based in McMaster Premium LiteratUre Service (PLUS) database; and 2) a Restrictive Search (ReSe) based on the least number of MeSH terms and free text words needed to locate all the references of each original recommendation.
We will perform a survival analysis of recommendations using the Kaplan-Meier method and we will use the log-rank test to analyse differences between survival curves according to the topic, the purpose, the strength of recommendations and the turnover. We will retrieve key references from the exhaustive search and evaluate their presence in the PLUS and ReSe search results.
Our project, using a highly structured and transparent methodology, will provide guidance of when recommendations are likely to be at risk of being out of date. We will also assess two novel restrictive search strategies which could reduce the workload without compromising rigour when CPGs developers check for the need of updating.
PMCID: PMC3765147  PMID: 23967896
Clinical practice guidelines; Diffusion of innovation; Dissemination and implementation; Evidence-based medicine; Information storage and retrieval; Knowledge translation; Methodology; Updating

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