Abstract Objective We conducted a systematic review and meta-analysis to address benefits and harms of using elastic compression stockings after lower-extremity deep vein thrombosis. Methods We ...searched 7 electronic databases through January 15, 2015, including randomized controlled trials (RCTs)/quasi-randomized trials reporting on elastic compression stocking efficacy on postthrombotic syndrome incidence, recurrent venous thromboembolism, mortality, and acute pain after deep vein thrombosis. Two reviewers independently screened records, extracted data, assessed risk of bias, and assessed confidence in effect estimates using Grading of Recommendations Assessment, Development, and Evaluation methodology. We applied random-effects meta-analysis models. Results We included 5 RCTs (n = 1418) reporting on postthrombotic syndrome. The hazard ratio (HR) for postthrombotic syndrome with elastic compression stockings was 0.69 (95% confidence interval CI, 0.47-1.02). We have very low confidence in this estimate due to heterogeneity and inclusion of unblinded studies at high risk of bias. Excluding high risk of bias studies, a single large RCT at low risk of bias provided moderate-quality evidence of no effect on postthrombotic syndrome (HR 1.00; 95% CI, 0.81-1.24). Moderate-quality evidence including all 5 studies suggests no effect of elastic compression stockings on recurrent venous thromboembolism (relative risk RR 0.88; 95% CI, 0.63-1.24) or mortality (RR 1.00; 95% CI, 0.73-1.37, 5 studies). Moderate-quality evidence from one large RCT does not suggest effect on acute pain after deep vein thrombosis. Conclusions The highest-quality evidence available suggests no effect of elastic compression stockings on postthrombotic syndrome or pain relief, from a single large RCT. However, results for preventing postthrombotic syndrome differ substantially across studies, and future guideline updates should reflect uncertainty about treatment effects. Elastic compression stockings are unlikely to prevent death or recurrent venous thromboembolism.
BACKGROUND Bridging the gap between clinical research and everyday health-care practice requires effective communication strategies. To address current shortcomings in conveying practice ...recommendations and supporting evidence, we are creating and testing presentation formats for clinical practice guidelines (CPGs). METHODS We carried out multiple cycles of brainstorming and sketching, developing a prototype. Physicians participating in the user testing viewed CPG formats linked to clinical scenarios and engaged in semistructured interviews applying a think-aloud method for exploring important aspects of user experience. RESULTS We developed a multilayered presentation format that allows clinicians to successively view more in-depth information. Starting with the recommendations, clinicians can, on demand, access a rationale and a key information section containing statements on quality of the evidence, balance between desirable and undesirable consequences, values and preferences, and resource considerations. We collected feedback from 27 stakeholders and performed user testing with 47 practicing physicians from six countries. Advisory group feedback and user testing of the first version revealed problems with conceptual understanding of underlying CPG methodology, as well as difficulties with the complexity of the layout and content. Extensive revisions made before the second round of user testing resulted in most participants expressing overall satisfaction with the final presentation format. CONCLUSIONS We have developed an electronic, multilayered, CPG format that enhances the usability of CPGs for frontline clinicians. We have implemented the format in electronic guideline tools that guideline organizations can now use when authoring and publishing their guidelines.
Pulmonary manifestations of tularaemia are reported to be infrequent in previous publications. During 2016, we noticed an increase in the number of hospitalised patients with pulmonary tularaemia in ...Eastern Norway. We aimed to investigate primary pulmonary tularaemia in Eastern Norway in terms of symptoms, radiological and microbiological findings, incidence and risk exposure.
A retrospective analysis of consecutive primary pulmonary tularaemia cases from 2016 until 2018 was conducted.
From 1 September, 2016 until 31 December, 2018, 22 patients were diagnosed with primary pulmonary tularaemia at Innlandet Hospital Trust, representing 48% of all reported tularaemia cases in the region. A peak annual incidence of 3.4 in 100 000 was found in 2017.All 22 patients lived in, or had recently visited, rural areas. Eighteen patients reported risk exposure for tularaemia, such as wood chopping, outdoor activities and farming prior to symptom onset. All patients experienced fever, and 19 patients had respiratory symptoms. Ten patients were in spontaneous recovery at diagnosis.All patients had a chest computed tomography scan. Overall, 19 patients had pulmonary lesions and 18 had enlarged intrathoracic lymph nodes. The computed tomography images were described as suspicious of malignancy in 17 patients.
Pulmonary manifestations in tularaemia occurred more frequently in our region than expected from previous reports. Although all patients had symptoms consistent with infection, the majority were primarily investigated considering lung cancer due to the radiology report. In endemic areas, pulmonary tularaemia may be an important differential diagnosis to lung cancer.
BACKGROUND The Antithrombotic Therapy and the Prevention of Thrombosis, 9th Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (AT9) represent trustworthy ...international guidelines for antithrombotic treatment and thromboprophylaxis. We describe major changes to the format and content resulting from applying new strategies for guideline adaptation and dissemination. METHODS A Norwegian guideline panel of 46 experts completed a structured and systematic adaptation process, updated the recommendations based on new evidence, and rewrote the recommendations in an electronic multilayered presentation format. We published the adapted guideline using the web-based Making GRADE the Irresistible Choice Guideline Authoring and Publication Platform. RESULTS We applied a novel presentation format to 333 recommendations from 11 of the 15 management chapters in AT9 and condensed and restructured them into 249 recommendations in a multilayered format. We added additional relevant information, such as 29 best-practice statements about new oral anticoagulants and practical information sections for 121 recommendations. Common reasons for modifications included feasibility of the recommendations in a national context, disagreement with applied baseline risk estimates, and reevaluation of the balance between the benefits and harms of interventions in relation to assumed typical patient preferences and values. The adapted guideline was published and disseminated online in November 2013. CONCLUSIONS New strategies for adapting, updating, and disseminating trustworthy guidelines proved feasible and will provide Norwegian health-care professionals and patients with up-to-date guidance tailored to national circumstances.
Standards and guidance for developing trustworthy clinical practice guidelines are now available, and a number of leading guidelines adhere to the key standards. Even current trustworthy guidelines, ...however, generally suffer from a cumbersome development process, suboptimal presentation formats, inefficient dissemination to clinicians at the point of care, high risk of becoming quickly outdated, and suboptimal facilitation of shared decision-making with patients. To address these limitations, we have—in our innovative research program and nonprofit organization, MAGIC (Making GRADE the Irresistible Choice)—constructed a conceptual framework and tools to facilitate the creation, dissemination, and dynamic updating of trustworthy guidelines. We have developed an online application that constitutes an authoring and publication platform that allows guideline content to be written and structured in a database, published directly on our web platform or exported in a computer-interpretable language (eg, XML) enabling dissemination through a wide range of outputs that include electronic medical record systems, web portals, and applications for smartphones/tablets. Modifications in guidelines, such as recommendation updates, will lead to automatic alterations in these outputs with minimal additional labor for guideline authors and publishers, greatly facilitating dynamic updating of guidelines. Semiautomated creation of a new generation of decision aids linked to guideline recommendations should facilitate face-to-face shared decision-making in the clinical encounter. We invite guideline organizations to partner with us ( www.magicproject.org ) to apply and further improve the tools for their purposes. This work will result in clinical practice guidelines that we cannot only trust, but also easily share and use.
BACKGROUND Adaptation of guidelines for use at the national or local level can facilitate their implementation. We developed and evaluated an adaptation process in adherence with standards for ...trustworthy guidelines and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, aiming for efficiency and transparency. This article is the first in a series describing our adaptation of Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines for a Norwegian setting. METHODS Informed by the ADAPTE framework, we developed a five-step adaptation process customized to guidelines developed using GRADE: (1) planning, (2) initial assessment of the recommendations, (3) modification, (4) publication, and (5) evaluation. We developed a taxonomy for describing how and why recommendations from the parent guideline were modified and applied a mixed-methods case study design for evaluation of the process. RESULTS We published the adapted guideline in November 2013 in a novel multilayered format. The taxonomy for adaptation facilitated transparency of the modification process for both the guideline developers and the end users. We excluded 30 and modified 131 of the 333 original recommendations according to the taxonomy and developed eight new recommendations. Unforeseen obstacles related to acquiring a licensing agreement and procuring a publisher resulted in a 9-month delay. We propose modifications of the adaptation process to overcome these obstacles in the future. CONCLUSIONS This case study demonstrates the feasibility of a novel guideline adaptation process. Replication is needed to further validate the usefulness of the process in increasing the organizational and methodologic efficiency of guideline adaptation.
Abstract
This study investigates the relationship between international inventor teams and the technological variety of multinational enterprises. We frame this relationship conceptually by ...considering two possible attributes of diversity in international inventor teams: cultural differences and heterogeneous knowledge. We employ a dataset for 454 multinational enterprises with 71,126 subsidiaries across 185 countries that applied for 139,066 priority patents during the period 2007–2014. Fixed-effects panel estimations indicate that international inventor teams are positively associated with both related and unrelated technological variety at the level of the MNE. Such relationships display diminishing marginal returns, pointing to management and coordination costs reducing the benefits from international inventor teams. In addition, we find that MNEs with higher technological innovation capability deal with the additional complexity from managing and coordinating international inventor teams by consolidating technological variety.
Decision aids can help shared decision making, but most have been hard to produce, onerous to update, and are not being used widely. Thomas Agoritsas and colleagues explore why and describe a new ...electronic model that holds promise of being more useful for clinicians and patients to use together at the point of care
PDF
