孕激素维持妊娠与黄体支持临床实践指南

近年来国内外关于孕激素在维持妊娠以及黄体支持领域的临床及基础研究十分活跃,不断有新的循证医学证据涌现。基于当前的最佳证据,本指南针对辅助生殖技术(assisted reproductive technology,ART)黄体支持、先兆流产、复发性流产以及早产中孕激素的应用方面,按照循证临床实践指南制订的方法和步骤,引入推荐意见分级的评估、制订及评价(grading of recommendations assessment,development and evaluation,GRADE)方法,结合临床医师的经验,考虑我国患者的偏好与价值观,平衡干预措施的利与弊,形成了15条推荐意见,以期为临床实践提供参考。     

太极运动防治骨质疏松症的系统评价再评价

目的多元评价太极运动防治骨质疏松症相关系统评价的文献质量及其结局指标的证据质量。方法计算机检索PubMed、Web of science、EMbase、The Cochrane Library、PROSPERO、CNKI、CBM、Wan Fang和VIP数据库,收集太极运动防治骨质疏松症的系统评价/Meta分析,分别采用AMSTAR-2量表、PRISMA得分对纳入文献进行方法学质量和报告质量评价,并依据GRADE系统对所纳入系统评价的结局指标进行证据质量分级。结果共纳入13篇系统评价/Meta分析,其中1篇文献方法学质量较高,其余文献均为低或极低质量,PRISMA得分在12～24分不等,主要问题存在于方案注册、偏倚风险评估、异质性、发表偏倚、数据合并分析等方面。GRADE评价结果显示纳入的44个结局指标中,8个结局指标质量为中,22个为低,14个为极低,中等质量的结局指标提示太极运动对脊柱、腰椎、股骨颈的骨密度改善作用优于对照组。结论太极运动防治骨质疏松症的系统评价/Meta分析文献质量总体不高,结局指标的证据强度较低,未来仍需进行大样本、高质量的研究进一步评估其有效性。     

Strengthening and sustainability of national immunization technical advisory groups (NITAGs) globally: Lessons and recommendations from the founding meeting of the global NITAG network

National Immunization Technical Advisory Groups (NITAGs) provide independent, evidence-informed advice to assist their governments in immunization policy formation. However, many NITAGs face challenges in fulfilling their roles. Hence the many requests for formation of a network linking NITAGs together so they can learn from each other. To address this request, the Health Policy and Institutional Development (HPID) Center (a WHO Collaborating Center at the Agence de Médecine Préventive - AMP), in collaboration with WHO, organized a meeting in Veyrier-du-Lac, France, on 11 and 12 May 2016, to establish a Global NITAG Network (GNN). The meeting focused on two areas: the requirements for (a) the establishment of a global NITAG collaborative network; and (b) the global assessment/evaluation of the performance of NITAGs. 35 participants from 26 countries reviewed the proposed GNN framework documents and NITAG performance evaluation. Participants recommended that a GNN should be established, agreed on its governance, function, scope and a proposed work plan as well as setting a framework for NITAG evaluation.     

Developing evidence-based immunization recommendations and GRADE

The Strategic Group of Advisory Experts (SAGE) on immunization is an independent advisory committee with a mandate to advise the World Health Organization (WHO) on the development of vaccine and immunization related policies. SAGE working groups are established on a time-limited basis to review and provide evidence-based recommendations, together with their implications, for open deliberation and decision-making by SAGE. In making its recommendations, SAGE takes into consideration: the epidemiologic and clinical characteristics of the disease; vaccine and immunization characteristics; economic analysis; health system considerations; the existence of and interaction with other intervention and control strategies; costing and social impacts; and legal and ethical concerns. Since 1998, WHO has produced evidence-based vaccine position papers for use primarily by national public health officials and immunization programme managers. Since April 2006 all new or updated position papers have been based on SAGE recommendations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach has been adopted by WHO and, since 2008, GRADE tables that rate the quality of evidence have been produced in support of key recommendations. SAGE previously expressed concern that GRADE was not ideally suited to many immunization-specific issues such as the vaccine population level effect and the inclusion of surveillance system data, particularly for vaccine safety. Extensive productive interactions with various advisory groups including the US Advisory Committee on Immunization Practices, the European Centres for Disease Control, the German Standing Committee on Vaccination (STIKO), WHO's Global Advisory Committee on Vaccine Safety and the GRADE working group resulted in key enhancements to accommodate vaccine-relevant evidence. This facilitated integration and acceptability of the GRADE approach in the development of immunization related SAGE and WHO recommendations. Ongoing utilisation should result in further fine-tuning of the approach to ensure that recommendations are based on the full range of appropriate evidence.     

Executive summary: Japanese pediatric guideline for the treatment and management of asthma (JPGL) 2020

This article covers the salient and updated themes of the Japanese Pediatric Guidelines for the Treatment and Management of Asthma (JPGL) 2020 published by the Japanese Society of Pediatric Allergy and Clinical Immunology. In the 2020 guidelines, five new clinical questions (CQs) have been added to address the 12 CQs regarding the treatment of childhood asthma. “Infant and preschool asthma” is diagnosed when young children (<6 years of age) have three or more episodes of clear expiratory wheezing, which continue for more than 24 h, and symptom improvement can be observed after beta-2 agonist inhalation. In children without clear improvement, diagnostic therapeutic trial for the duration of 1 month with controller treatment can be used. Since long-term management is initiated, the treatment level is adjusted based on the current control status and the management of risk factors, with the provision for holistic care. This underscores the smooth transition of pediatric patients into adult services. There are several differences between the JPGL and the guidelines of other countries. Further evidence is obtained as the utility of the newly proposed management plans should be evaluated in the Japanese population.     

Senior GRADE methodologists encounter challenges as part of WHO guideline development panels: an inductive content analysis

BackgroundThe World Health Organization (WHO) classifies a substantial proportion of their recommendations as strong despite low or very low confidence (certainty) in estimates of effect. Such discordant recommendations are often inconsistent with Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance.ObjectiveTo gain the perspective of senior WHO methodology chairs regarding panels' use of GRADE, particularly regarding discordant recommendations.Data sourcesSenior active GRADE methodologists who had served on at least two WHO panels and were an author on at least one peer-reviewed published article on GRADE methodology.MethodsFive eligible methodologists participated in detailed semistructured interviews. Respondents answered questions regarding how they were viewed by other panelists and WHO leadership, and how they handled situations when panelists made discordant recommendations they felt were inappropriate. They also provided information on how the process can be improved. Interviews were recorded and transcribed, and inductive content analysis was used to derive codes, categories, and emergent themes.ResultsThree themes emerged from the interviews of five methodologists: (1) The perceived role of methodologists in the process, (2) Contributors to discordant recommendations, and (3) Strategies for improvement. Salient findings included (1) a perceived tension between methodologists and WHO panels as a result of panel members' resistance to adhering to GRADE guidance; (2) both financial and nonfinancial conflicts of interest among panel members as an explanation for discordant recommendations; and (3) the need for greater clarity of, and support for, the role of methodologists as co-chairs of panels.ConclusionsThese findings suggest that the role of the GRADE methodologist as a co-chair needs to be clarified by the WHO leadership. They further suggest the need for additional training for panelists, quality monitoring, and feedback to ensure optimal use of GRADE in guideline development at WHO.     

Diagnosis and treatment of severely malnourished children with diarrhoea

Children with severe acute malnutrition complicated by diarrhoea require special care due to their unique physiological vulnerability and increased mortality risks. A systematic literature review (1950–2013) was conducted to identify the most effective diagnostic and therapeutic measures for the community‐based management of severely malnourished children with diarrhoea. No studies directly addressed this question, so the search was broadened to include inpatient care. Of the 129 studies identified, 32 were selected for full review and found to contain varying degrees of indirectness, inconsistency and bias. Evidence from diagnostic studies point to the use of both prolonged and persistent diarrhoea as morbidity markers, rapid hypoglycaemia diagnosis and the frequent aetiological role of Cryptosporidium. Therapeutic studies suggest benefits from routine antiparasitic medication and feeding regimens with ready‐to‐use‐therapeutic foods, lactose‐free diets and zinc supplementation. Existing rehydration treatment guidelines were affirmed, but the utility of glutamine and low osmolarity feeds were inconclusive.