Evidence Synthesis International (ESI): Position Statement

This paper is the initial Position Statement of Evidence Synthesis International, a new partnership of organizations that produce, support and use evidence synthesis around the world. The paper (i) argues for the importance of synthesis as a research exercise to clarify what is known from research evidence to inform policy, practice and personal decision making; (ii) discusses core issues for research synthesis such as the role of research evidence in decision making, the role of perspectives, participation and democracy in research and synthesis as a core component of evidence ecosystems; (iii) argues for 9 core principles for ESI on the nature and role of research synthesis; and (iv) lists the 5 main goals of ESI as a coordinating partnership for promoting and enabling the production and use of research synthesis

A framework for identifying and mitigating the equity harms of COVID-19 policy interventions.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a global pandemic. Governments have implemented combinations of "lockdown" measures of various stringencies, including school and workplace closures, cancellations of public events, and restrictions on internal and external movements. These policy interventions are an attempt to shield high-risk individuals and to prevent overwhelming countries' healthcare systems, or, colloquially, "flatten the curve." However, these policy interventions may come with physical and psychological health harms, group and social harms, and opportunity costs. These policies may particularly affect vulnerable populations and not only exacerbate pre-existing inequities but also generate new ones. METHODS: We developed a conceptual framework to identify and categorize adverse effects of COVID-19 lockdown measures. We based our framework on Lorenc and Oliver's framework for the adverse effects of public health interventions and the PROGRESS-Plus equity framework. To test its application, we purposively sampled COVID-19 policy examples from around the world and evaluated them for the potential physical, psychological, and social harms, as well as opportunity costs, in each of the PROGRESS-Plus equity domains: Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, and disability). RESULTS: We found examples of inequitably distributed adverse effects for each COVID-19 lockdown policy example, stratified by a low- or middle-income country and high-income country, in every PROGRESS-Plus equity domain. We identified the known policy interventions intended to mitigate some of these adverse effects. The same harms (anxiety, depression, food insecurity, loneliness, stigma, violence) appear to be repeated across many groups and are exacerbated by several COVID-19 policy interventions. CONCLUSION: Our conceptual framework highlights the fact that COVID-19 policy interventions can generate or exacerbate interactive and multiplicative equity harms. Applying this framework can help in three ways: (1) identifying the areas where a policy intervention may generate inequitable adverse effects; (2) mitigating the policy and practice interventions by facilitating the systematic examination of relevant evidence; and (3) planning for lifting COVID-19 lockdowns and policy interventions around the world

Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19 A Living Systematic Review of Multiple Streams of Evidence

Background: Mechanical ventilation is used to treat respiratory failure in coronavirus disease 2019 (COVID-19). Purpose: To review multiple streams of evidence regarding the benefits and harms of ventilation techniques for coronavirus infections, including that causing COVID-19. (PROSPERO registration: CRD42020178187) Data Sources: 21 standard, World Health Organization–specific and COVID-19–specific databases, without language restrictions, until 1 May 2020. Study Selection: Studies of any design and language comparing different oxygenation approaches in patients with coronavirus infections, including severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS), or with hypoxemic respiratory failure. Animal, mechanistic, laboratory, and preclinical evidence was gathered regarding aerosol dispersion of coronavirus. Studies evaluating risk for virus transmission to health care workers from aerosol-generating procedures (AGPs) were included. Data Extraction: Independent and duplicate screening, data abstraction, and risk of bias assessment (GRADE for certainty of evidence and AMSTAR 2 for included systematic reviews). Data Synthesis: 123 studies were eligible (45 on COVID-19, 70 on SARS, 8 on MERS), but only 5 studies (1 on COVID-19, 3 on SARS, 1 on MERS) adjusted for important confounders. A study in hospitalized patients with COVID-19 reported slightly higher mortality with noninvasive ventilation (NIV) than with invasive mechanical ventilation (IMV), but 2 opposing studies, 1 in patients with MERS and 1 in patients with SARS, suggest a reduction in mortality with NIV (very low-certainty evidence). Two studies in patients with SARS report a reduction in mortality with NIV compared with no mechanical ventilation (low-certainty evidence). Two systematic reviews suggest a large reduction in mortality with NIV compared with conventional oxygen therapy. Other included studies suggest increased odds of transmission from AGPs. Limitation: Direct studies in COVID-19 are limited and poorly reported. Conclusion: Indirect and low-certainty evidence suggests that use of NIV, similar to IMV, probably reduces mortality but may increase the risk for transmission of COVID-19 to health care workers

Update Alert 2: Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19.

We have updated the protocol of our living systematic review (PROSPERO registration: CRD42020178187). This most recent search update, which was done on 11 July 2020, identified 2756 citations. Of these, we included 3 observational cohort studies of patients with coronavirus disease 2019 (COVID-19) in the updated quantitative synthesis (1–3). One of the new studies compared bilevel positive airway pressure (BiPAP) with continuous positive airway pressure (CPAP) (1), 1 compared high-flow oxygen by nasal cannula (HFNC) with invasive mechanical ventilation (IMV) (2), and the last compared noninvasive ventilation (NIV) with IMV (3) (Supplement Table 1)

Towards understanding the features of the waterpipe tobacco industry: findings from two consecutive visits to the International Hookah Fair

Background Understanding the internal structures of the tobacco industry is vital in the development of effective tobacco policy. Currently, little is known about the waterpipe tobacco industry. We aimed to understand more about product development, marketing methods, compliance with legislation and features of the waterpipe tobacco industry. Methods We attended two annual waterpipe tobacco industry exhibitions held in Frankfurt, Germany, in 2014 and 2015. We collected information on the types of products on display, analysed marketing material, assessed compliance with health warning and labelling requirements, and questioned exhibitors to gather information about the features of the industry, including supply chains, cross-industry collaborations, customer loyalty, and lobby group membership. Results Despite its presentation as a waterpipe trade exhibition, the fair was dominated by electronic cigarette (e-cigarette) companies and e-cigarette-like technology in waterpipe apparatuses. Waterpipe tobacco companies appeared distinct from those marketing e-cigarette-like waterpipe products. Marketing material across waterpipe tobacco products and accessories included claims of reduced harm (compared to cigarette smoking), safety, and quality. None of the 15 tobacco products collected complied with health warning and labelling requirements of FCTC Article 11, and over half of charcoal products contained misleading descriptors of safety and quality. Discussions with exhibitors identified a globalised but decentralised and industry with growing ties to transnational tobacco companies. Most waterpipe tobacco companies are family-run businesses with an absence of strategic partnerships such as lobby group membership. Deliberate breaches of tobacco policy, such as the use of high levels of glycerine in the tobacco manufacturing process, were confirmed by company representatives. Conclusions Our observations add insight into key features of the waterpipe tobacco industry and can guide policy dialogue. We call for a waterpipe-specific policy framework to address unique aspects of the industry and the regulatory challenges it poses

The implementation of prioritization exercises in the development and update of health practice guidelines: A scoping review.

BACKGROUND:The development of trustworthy guidelines requires substantial investment of resources and time. This highlights the need to prioritize topics for guideline development and update. OBJECTIVE:To systematically identify and describe prioritization exercises that have been conducted for the purpose of the de novo development, update or adaptation of health practice guidelines. METHODS:We searched Medline and CINAHL electronic databases from inception to July 2019, supplemented by hand-searching Google Scholar and the reference lists of relevant studies. We included studies describing prioritization exercises that have been conducted during the de novo development, update or adaptation of guidelines addressing clinical, public health or health systems topics. Two reviewers worked independently and in duplicate to complete study selection and data extraction. We consolidated findings in a semi-quantitative and narrative way. RESULTS:Out of 33,339 identified citations, twelve studies met the eligibility criteria. All included studies focused on prioritizing topics; none on questions or outcomes. While three exercises focused on updating guidelines, nine were on de novo development. All included studies addressed clinical topics. We adopted a framework that categorizes prioritization into 11 steps clustered in three phases (pre-prioritization, prioritization and post-prioritization). Four studies covered more than half of the 11 prioritization steps across the three phases. The most frequently reported steps for generating initial list of topics were stakeholders' input (n = 8) and literature review (n = 7). The application of criteria to determine research priorities was used in eight studies. We used and updated a common framework of 22 prioritization criteria, clustered in 6 domains. The most frequently reported criteria related to the health burden of disease (n = 9) and potential impact of the intervention on health outcomes (n = 5). All the studies involved health care providers in the prioritization exercises. Only one study involved patients. There was a variation in the number and type of the prioritization exercises' outputs. CONCLUSIONS:This review included 12 prioritization exercises that addressed different aspects of priority setting for guideline development and update that can guide the work of researchers, funders, and other stakeholders seeking to prioritize guideline topics

Free versus Fixed Combination Antihypertensive Therapy for Essential Arterial Hypertension: A Systematic Review and Meta-Analysis

<div><p>Background</p><p>In a free drug combination, each Blood pressure (BP)-lowering drug is administered as a separate pill, while in a fixed drug combination several BP-lowering agents are combined in a single pill. Using a single pill may enhance compliance and simplify treatment, which would translate into better clinical outcomes. The objective of this meta-analysis is to compare the effects of using a fixed combination versus free combination of BP-lowering agents in the management of patients with essential hypertension.</p><p>Methods</p><p>We searched Cochrane CENTRAL, MEDLINE, and EMBASE for randomized clinical trials (RCTs) addressing the objective of the review and assessing at least one of the following outcomes: BP-lowering efficacy, rapidity in achieving BP target, compliance, incidence of side effects, mortality, and morbidity. Two review authors independently selected eligible studies, abstracted data, and assessed risk of bias of included trials. The primary meta-analyses used a random-effects model.</p><p>Results</p><p>We identified seven RCTs with a total of 397 participants. Meta-analysis of efficacy in controlling BP showed a non-significant reduction of mean systolic BP of 0.81 mmHg (95% CI -3.25, 1.64) favoring the fixed combination group. As for adverse events, results showed a non-significant 13% risk reduction favoring the free combination (risk ratio 1.13, 95% CI 0.85, 1.5). Low quality of evidence was noted for both outcomes. Rapidity in achieving BP target was assessed in only one trial, and the results favored the fixed combination. Adherence to treatment was assessed in three trials, no pooled analysis was possible for this outcome. None of the included trials assessed mortality and morbidity.</p><p>Conclusion</p><p>The available low quality evidence does not confirm or rule out a substantive difference between fixed combination and free combination therapy in the management of HTN. Well designed RCTs with a long duration of follow-up and assessment of morbidity and mortality outcomes are needed.</p></div