WHO Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup on Policy Actions- December 2019

Dr. Elie Akl, the director of the AUB GRADE center, acted as a guideline methodologist for the Second meeting of the WHO Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup on Policy Actions, held in Qingdao, China between 9- 13 December 2019.

Adaptation of the ASH VTE guidelines in the region

Along the 2019 Highlights of ASH meeting, ASH leadership organized a meeting with partner organizations from the region to discuss the potential for collaboration on the adaptation of the ASH VTE guidelines. Dr. Elie Akl, the AUB GRADE center director, presented about the experiences of guideline adaptation in the region, and provided an overview of the GRADE adolopment methodology. The collaborative project will be moving forward with the plan for the AUB GRADE center to provide the needed methodological support.

Cochrane's 30 under 30: Lara A Kahale

Ms. Lara Kahale, the coordinator of the AUB GRADE center, has been recognized by Cochrane on her work and contribution to the Collaboration. She was one of the first to be featured in a new series called Cochrane’s “30 under 30."  Here is the link to the full interview: https://www.cochrane.org/news/cochranes-30-under-30-lara-kahale

The AUB GRADE center coordinates the update of the American College of Rheumatology guidelines on the medical management of patients with Rheumatoid Arthritis

The American College of Rheumatology has selected the AUB GRADE center to lead the evidence synthesis for its upcoming 2020 guidelines on the medical management of patients with Rheumatoid Arthritis. The guidelines will be an update of the 2015 version and are expected to include 95 questions recommendation. The AUB GRADE center team will be coordinating the conduct of the systematic reviews and its director, Dr. Elie Akl, will act as the guideline methodologist for the project.

The AUB GRADE center delivers a workshop on the development and adaptation of clinical practice guideline in Lebanon (December 2018)

The AUB GRADE center conducted a two-day workshop entitled “Development and Adaptation of Practice Guidelines” on December 6 and 7 2018 at the American University of Beirut, Lebanon. The workshop was facilitated by Dr. Elie Akl, director of the AUB GRADE center, Dr. Assem Khamis, research fellow at the Clinical Research Institute in Lebanon, and Dr. Tamara Lotfi, coordinator of the Global Evidence Synthesis Initiative. Sixteen administrators, nurses, physicians, and researchers from multidisciplinary backgrounds participated in the workshop. They represented various universities and medical centers in Lebanon. The program included introduction to guidelines, the use of the GRADE methodology, and practical exercises using the online guideline development tool (GRADEPro).

The AUB GRADE center supports the Adolopment of the European Commission Initiative on Breast Cancer (ECIBC) Screening Guidelines for Tunisia

The AUB GRADE center has supported the Tunisian “Instance Nationale de l’Evaluation et de l’Accrediation en Santé” (INEAS) with the adolopment of the European Commission Initiative on Breast Cancer (ECIBC) Screening Guidelines for the Tunisian context. Dr. Elie Akl and Ms. Lara Kahale acted as the methodological co-chairs during the guideline meeting that was held in Tunis on the 20^th and 21^st of December 2018. Twelve experts including medical and surgical oncologists, gynecologists, family medicine, radiologists, and governmental representatives actively participated in the guideline meeting and drafted six recommendations. The guideline project was a collaborative effort between INEAS and the Tunisian Ministry of Health. It was supported by the European Commission Initiative and funded by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH.

WHO guidelines on the use of fexinidazole in patients with Human African Trypanosomiasis

Dr. Elie Akl, the director of the AUB GRADE center, participated recently in the World Health Organization (WHO) department of Neglected Tropical Disease guidelines on the use of fexinidazole in patients with Human African Trypanosomiasis (HAT). Dr. Akl acted as the GRADE methodologist and co-chair for the guideline.

HAT is a neglected tropical disease that occurs in sub-Saharan Africa, within the distributional limits of its vector, the tsetse fly. It caused devastating epidemics during the 20th century, but thanks to sustained and coordinated efforts over the past 15 years, the number of reported cases has fallen to historically low levels. Fexinidazole is an emerging therapeutic option for HAT that was recently approved by the European Medicines Agency (EMA),

The WHO guideline development group meeting was held on 3-4 December 2018 in the WHO headquarters in Geneva.

The AUB GRADE center builds capacity in developing and adapting clinical practice guidelines in Tunisia

The AUB GRADE center has been selected by the “Instance Nationale de l’Evaluation et de l’Accrediation en Santé” (INEAS) to build capacity in adapting clinical practice guidelines for Tunisia. The objectives of this project are the (1) elaboration of a handbook on the adaption of clinical practice guidelines in Tunisia, (2) training of the INEAS team in adapting guidelines using the GRADE methodology, and (3) adapting a real guideline for the Tunisian context. This project is being executed via short-term expert missions and is supported by the “Programme d’Appui a la Competitivité des Services” (PACS) Santé technical assistance and is funded by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH.

Dr. Elie Akl, the director of the AUB GRADE center, trained INEAS staff on how to conduct systematic reviews and meta-analyses. The workshop took place in INEAS center, Tunis on the 14^th and 15^th of May 2018.

Ms. Lara Kahale, the coordinator of the AUB GRADE center, delivered a three-day workshop on the “Adaptation of Practice Guidelines using the GRADE methodology”. The workshop took place in INEAS center, Tunis on the 10^th, 11^th, and 12^th of July 2018. Ms. Kahale was on a second mission from the 3^rd till the 5^th of September 2018 to help and guide INEAS staff in preparing for the guideline panel meeting on the adaptation of the European Commission Initiative on Breast Cancer Screening Guidelines which is expected to be held in December 2018. Also, together with INEAS staff, she is drafting the handbook on the adaption of clinical practice guidelines for Tunisia.

The AUB GRADE center delivers a workshop on the development and adaptation of clinical practice guideline in Lebanon (February 2018)

The AUB GRADE center conducted a two-day workshop entitled “Development and Adaptation of Practice Guidelines” on February 27 and 28 2018 at the American University of Beirut, Lebanon. Dr. Elie Akl, the director of the AUB GRADE center, and Ms. Lara Kahale, the coordinator of the center, facilitated the workshop. Twenty-nine administrators, nurses, physicians, and researchers from multidisciplinary backgrounds participated in the workshop. They included representatives from various universities, medical centers, non-governmental organizations and the ministry of public health in Lebanon. Participants were introduced to guideline development using the GRADE methodology and guideline adaptation using the ‘adolopment’ methodology. They also received training in using the online guideline development tool (GRADEPro).

The AUB GRADE center coordinates the Adaptation of Rheumatoid Arthritis Guidelines for the Brazilian Ministry of Health

The AUB GRADE center recently coordinated the Adaptation of Rheumatoid Arthritis Guidelines in Brazil. The objective of this project was to adapt the 2015 American College of Rheumatology (ACR) Rheumatoid Arthritis (RA) guidelines for the Brazilian context. The project was a collaborative effort between Hospital Moinhos de Vento and the Brazilian Ministry of Health. It used the ‘adolopment’ methodology and was based on the model of adaptation of the same guidelines followed for the Eastern Mediterranean Region. Ms. Lara Kahale, the coordinator of the AUB GRADE center, participated in the two guideline panel meetings that took place in Porto Alegre Brazil on the 14^th and 15^th of November 2017 and 17^th and 18^th of May 2018.

The AUB GRADE center conducts a workshop on the development and adaptation of clinical practice guideline in Brazil

The AUB GRADE center was invited to deliver a workshop in Brazil on the development and adaptation of clinical practice guideline. The workshop was held on the 16^th and 17^th of November in Porto Alegre, Brazil. It was part of the conference Evidence in Health 2017 - The value of information: from science to decision-making organized by Hospital Moinhos de Vento and the Brazilian Ministry of Health. Twenty researchers from multidisciplinary backgrounds participated in the workshop. They included representatives from various universities, medical centers, non-governmental organizations and the ministry of health in Brazil. Participants were introduced to the development of practice guidelines using the GRADE methodology. Practical exercises were applied using the online guideline development tool (GRADEPro).

The World Health Organization Guidance on Clinical Management of Crimean- Congo Haemorrhagic Fever

Dr. Elie Akl, the director of the AUB GRADE center, co-chaired the panel meeting for the development of the World Health Organization (WHO) guidance on clinical management of Crimean-Congo Haemorrhagic Fever (CCHF).

CCHF is one of the most widespread tick-borne diseases in humans and endemic in areas including the middle east and has a case-fatality rate between 10% and 40%. WHO has included CCHF in its list of priority pathogens for which urgent research and developmental action is required.

The panel meeting was co-hosted by the Robert Koch Institute in Germany and the WHO Experts Network Unit (formerly the Epidemic clinical Management Unit) and was held on April 4-5 in Berlin, Germany.

The American Society of Hematology (ASH) guidelines on management of venous thromboembolism in patients with cancer

Ms. Lara Kahale, the coordinator of the Clinical Epidemiological Unit at the Clinical Research Institute, contributed to the second panel meeting of the American Society of Hematology (ASH guidelines) that developed recommendations for the management of venous thromboembolism in patients with cancer. Ms. Kahale and the AUB team coordinated the work related to evidence synthesis and evidence presentation for that guideline. The meeting took place in the ASH headquarters in Washington D.C. on March 1 and 2, 2017 and included meetings for expert panels of an additional two of the ten guidelines being developed as part of this project.

Canadian Guideline for Safe and Effective Use of Opioids for chronic non cancer pain

Dr. Elie Akl, the director of the AUB GRADE center, participated as a panelist in the
Canadian Guideline for Safe and Effective Use of Opioids for chronic non cancer pain guideline panel meeting. The guidelines project is funded by Health Canada and took place in Hamilton, Ontario on the 5th and 6th of January 2017.

RARE- Best practices conference: use of GRADE in rare diseases

Dr. Andrea Darzi, the assistant director of the AUB GRADE center was invited to present on the "sickle cell disease pilot guidelines" at a conference in Rome, Italy on the 24th of November 2016. The RARE- Best practices project, funded by the European Union, organised the conference to disseminate its findings and offer a forum for discussing how this work could contribute to delivering better health decision-making and health policies for rare diseases. Dr. Darzi highlighted how the GRADE methodology can be used to develop and adapt guidelines for rare diseases. The AUB GRADE center took the lead in coordinating the "sickle cell disease pilot guidelines".

The American Society of Hematology (ASH) guidelines on management of venous thromboembolism

Dr. Andrea Darzi, the assistant director of the AUB GRADE center, contributed to the first panel meeting of the American Society of Hematology (ASH guidelines) project addressing the management of venous thromboembolism guideline effort. The meeting took place in the ASH headquarters in Washington D.C. from November 14 to 18, 2016 and included meetings for expert panels of five of the ten guidelines being developed as part of this project. 

RARE Best Practices Sickle Cell Disease Pilot Guideline

The AUB GRADE center recently coordinated the RARE Best practices sickle cell disease pilot guideline project, which was funded by the European union. Dr. Elie Akl, Dr. Andrea Darzi and Ms. Rana Charide from the AUB GRADE center served as methodologists in the meeting that took place in Freiburg, Germany from the 16th to the 18th of June. Dr. Miguel Abboud, chair of the department of Pediatrics at AUB, and an internationally renowned expert in sickle cell disease served on the expert panel.  The objective of this project was to assess whether the GRADe methodology could be used to develop guidelines for rare diseases. This project took place as part of a collaborative effort between RARE- Best practices, the MacGRADE Centre at McMaster University in Canada, the American University of Beirut (AUB) GRADE Center, and the German GRADE Center. 

The AUB GRADE center organized an Expert Consultation meeting on Adapting the World Health Organization (WHO) Guidelines

The AUB GRADE center, directed by Dr. Elie Akl, organized an expert consultation meeting on the adaptation of WHO guidelines to the Eastern Mediterranean Region. The Two-day meeting took place on AUB campus, on the 30th and 31st of May 2016, and was in collaboration with the Eastern Mediterranean Regional Office (EMRO) of the World Health Organization (WHO). The expert panel included Drs. Kahled Younis and Fadi El- Jardali from AUB, international experts in guideline development as well as representation from WHO EMRO. It was also an opportunity for junior members and trainees at the AUB GRADE center to participate or observe a high level consultative meeting. This meeting built on an earlier expert consultation meeting organized by the WHO EMRO in november 2015 in Cairo, Egypt, and in which the AUB GRADE center was represented . It also took advantage of ongoing methodological work at the AUB GRADE center on the topic of guideline adaptation 

The AUB GRADE center coordinated the Adaptation of Rheumatoid Arthritis Guidelines for the Eastern Mediterranean Region

The AUB GRADE center recently coordinated the Adaptation of Rheumatoid Arthritis Guidelines for the Eastern Mediterranean Region project. Three of the center team members, Dr. Elie Akl, Dr. Andrea Darzi and Ms. Manale Harfouche served as methodologists in the meeting that took place in Qatar from the 27th to the 29th of May 2016. Dr. Imad Uthman from AUB served as a member of the expert panel that included experts from 7 countries from the region, as well as from Canada, Denmark, and the United States. The objective of this project was to adapt the recently published American College of Rheumatology (ACR) Rheumatoid Arthritis (RA) guidelines to the Eastern Mediterranean Region. The project was a collaborative effort between the Weill Cornell Medical College in Qatar represented by Dr. Thurayya Arayssi, the Middle East Rheumatoid Arthritis Consortium (MERAC), and the American University of Beirut (AUB) GRADE Center. The project received funding from both the Qatar National Research Fund and Weill Cornell Medical College in Qatar. 

New GRADE working group guidance on assessing risk of bias associated with missing participant outcome data

The GRADE working group has recently adopted guidance for assessing the risk of bias associated with missing participant outcome data across an entire body of evidence. This post summarizes the guidance, provides a background, relevant references, and links to excel documents with calculators to facilitate the use of the guidance.

The Guidance

·      Start with a primary meta-analysis using a complete case analysis (i.e., excluding those with missing data)

·      Then conduct sensitivity meta-analyses imputing, in each study, data for those with missing data, and then pooling across studies. 

o   For binary outcomes: we suggest use of “plausible worst case” in which review authors assume that those with missing data in treatment arms have proportionally higher event rates than those followed successfully. 

o   For continuous outcomes: use imputed mean values from other studies within the systematic review, and the standard deviation from the median standard deviations of the control arms of all studies.  For meta-analyses in which investigators have used different instruments to address the same construct, convert all scores to standardized mean difference (SMD) or to the units of a selected reference instrument. 

·      If the results of the primary meta-analysis are robust to the most extreme plausible assumptions, do not rate down quality of evidence for risk of bias due to missing participant outcome data. 

·      If the results of the primary meta-analysis are not robust to the most extreme plausible assumptions, consider rating down quality for risk of bias.  

References

·      http://www.ncbi.nlm.nih.gov/pubmed/23451162

·      http://www.ncbi.nlm.nih.gov/pubmed/23774111

·      http://www.ncbi.nlm.nih.gov/pubmed/24613497

·      http://www.ncbi.nlm.nih.gov/pubmed/26202162

·      http://www.ncbi.nlm.nih.gov/pubmed/26944294

Links to MPD assumptions calculators

Binary variables: A freely downloadable Excel document to determine the numerators and denominators to be used for each trial included in the metaanalysis according to the selected assumption: https://www.dropbox.com/s/opstwgm45qiq57k/Assumptions%20about%20MPD%20v5.xls?dl=0

Continuous variables: A freely downloadable Excel document to determine the means and SDs to be used for each trial included in the meta-analysis according to the selected assumption per strategy:

https://www.dropbox.com/s/3ie12qfwjnfwx0z/MPD%20for%20continuous%20outcomes_Template.xlsx?dl=0