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Tenth European Consensus Conference on Hyperbaric Medicine: preliminary report
Abstract
The tenth European Consensus Conference on Hyperbaric Medicine took place in Lille, France, 14-16 April, 2016, attended by a large delegation of experts from Europe and elsewhere. The focus of the meeting was the revision of the European Committee on Hyperbaric Medicine (ECHM) list of accepted indications for hyperbaric oxygen treatment (HBOT), based on a thorough review of the best available research and evidence-based medicine (EBM). For this scope, the modified GRADE system for evidence analysis, together with the DELPHI system for consensus evaluation, were adopted. The indications for HBOT, including those promulgated by the ECHM previously, were analyzed by selected experts, based on an extensive review of the literature and of the available EBM studies. The indications were divided as follows: Type 1, where HBOT is strongly indicated as a primary treatment method, as it is supported by sufficiently strong evidence; Type 2, where HBOT is suggested as it is supported by acceptable levels of evidence; Type 3, where HBOT can be considered as a possible/optional measure, but it is not yet supported by sufficiently strong evidence. For each type, three levels of evidence were considered: A, when the number of randomised controlled trials (RCT) is considered sufficient; B, when there are some RCT studies in favour of the indication and there is ample expert consensus; C, when the conditions do not allow for proper RCT studies but there is ample and international expert consensus. Finally, the conference also issued 'negative' recommendations for those conditions where there is evidence not to use HBOT and HBOT is considered as not indicated with a Type 1 recommendation. Table 1 is a concise summary of the conclusions reached by the ECHM 2016 Consensus Conference. There were no Type 1A indications for HBOT identified by the conference, indicating that much clinical research is still required to clarify the role of HBOT in clinical practice. A full report is being prepared for publication.
... Hyperbaric oxygen therapy (HBOT) is a safe and effective option for patients with early stages of FHN. Radiographic improvements, reduced self-reported pain scores, increased range of motion, and improved patient's quality of life is often reported early after the beginning of HBO treatments [26,[91][92][93][94][95][96]. ...
... In 2016, at the Consensus Conference in Lille, FHN was accepted as an indication for hyperbaric oxygen therapy in the European Community level 2B [95]. Despite some clinical studies that support the benefits of HBO therapy in patients afflicted by osteonecrosis [26,94,95], this therapy is still not worldwide approved. ...
... In 2016, at the Consensus Conference in Lille, FHN was accepted as an indication for hyperbaric oxygen therapy in the European Community level 2B [95]. Despite some clinical studies that support the benefits of HBO therapy in patients afflicted by osteonecrosis [26,94,95], this therapy is still not worldwide approved. Hence, this work aims to prove to extend the indication also for non-European countries. ...
Although many studies have shown that hyperbaric oxygen (HBO) therapy can significantly improve symptoms and quality of life of patients affected by femoral head necrosis, this therapy is not worldwide approved yet. This meta-analysis was performed to evaluate its clinical effect. Relevant studies published before May 2020 were systematically searched using terms related to HBO and femoral head necrosis. Fixed and random-effects models were used to estimate the odds ratio (OR) with 95% confidence intervals (CI). Subgroup analyses and publication bias tests were carried out to explore potential study heterogeneity and bias. Ten studies involving 353 controls and 368 HBO-treated cases were included, most of which were conducted on Asian population. The clinical effect in the HBO therapy group was 3.84 times higher than in the control group (OR = 3.84, 95% CI (2.10, 7.02), p < 0.00001). Subgroup analyses showed that the clinical effect of HBO therapy was statistically significant in the Asian subpopulation which represented most of the subjects (OR = 3.53, 95% CI (1.87, 6.64), p < 0.00001), but not in the non-Asian subpopulation, probably because of insufficient numerosity (OR = 7.41, 95% CI (0.73, 75.71), p = 0.09). The results of this meta-analysis suggest that patients with femoral head necrosis treated with HBO therapy can achieve a significant clinical improvement.
Keywords: femoral head necrosis; hyperbaric oxygen therapy; necrosis; osteonecrosis; oxygen; microcirculation; pain
... It raises the social costs of diabetes [4]. The consensus conference of hyperbaric oxygen therapy association postulates that diabetic foot ulcers are a confirmed clinical indication for HBOT with a strong agreement [5]. The effect of hyperoxygenation on tissues is performed by an improvement of compromised tissue oxygenation, an antimicrobial action and a promotion of wound healing through stimulating fibroblasts proliferation, collagen synthesis, and neoangiogenisis [1,6]. ...
... Diabetic retinopathy and cystoid macular edema are considered as potential indications of this treatment [11,12]. Other reported ophthalmological indications are: retinal artery and vein occlusions, anterior segment ischemia, macular degeneration, retinitis pigmentosa and glaucoma [5,6]. ...
Purpose:
The objective of this study was to prospectively assess the effect of hyperbaric oxygen therapy (HBOT) on diabetic retinopathy lesions and macular edema in patients undergoing the treatment for diabetic foot ulcers.
Methods:
We compared two groups: a first group including 25 patients with non-proliferative diabetic retinopathy treated by HBOT for foot ulcers, and a second group (control group) composed of 25 patients with diabetic retinopathy who did not receive HBOT. The HBOT protocol performed for the patients in the first group was: 30 sessions of 90 minutes each at 2.5 ATA with a mean frequency of five sessions per week. All patients had an ophthalmological exam at baseline (visual acuity, intraocular pressure, fundus exam), fundus photography and an OCT exam. A follow-up exam was performed at the conclusion of the HBOT.
Results:
Compared to the control group, patients treated with HBOT showed a regression or stabilization of diabetic retinopathy lesions and a decrease in central macular thickness (CMT).
Conclusion:
Hyperbaric oxygen therapy may improve diabetic retinopathy and diabetic macular edema. This therapy may serve as an adjunctive treatment in the management of retinal ischemia and capillary hyperpermeability in diabetic retinopathy.
... Recently, implantation of autologous osteogenic cells or osteochondral grafting has been described (14,19). Moreover, hyperbaric oxygen therapy (HBO) has a beneficial impact on ON providing a higher oxygen concentration to all tissues and ischemic bone cells as well (20,21). There is no evidence that HBO acts on tumor growth and recurrence, in vitro, while in vivo and clinical studies suggest a neutral effect of HBO on tumor growth (22). ...
... HBO is prescribed in the treatment of non-healing lesions via reactive oxygen and nitrogen species modulation (44), but recently there is speculation that the underlying HBO mechanism is related to an augmented signaling for bone turnover and osteoclast differentiation (20,43). In Europe, HBO is recognized with a level of evidence B and regularly used in adults affected by idiopathic ON diagnosed at early stages (ARCO 1, 2a/b), obtaining the alleviation of pain, functional disabilities and radiological images (21,46). ...
BACKGROUND/AIM: In the last few decades, treatment strategies for acute lymphoblastic leukemia (ALL) have been associated not only with improvement of prognosis, but also with an increasing rate of late complication as osteonecrosis (ON). Herein, the cumulative incidence, risk factors, new conservative therapeutic strategies as hyperbaric oxygen therapy (HBO), and outcome of symptomatic ON were studied in pediatric patients with ALL. PATIENTS AND METHODS: Between 2000 and 2017, 495 children and young adolescents with a diagnosis of ALL were evaluated. All the symptomatic patients underwent magnetic resonance imaging (MRI) to detect bone vascularization and structure. RESULTS: Twenty-three out of 495 patients presented ON (4.6%). ON was associated with an older age (p<0.0001) and a higher steroid dose (p=0.0013). All the patients underwent standard therapies and HBO was performed in 8 of 23 patients. During the follow-up, 15 patients were stable: 6 were totally asymptomatic, 5 complained of pain during activity, and 4 presented mild function limitation. CONCLUSION: Our data highlight the importance of early diagnosis of ON by screening MRI in asymptomatic patients, in order to start conservative treatment strategies. Moreover, HBO could have beneficial effects on ON patients. Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
... With restriction to the stage considered, Camporesi et al. showed that HBO should be considered the primary treatment modality in any patients and especially in young patients where the goal is to delay total hip arthroplasty as long as possible [5]. Therefore, the European Community accepted femoral head necrosis as an indication for hyperbaric oxygen therapy (HBOT) during the Consensus Conference in Lille, France [11]. ...
... The actual inability to establish which will be the correct dose of HBO 2 to administer in each case is still depending on the lack in Level 1 evidence [1,11]; as a mater of fact, the current scientiic literature does not yet allow a clear identiication of the optimal treatment protocol. ...
Femoral head necrosis (FHN) is a disease process resulting from inadequate blood perfu-sion of subchondral bone. While the etiology of this disease is still not fully understood, there are multiple traumatic and atraumatic factors that are associated with the disease. Pathophysiology of the disease is characterized by the death of bone marrow and osteo-cytes. If left untreated, the disease may progress to joint collapse. While initial stages of the disease are asymptomatic, painful limitation of active and passive motion of the hip is eventually present. The current body of literature cannot identify an optimal treatment protocol for FHN. Postcollapse cases require surgical intervention, core decom-pression, or total hip arthroplasty. However, current strides in conservative management are being made. One of the possible conservative modalities that may efectively delay hip arthroplasty or even prevent the need for a surgical approach is hyperbaric oxygen (HBO 2) therapy. HBO 2 increases extracellular oxygen concentration and reduces cellular ischemia and edema by inducing vasoconstriction. Studies have reported radiographic improvement, reduction in pain, and increases in range of motion for early stages of the disease. Hyperbaric oxygen therapy has also been shown to stimulate angiogenesis and enhance osteoclast and osteoblast function for remodeling and repair.
... Indications valid in the Slovak Republic are drawn up by individual health insurance companies in accordance with the criteria of the European Society of Hyperbaric Medicine [18], but they are not uniform. HBOT is a standard therapy e.g. for the treatment of decompression sickness, gas embolism and carbon monoxide poisoning. ...
In the case of the cancer diseases, the hyperbaric oxygen therapy (HBOT) is auxiliary and not primarily life-saving treatment. Thanks to its multiple and general effect on the all tissue and organ systems it seems however to be an important tool of adjuvant therapy in the treatment of late effects of radiotherapy. HBOT is applied during and after breast-conserving therapy, and it is used in the treatment of breast-cancer co-morbidities, e.g. arm/shoulder pain, arm/hand swollen, pain in the affected area, and oversensitivity and skin problems in the area of affected breast. Further research in this area has to be carried out due to the multiple complexity of HBOT effects.
... Although many authors have advocated treatments based on age, symptoms, stage and/or medical status [5][6][7], the orthopedic community has not adopted an algorithm for treatment. This manuscript is a summary of the Consensus Conference in Lille, France, which accepted femoral head necrosis as an indication for hyperbaric oxygen (HBO 2 ) therapy in the European community [8]. ...
Background: Femoral head necrosis (FHN) is a common invalidating disease with an unclear etiology and pathophysiology that affects middle-aged people. FHN may lead to joint collapse and require invasive treatments. Because of its clinical and socioeconomic significance, an early diagnosis, staging and appropriate treatment are required. Unfortunately, to date a unique algorithm for the treatment of FHN has not been defined.
Objective: In this report we summarize the Tenth European Consensus Conference on hyperbaric medicine (April 2016, France), during which experts from Europe revised the list of accepted indications for hyperbaric oxygen (HBO2) treatment, including FHN.
Methods: In this report all aspects of osteonecrosis discussed during the meeting have been considered: pathophysiology, clinical presentation, standard management, HBO2 therapy
and evidence-based review of its efficacy. All observations are based on a thorough review of the best available research and evidence-based medicine.
Conclusions: The Consensus Conference in Lille established FHN as an indication for HBO2 therapy and suggested a protocols guideline to adopt for this pathology.
... A preliminary report with the short list of indications for hyperbaric oxygen treatment (HBOT) was published recently. 4 Here, we present the full report, including methodology and detailed recommendations given at the conference. Additional files with literature queries and analysis of published evidence using the GRADE system can be found on the ECHM website (www.ECHM.org). ...
The tenth European Consensus Conference on Hyperbaric Medicine took place in April 2016, attended by a large delegation of experts from Europe and elsewhere. The focus of the meeting was the revision of the European Committee on Hyperbaric Medicine (ECHM) list of accepted indications for hyperbaric oxygen treatment (HBOT), based on a thorough review of the best available research and evidence-based medicine (EBM). For this scope, the modified GRADE system for evidence analysis, together with the DELPHI system for consensus evaluation, were adopted. The indications for HBOT, including those promulgated by the ECHM previously, were analysed by selected experts, based on an extensive review of the literature and of the available EBM studies. The indications were divided as follows: Type 1, where HBOT is strongly indicated as a primary treatment method, as it is supported by sufficiently strong evidence; Type 2, where HBOT is suggested as it is supported by acceptable levels of evidence; Type 3, where HBOT can be considered as a possible/optional measure, but it is not yet supported by sufficiently strong evidence. For each type, three levels of evidence were considered: A, when the number of randomised controlled trials (RCTs) is considered sufficient; B, when there are some RCTs in favour of the indication and there is ample expert consensus; C, when the conditions do not allow for proper RCTs but there is ample and international expert consensus. For the first time, the conference also issued 'negative' recommendations for those conditions where there is Type 1 evidence that HBOT is not indicated. The conference also gave consensus-agreed recommendations for the standard of practice of HBOT.
Purpose
To evaluate the acute effect of hyperbaric oxygen therapy (HBOT) on central macular thickness (CMT) and choroidal thickness (CT) in patients with type 2 diabetes mellitus (T2D) undergoing HBOT due to diabetic foot ulcer (DFU).
Methods
For this cross-sectional study, patients with T2D were recruited between May 2019 and June 2020. Only eyes with non-proliferative or no diabetic retinopathy (DR) were included. CMT and subfoveal, nasal, and temporal CT values measured by spectral-domain optical coherence tomography (Nidek RS-3000 Advance, Aichi, Japan) before and 45 minutes after the first HBOT session were compared between eyes with and without DR and between patients receiving only insulin therapy (group 1) or insulin+oral antidiabetic (group 2). Relationships between post-HBOT change in these parameters and age, sex, HbA1c level, and DR presence and stage were evaluated.
Results
The study included 49 eyes of 26 patients with DFU (aged 43-75 years). Post-HBOT changes in CMT and CT were not significant or associated with age, gender, DR stage, or HbA1c level (p>0.05). Eyes with DR had significantly higher pre- and post-HBOT CMT, nasal CT, and temporal CT values compared to non-DR eyes. Nasal CT increased significantly after HBOT in eyes with DR. Group 1 (28 eyes, 15 patients) had higher pre-HBOT mean subfoveal CT and greater post-HBOT change in subfoveal CT than group 2 (21 eyes, 11 patients).
Conclusions
HBOT was not associated with acute changes in CMT or CT in patients with T2D, although an increase in nasal CT was observed in eyes with DR.
Objective
To investigate the clinical effects of time window on hyperbaric oxygen treatment (HBOT) in patients with disorders of consciousness (DOC).Methods
All the clinical research literature regarding HBOT for DOC published between January 2000 and November 2020 were retrieved from China National Knowledge Infrastructure (CNKI), Wanfang Standards Database (WFSD) and VIP Database using Chinese key words disorders of consciousness, the vegetable state, minimally conscious state, or hyperbaric oxygen followed by a comprehensive meta-analysis.ResultsThe query gave rise to 348 results, in which 21 articles were eventually selected for meta-analysis. Among the selected 21 articles, 18 articles involved a time window comparison. All the patients were classified into Z = 11.28, P = 0.000, odds ratio = 3.80, 95% CI = 3.02-4.80). Additionally, the adverse reaction rate of the Z = 10.01, P = 0.000, odds ratio = 4.82, 95% CI = 3.54-6.56). The funnel diagram in articles related to curative effect analysis and time window evaluation is inverted and symmetrical, indicating that publication bias was not significant.Conclusions
The clinical curative effect of the HBOT group is higher compared with that of the control group. However, the conclusions based on meta-analysis are limited because of the methodological problems of some studies. Therefore, the clinical efficacy needs to be further tested using carefully designed large sample trials (multicenter, randomized, controlled, and double-blind).
INTRODUCTION: Diabetic foot is a frequent complication of diabetes mellitus with relevant economic and psychosocial issues, which requires optimisation of the therapeutic approach from health care providers. The main purpose was to review the literature on the clinical utility and future perspectives of hyperbaric oxygen therapy in the adjunctive treatment of the diabetic foot.
MATERIAL AND METHODS: PubMed, CINAHL, Cochrane and Google Academic search engines were used, for articles since 2014, with an analysis of the following keywords: diabetic foot, diabetic ulcer and hyperbaric oxygen therapy. Thirty-two publications were analysed and six review articles selected.
RESULTS: Hyperbaric oxygen has been reported to benefit healing process in follow-up periods up to six months and promising for a follow-up equal to or greater than twelve months. Low incidence of side effects was reported. The transcutaneous oxygen saturation of the foot was more significant in the groups of patients treated with this complementary therapy, and there was a decrease in the need for major amputation of the lower limbs.
DISCUSSION: Current evidence points to the clinical utility of hyperbaric oxygen therapy as a complementary treatment. It has yet to be found the optimal clinical profile that would benefit from this type of treatment due to limitations on the analysed studies. Randomised, prospective clinical trials are essential to confirm these findings.
Background: Oxygen is mandatory for almost all wound healing processes, in particular the processes of cell regeneration and angiogenesis. As it is lacking in chronic and even acute wounds, oxygen substitution seems to be an obvious adjuvant tool. In vitro and in vivo tests showed improvement of microenvironment essential for the onset of appropriate healing processes.
Synonyms of decompression illness (DCI) are dysbaric illness (DI), decompression sickness (DCS), decompression accident or caisson disease. As DCS and AGE quite often occur together, these are commonly summarised as DCI or DI which is used as the preferred term for decompression-related accidents. DCS alone is rather subject to inert gas bubbles related to decompression effects as aetiology by itself. Neurological symptoms of DCS might be quite similar to AGE caused by pulmonary barotrauma. However, spinal symptoms are only found in DCS. DCI is a spectrum, which may have no symptoms at all, minor unspecific symptoms like fatigue up to fatal complications.
The professional activity of divers (aquanauts) is followed by formation at them the special infectious and
immunological status, substantially connected with indicators of morbidity, temporary disability, early dismissal for health reasons. Among them are known the cases of immunomediated diseases with lethal outcome. In article are investigated some aspects of infectious and immunological status of divers (aquanauts), both acting and finished the dives. The detailed retrospective analysis of materials of earlier executed hospitalizations, the own experimental and clinical, including prospective, researches
are carried out. Our work covers a considerable time interval. As a result in divers (aquanauts) are found the specific changes of immunity which are formed during the period of professional activity and remaining further. The modern diagnostic protocol, applied at their inspection, needs an expansion. In diving personnel
it is necessary to pay attention to active search and sanitation of chronic focal infection, identification and elimination of hidden infectious pathogens, quality and comprehensive assessment of immune status, due immune prevention and correction (2 figs, 6 tables, bibliography: 30 refs).
Background:
The BBraun Perfusor Space™ syringe driver is already in use by ambulance services and retrieval teams but has not previously been assessed for hyperbaric chamber use.
Methods:
Pump flow accuracy was tested at rates between 1 and 40 ml· h⁻¹ using three different brands of 50 ml syringe. Function of the occlusion alarms was assessed using the same syringes. The hyperbaric profile involved pressurisation to 284 kPa at 30 kPa· min⁻¹, 30 min at 284 kPa and decompression at 30 kPa· min⁻¹. Output was recorded from differences in weight of collection containers. A single device was tested.
Results:
Performance was highly dependent on the syringe type used, with two of the three 50 ml syringes used demonstrating 'stiction' at both low and high occlusion pressure alarm settings, most marked during pressurisation. On decompression from 284 kPa all syringes alarmed at significantly lower pressures. Because of the stiction problems only the flow measurements for the BBrown Omni¬ x 50 ml syringes are reported. At a pressure of 284 kPa, the difference between programmed and delivered rates was within the manufacturer's specification of 10%: at 40 ml· h⁻¹ (median variation 1.25%, IQR 0.5-1.7%), 10 ml· h⁻¹ (8.6%, IQR 8-9.2%), 5 ml· h⁻¹ (-8.8%, IQR - 1.6-8.8%) and 1 ml· h⁻¹ (-4%, IQR 4-12%). Pressurisation was associated with significantly lower flow rates whilst decompression was associated with significantly increased rates. Limited testing at 405 kPa was also within the manufacturer's specifications.
Conclusion:
A BBraun Infusor Space syringe driver performed within acceptable performance criteria but is highly dependent on syringe type and flow rates. The potential for the device to under deliver on pressurisation and over deliver on depressurisation, however, suggests vigilance and appropriate rate adjustments may be necessary during these phases.
Introduction
Patients surviving a self-attempted hanging have a total neurological recovery in 57–77% of cases at hospital discharge, but no long-term data are available.
Methods
In this observational study, all patients hospitalized post-self-attempted hanging in the intensive care unit (ICU) in a 5-year period were included. Neurological evaluations at 6 and 12 months were performed according to Cerebral Performance Category (CPC) scores. Factors associated with neurological recovery were determined by comparing CPC2 + 3 + 4 (bad recovery) vs. CPC1 (good recovery).
Results
Of 231 patients included, 104 (47%) were found to have cardiac arrest (CA). Ninety-five (41%) patients died in the ICU: 93 (89%) in the CA group and 2 (1.6%) in the group without CA. Neurological evaluations at 6 and 12 months were obtained in 97 of the 136 surviving patients. At 6 months, in the CA group (n = 9), the CPC score was 1 for 6 patients, 2 for 2, and 4 for 1 patient. In the group without CA (n = 88), 79 patients had normal neurological status at 6 months and 78 at 12 months. Among these patients, 96% returned home, 77% returned to work, 16 (18%) patients re-attempted suicide within the year. Risk factors of neurological sequelae at 6 months were a CA at the hanging site (P = 0.045), an elevated diastolic blood pressure (87 vs. 70 mm Hg; P = 0.04), a lower initial Glasgow score (4 vs. 5; P = 0.04), and an elevated blood glucose level (139 vs. 113 mg/dL; P < 0.001).
Conclusion
Patients surviving a self-attempted hanging who did not have a CA had a good neurological outcome. The rate of suicidal recidivism is particularly important, which justifies joint work with psychiatrists.
Selective use of systemic hyperbaric oxygen therapy (HBOT) is a treatment that deserves further study and analysis. The current situation in the United Kingdom (UK) is discussed in relation to available evidence and practices elsewhere. It would appear that there is increasing evidence that HBOT could benefit many patients and health care budgets through improved clinical efficacy and cost-efficiency in the treatment of specific conditions, notably nonhealing diabetic ulceration of the lower limbs. This is not only disabling, it may lead to amputation. It is also a financial burden to patients and health service providers. In the UK, it is estimated that chronic wound care costs more than pound1 billion a year, with diabetic ulceration accounting for a substantial part of that staggering sum. It has been said repeatedly, and quite correctly, that there is insufficient good-quality evidence upon which a properly informed decision may be made on the contribution HBOT might make to alleviate that situation. It is intriguing that no determined effort is apparent that would seek to settle the issue by encouraging and facilitating appropriately designed and conducted randomized controlled trials to assess the actual effects of this treatment. Indeed, a proposed government research initiative appears to have been cancelled. Is lack of research preventing provision of HBOT?
Objective
To investigate how consensus is operationalized in Delphi studies and to explore the role of consensus in determining the results of these studies.
Study Design and Settings
Systematic review of a random sample of 100 English language Delphi studies, from two large multidisciplinary databases [ISI Web of Science (Thompson Reuters, New York, NY) and Scopus (Elsevier, Amsterdam, NL)], published between 2000 and 2009.
Results
About 98 of the Delphi studies purported to assess consensus, although a definition for consensus was only provided in 72 of the studies (64 a priori). The most common definition for consensus was percent agreement (25 studies), with 75% being the median threshold to define consensus. Although the authors concluded in 86 of the studies that consensus was achieved, consensus was only specified a priori (with a threshold value) in 42 of these studies. Achievement of consensus was related to the decision to stop the Delphi study in only 23 studies, with 70 studies terminating after a specified number of rounds.
Conclusion
Although consensus generally is felt to be of primary importance to the Delphi process, definitions of consensus vary widely and are poorly reported. Improved criteria for reporting of methods of Delphi studies are required.
Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide Summary points Failure to consider the quality of evidence can lead to misguided recommendations; hormone replacement therapy for post-menopausal women provides an instructive example High quality evidence that an intervention’s desirable effects are clearly greater than its undesirable effects, or are clearly not, warrants a strong recommendationUncertainty about the trade-offs (because of low quality evidence or because the desirable and undesirable effects are closely balanced) warrants a weak recommendationGuidelines should inform clinicians what the quality of the underlying evidence is and whether recommendations are strong or weakThe Grading of Recommendations Assessment, Development and Evaluation (GRADE ) approach provides a system for rating quality of evidence and strength of recommendations that is explicit, comprehensive, transparent, and pragmatic and is increasingly being adopted by organisations worldwideGuideline developers around the world are inconsistent in how they rate quality of evidence and grade strength of recommendations. As a result, guideline users face challenges in understanding the messages that grading systems try to communicate. Since 2006 the BMJ has requested in its “Instructions to Authors” on bmj.com that authors should preferably use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for grading evidence when submitting a clinical guidelines article. What was behind this decision?In this first in a series of five articles we will explain why many organisations use formal systems to grade evidence and recommendations and why this is important for clinicians; we will focus on the GRADE approach to recommendations. In the next two articles we will examine how the GRADE system categorises quality of evidence and strength of recommendations. The final two articles will …
This report describes the results of an extensive set of experiments, conducted at RAND, concerned with evaluating the effectiveness of the Delphi procedures for formulating group judgements. The study represents a small beginning in the field of research that could be called ‘opinion technology’, and is of direct relevance for the use of experts as advisers in decision making, especially in areas of broad or long-range policy formulation.