The Quality of Practice Guidelines for Melanoma: A Methodologic Appraisal with the AGREE II and AGREE-REX Instruments

Methodological Quality of Pulmonary Arterial Hypertension Treatment Evidence-Based Guidelines: A Systematic Review Using the AGREE II and AGREE REX Tools

PURPOSE

Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis, and its management should be grounded in well-developed clinical practice guidelines (CPG). Thus, we critically assess the methodological quality of the available CPG for pharmacological treatments for PAH.

METHODS

A systematic review (CRD42023387168) was performed in PubMed, Cochrane, Embase, and Tripdatabase (Jan-2023). Eligible records were appraised by four reviewers using the Appraisal of Guidelines, Research, and Evaluation Collaboration tool (AGREE II) and the complementary tool for assessing recommendations' quality and certainty, AGREE REX. Descriptive statistics were used to summarize the data.

RESULTS

Overall, 31 guidelines, mainly authored by professional societies (90%), targeting only physicians as primary users (84%), were identified. Guidelines presented a moderate overall quality (scores of 63% and 51% in AGREE II and AGREE REX, respectively), with a few domains showing slight improvements over the years. AGREE II "Scope and Purpose" (94%) and "Presentation Clarity" (99%) domains obtained the highest scores. The items related to "Stakeholder involvement," "Editorial independence," and "Clinical applicability" (AGREE REX) were fairly reported. Conversely, CPG lacks rigor in development (32% score, AGREE II), scarcely discusses the role of stakeholders, and provides deficient data on the implementation of recommendations (scores of 35% and 46% in AGREE II and AGREE REX, respectively). No differences in the quality of guidelines published by different developers or countries were observed (p > 0.05).

CONCLUSION

Methodological weaknesses are common among guidelines addressing PAH treatment, especially regarding scientific rigor, stakeholders' values and preferences, and facilitators and barriers to implementability. Particular attention should be given to developing future guidelines.

Methodological quality and clinical recommendations of guidelines on the management of dyslipidaemias for cardiovascular disease risk reduction: a systematic review and an appraisal through AGREE II and AGREE REX tools

BACKGROUND

Clinical practice guidelines (CPGs) are statements to assist practitioners and stakeholders in decisions about healthcare. Low methodological quality guidelines may prejudice decision-making and negatively affect clinical outcomes in non-communicable diseases, such as cardiovascular diseases worsted by poor lipid management. We appraised the quality of CPGs on dyslipidemia management and synthesized the most updated pharmacological recommendations.

METHODS

A systematic review following international recommendations was performed. Searches to retrieve CPG on pharmacological treatments in adults with dyslipidaemia were conducted in PubMed, Scopus, and Trip databases. Eligible articles were assessed using AGREE II (methodological quality) and AGREE-REX (recommendation excellence) tools. Descriptive statistics were used to summarize data. The most updated guidelines (published after 2019) had their recommendations qualitatively synthesized in an exploratory analysis.

RESULTS

Overall, 66 guidelines authored by professional societies (75%) and targeting clinicians as primary users were selected. The AGREE II domains Scope and Purpose (89%) and Clarity of Presentation (97%), and the AGREE-REX item Clinical Applicability (77.0%) obtained the highest values. Conversely, guidelines were methodologically poorly performed/documented (46%) and scarcely provided data on the implementability of practical recommendations (38%). Recommendations on pharmacological treatments are overall similar, with slight differences concerning the use of supplements and the availability of drugs.

CONCLUSION

High-quality dyslipidaemia CPG, especially outside North America and Europe, and strictly addressing evidence synthesis, appraisal, and recommendations are needed, especially to guide primary care decisions. CPG developers should consider stakeholders' values and preferences and adapt existing statements to individual populations and healthcare systems to ensure successful implementation interventions.

A model based on immunogenic cell death-related genes predicts prognosis and response to immunotherapy in kidney renal clear cell carcinoma

Background

The prognosis of patients with kidney renal clear cell carcinoma (KIRC), a life-threatening condition, is poor. Immunogenic cell death (ICD) induces regulated cell death via immunogenic signal secretion and exposure. ICD induces regulated cell death through immunogenic signal secretion and exposure. ICD plays an essential role in tumorigenesis, however, the role of ICD in KIRC remains unclear.

Methods

This study examined the expression levels of 34 ICD-related genes in The Cancer Genome Atlas (TCGA) data set. Signature genes linked to KIRC survival were identified using Cox regression. Next, a prognostic risk model (RM) was built. Subsequently, the KIRC patients were divided into low- and high-risk groups. Kaplan-Meier curves and receiver operating characteristic (ROC) curves were plotted. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses were carried out to investigate the possible role of differential gene expression between the two groups. The immune microenvironment (IME) was assessed using Estimation of STromal and Immune cells in MAlignant Tumor tissues using Expression, CIBERSORT, and single-sample gene-set enrichment analysis algorithms. An enrichment analysis was used to determine the biological significance of these regulatory networks we conducted. The relationship between immune checkpoint gene expression and risk score, and the relationship between treatment outcome and gene expression were assessed using correlation analyses.

Results

We developed a KIRC RM based on five ICD-related genes (i.e., FOXP3, IFNB1, IL6, LY96, and TLR4), which were identified as the prognostic signature genes. Using the TCGA data set, we conducted a survival analysis and found that the 3-year RM had an area under the curve (AUC) of 0.735, which validated the reliability of the signature. Similarly, using the International Cancer Genome Consortium (ICGC) data set, we found that the 3-year RM had an AUC of 0.732.

Conclusions

A RM based on five ICD-related genes was built to predict the prognosis of KIRC patients. This RM predicted patient prognosis and reflected the tumor IME of KIRC patients. Thus, this RM could be used to promote individualized treatments and provide potential novel targets for immunotherapy.

BRAF-Mutated Melanoma Journey in Latin America: Expert Recommendations From Diagnosis to Treatment

OBJECTIVES

• Gather a panel of Latin American experts in testing and treating BRAF-melanoma. • Describe the current landscape of BRAF-mutated melanoma in Latin America. • Outline the current gaps in testing and recommend improvements for testing and treating BRAF-mutated melanoma in the region.

INTRODUCTION

Melanoma prevalence in Latin America is lower than in high- and middle-income countries. However, recent data indicate that the region's incidence and mortality are rising, with more stage IV patients being diagnosed. According to international clinical practice guidelines, conducting BRAF-mutation testing in patients with stage III or stage IV melanoma and high-risk resected disease is imperative. Still, BRAF-mutation testing and targeted therapies are inconsistently available in the region.

METHODS

Americas Health Foundation convened a meeting of Latin American experts on BRAF-mutated melanoma to develop guidelines and recommendations for diagnosis through treatment.

RESULTS AND CONCLUSIONS

Some recommendations for improving diagnostics through improving access and reducing the cost of BRAF-mutation testing, enhancing efficiency in pathology laboratories, and creating country-specific local guidelines. The panel also gave treatment recommendations for neo-adjuvant therapy, adjuvant therapy, and therapy for patients with metastatic disease in Latin America.

Assessing the methodological strengths and limitations of the Spanish Society of Medical Oncology (SEOM) guidelines: a critical appraisal using AGREE II and AGREE-REX tool

BACKGROUND

The Spanish Society of Medical Oncology (SEOM) has provided open-access guidelines for cancer since 2014. However, no independent assessment of their quality has been conducted to date. This study aimed to critically evaluate the quality of SEOM guidelines on cancer treatment.

METHODS

Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE-REX tool was used to evaluate the qualities of the guidelines.

RESULTS

We assessed 33 guidelines, with 84.8% rated as "high quality". The highest median standardized scores (96.3) were observed in the domain "clarity of presentation", whereas "applicability" was distinctively low (31.4), with only one guideline scoring above 60%. SEOM guidelines did not include the views and preferences of the target population, nor did specify updating methods.

CONCLUSIONS

Although developed with acceptable methodological rigor, SEOM guidelines could be improved in the future, particularly in terms of clinical applicability and patient perspectives.

The Reporting and Methodological Quality of Systematic Reviews Underpinning Clinical Practice Guidelines Focused on the Management of Cutaneous Melanoma: Cross-Sectional Analysis

BACKGROUND

Clinical practice guidelines (CPGs) inform evidence-based decision-making in the clinical setting; however, systematic reviews (SRs) that inform these CPGs may vary in terms of reporting and methodological quality, which affects confidence in summary effect estimates.

OBJECTIVE

Our objective was to appraise the methodological and reporting quality of the SRs used in CPGs for cutaneous melanoma and evaluate differences in these outcomes between Cochrane and non-Cochrane reviews.

METHODS

We conducted a cross-sectional analysis by searching PubMed for cutaneous melanoma guidelines published between January 1, 2015, and May 21, 2021. Next, we extracted SRs composing these guidelines and appraised their reporting and methodological rigor using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) checklists. Lastly, we compared these outcomes between Cochrane and non-Cochrane SRs. All screening and data extraction occurred in a masked, duplicate fashion.

RESULTS

Of the SRs appraised, the mean completion rate was 66.5% (SD 12.29%) for the PRISMA checklist and 44.5% (SD 21.05%) for AMSTAR. The majority of SRs (19/50, 53%) were of critically low methodological quality, with no SRs being appraised as high quality. There was a statistically significant association (P<.001) between AMSTAR and PRISMA checklists. Cochrane SRs had higher PRISMA mean completion rates and higher methodological quality than non-Cochrane SRs.

CONCLUSIONS

SRs supporting CPGs focused on the management of cutaneous melanoma vary in reporting and methodological quality, with the majority of SRs being of low quality. Increasing adherence to PRISMA and AMSTAR checklists will likely increase the quality of SRs, thereby increasing the level of evidence supporting cutaneous melanoma CPGs.

Evaluation of the clinical practice guidelines and consensuses on calcium and vitamin D supplementation in healthy children using the Appraisal of Guidelines for Research and Evaluation II instrument and Reporting Items for Practice Guidelines in Healthcare statement

Background

This study aimed to assess the methodological and reporting quality of the guidelines and consensus on calcium and vitamin D supplementation in healthy children, and the consistency of these recommendations.

Methods

A systematic search of relevant guideline websites and databases, including PubMed, Embase, CNKI, WangFang, and SinoMed, was undertaken from inception to April 7, 2021, by two independent reviewers who assessed the eligible guidelines using the validated Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Reporting Items for Practice Guidelines in Healthcare (RIGHT) tools. Overall, the between-reviewer agreement was evaluated using an intra-class correlation coefficient.

Results

A total of 24 guidelines and consensuses from 2002 to 2022 were identified from China, the United States, Canada, France, Australia, New Zealand, Europe, and other countries and regions. These were of mixed quality, and scored poorly in the rigor of development, editorial independence, and applicability of the domains of AGREE II. Among the seven domains of the RIGHT checklist, domain one (basic information) had the highest reporting rate (69.3%), whereas domain five (review and quality assurance) had the lowest reporting rate (11.5%). The overall quality of the included guidelines and consensuses was low. Only 12 guidelines were recommended, with modifications. The recommended calcium intake for children of different ages varies greatly (400–1,150 mg/day). Among the included guidelines and consensuses, a vitamin D (VD) prevention dose of 400 IU/day in infants was generally considered safe, and 25-hydroxyvitamin-D [25(OH)D] levels of <20 ng/mL (50 nmol/L) or 20–30 ng/mL (50–75 nmol/L) indicated VD deficiency or insufficiency. However, the recommended amount of VD for children of different age groups and risk strata differed considerably (400–4,000 IU/day or 10–100 μg/day). The choice of VD2 or VD3 supplements and sunlight exposure also differed across the guidelines and consensuses.

Conclusion

There is considerable variability in calcium and VD guidelines and consensus development methods in calcium and VD supplementation for healthy children. Therefore, efforts are necessary to strengthen the methodological rigor of guideline development and utilize the best available evidence to underpin recommendations.

Significance of immunogenic cell death-related genes in prognosis prediction and immune microenvironment landscape of patients with cutaneous melanoma

Cutaneous melanoma (CM) is one of the most life-threatening tumors. Although targeted therapies and immune checkpoint inhibitors have significantly improved patient outcomes over the past decades, they still have their efficacy limitations. Immunogenic cell death (ICD) induces regulated cell death through immunogenic signal secretion and exposure. Accumulated evidence suggests that the ICD process is an effective target for the treatment of a variety of tumor types, including CM. However, the research on ICD in CM is far from complete, and its clinical value has not been widely concerned. By analyzing the Cancer Genome Atlas (TCGA) database, we constructed a new risk model based on 4 ICD-related genes and validated its ability to predict the prognosis of CM patients. In addition, we comprehensively analyzed the tumor microenvironment (TME) of CM patients and showed a significant immunosuppressive TME in the high-risk group compared with the low-risk group. By Immunophenoscore (IPS), we further explored the correlation between the model and immunotherapy response. The data of Genomics of Drug Sensitivity in Cancer (GDSC) database were further extracted to analyze drug sensitivity and evaluate its correlation with the established risk model. In the end, differential expressed genes (DEGs) were analyzed by Gene Set Variation Analysis (GSVA) to preliminarily explore the possible signaling pathways related to the prognosis of ICD and CM. The results of this study provide new perspectives and insights for individualized and accurate treatment strategies for CM patients.

The Quality and Clinical Applicability of Recommendations in Ostomy Guidelines: A Systematic Review

Aim

To systematically search ostomy clinical practice guidelines, critically assess their quality and clinical applicability of recommendations, and summarize the recommendations.

Design

Systematic review.

Data Sources

The PubMed, ProQuest and CINAHL databases, eight guideline databases, and three ostomy institution websites were searched on September 3, 2021.

Review Methods

Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE Recommendation EXcellence (AGREE-REX) were used to assess the guideline.

Results

The initial search identified 1475 documents. Of these, 27 full-text documents were reviewed. Finally, 10 guidelines were included. Among these, the 2019 Registered Nurses’ Association of Ontario (RNAO) guidelines had the highest total scores using AGREE II and AGREE-REX. The 2019 National Institute for Health and Care Excellence (NICE) and 2018 European Hernia Society (EHS) were also ranked as high-quality and evaluated as “recommended.” The median of the “applicability” domain was the lowest (45%) among the six AGREE II domains. The median of the “values and preferences” domain was the lowest (38%) among the three AGREE-REX domains. In total, 172 recommendations were summarized and parastomal hernia received the most attention among the recommendations.

Conclusion

The quality of the 10 clinical practice guidelines varied widely. The three identified high-quality guidelines might be appropriate first choices in daily ostomy care and management practice and can be tailored to the local context. Ostomy guidelines require further improvement in the “applicability” and “values and preferences” domains.

No Patient or Public Contribution

This review only searched and evaluated relevant documents, so such details do not apply to this review.

DIRAS2 Is a Prognostic Biomarker and Linked With Immune Infiltrates in Melanoma

Background

Skin cutaneous melanoma (SKCM) is a highly malignant skin tumor. DIRAS2 is considered to be a tumor suppressor gene; however, its function in SKCM has not been explored.

Methods

The Gene Expression Profiling Interactive Analysis (GEPIA) was implemented to investigate the expression of DIRAS2 in SKCM, and plot the survival curve to determine the effect of DIRAS2 on the survival rates of SKCM patients. Then, the correlation between DIRAS2 and tumor immune infiltration was also discussed, and the expression of DIRAS2 and immune infiltration level in SKCM immune cells was determined using TIMER. The top 100 genes most associated with DIRAS2 expression were used for functional enrichment analysis. In order to confirm the anti-cancer effects of DIRAS2 in SKCM in the data analysis, in vitro assays as well as in vivo studies of DIRAS2 on SKCM tumor cell proliferation, migration, invasion, and metastasis were conducted. Western blot and immunofluorescence assay were employed to study the relationship between DIRAS2 and Wnt/β-catenin signaling pathway in SKCM.

Results

DIRAS2 expression was shown to be significantly correlated with tumor grade using univariate logistic regression analysis. DIRAS2 was found to be an independent prognostic factor for SKCM in multivariate analysis. Of note, DIRAS2 expression levels were positively correlated with the infiltration levels of B cells, CD4+ T cells, and CD8+ T cells in SKCM. The infiltration of B cells, CD4+ T cells, and CD8+ T cells was positively correlated with the cumulative survival rate of SKCM patients. In vitro experiments suggested that proliferation, migration, invasion, and metastasis of SKCM tumor cells were distinctly enhanced after DIRAS2 knockdown. Furthermore, DIRAS2 depletion promoted melanoma growth and metastasis in vivo. As for the mechanism, silencing DIRAS2 can activate the signal transduction of the Wnt/β-catenin signaling pathway.

Conclusion

DIRAS2 functions as a tumor suppressor gene in cases of SKCM by inhibiting the Wnt/β-catenin signaling. It is also associated with immune infiltration in SKCM.

Quality and clinical applicability of recommendations for incontinence-associated dermatitis: A systematic review of guidelines and consensus statements

AIMS AND OBJECTIVES

The aim of this study was to assess methodological quality of all currently available guidelines and consensus statements for IAD using the Appraisal of Guidelines, Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence (AGREE-REX) instruments.

BACKGROUND

Globally, incontinence-associated dermatitis (IAD) is a significant health challenge. IAD is a complex healthcare problem that reduces quality of life of patients, increases healthcare costs and prolongs hospital stays. Several guidelines and consensus statements are available for IAD. However, the quality of these guidelines and consensus statements remains unclear.

DESIGN

A systematic review of guidelines and consensus statements.

METHODS

Our study was undertaken using PRISMA guidelines. We searched seven electronic databases. Guidelines and consensus statements had to be published in English, Chinese or German languages. Five independent reviewers assessed the methodological quality of guidelines and consensus statements using the AGREE II and AGREE-REX instruments. Mean with standard deviation (SD) and median with interquartile range (IQR) were calculated for descriptive analyses. We generated bubble plots to describe the assessment results of each domain of each guideline and consensus statement.

RESULTS

We included ten guidelines and consensus statements. The NICE guidelines, obtained the highest scores, fulfilled 86.11%-98.61% of criteria in AGREE II and 76.67%-91.11% for AGREE-REX. In the domains 'Stakeholder Involvement' (4.39 ± 1.64), 'Rigor of Development' (3.38 ± 1.86), 'Applicability' (3.62 ± 1.64), 'Editorial Independence' (3.91 ± 2.56) and 'Values and Preferences' (2.98 ± 1.41), the remaining guidelines and consensus statements showed deficiencies.

CONCLUSIONS

Altogether, this study demonstrated that the currently available guidelines and consensus statements for IAD have room for methodological improvement. NICE guidelines on faecal incontinence and urinary incontinence have better quality. Remaining guidelines and consensus statements showed substantial methodological weaknesses, especially the domains of 'Stakeholder Involvement', 'Rigor of Development', 'Applicability', 'Editorial independence' and 'Values and Preferences'. This study was registered on INPLASY. (Registration number: INPLASY202190078).

RELEVANCE TO CLINICAL PRACTICE

The currently available guidelines and consensus statements on IAD have room for methodological improvement.

The quality and clinical applicability of recommendations in anxiety disorders guidelines: A systematic review of seventeen guidelines from seven countries

BACKGROUND

Anxiety disorders are the most common mental disorders, for which some countries and organizations have developed guidelines. It is necessary to understand the quality of these guidelines.

METHODS

The relevant guidelines were searched systematically by five reviewers using Appraisal of Guidelines for Research and Evaluation (AGREE) II and AGREE Recommendation Excellence (AGREE-REX) instruments. The scores in each domain were descriptively analyzed, and guidelines from different countries were compared.

RESULTS

Seventeen guidelines were included. The scores in the domains "rigor of development" and "applicability" were the lowest and ranged from 16% to 77% and 25% to 71%, respectively. The scores in the domains "implementability" and "values and preferences" were similar and ranged from 30% to 67% and 25% to 77%. In terms of the comparison among countries, the Canadian guidelines achieved the highest scores in many domains but only scored 43% in the domain of "values and preferences". The Indian guidelines scored less than 50% in many domains but achieved a high score of 83% in the domain "scope and purpose".

LIMITATIONS

Language restrictions may cause selection bias. Besides, insufficient reports may lead to deviation of assessment results.

CONCLUSIONS

There was no obvious advantage in guidelines from different countries. There was still a lot of room for improvement in some domains, especially "applicability", "implementability", "rigor of development" and "values and preferences".

A Critical Appraisal of Evidence- and Consensus-Based Guidelines for Actinic Keratosis

Actinic keratoses (AK) are common lesions of the skin that can be effectively treated with several lesion- and field-directed treatments. Clinical practice guidelines assist physicians in choosing the appropriate treatment options for their patients. Here, we aimed to systematically identify and evaluate the methodological quality of currently available guidelines for AK. Guidelines published within the last 5 years were identified in a systematic search of guideline databases, Medline and Embase. Then, six independent reviewers evaluated the methodological quality using the tools "Appraisal of Guidelines for Research and Evaluation" (AGREE II) and "Recommendation EXcellence" (AGREE-REX). The Kruskal-Wallis (H) test was used to explore differences among subgroups and Spearman's correlation to examine the relationship between individual domains. Three guidelines developed by consortia from Canada, Germany and the United Kingdom were eligible for the evaluation. The German guideline achieved the highest scores, fulfilling 65 to 92% of the criteria in AGREE II and 67 to 84% in AGREE-REX, whereas the Canadian guideline scored 31 to 71% of the criteria in AGREE II and 33 to 46% in AGREE-REX. The domains "stakeholder involvement" and "values and preferences" were identified as methodological weaknesses requiring particular attention and improvement in future guideline efforts.

Knowledge Translation in Physical Medicine and Rehabilitation: A Citation Analysis of the Knowledge-to-Action Literature

OBJECTIVES

To (1) provide an overview of the use of the Knowledge-to-Action Cycle (KTA) to guide a clinical implementation project; (2) identify activities performed in each phase of the KTA; and (3) provide suggestions to improve KTA activities in physical medicine and rehabilitation.

DATA SOURCES

Google Scholar and PubMed were searched through December 31, 2019.

STUDY SELECTION

Two reviewers screened titles, abstracts, and full-text articles to identify published studies that used the KTA to implement a project.

DATA EXTRACTION

Two reviewers examined full-text articles. Data extraction included activities performed in each phase of the KTA, including measurements used to evaluate the project's effectiveness.

DATA SYNTHESIS

Commonly performed KTA activities were identified and country of study, area of rehabilitation, and other factors related to the use of the KTA in rehabilitation were described. A total of 46 articles that met the study's inclusion criteria provided an overview of the use of the KTA in rehabilitation. Strengths and weaknesses of the articles are discussed and recommendations for improved KTA use are provided.

CONCLUSIONS

Implementation of evidence-based practice requires focused engineering and efforts. This review provides an overview of the knowledge translation activities occurring in physical medicine and rehabilitation and considerations to improve knowledge translation research and practice.