Application of clinical value assessment of treatment protocols in guideline development: taking the WFAS Clinical Practice Guideline of Acupuncture and Moxibustion for Migraine as an example

To enhance the clinical applicability of guidelines and provide more effective guidance for clinical practice, a clinical value assessment was conducted during the development of the World Federation of Acupuncture-Moxibustion Societies (WFAS) Clinical Practice Guideline of Acupuncture and Moxibustion for Migraine, which involved the evaluation of 59 acupuncture and moxibustion treatment protocols from randomized controlled trials (RCTs). This article introduced the methodology, content and results of the clinical value assessment of RCT-based acupuncture and moxibustion treatment protocols, which involved the integration of historical and contemporary medical evidence and expert consensus. It served as a methodological reference for the future development of acupuncture and moxibustion clinical practice guidelines.

Development of an Evidence-Based Risk Assessment Framework

Assessment of potential human health risks associated with environmental and other agents requires careful evaluation of all available and relevant evidence for the agent of interest, including both data-rich and data-poor agents. With the advent of new approach methodologies in toxicological risk assessment, guidance on integrating evidence from mul-tiple evidence streams is needed to ensure that all available data is given due consideration in both qualitative and quantitative risk assessment. The present report summarizes the discussions among academic, government, and private sector participants from North America and Europe in an international workshop convened to explore the development of an evidence-based risk assessment framework, taking into account all available evidence in an appropriate manner in order to arrive at the best possible characterization of potential human health risks and associated uncertainty. Although consensus among workshop participants was not a specific goal, there was general agreement on the key consider-ations involved in evidence-based risk assessment incorporating 21st century science into human health risk assessment. These considerations have been embodied into an overarching prototype framework for evidence integration that will be explored in more depth in a follow-up meeting.

Conflict Detection in a Sequential Decision Task Is Associated with Increased Cortico-Subthalamic Coherence and Prolonged Subthalamic Oscillatory Response in the β Band

Making accurate decisions often involves the integration of current and past evidence. Here, we examine the neural correlates of conflict and evidence integration during sequential decision-making. Female and male human patients implanted with deep-brain stimulation (DBS) electrodes and age-matched and gender-matched healthy controls performed an expanded judgment task, in which they were free to choose how many cues to sample. Behaviorally, we found that while patients sampled numerically more cues, they were less able to integrate evidence and showed suboptimal performance. Using recordings of magnetoencephalography (MEG) and local field potentials (LFPs; in patients) in the subthalamic nucleus (STN), we found that β oscillations signaled conflict between cues within a sequence. Following cues that differed from previous cues, β power in the STN and cortex first decreased and then increased. Importantly, the conflict signal in the STN outlasted the cortical one, carrying over to the next cue in the sequence. Furthermore, after a conflict, there was an increase in coherence between the dorsal premotor cortex and STN in the β band. These results extend our understanding of cortico-subcortical dynamics of conflict processing, and do so in a context where evidence must be accumulated in discrete steps, much like in real life. Thus, the present work leads to a more nuanced picture of conflict monitoring systems in the brain and potential changes because of disease.SIGNIFICANCE STATEMENT Decision-making often involves the integration of multiple pieces of information over time to make accurate predictions. We simultaneously recorded whole-head magnetoencephalography (MEG) and local field potentials (LFPs) from the human subthalamic nucleus (STN) in a novel task which required integrating sequentially presented pieces of evidence. Our key finding is prolonged β oscillations in the STN, with a concurrent increase in communication with frontal cortex, when presented with conflicting information. These neural effects reflect the behavioral profile of reduced tendency to respond after conflict, as well as relate to suboptimal cue integration in patients, which may be directly linked to clinically reported side-effects of deep-brain stimulation (DBS) such as impaired decision-making and impulsivity.

Systematic review in evidence-based risk assessment

Systematic reviews provide a structured framework for summarizing the available evidence in a comprehensive, objective, and transparent manner. They inform evidence-based guidelines in medicine, public policy, and more recently, in environmental health and toxicology. Many regulatory agencies have extended and adapted the well-established systematic review methods, initially developed for clinical studies, for their assessment needs. The use of systematic reviews to summarize evidence from existing human, animal, and mechanistic studies can reduce reliance on animal test data in risk assessment and can help avoid unnecessary duplication of animal experiments that have already been conducted. As alternative test methods can be expected to play an increasing role in human health risk assessment in the future, systematic reviews can be particularly helpful in validating these alternatives. The field of evidence-based toxicology has undergone extensive development since its first meeting in 2007 as a result of collaborative efforts among international experts and public health agencies, particularly with respect to the use of mechanistic data and evidence integration. The continued development and wider adoption of systematic review methodology can lead to better 3R implementation. As undertaking a systematic review can be a complex and lengthy process, it is important to understand the main steps involved. Key steps, along with current best practices, are described with references to guidance from organizations with expertise in evidence synthesis. Applications of systematic reviews in clinical, observational, and experimental studies are presented. Finally, software tools available to facilitate and increase the efficiency of completing a systematic review are described.

Application of adverse outcome pathway networks to integrate mechanistic data informing the choice of a point of departure for hydrogen sulfide exposure limits

Acute exposure to hydrogen sulfide initiates a series of hallmark biological effects that occur progressively at increasing exposure levels: odor perception, conjunctivitis, olfactory paralysis, "knockdown," pulmonary edema, and apnea. Although effects of exposure to high concentrations of hydrogen sulfide are clear, effects associated with chronic, low-level exposure in humans is under debate, leading to uncertainty in the critical effect used in regulatory risk assessments addressing low dose exposures. This study integrates experimental animal, observational epidemiology, and occupational exposure evidence by applying a pathway-based approach. A hypothesized adverse outcome pathway (AOP) network was developed from 34 studies, composed of 4 AOPs sharing 1 molecular initiating events (MIE) and culminating in 4 adverse outcomes. A comparative assessment of effect levels and weight of evidence identified an AOP leading to a biologically-plausible, low-dose outcome relative to the other outcomes (nasal lesions, 30 ppm versus olfactory paralysis, >100 ppm; neurological effects, >80 ppm; pulmonary edema, >80 ppm). This AOP (i.e. AOP1) consists of the following key events: cytochrome oxidase inhibition (>10 ppm), neuronal cell loss (>30 ppm), and olfactory nasal lesions (defined as both neuronal cell loss and basal cell hyperplasia; >30 ppm) in rodents. The key event relationships in this pathway were supported by moderate empirical evidence and have high biological plausibility due to known mechanistic understanding and consistency in observations for diverse chemicals.

Extended Analysis and Evidence Integration of Chloroprene as a Human Carcinogen

β-Chloroprene is used in the production of polychloroprene, a synthetic rubber. In 2010, Environmental Protection Agency (EPA) published the Integrated Risk Information System "Toxicological Review of Chloroprene," concluding that chloroprene was "likely to be carcinogenic to humans." This was based on findings from a 1998 National Toxicology Program (NTP) study showing multiple tumors within and across animal species; results from occupational epidemiological studies; a proposed mutagenic mode of action; and structural similarities with 1,3-butadiene and vinyl chloride. Using mouse data from the NTP study and assuming a mutagenic mode of action, EPA calculated an inhalation unit risk (IUR) for chloroprene of 5 × 10^-4 per µg/m³ . This is among the highest IURs for chemicals classified by IARC or EPA as known or probable human carcinogens and orders of magnitude higher than the IURs for carcinogens such as vinyl chloride, benzene, and 1,3-butadiene. Due to differences in pharmacokinetics, mice appear to be uniquely responsive to chloroprene exposure compared to other animals, including humans, which is consistent with the lack of evidence of carcinogenicity in robust occupational epidemiological studies. We evaluated and integrated all lines of evidence for chloroprene carcinogenicity to assess whether the 2010 EPA IUR could be scientifically substantiated. Due to clear interspecies differences in carcinogenic response to chloroprene, we applied a physiologically based pharmacokinetic model for chloroprene to calculate a species-specific internal dose (amount metabolized/gram of lung tissue) and derived an IUR that is over 100-fold lower than the 2010 EPA IUR. Therefore, we recommend that EPA's IUR be updated.

[Construction of the integrative evidence chain in clinical trial of acupuncture and moxibustion]

The research aims to propose the approaches to the clinical trial of acupuncture and moxibustion and provide the methodological guide for the research in this field in terms of the inadequate systematic collection, lack of the specific characteristics of acupuncture-moxibustion treatment and insufficient persuasion in clinical evidences of acupuncture-moxibustion research. Through a systematic review of the registration of acupuncture-moxibustion clinical trials at home and abroad, the distribution of diseases with the recommendation of acupuncture and moxibustion in Cochrane Library database, combined with the evidence grade of the evidence-based medicine and the individual characteristics of clinical practice with acupuncture and moxibustion, some research ideas and framework are proposed for the clinical trial of acupuncture and moxibustion. To take the curative effect as the forerumer, the dominant disease and therapeutic methods of acupuncture and moxibustion should be initially generalized by the case experiences and clinical observation at the first. In view of the potential function of acupuncture and moxibustion in treatment, the rigorous and standardized clinical trial should be carried out to verify their therapeutic effect. Finally, the experimental research is adopted to explore the mechanism of acupuncture and moxibustion. Through the combination of quantitative and qualitative methods, all of the evidences are integrated to form an integrative evidence chain. It is anticipated that the construction of the integrative evidence chain in clinical trial of acupuncture and moxibustion may enhance the promotion of clinical practice with acupuncture and moxibustion and increase the influence of acupuncture-moxibusiton discipline.

Managing evidence in food safety and nutrition

Evidence (‘data’) is at the heart of EFSA's 2020 Strategy and is addressed in three of its operational objectives: (1) adopt an open data approach, (2) improve data interoperability to facilitate data exchange, and (3) migrate towards structured scientific data. As the generation and availability of data have increased exponentially in the last decade, potentially providing a much larger evidence base for risk assessments, it is envisaged that the acquisition and management of evidence to support future food safety risk assessments will be a dominant feature of EFSA's future strategy. During the breakout session on ‘Managing evidence’ of EFSA's third Scientific Conference ‘Science, Food, Society’, current challenges and future developments were discussed in evidence management applied to food safety risk assessment, accounting for the increased volume of evidence available as well as the increased IT capabilities to access and analyse it. This paper reports on presentations given and discussions held during the session, which were centred around the following three main topics: (1) (big) data availability and (big) data connection, (2) problem formulation and (3) evidence integration.

Predicting Genes in Single Genomes with AUGUSTUS

AUGUSTUS is a tool for finding protein-coding genes and their exon-intron structure in genomic sequences. It does not necessarily require additional experimental input, as it can be applied in so-called ab initio mode. However, extrinsic evidence from various sources such as transcriptome sequencing or the annotations of closely related genomes can be integrated in order to improve the accuracy and completeness of the annotation. AUGUSTUS can be applied to single genomes, or simultaneously to several aligned genomes. Here, we describe steps required for training AUGUSTUS for the annotation of individual genomes and the steps to do the actual structural annotation. Further, we describe the generation and integration of evidence from various sources of extrinsic evidence. © 2018 by John Wiley & Sons, Inc.

Evidence Integration in Natural Acoustic Textures during Active and Passive Listening

Many natural sounds can be well described on a statistical level, for example, wind, rain, or applause. Even though the spectro-temporal profile of these acoustic textures is highly dynamic, changes in their statistics are indicative of relevant changes in the environment. Here, we investigated the neural representation of change detection in natural textures in humans, and specifically addressed whether active task engagement is required for the neural representation of this change in statistics. Subjects listened to natural textures whose spectro-temporal statistics were modified at variable times by a variable amount. Subjects were instructed to either report the detection of changes (active) or to passively listen to the stimuli. A subset of passive subjects had performed the active task before (passive-aware vs passive-naive). Psychophysically, longer exposure to pre-change statistics was correlated with faster reaction times and better discrimination performance. EEG recordings revealed that the build-up rate and size of parieto-occipital (PO) potentials reflected change size and change time. Reduced effects were observed in the passive conditions. While P2 responses were comparable across conditions, slope and height of PO potentials scaled with task involvement. Neural source localization identified a parietal source as the main contributor of change-specific potentials, in addition to more limited contributions from auditory and frontal sources. In summary, the detection of statistical changes in natural acoustic textures is predominantly reflected in parietal locations both on the skull and source level. The scaling in magnitude across different levels of task involvement suggests a context-dependent degree of evidence integration.

Using systematic review in occupational safety and health

Evaluation of scientific evidence is critical in developing recommendations to reduce risk. Healthcare was the first scientific field to employ a systematic review approach for synthesizing research findings to support evidence-based decision-making and it is still the largest producer and consumer of systematic reviews. Systematic reviews in the field of occupational safety and health are being conducted, but more widespread use and adoption would strengthen assessments. In 2016, NIOSH asked RAND to develop a framework for applying the traditional systematic review elements to the field of occupational safety and health. This paper describes how essential systematic review elements can be adapted for use in occupational systematic reviews to enhance their scientific quality, objectivity, transparency, reliability, utility, and acceptability.

Integrating proven falls prevention interventions into government programs

OBJECTIVE

To identify Department of Health programs with high potential to integrate evidence-based interventions to prevent falls among older people.

METHODS

Broad consultation within the Department followed by structured decision making. This work was informed by an analysis of Victorian hospital separations data and a Cochrane Systematic Review to identify relevant target groups and interventions. Ranking of the integration potential of interventions for a broad range of Department program areas was achieved through a facilitated workshop. A short list of program areas was then developed and scored, using pre-defined criteria, for their match with the interventions.

RESULTS

The ranked order of interventions, from most to least suitable for integration, were: multifactorial risk assessment and intervention; multi-component group exercise; medication review; occupational therapy-based home safety; home-based exercise; and first eye cataract surgery. Four of six program areas had a strong match (a score of ≥75% of the maximum score) with one or more of three interventions. Two program areas (Primary Care Partnerships, and Home and Community Care) had strong matches with three interventions (group- and home-based exercise; occupational therapy-based home safety) and were selected as priority areas. The Hospital Admissions Risk Program had strong and good matches respectively with home-based exercise and medication review, and was also selected.

CONCLUSIONS

Our systematic methods identified Department programs with strong potential for integration of proven falls prevention interventions.

IMPLICATIONS

Matching departmental programs and evidence-based interventions for integration may lead to more efficient resource allocation for falls prevention in Victoria.