The effects of radiofrequency exposure on cognition: A systematic review and meta-analysis of human observational studies.

BACKGROUND: We aimed to assess evidence of long-term effects of exposure to radiofrequency (RF) electromagnetic fields (EMF) on indicators of cognition, including domains of learning and memory, executive function, complex attention, language, perceptual motor ability and social cognition, and of an exposure-response relationship between RF-EMF and cognition. METHODS: We searched PubMed, Embase, PsycInfo and the EMF-Portal on September 30, 2022 without limiting by date or language of publication. We included cohort or case-control studies that evaluated the effects of RF exposure on cognitive function in one or more of the cognitive domains. Studies were rated for risk of bias using the OHAT tool and synthesised using fixed effects meta-analysis. We assessed the certainty of the evidence using the GRADE approach and considered modification by OHAT for assessing evidence of exposures. RESULTS: We included 5 studies that reported analyses of data from 4 cohorts with 4639 participants consisting of 2808 adults and 1831 children across three countries (Australia, Singapore and Switzerland) conducted between 2006 and 2017. The main source of RF-EMF exposure was mobile (cell) phone use measured as calls per week or minutes per day. For mobile phone use in children, two studies (615 participants) that compared an increase in mobile phone use to a decrease or no change were included in meta-analyses. Learning and memory. There was little effect on accuracy (mean difference, MD -0.03; 95% CI -0.07 to 0.02) or response time (MD -0.01; 95% CI -0.04 to 0.02) on the one-back memory task; and accuracy (MD -0.02; 95%CI -0.04 to 0.00) or response time (MD -0.01; 95%CI -0.04 to 0.03) on the one card learning task (low certainty evidence for all outcomes). Executive function. There was little to no effect on the Stroop test for the time ratio ((B-A)/A) response (MD 0.02; 95% CI -0.01 to 0.04, very low certainty) or the time ratio ((D-C)/C) response (MD 0.00; 95% CI -0.06 to 0.05, very low certainty), with both tests measuring susceptibility to interference effects. Complex attention. There was little to no effect on detection task accuracy (MD 0.02; 95% CI -0.04 to 0.08), or response time (MD 0.02;95% CI 0.01 to 0.03), and little to no effect on identification task accuracy (MD 0.00; 95% CI -0.04 to 0.05) or response time (MD 0.00;95% CI -0.01 to 0.02) (low certainty evidence for all outcomes). No other cognitive domains were investigated in children. A single study among elderly people provided very low certainty evidence that more frequent mobile phone use may have little to no effect on the odds of a decline in global cognitive function (odds ratio, OR 0.81; 95% CI 0.42 to 1.58, 649 participants) or a decline in executive function (OR 1.07; 95% CI 0.37 to 3.05, 146 participants), and may lead to a small, probably unimportant, reduction in the odds of a decline in complex attention (OR 0.67;95%CI 0.27 to 1.68, 159 participants) and a decline in learning and memory (OR 0.75; 95% CI 0.29 to 1.99, 159 participants). An exposure-response relationship was not identified for any of the cognitive outcomes. DISCUSSION: This systematic review and meta-analysis found only a few studies that provided very low to low certainty evidence of little to no association between RF-EMF exposure and learning and memory, executive function and complex attention. None of the studies among children reported on global cognitive function or other domains of cognition. Only one study reported a lack of an effect for all domains in elderly persons but this was of very low certainty evidence. Further studies are needed to address all types of populations, exposures and cognitive outcomes, particularly studies investigating environmental and occupational exposure in adults. Future studies also need to address uncertainties in the assessment of exposure and standardise testing of specific domains of cognitive function to enable synthesis across studies and increase the certainty of the evidence. OTHER: This review was partially funded by the WHO radioprotection programme and prospectively registered on PROSPERO CRD42021257548.

Development of a search filter to retrieve reports of interrupted time series studies from MEDLINE and PubMed.

BACKGROUND: Interrupted time series (ITS) studies contribute importantly to systematic reviews of population-level interventions. We aimed to develop and validate search filters to retrieve ITS studies in MEDLINE and PubMed. METHODS: A total of 1017 known ITS studies (published 2013-2017) were analysed using text mining to generate candidate terms. A control set of 1398 time-series studies were used to select differentiating terms. Various combinations of candidate terms were iteratively tested to generate three search filters. An independent set of 700 ITS studies was used to validate the filters' sensitivities. The filters were test-run in Ovid MEDLINE and the records randomly screened for ITS studies to determine their precision. Finally, all MEDLINE filters were translated to PubMed format and their sensitivities in PubMed were estimated. RESULTS: Three search filters were created in MEDLINE: a precision-maximising filter with high precision (78%; 95% CI 74%-82%) but moderate sensitivity (63%; 59%-66%), most appropriate when there are limited resources to screen studies; a sensitivity-and-precision-maximising filter with higher sensitivity (81%; 77%-83%) but lower precision (32%; 28%-36%), providing a balance between expediency and comprehensiveness; and a sensitivity-maximising filter with high sensitivity (88%; 85%-90%) but likely very low precision, useful when combined with specific content terms. Similar sensitivity estimates were found for PubMed versions. CONCLUSION: Our filters strike different balances between comprehensiveness and screening workload and suit different research needs. Retrieval of ITS studies would be improved if authors identified the ITS design in the titles.

Effectiveness of care bundles for prevention and treatment of postpartum hemorrhage: a systematic review.

OBJECTIVE: Care bundles are a promising approach to reducing postpartum hemorrhage-related morbidity and mortality. We assessed the effectiveness and safety of care bundles for postpartum hemorrhage prevention and/or treatment. DATA SOURCES: We searched MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and Global Index Medicus (inception to June 9, 2023) and ClinicalTrials.gov and the International Clinical Trials Registry Platform (last 5 years) using a phased search strategy, combining terms for postpartum hemorrhage and care bundles. STUDY ELIGIBILITY CRITERIA: Peer-reviewed studies evaluating postpartum hemorrhage-related care bundles were included. Care bundles were defined as interventions comprising ≥3 components implemented collectively, concurrently, or in rapid succession. Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies (controlled or uncontrolled) were eligible. METHODS: Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (nonrandomized studies). For controlled studies, we reported risk ratios for dichotomous outcomes and mean differences for continuous outcomes, with certainty of evidence determined using GRADE. For uncontrolled studies, we used effect direction tables and summarized results narratively. RESULTS: Twenty-two studies were included for analysis. For prevention-only bundles (2 studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization, and intensive care unit stay, and maternal well-being. For treatment-only bundles (9 studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (risk ratio, 0.40; 95% confidence interval, 0.32-0.50) and blood transfusion for bleeding, postpartum hemorrhage, severe postpartum hemorrhage, and mean blood loss. One nonrandomized trial and 7 uncontrolled studies suggest that other postpartum hemorrhage treatment bundles might reduce blood loss and severe postpartum hemorrhage, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative care bundle may reduce severe maternal morbidity (risk ratio, 0.64; 95% confidence interval, 0.57-0.72). Ten uncontrolled studies variably showed possible benefits, no effects, or harms for other bundle types. Nearly all uncontrolled studies did not use suitable statistical methods for single-group pretest-posttest comparisons and should thus be interpreted with caution. CONCLUSION: The E-MOTIVE intervention improves postpartum hemorrhage-related outcomes among women delivering vaginally, and the California Maternal Quality Care Collaborative bundle may reduce severe maternal morbidity. Other bundle designs warrant further effectiveness research before implementation is contemplated.

Evidence surveillance for a living clinical guideline: Case study of the Australian stroke guidelines.

BACKGROUND: Continual evidence surveillance is an integral feature of living guidelines. The Australian Stroke Guidelines include recommendations on 100 clinical topics and have been 'living' since 2018. OBJECTIVES: To describe the approach for establishing and evaluating an evidence surveillance system for the living Australian Stroke Guidelines. METHODS: We developed a pragmatic surveillance system based on an analysis of the searches for the 2017 Stroke Guidelines and evaluated its reliability by assessing the potential impact on guideline recommendations. Search retrieval and screening workload are monitored monthly, together with the frequency of changes to the guideline recommendations. RESULTS: Evidence surveillance was guided by practical considerations of efficiency and sustainability. A single PubMed search covering all guideline topics, limited to systematic reviews and randomised trials, is run monthly. The search retrieves about 400 records a month of which a sixth are triaged to the guideline panels for further consideration. Evaluations with Epistemonikos and the Cochrane Stroke Trials Register demonstrated the robustness of adopting this more restrictive approach. Collaborating with the guideline team in designing, implementing and evaluating the surveillance is essential for optimising the approach. CONCLUSION: Monthly evidence surveillance for a large living guideline is feasible and sustainable when applying a pragmatic approach.

Are COVID-19 systematic reviews up to date and can we tell? A cross-sectional study.

BACKGROUND: COVID-19 led to a rapid acceleration in the number of systematic reviews. Readers need to know how up to date evidence is when selecting reviews to inform decisions. This cross-sectional study aimed to evaluate how easily the currency of COVID-19 systematic reviews published early in the pandemic could be determined and how up to date these reviews were at the time of publication. METHODS: We searched for systematic reviews and meta-analyses relevant to COVID-19 added to PubMed in July 2020 and January 2021, including any that were first published as preprints. We extracted data on the date of search, number of included studies, and date first published online. For the search date, we noted the format of the date and where in the review this was reported. A sample of non-COVID-19 systematic reviews from November 2020 served as a comparator. RESULTS: We identified 246 systematic reviews on COVID-19. In the abstract of these reviews, just over half (57%) reported the search date (day/month/year or month/year) while 43% failed to report any date. When the full text was considered, the search date was missing from 6% of reviews. The median time from last search to publication online was 91 days (IQR 63-130). Time from search to publication was similar for the subset of 15 rapid or living reviews (92 days) but shorter for the 29 reviews published as preprints (37 days). The median number of studies or publications included per review was 23 (IQR 12-40). In the sample of 290 non-COVID SRs, around two-thirds (65%) reported the search date while a third (34%) did not include any date in the abstract. The median time from search to publication online was 253 days (IQR 153-381) and each review included a median of 12 studies (IQR 8-21). CONCLUSIONS: Despite the context of the pandemic and the need to easily ascertain the currency of systematic reviews, reporting of the search date information for COVID-19 reviews was inadequate. Adherence to reporting guidelines would improve the transparency and usefulness of systematic reviews to users.

Weekly updating of guideline recommendations was feasible: the Australian National COVID-19 clinical evidence Taskforce.

OBJECTIVES: To investigate how quickly evidence was incorporated into the Australian living guidelines for COVID-19 during the first 12 months of the pandemic. STUDY DESIGN AND SETTING: For each study concerning drug therapies included in the guideline from April 3, 2020 to April 1, 2021, we extracted the publication date of the study, and the guideline version the study was included in. We analyzed two subgroups of studies as follows: those published in high impact factor journals and those with 100 or more participants. RESULTS: In the first year, we published 37 major versions of the guidelines, incorporating 129 studies that investigated 48 drug therapies informing 115 recommendations. The median time from first publication of a study to incorporation in the guideline was 27 days (interquartile range [IQR], 16 to 44), ranging from 9 to 234 days. For the 53 studies in the highest impact factor journals, the median was 20 days (IQR 15 to 30), and for the 71 studies with 100 or more participants the median was 22 days (IQR 15 to 36). CONCLUSION: Developing and sustaining living guidelines where evidence is rapidly incorporated is a resource- and time-intensive undertaking; however, this study demonstrates that it is feasible, even over a long period.

Methods for living guidelines: early guidance based on practical experience. Paper 4: search methods and approaches for living guidelines.

OBJECTIVES: To describe the key features of a continual evidence surveillance process that can be implemented for living guidelines and to outline the considerations and trade-offs in adopting different approaches. STUDY DESIGN AND SETTING: Members of the Australian Living Evidence Consortium (ALEC), National Institute of Health and Care Excellence (NICE), and the US GRADE Network (USGN) shared their practical experiences of and approaches to establishing surveillance systems for living guidelines. We identified several common components of evidence surveillance and listed the key features and considerations for each component drawn from case studies, highlighting differences with standard guidelines. RESULTS: We developed guidance that covers the initial information needed to support decisions around suitability for living mode and the practical considerations in setting up continual search surveillance systems (search frequency, sources to search, use of automation, reporting the search, ongoing resources, and evaluation). The case studies draw on our experiences with developing guidelines for COVID-19, as well as for other conditions such as stroke and diabetes, and cover a range of practical approaches, including the use of automation. CONCLUSION: This paper highlights different approaches to continual evidence surveillance that can be implemented in living guidelines.

Methods for living guidelines: early guidance based on practical experience. Paper 1: Introduction.

OBJECTIVES: To introduce methods for living guidelines based on practical experiences by the Australian Living Evidence Consortium (ALEC), the National Institute of Health and Care Excellence (NICE), and the Infectious Diseases Society of America (IDSA), with methodological support from the US Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Network. STUDY DESIGN AND SETTING: Members of ALEC, NICE, and the US GRADE Network, convened a working group to share experiences of the methods used to develop living guidelines and outline the key differences between traditional and living guidelines methods. RESULTS: The guidance includes the following steps: 1) deciding if the guideline is a priority for a living approach, 2) preparing for living guideline development, 3) literature surveillance and frequency of searching, 4) assessment and synthesis of the evidence, 5) publication and dissemination, and 6) transitioning recommendations out of living mode. CONCLUSION: This paper introduces methods for living guidelines and provides examples of the similarities and differences in approach across multiple organizations conducting living guidelines. It also introduces a series of papers exploring methods for living guidelines based on our practical experiences, including consumer involvement, selecting and prioritizing questions, search decisions, and methods decisions.

Pragmatic and open science-based solution to a current problem in the reporting of living systematic reviews.

Living systematic reviews (LSRs) are an increasingly common approach to keeping reviews up to date, in which new relevant studies are incorporated as they become available, so as to inform healthcare policy and practice in a timely manner. While journal publishers have been exploring the publication of LSRs using different updating and publishing approaches, readers cannot currently assess if the evidence underpinning a published LSR is up to date, as neither the search details, the selection process, nor the list of identified studies is made available between the publication of updates. We describe a new method to transparently report the living evidence surveillance process that occurs between published LSR versions. We use the example of the living Cochrane Review on nirmatrelvir combined with ritonavir (Paxlovid) for preventing and treating COVID-19 to illustrate how this can work in practice. We created a publicly accessible spreadsheet on the Open Science Framework platform, linking to the living Cochrane Review, that details the search and study selection process, enabling readers to track the progress of eligible ongoing or completed studies. Further automation of the evidence surveillance process should be explored.

A declaração PRISMA 2020: diretriz atualizada para relatar revisões sistemáticas*

[RESUMO]. A declaração dos Principais Itens para Relatar Revisões Sistemáticas e Meta-análises (PRISMA), publicada em 2009, foi desenvolvida para ajudar revisores sistemáticos a relatar de forma transparente por que a revisão foi feita, os métodos empregados e o que os autores encontraram. Na última década, os avanços na metodo- logia e terminologia de revisões sistemáticas exigiram a atualização da diretriz. A declaração PRISMA 2020 substitui a declaração de 2009 e inclui novas orientações para relato que refletem os avanços nos métodos para identificar, selecionar, avaliar e sintetizar estudos. A estrutura e apresentação dos itens foram modifi- cadas para facilitar a implementação. Neste artigo, apresentamos a lista de checagem PRISMA 2020 de 27 itens, uma lista de checagem expandida que detalha as recomendações para relato para cada item, a lista de checagem PRISMA 2020 para resumos e os fluxogramas revisados para novas revisões e para atualização de revisões.

[ABSTRACT]. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, published in 2009, was designed to help systematic reviewers transparently report why the review was done, what the authors did, and what they found. Over the past decade, advances in systematic review methodology and terminology have necessitated an update to the guideline. The PRISMA 2020 statement replaces the 2009 statement and includes new reporting guidance that reflects advances in methods to identify, select, appraise, and synthesise studies. The structure and presentation of the items have been modified to facilitate imple- mentation. In this article, we present the PRISMA 2020 27-item checklist, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews.

[RESUMEN]. La declaración PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), publicada en 2009, se diseñó para ayudar a los autores de revisiones sistemáticas a documentar de manera transparente el porqué de la revisión, qué hicieron los autores y qué encontraron. Durante la última década, ha habido muchos avances en la metodología y terminología de las revisiones sistemáticas, lo que ha requerido una actualización de esta guía. La declaración PRISMA 2020 sustituye a la declaración de 2009 e incluye una nueva guía de presentación de las publicaciones que refleja los avances en los métodos para identificar, seleccionar, evaluar y sintetizar estudios. La estructura y la presentación de los ítems ha sido modificada para facilitar su implementación. En este artículo, presentamos la lista de verificación PRISMA 2020 con 27 ítems, y una lista de verificación ampliada que detalla las recomendaciones en la publicación de cada ítem, la lista de verificación del resumen estructurado PRISMA 2020 y el diagrama de flujo revisado para revisiones sistemáticas.

Changing patterns in reporting and sharing of review data in systematic reviews with meta-analysis of the effects of interventions: cross sectional meta-research study.

OBJECTIVES: To examine changes in completeness of reporting and frequency of sharing data, analytical code, and other review materials in systematic reviews over time; and factors associated with these changes. DESIGN: Cross sectional meta-research study. POPULATION: Random sample of 300 systematic reviews with meta-analysis of aggregate data on the effects of a health, social, behavioural, or educational intervention. Reviews were indexed in PubMed, Science Citation Index, Social Sciences Citation Index, Scopus, and Education Collection in November 2020. MAIN OUTCOME MEASURES: The extent of complete reporting and the frequency of sharing review materials in the systematic reviews indexed in 2020 were compared with 110 systematic reviews indexed in February 2014. Associations between completeness of reporting and various factors (eg, self-reported use of reporting guidelines, journal policies on data sharing) were examined by calculating risk ratios and 95% confidence intervals. RESULTS: Several items were reported suboptimally among 300 systematic reviews from 2020, such as a registration record for the review (n=113; 38%), a full search strategy for at least one database (n=214; 71%), methods used to assess risk of bias (n=185; 62%), methods used to prepare data for meta-analysis (n=101; 34%), and source of funding for the review (n=215; 72%). Only a few items not already reported at a high frequency in 2014 were reported more frequently in 2020. No evidence indicated that reviews using a reporting guideline were more completely reported than reviews not using a guideline. Reviews published in 2020 in journals that mandated either data sharing or inclusion of data availability statements were more likely to share their review materials (eg, data, code files) than reviews in journals without such mandates (16/87 (18%) v 4/213 (2%)). CONCLUSION: Incomplete reporting of several recommended items for systematic reviews persists, even in reviews that claim to have followed a reporting guideline. Journal policies on data sharing might encourage sharing of review materials.

Portable ultrasound technologies for estimating gestational age in pregnant women: a scoping review and analysis of commercially available models.

OBJECTIVES: To identify all available studies assessing the use of portable ultrasound devices for pregnant women, with the specific aim of finding evidence for devices used to determine gestational age and their validity when compared with conventional ultrasound machines. We also wanted to determine what portable ultrasound models are commercially available for obstetric use. DESIGN: Systematic scoping review. PRIMARY AND SECONDARY OUTCOME MEASURES: Extracted variables included study design, population, method of ultrasound measurement, devices used and whether studies formally validated accuracy against conventional ultrasound. RESULTS: We searched four databases-Medline, Embase, CINAHL and Maternal and Infant Care. In total 56 studies from 34 countries were identified; most were observational studies. Across all studies, 27 different portable ultrasound models (from 17 manufacturers) were evaluated. Twenty-one studies assessed use of portable ultrasound for evaluating fetal characteristics or estimating gestational age, and 10 of these were formal validation studies. In total, six portable devices have been validated for gestational age estimation against a conventional ultrasound comparator. The web searches identified 102 portable devices (21 manufacturers). These were a mix of handheld devices that connected to a phone or computer, or laptop-style portable ultrasound devices. Prices ranged from US$1190 to US$30 000 and weight ranged from 0.9 kg to 13.0 kg. CONCLUSION: While the number of commercially available portable ultrasound devices continues to grow, there remains a lack of peer-reviewed, quality evidence demonstrating their accuracy and validity when compared with conventional ultrasound machines. This review identified some models that may be useful in gestational age estimation in low-resource settings, but more research is required to help implement the technology at scale. TRIAL REGISTRATION NUMBER: Registered via Open Science Framework (DOI: 10.17605/OSF.IO/U8KXP).

The National COVID-19 Clinical Evidence Taskforce: pregnancy and perinatal guidelines.

INTRODUCTION: Pregnant women are at higher risk of severe illness from coronavirus disease 2019 (COVID-19) than non-pregnant women of a similar age. Early in the COVID-19 pandemic, it was clear that evidenced-based guidance was needed, and that it would need to be updated rapidly. The National COVID-19 Clinical Evidence Taskforce provided a resource to guide care for people with COVID-19, including during pregnancy. Care for pregnant and breastfeeding women and their babies was included as a priority when the Taskforce was set up, with a Pregnancy and Perinatal Care Panel convened to guide clinical practice. MAIN RECOMMENDATIONS: As of May 2022, the Taskforce has made seven specific recommendations on care for pregnant women and those who have recently given birth. This includes supporting usual practices for the mode of birth, umbilical cord clamping, skin-to-skin contact, breastfeeding, rooming-in, and using antenatal corticosteroids and magnesium sulfate as clinically indicated. There are 11 recommendations for COVID-19-specific treatments, including conditional recommendations for using remdesivir, tocilizumab and sotrovimab. Finally, there are recommendations not to use several disease-modifying treatments for the treatment of COVID-19, including hydroxychloroquine and ivermectin. The recommendations are continually updated to reflect new evidence, and the most up-to-date guidance is available online (https://covid19evidence.net.au). CHANGES IN MANAGEMENT RESULTING FROM THE GUIDELINES: The National COVID-19 Clinical Evidence Taskforce has been a critical component of the infrastructure to support Australian maternity care providers during the COVID-19 pandemic. The Taskforce has shown that a rapid living guidelines approach is feasible and acceptable.

Care for adults with COVID-19: living guidelines from the National COVID-19 Clinical Evidence Taskforce.

INTRODUCTION: The Australian National COVID-19 Clinical Evidence Taskforce was established in March 2020 to maintain up-to-date recommendations for the treatment of people with coronavirus disease 2019 (COVID-19). The original guideline (April 2020) has been continuously updated and expanded from nine to 176 recommendations, facilitated by the rapid identification, appraisal, and analysis of clinical trial findings and subsequent review by expert panels. MAIN RECOMMENDATIONS: In this article, we describe the recommendations for treating non-pregnant adults with COVID-19, as current on 1 August 2022 (version 61.0). The Taskforce has made specific recommendations for adults with severe/critical or mild disease, including definitions of disease severity, recommendations for therapy, COVID-19 prophylaxis, respiratory support, and supportive care. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE: The Taskforce currently recommends eight drug treatments for people with COVID-19 who do not require supplemental oxygen (inhaled corticosteroids, casirivimab/imdevimab, molnupiravir, nirmatrelvir/ritonavir, regdanvimab, remdesivir, sotrovimab, tixagevimab/cilgavimab) and six for those who require supplemental oxygen (systemic corticosteroids, remdesivir, tocilizumab, sarilumab, baricitinib, casirivimab/imdevimab). Based on evidence of their achieving no or only limited benefit, ten drug treatments or treatment combinations are not recommended; an additional 42 drug treatments should only be used in the context of randomised trials. Additional recommendations include support for the use of continuous positive airway pressure, prone positioning, and endotracheal intubation in patients whose condition is deteriorating, and prophylactic anticoagulation for preventing venous thromboembolism. The latest updates and full recommendations are available at www.covid19evidence.net.au.

Prevention and control of non-communicable diseases in antenatal, intrapartum, and postnatal care: a systematic scoping review of clinical practice guidelines since 2011.

BACKGROUND: Non-communicable diseases (NCDs) are a leading cause of maternal mortality and morbidity worldwide. The World Health Organization is developing new recommendations focusing on the management of NCDs for pregnant, intrapartum, and postnatal women. Thus, to support the development of new guidelines and recommendations, we aimed to determine the availability, focus, and scope of recommendations of current guidelines for the management of NCDs during pregnancy, intrapartum, and postnatal period. METHODS: PubMed, Global Index Medicus, TRIP, and Guideline International Network databases were searched on 31 May 2021, to identify any NCD-related guidelines published between 2011 and 2021 with no language or country restrictions. Websites of 165 professional organizations were also searched. Characteristics of included guidelines were analyzed, and recommendations were extracted from guidelines of five high-priority NCD conditions (diabetes, chronic hypertension, respiratory conditions, hemoglobinopathies and sickle cell disease, and mental and substance use disorders). RESULTS: From 6026 citations and 165 websites, 405 guidelines were included of which 132 (33%) were pregnancy-specific and 285 (88%) were developed in high-income countries. Among pregnancy-specific guidelines, the most common conditions for which recommendations were provided were gestational diabetes, circulatory diseases, thyroid disorders, and hypertensive disorders of pregnancy. For the five high-priority conditions, 47 guidelines were identified which provided 1834 recommendations, largely focused on antenatal care interventions (62%) such as early detection, screening tools, pharmacological treatment, and lifestyle education. Postnatal recommendations largely covered postnatal clinical assessments, lifestyle education, and breastfeeding. Health system recommendations largely covered multidisciplinary care teams and strengthening referral pathways. CONCLUSIONS: This study provides a robust assessment of currently available guidelines and mapping of recommendations on NCD management within maternal health services, which will inform the scope of the World Health Organization's future guideline development activities. This study identified a need to develop guidelines that consider NCDs holistically, with an integrated approach to antenatal, intrapartum, and postnatal care, and that are relevant for resource-limited contexts. Any such guidelines should consider what interventions are most essential to improving outcomes for women with NCDs and their newborns, and how variations in quality of NCD-related care can be addressed.

Randomised trials in maternal and perinatal health in low and middle-income countries from 2010 to 2019: a systematic scoping review.

OBJECTIVES: To identify and map all trials in maternal health conducted in low and middle-income countries (LMIC) over the 10-year period from 2010 to 2019, to identify geographical and thematic trends, as well as comparing to global causes of maternal death and preidentified priority areas. DESIGN: Systematic scoping review. PRIMARY AND SECONDARY OUTCOME MEASURES: Extracted data included location, study characteristics and whether trials corresponded to causes of mortality and identified research priority topics. RESULTS: We searched the Cochrane Central Register of Controlled Trials database, a combined registry of trials from multiple sources. Our search identified 7269 articles, 874 of which were included for analysis. Between 2010 and 2019, maternal health trials conducted in LMICs more than doubled (50-114). Trials were conducted in 61 countries-231 trials (26.4%) were conducted in Iran. Only 225 trials (25.7%) were aligned with a cause of maternal mortality. Within these trials, pre-existing medical conditions, embolism, obstructed labour and sepsis were all under-represented when compared with number of maternal deaths globally. Large numbers of studies were conducted on priority topics such as labour and delivery, obstetric haemorrhage and antenatal care. Hypertensive disorders of pregnancy, diabetes and health systems and policy-despite being high-priority topics-had relatively few trials. CONCLUSION: Despite trials conducted in LMICs increasing from 2010 to 2019, there were significant gaps in geographical distribution, alignment with causes of maternal mortality and known research priority topics. The research gaps identified provide guidance and insight for future research conduct in low-resource settings. TRIAL REGISTRATION NUMBER: 10.17605/OSF.IO/QUJP5.

Effectiveness of aromatherapy for prevention or treatment of disease, medical or preclinical conditions, and injury: protocol for a systematic review and meta-analysis.

BACKGROUND: Aromatherapy - the therapeutic use of essential oils from plants (flowers, herbs or trees) to treat ill health and promote physical, emotional and spiritual well-being - is one of the most widely used natural therapies reported by consumers in Western countries. The Australian Government Department of Health (via the National Health and Medical Research Council) has commissioned a suite of independent evidence evaluations to inform the 2019-20 Review of the Australian Government Rebate on Private Health Insurance for Natural Therapies. This protocol is for one of the evaluations: a systematic review that aims to examine the effectiveness of aromatherapy in preventing and/or treating injury, disease, medical conditions or preclinical conditions. METHODS: Eligibility criteria: randomised trials comparing (1) aromatherapy (delivered by any mode) to no aromatherapy (inactive controls), (2) aromatherapy (delivered by massage) to massage alone or (3) aromatherapy to 'gold standard' treatments. POPULATIONS: any condition, pre-condition, injury or risk factor (excluding healthy participants without clearly identified risk factors). OUTCOMES: any for which aromatherapy is indicated. Searches: Cochrane Central Register of Controlled Trials (CENTRAL), with a supplementary search of PubMed (covering a 6-month lag period for processing records in CENTRAL and records not indexed in MEDLINE), AMED and Emcare. No date, language or geographic limitations will be applied. DATA AND ANALYSIS: screening by two authors, independently (records indexed by Aromatherapy or Oils volatile or aromatherapy in title; all full text) or one author (remaining records) with second author until 80% agreement. Data extraction and risk of bias assessment (ROB 2.0) will be piloted by three authors, then completed by a single author and checked by a second. Comparisons will be based on broad outcome categories (e.g. pain, emotional functioning, sleep disruption) stratified by population subgroups (e.g. chronic pain conditions, cancer, dementia) as defined in the analytic framework for the review. Meta-analysis or other synthesis methods will be used to combine results across studies. GRADE methods will be used to assess certainty of evidence and summarise findings. DISCUSSION: Results of the systematic review will provide a comprehensive and up-to-date synthesis of evidence about the effectiveness of aromatherapy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021268244.

How frequently should "living" guidelines be updated? Insights from the Australian Living Stroke Guidelines.

BACKGROUND: "Living guidelines" are guidelines which are continually kept up to date as new evidence emerges. Living guideline methods are evolving. The aim of this study was to determine how frequently searches for new evidence should be undertaken for the Australian Living Stroke Guidelines. METHODS: Members of the Living Stroke Guidelines Development Group were invited to complete an online survey. Participants nominated one or more recommendation topics from the Living Stroke Guidelines with which they had been involved and answered questions about that topic, assessing whether it met criteria for living evidence synthesis, and how frequently searches for new evidence should be undertaken and why. For each topic we also determined how many studies had been assessed and included, and whether recommendations had been changed. RESULTS: Fifty-seven assessments were received from 33 respondents, covering half of the 88 guideline topic areas. Nearly all assessments (49, 86%) were that the continual updating process should be maintained. Only three assessments (5%) deemed that searches should be conducted monthly; 3-monthly (14, 25%), 6-monthly (13, 23%) and yearly (17, 30%) searches were far more frequently recommended. Rarely (9, 16%) were topics deemed to meet all three criteria for living review. The vast majority of assessments (45, 79%) deemed the topic a priority for decision-making. Nearly half indicated that there was uncertainty in the available evidence or that new evidence was likely to be available soon. Since 2017, all but four of the assessed topic areas have had additional studies included in the evidence summary. For eight topics, there have been changes in recommendations, and revisions are underway for an additional six topics. Clinical importance was the most common reason given for why continual evidence surveillance should be undertaken. Workload for reviewers was a concern, particularly for topics where there is a steady flow of publication of small trials. CONCLUSIONS: Our study found that participants felt that the vast majority of topics assessed in the Living Stroke Guidelines should be continually updated. However, only a fifth of topic areas were assessed as conclusively meeting all three criteria for living review, and the definition of "continual" differed widely. This work has informed decisions about search frequency for the Living Stroke Guidelines and form the basis of further research on methods for frequent updating of guidelines.

Most published systematic reviews of remdesivir for COVID-19 were redundant and lacked currency.

OBJECTIVE: To investigate the completeness and currency of published systematic reviews of remdesivir for COVID-19 and to compare this with a living guidelines approach. STUDY DESIGN AND SETTING: In this cross-sectional study, we searched Europe PMC on May 20, 2021 for systematic reviews of remdesivir (including preprints, living review updates). Completeness and currency were based on the inclusion of four major randomized trials of remdesivir available at the time of publication of the review (including as preliminary results and preprints). RESULTS: We included 38 reviews (45 reports), equivalent to a new publication every 9 days. 23 (51%) reports were out of date at the time of publication. Eleven reviews that were current on publication had a median survival time of 10 days (range 4-57). A third of reviews cited other systematic reviews, but only four provided justifications for why another review was necessary. Eight (21%) of the reviews were registered in PROSPERO. The Australian COVID-19 Clinical Evidence Taskforce living guidelines were updated within 14 days for three of the remdesivir trials, and within 28 days for the fourth. CONCLUSION: There was considerable duplication of systematic reviews of remdesivir, and half were already out of date at the time of publication.