Assessing the Certainty of the Evidence in Systematic Reviews: Importance, Process, and Use.

When interpreting results and drawing conclusions, authors of systematic reviews should consider the limitations of the evidence included in their review. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach provides a framework for the explicit consideration of the limitations of the evidence included in a systematic review, and for incorporating this assessment into the conclusions. Assessments of certainty of evidence are a methodological expectation of systematic reviews. The certainty of the evidence is specific to each outcome in a systematic review, and can be rated as high, moderate, low, or very low. Because it will have an important impact, before conducting certainty of evidence, reviewers must clarify the intent of their question: are they interested in causation or association. Serious concerns regarding limitations in the study design, inconsistency, imprecision, indirectness, and publication bias can decrease the certainty of the evidence. Using an example, this article describes and illustrates the importance and the steps for assessing the certainty of evidence and drawing accurate conclusions in a systematic review.

Biomarkers to inform the management of polycystic ovary syndrome: A review of systematic reviews.

INTRODUCTION: Polycystic ovarian syndrome (PCOS) is the commonest endocrine condition affecting reproductive age women. Many biomarkers may aid assessment and management, however evidence is limited on their utility in clinical practice. We conducted a review of systematic reviews to identify the most useful biomarkers in the clinical management of PCOS. METHODS: We searched MEDLINE, EMBASE, CENTRAL and HTA until August 2023 for reviews evaluating biomarkers in PCOS women compared to healthy controls. Methodological quality was assessed using the AMSTAR2 tool. We reported pooled evidence for each biomarker with 95% confidence intervals from the most recent, up-to-date, and best quality review. RESULTS: From 3360 citations, we included 75 systematic reviews (88 biomarkers, 191,792 women). Most reviews (50/75, 67%) were moderate quality, but reported high heterogeneity (66/75, 88%). We identified 63 abnormal biomarkers in women with PCOS versus healthy controls. Of these, 22 core biomarkers could help evaluate the multisystemic impact of PCOS and inform patient management and surveillance: dehydroepiandrosterone, prolactin, sex hormone-binding globulin, total and free testosterone, anti-Mullerian hormone, systolic and diastolic blood pressure, c-reactive protein, fibrinogen, oral glucose tolerance test, homoeostatic model assessment-insulin resistance index, fasting insulin, total cholesterol, triglycerides, lipoprotein(a), HDL, LDL, non-HDL-cholesterol, ferritin, iron, and 25-hydroxy-vitamin D. CONCLUSION: We identified 22 core biomarkers assessing the multisystemic impact of PCOS and inform its clinical management. Future research is required to establish validated healthcare pathways.

Patient's perspectives of epilepsy care by specialists and generalists: qualitative evidence synthesis.

BACKGROUND: In the UK, epilepsy care involves both specialists (eg, neurologists) and generalists (eg, general practitioners). Policymakers typically consider that epilepsy care should be integrated and involve both specialists and generalists. However, few understand exactly how patients view and compare specialist and generalist care. AIM: This systematic review aimed to explore patient perspectives of specialist care and generalist care for epilepsy in a qualitative evidence synthesis. DESIGN & SETTING: Systematic Review, qualitative evidence synthesis using an identified framework. METHOD: Systematic searches in 5 databases retrieved 17 eligible studies. Data was extracted and synthesised using framework analysis informed by the 'United Model of Generalism'. RESULTS: Three themes were developed: 'Epilepsy care can be burdensome' (eg, through care fragmentation); 'Patient's experience is that care is not always accessible' (eg, lack of a continuum between standardised and interpretive care); 'How care could change for people with epilepsy' (eg, clinicians currently have insufficient time to deviate from protocol-driven care to address psychosocial needs). People with epilepsy frequently observe that generalists lack expertise in epilepsy management. CONCLUSIONS: This synthesis of patient experiences indicates recommendations should focus on improving communication and integration between specialists and generalists for epilepsy care. Patient experiences indicate specialist care risks being burdensome and generalist knowledge insufficient, requiring enhanced primary care clinician skills and improved awareness of patient psychosocial needs. The findings argue in favour of healthcare policies, materials and tools to continually support patient perspectives in developing epilepsy services.

Whole body resistance training on functional outcomes of patients with Stage 4 or 5 chronic kidney disease: A systematic review.

Chronic kidney disease (CKD) causes skeletal muscle wasting, resulting in reduced function and inability to live independently. This systematic review critically appraised the scientific literature regarding the effects of full-body resistance training on clinically-relevant functional capacity measures in CKD. The study population included studies of people with Stage 4 or 5 CKD and a mean age of 40+ years old. Eight databases were searched for eligible studies: Pubmed, Embase, Cochrane, CINAHL, Scopus, Web of Science, MEDLINE, and AGELINE. MeSH terms and keyword combinations were used for screening following the PRISMA conduct. Inclusion criteria were based on PICO principles and no date of publication filter was applied. The intervention was training 2 days/week of structured resistance exercises using major upper and lower muscle groups. Minimum intervention period was 7 weeks. Comparison groups maintained their habitual activity without structured exercise training. Outcome measures of interest were: 6-min walk test, grip strength, timed up-and-go test, and sit-to-stand. Eight randomized controlled trials and one nonequivalent comparison-group study fulfilled the inclusion criteria and underwent data extraction. All studies were of hemodialysis patients. The evidence indicates that full-body resistance exercise significantly improved grip strength, timed up and go and sit to stand tests; metrics associated with enhanced quality and quantity of life.

A re-analysis of about 60,000 sparse data meta-analyses suggests that using an adequate method for pooling matters.

In sparse data meta-analyses (with few trials or zero events), conventional methods may distort results. Although better-performing one-stage methods have become available in recent years, their implementation remains limited in practice. This study examines the impact of using conventional methods compared to one-stage models by re-analysing meta-analyses from the Cochrane Database of Systematic Reviews in scenarios with zero event trials and few trials. For each scenario, we computed one-stage methods (Generalised linear mixed model [GLMM], Beta-binomial model [BBM], Bayesian binomial-normal hierarchical model using a weakly informative prior [BNHM-WIP]) and compared them with conventional methods (Peto-Odds-ratio [PETO], DerSimonian-Laird method [DL] for zero event trials; DL, Paule-Mandel [PM], Restricted maximum likelihood [REML] method for few trials). While all methods showed similar treatment effect estimates, substantial variability in statistical precision emerged. Conventional methods generally resulted in smaller confidence intervals (CIs) compared to one-stage models in the zero event situation. In the few trials scenario, the CI lengths were widest for the BBM on average and significance often changed compared to the PM and REML, despite the relatively wide CIs of the latter. In agreement with simulations and guidelines for meta-analyses with zero event trials, our results suggest that one-stage models are preferable. The best model can be either selected based on the data situation or, using a method that can be used in various situations. In the few trial situation, using BBM and additionally PM or REML for sensitivity analyses appears reasonable when conservative results are desired. Overall, our results encourage careful method selection.

Searchsmart.org: Guiding researchers to the best databases and search systems for systematic reviews and beyond.

When searching for scholarly documents, researchers often stick with the same familiar handful of databases. Yet, just beyond these limited horizons lie dozens of alternatives with which they could search more effectively, whether for quick lookups or thorough searches in systematic reviews or meta-analyses. Searchsmart.org is a free website that guides researchers to particularly suitable search options for their particular disciplines, offering a wide array of resources, including search engines, aggregators, journal platforms, repositories, clinical trials databases, bibliographic databases, and digital libraries. Search Smart currently evaluates the coverage and functionality of more than a hundred leading scholarly databases, including most major multidisciplinary databases and many that are discipline-specific. Search Smart's primary use cases involve database-selection decisions as part of systematic reviews, meta-analyses, or bibliometric analyses. Researchers can use up to 583 criteria to filter and sort recommendations of databases and the interfaces through which they can be accessed for user-friendliness, search rigor, or relevance. With specific pre-defined filter settings, researchers can quickly identify particularly suitable databases for Boolean keyword searching and forward or backward citation searching. Overall, Search Smart's recommendations help researchers to discover knowledge more effectively and efficiently by selecting the more suitable databases for their tasks.

What influences the implementation of clinical guidelines related to enteral nutrition in the intensive care unit: A mixed-methods systematic review.

AIMS: To systematically evaluate and analyse literature concerning the factors influencing the implementation of clinical practice guidelines related to enteral nutrition in the adult intensive care unit. BACKGROUND: Guidelines serve as crucial tools for guiding clinical practice. However, a significant gap persists between current clinical practice and guidelines pertaining to enteral nutrition. It is essential to identify the reasons behind this disparity to foster clinical transformation. METHODS: A mixed-methods systematic review. DATA SOURCES: A systematic search was conducted across PubMed, Embase, Medline, Cochrane, PsycINFO and CNKI databases to identify impediments and facilitators to the implementation of ICU clinical practice guidelines related to enteral nutrition. The types of studies included quantitative, qualitative and mixed-methods studies. The search spanned from January 2003 to January 2024 and was updated in May 2024. The quality assessment of the included literature was conducted using the Mixed-Methods Study Evaluation Tool (MMAT). Data analysis was performed using a data-based convergent integration approach. The protocol for this study was prospectively registered (PROSPERO2023, CRD42023483287). RESULTS: Twenty papers were finally included, and 65 findings were extracted, integrating a total of three categories, Category 1: healthcare provider factors, including three sub-themes: knowledge of guideline-related knowledge and awareness of guideline application; social/professional roles and identity domains; beliefs, attitudes and self-efficacy; collaboration, Category 2: practice environments, including two sub-themes: environmental factors and resource areas; systems and behavioural norms, Category 3: patient values and nutritional support preferences including two sub-themes: patient disease status and value orientation. CONCLUSION: Healthcare professionals should analyse obstacles and facilitators to guideline implementation from multiple perspectives, strengthen healthcare collaboration, improve education and training systems, correct misperceptions and increase awareness of evidence-based practice.

Longitudinal Coadaptation of Older Adults With Wearables and Voice-Activated Virtual Assistants: Scoping Review.

BACKGROUND: The integration of smart technologies, including wearables and voice-activated devices, is increasingly recognized for enhancing the independence and well-being of older adults. However, the long-term dynamics of their use and the coadaptation process with older adults remain poorly understood. This scoping review explores how interactions between older adults and smart technologies evolve over time to improve both user experience and technology utility. OBJECTIVE: This review synthesizes existing research on the coadaptation between older adults and smart technologies, focusing on longitudinal changes in use patterns, the effectiveness of technological adaptations, and the implications for future technology development and deployment to improve user experiences. METHODS: Following the Joanna Briggs Institute Reviewer's Manual and PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, this scoping review examined peer-reviewed papers from databases including Ovid MEDLINE, Ovid Embase, PEDro, Ovid PsycINFO, and EBSCO CINAHL from the year 2000 to August 28, 2023, and included forward and backward searches. The search was updated on March 1, 2024. Empirical studies were included if they involved (1) individuals aged 55 years or older living independently and (2) focused on interactions and adaptations between older adults and wearables and voice-activated virtual assistants in interventions for a minimum period of 8 weeks. Data extraction was informed by the selection and optimization with compensation framework and the sex- and gender-based analysis plus theoretical framework and used a directed content analysis approach. RESULTS: The search yielded 16,143 papers. Following title and abstract screening and a full-text review, 5 papers met the inclusion criteria. Study populations were mostly female participants and aged 73-83 years from the United States and engaged with voice-activated virtual assistants accessed through smart speakers and wearables. Users frequently used simple commands related to music and weather, integrating devices into daily routines. However, communication barriers often led to frustration due to devices' inability to recognize cues or provide personalized responses. The findings suggest that while older adults can integrate smart technologies into their lives, a lack of customization and user-friendly interfaces hinder long-term adoption and satisfaction. The studies highlight the need for technology to be further developed so they can better meet this demographic's evolving needs and call for research addressing small sample sizes and limited diversity. CONCLUSIONS: Our findings highlight a critical need for continued research into the dynamic and reciprocal relationship between smart technologies and older adults over time. Future studies should focus on more diverse populations and extend monitoring periods to provide deeper insights into the coadaptation process. Insights gained from this review are vital for informing the development of more intuitive, user-centric smart technology solutions to better support the aging population in maintaining independence and enhancing their quality of life. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/51129.

Performance of artificial intelligence in predicting the prognossis of severe COVID-19: a systematic review and meta-analysis.

Background: COVID-19-induced pneumonia has become a persistent health concern, with severe cases posing a significant threat to patient lives. However, the potential of artificial intelligence (AI) in assisting physicians in predicting the prognosis of severe COVID-19 patients remains unclear. Methods: To obtain relevant studies, two researchers conducted a comprehensive search of the PubMed, Web of Science, and Embase databases, including all studies published up to October 31, 2023, that utilized AI to predict mortality rates in severe COVID-19 patients. The PROBAST 2019 tool was employed to assess the potential bias in the included studies, and Stata 16 was used for meta-analysis, publication bias assessment, and sensitivity analysis. Results: A total of 19 studies, comprising 26 models, were included in the analysis. Among them, the models that incorporated both clinical and radiological data demonstrated the highest performance. These models achieved an overall sensitivity of 0.81 (0.64-0.91), specificity of 0.77 (0.71-0.82), and an overall area under the curve (AUC) of 0.88 (0.85-0.90). Subgroup analysis revealed notable findings. Studies conducted in developed countries exhibited significantly higher predictive specificity for both radiological and combined models (p < 0.05). Additionally, investigations involving non-intensive care unit patients demonstrated significantly greater predictive specificity (p < 0.001). Conclusion: The current evidence suggests that artificial intelligence prediction models show promising performance in predicting the prognosis of severe COVID-19 patients. However, due to variations in the suitability of different models for specific populations, it is not yet certain whether they can be fully applied in clinical practice. There is still room for improvement in their predictive capabilities, and future research and development efforts are needed. Systematic review registration: https://www.crd.york.ac.uk/prospero/ with the Unique Identifier CRD42023431537.

COSMIN guideline for systematic reviews of patient-reported outcome measures version 2.0.

PURPOSE: Systematic reviews of patient-reported outcome measures (PROMs) are important tools to select the most suitable PROM for a study or clinical application. Conducting these reviews is challenging, and the quality of these reviews needs to be improved. We updated the COSMIN guideline for systematic reviews of PROMs, including the COSMIN Risk of Bias checklist, and the COSMIN criteria for good measurement properties. METHODS: Adaptations to the methodology were based on our experience with applying the COSMIN guideline, through discussions among the authors, and results from two related Delphi studies. RESULTS: The updated guideline places more emphasis on key aspects that are often missing or sub optimally conducted in published systematic reviews of PROMs, such as formulating a well-defined research question and developing a comprehensive search strategy, assessing risk of bias, applying criteria for good measurement properties, summarizing results, and grading the quality of the evidence. We also stress the importance of evaluating the measurement properties of each subscale of a PROM separately and evaluating content validity of all included PROMs. CONCLUSION: The quality of systematic reviews of PROMs can be improved by using this updated version of the COSMIN guideline for systematic reviews of PROMs. Improved quality will lead to better PROM selection and increased standardization of PROM use.

Patient-reported outcome measures (PROMs) are questionnaires that measure aspects of health from the patient perspective. To measure a specific health aspect, often dozens of PROMs are available. To choose the best PROM, a systematic review of PROMs can be conducted, in which all information on the quality and feasibility of each available PROM is collected, rated, and compared. Based on such a review a choice for the most suitable PROM for a certain study or clinical application can be made. However, conducting a systematic review of PROMs is very challenging, because nine quality aspects of PROMs need to be taken into account.In this article, we present an updated step-by-step guideline for conducting systematic reviews of PROMs. Each of these steps is described in detail in an accompanying manual. This updated guideline helps researchers to conduct systematic reviews of PROMs in a systematic and transparent way. It also helps readers of systematic reviews to understand how the review was conducted and to check the conclusions about which PROMs are recommended based on their quality.

Active video games as an adjunct to pulmonary rehabilitation of patients with Chronic Obstructive Pulmonary Disease: a commentary on a systematic review.

Pulmonary rehabilitation is a key evidence-based intervention to improve the outcomes of people living with Chronic Obstructive Pulmonary Disease (COPD). However, there are challenges in delivering pulmonary rehabilitation including reduced referral rates and suboptimal uptake and completion rates. Active video game interventions, when used as an adjunct, may increase the adoption of and access to pulmonary rehabilitation. This commentary summarises and critically appraises a systematic review which investigated the effectiveness of active video games as a supplementary component in the pulmonary rehabilitation of individuals suffering from chronic obstructive pulmonary disease.

Most meta-analyses in oral health do not have conclusive and robust results.

OBJECTIVES: In meta-analyses with few studies, between-study heterogeneity is poorly estimated. The Hartung and Knapp (HK) correction and the prediction intervals can account for the uncertainty in estimating heterogeneity and the range of effect sizes we may encounter in future trials, respectively. The aim of this study was to assess the reported use of the HK correction in oral health meta-analyses and to compare the published reported results and interpretation i) to those calculated using eight heterogeneity estimators and the HK adjustment ii) and to the prediction intervals (PIs). METHODS: We sourced systematic reviews (SRs) published between 2021 and 2023 in eighteen leading specialty and general dental journals. We extracted study characteristics at the SR and meta-analysis level and re-analyzed the selected meta-analyses via the random-effects model and eight heterogeneity estimators, with and without the HK correction. For each meta-analysis, we re-calculated the overall estimate, the P-value, the 95 % confidence interval (CI) and the PI. RESULTS: We analysed 292 meta-analyses. The median number of primary studies included in meta-analysis was 8 (interquartile range [IQR] = [5.75-15] range: 3-121). Only 3/292 meta-analyses used the HK adjustment and 12/292 reported PIs. The percentage of statistically significant results that became non-significant varied across the heterogeneity estimators (7.45 %- 16.59 %). Based on the PIs, >60 % of meta-analyses with statistically significant results are likely to change in the future and >40 % of the PIs included the opposite pooled effect. CONCLUSIONS: The precision and statistical significance of the pooled estimates from meta-analyses with at least three studies is sensitive to the HK correction, the heterogeneity variance estimator, and the PIs. CLINICAL SIGNIFICANCE: Uncertainty in meta-analyses estimates should be considered especially when a small number of trials is available or vary notably in their precision. Misinterpretation of the summary results can lead to ineffective interventions being applied in clinical practice.

ARE PIT AND FISSURE SEALANTS EFFECTIVE IN PREVENTING AND ARRESTING OCCLUSAL CARIES IN PRIMARY AND PERMANENT TEETH? AN OVERVIEW OF SYSTEMATIC REVIEWS.

OBJECTIVES: To compile the evidence from systematic reviews (SRs) about the use of sealants for preventing and arresting pit and fissure occlusal caries in primary and permanent teeth. MATERIALS AND METHODS: A search was performed in six databases and gray literature up to May 2023. Systematic reviews (SRs) that included randomized trials (RCTs) and nonrandomized clinical trials (n-RCTs) aiming to answer the PICO-based focused question "are pit and fissure sealants (I) more effective than other interventions, control or no treatment (C) in preventing and arresting occlusal caries (O) in primary and permanent teeth (P)?", were included. The methodological quality was assessed using the AMSTAR-2. The overlap between reviews was calculated (corrected covered, CCA). RESULTS: Among the 25 included SRs, 18 underwent meta-analysis. Eighteen SRs considered sealing enamel caries lesions, one considered sealing dentine caries, and six considered both. Seventeen SRs were devoted to preventive sealing (RCT only, n = 12; RCT and n-RCT, n = 5), while eight were devoted to prevention and arrest of dental caries (RCT only, n = 5; RCT and n-RCT, n = 3). Nine SRs showed positive results for the primary dentition, and the most frequent periods of follow-up were at least 6 (n = 5) and 12 months (n = 4). According to our meta-analysis, a significant association between resin-based sealants (RBS) and dental caries prevention was detected at 6 months (n = 1) and over longer follow-up periods (n = 4), and the DMFT and dmft indices decreased (n = 2). RBS was better than fluoride varnish at preventing dentine caries (n = 1). A lower caries incidence rate was observed in the resin-modified glass ionomer group at 6 months (n = 1). Overall, the sealants were superior (n = 11), similar (n = 21), or inferior (n = 1) to the other treatments. The AMSTAR-2 scores for studies on preventive sealing were critically low (n = 8), low (n = 6), moderate (n = 1) and high (n = 2) for studies on preventive sealing and critically low (n = 5), low (n = 2) and high (n = 1) for studies on the prevention and arrest of caries lesions. The overlap was low (CCA = 3%). CONCLUSION: This overview suggests that pit and fissure sealants are not inferior to other interventions in preventing and arresting dental caries lesions in primary and permanent teeth.

Characteristics and completeness of reporting of systematic reviews of prevalence studies in adult populations: a metaresearch study.

OBJECTIVES: The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, first published in 2009, has been widely endorsed and compliance is high in systematic reviews (SRs) of intervention studies. SRs of prevalence studies are increasing in frequency, but their characteristics and reporting quality have not been examined in large studies. Our objectives were to describe the characteristics of SRs of prevalence studies in adults, evaluate the completeness of reporting, and explore study-level characteristics associated with the completeness of reporting. STUDY DESIGN AND SETTING: We did a metaresearch study. We searched 5 databases from January 2010 to December 2020 to identify SRs of prevalence studies in adult populations. We used the PRISMA 2009 checklist to assess completeness of reporting and recorded additional characteristics. We conducted a descriptive analysis of review characteristics and linear regression to assess the relationship between compliance with PRISMA and publication characteristics. RESULTS: We included 1172 SRs of prevalence studies. The number of reviews increased from 25 in 2010 to 273 in 2020. The median PRISMA score for SRs without meta-analysis was 17.5 of a maximum of 23, and for SRs with meta-analysis, 22 of a maximum of 25. Completeness of reporting, particularly for key items in the methods section, was suboptimal. SRs that included a meta-analysis or reported using a reporting or conduct guideline were the factors most strongly associated with increased compliance with PRISMA 2009. CONCLUSION: Reporting of SRs of prevalence was adequate for many PRISMA items. Nonetheless, this study highlights aspects for which special attention is needed. Development of a specific tool to assess the risk of bias in prevalence studies and an extension to the PRISMA statement could improve the conduct and reporting of SRs of prevalence studies.

Disparities in perioperative mortality outcomes between First Nations and non-First Nations peoples in Australia: protocol for a systematic review and planned meta-analysis.

BACKGROUND: Health inequities persist among First Nations people living in developed countries. Surgical care is pivotal in addressing a significant portion of the global disease burden. Evidence regarding surgical outcomes among First Nations people in Australia is limited. The perioperative mortality rate (POMR) indicates timely access to safe surgery and predicts long-term survival after major surgery. This systematic review will examine POMR among First Nations and non-First Nations peoples in Australia. METHODS: A systematic search strategy using MEDLINE, Embase, Emcare, Global Health, and Scopus will identify studies that include First Nations people and non-First Nations people who underwent a surgical intervention under anaesthesia in Australia. The primary focus will be on documenting perioperative mortality outcomes. Title and abstract screening and full-text review will be conducted by independent reviewers, followed by data extraction and bias assessment using the ROBINS-E tool. Meta-analysis will be considered if there is sufficient homogeneity between studies. The quality of cumulative evidence will be evaluated following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. DISCUSSION: This protocol describes the comprehensive methodology for the proposed systematic review. Evaluating disparities in perioperative mortality rates between First Nations and non-First Nations people remains essential in shaping the discourse surrounding health equity, particularly in addressing the surgical burden of disease. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021258970.

A systematic review of the value of clinical decision support systems in the prescription of antidiabetic drugs.

INTRODUCTION: The management of chronic diabetes mellitus and its complications demands customized glycaemia control strategies. Polypharmacy is prevalent among people with diabetes and comorbidities, which increases the risk of adverse drug reactions. Clinical decision support systems (CDSSs) may constitute an innovative solution to these problems. The aim of our study was to conduct a systematic review assessing the value of CDSSs for the management of antidiabetic drugs (AD). MATERIALS AND METHODS: We systematically searched the scientific literature published between January 2010 and October 2023. The retrieved studies were categorized as non-specific or AD-specific. The studies' quality was assessed using the Mixed Methods Appraisal Tool. The review's results were reported in accordance with the PRISMA guidelines. RESULTS: Twenty studies met our inclusion criteria. The majority of AD-specific studies were conducted more recently (2020-2023) compared to non-specific studies (2010-2015). This trend hints at growing interest in more specialized CDSSs tailored for prescriptions of ADs. The nine AD-specific studies focused on metformin and insulin and demonstrated positive impacts of the CDSSs on different outcomes, including the reduction in the proportion of inappropriate prescriptions of ADs and in hypoglycaemia events. The 11 nonspecific studies showed similar trends for metformin and insulin prescriptions, although the CDSSs' impacts were not significant. There was a predominance of metformin and insulin in the studied CDSSs and a lack of studies on ADs such as sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. CONCLUSION: The limited number of studies, especially randomized clinical trials, interested in evaluating the application of CDSS in the management of ADs underscores the need for further investigations. Our findings suggest the potential benefit of applying CDSSs to the prescription of ADs particularly in primary care settings and when targeting clinical pharmacists. Finally, establishing core outcome sets is crucial for ensuring consistent and standardized evaluation of these CDSSs.

GRADE Guidance 39: Using GRADE-ADOLOPMENT to adopt, adapt or create contextualized recommendations from source guidelines and evidence syntheses.

INTRODUCTION: The GRADE-ADOLOPMENT methodology has been widely used to adopt, adapt or de novo develop recommendations from existing or new guideline and evidence synthesis efforts. This guidance refines the operationalization for applying GRADE-ADOLOPMENT. METHODS: Through iterative discussions, online meetings and email communications, the GRADE-ADOLOPMENT Project Group drafted the updated guidance. We then conducted a review of handbooks of guideline-producing organizations, and a scoping review of published and planned Adolopment guideline projects. The lead authors refined the existing approach based on the scoping review findings and feedback from members of the GRADE Working Group. We presented the revised approach to the group in November 2022 (approximately 115 people), in May 2023 (approximately 100 people) and twice in September 2023 (approximately 60 and 90 people) for approval. RESULTS: This GRADE guidance shows how to effectively and efficiently contextualize recommendations using the GRADE-ADOLOPMENT approach by: (1) showcasing alternative pathways for starting an adolopment effort; (2) elaborating on the different essential steps of this approach, such as building on existing EtDs when available or developing new EtDs if necessary; and (3) providing examples from adolopment case studies to facilitate the application of the approach. We demonstrate how to use contextual evidence to make judgments about EtD criteria, and highlight the importance of making the resulting EtDs available to facilitate adolopment efforts by others. CONCLUSION: This updated GRADE guidance further operationalizes the application of GRADE-ADOLOPMENT based on over six years of experience. It serves to support uptake and application by end users interested in contextualizing recommendations to a local setting or specific reality in a short period of time or with limited resources.