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The development of premature ovarian failure and subsequent infertility are possible consequences of chemotherapy use in pre-menopausal women with early-stage breast cancer. Among the available strategies for fertility preservation, pharmacological protection of the ovaries using luteinising hormone-releasing hormone analogues (LHRHa) during chemotherapy has the potential to restore ovarian function and fertility after anticancer treatments; however, the possible efficacy and clinical application of this strategy has been highly debated in the last years. Following the availability of new data on this controversial topic, the Panel of the Italian Association of Medical Oncology (AIOM) Clinical Practice Guideline on fertility preservation in cancer patients decided to apply the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology around the relevant and current question on the clinical utility of temporary ovarian suppression with LHRHa during chemotherapy as a strategy to preserve ovarian function and fertility in breast cancer patients. To answer this question, preservation of ovarian function and fertility were judged as critical outcomes for the decision-making. Three possible outcomes of harm were identified: LHRHa-associated toxicities, potential antagonism between concurrent LHRHa and chemotherapy, and lack of the prognostic impact of chemotherapy-induced premature ovarian failure. According to the GRADE evaluation conducted, the result was a strong positive recommendation in favour of using this option to preserve ovarian function and fertility in breast cancer patients. The present manuscript aims to update and summarise the evidence for the use of this strategy in light of the new data published up to January 2016, according to the GRADE process.

Background and aims. Cerebral bypasses are categorized according to function (flow augmentation or flow preservation) and to characteristics: direct, indirect or combined bypass, extra-to-intracranial or intra-to-intracranial bypass, and high-, moderate- or low-capacity bypass. We critically summarize the current state of evidence and grades of recommendation for cerebral bypass surgery.

The Abdominal Compartment Society (www.wsacs.org) previously created highly cited Consensus Definitions/Management Guidelines related to intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Implicit in this previous work, was a commitment to regularly reassess and update in relation to evolving research. Two years preceding the Fifth World Congress on Abdominal Compartment Syndrome, an International Guidelines committee began preparation. An oversight/steering committee formulated key clinical questions regarding IAH//ACS based on polling of the Executive to redundancy, structured according to the Patient, Intervention, Comparator, and Outcome (PICO) format. Scientific consultations were obtained from Methodological GRADE experts and a series of educational teleconferences were conducted to educate scientific review teams from among the wscacs. org membership. Each team conducted systematic or structured reviews to identify relevant studies and prepared evidence summaries and draft Grades of Recommendation Assessment, Development and Evaluation (GRADE) recommendations. The evidence and draft recommendations were presented and debated in person over four days. Updated consensus definitions and management statements were derived using a modified Delphi method. A writing committee subsequently compiled the results utilizing frequent Internet discussion and Delphi voting methods to compile a robust online Master Report and a concise peer-reviewed summarizing publication. A dedicated Paediatric Guidelines Subcommittee reviewed all recommendations and either accepted or revised them for appropriateness in children. Of the original 12 IAH/ACS definitions proposed in 2006, three (25%) were accepted unanimously, with four (33%) accepted by >80%, and four (33%) accepted by >50%, but required discussion to produce revised definitions. One (8%) was rejected by >50%. In addition to previous 2006 definitions, the panel also defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, abdominal compliance, and suggested a refined open abdomen classification system. Recommendations were possible regarding intra-abdominal pressure (IAP) measurement, approach to sustained IAH, philosophy of protocolized IAP management and same-hospital-stay fascial closure, use of decompressive laparotomy, and negative pressure wound therapy. Consensus suggestions included use of non-invasive therapies for treating IAH/ACS, considering body position and IAP, damage control resuscitation, prophylactic open abdomen usage, and prudence in early biological mesh usage. No recommendations were made for the use of diuretics, albumin, renal replacement therapies, and utilizing abdominal perfusion pressure as a resuscitation-endpoint. Collaborating Methodological Guideline Development and Clinical Experts produced Consensus Definitions/Clinical Management statements encompassing the most contemporary evidence. Data summaries now exist for clinically relevant IAH/ACS questions, which will facilitate future scientific reanalysis.

Existen múltiples propuestas y clasificaciones que jerarquizan la evidencia, que pueden confundir a quienes se dedican a generar la evidencia tanto en evaluaciones de tecnología sanitaria, elaboración de guías clínicas, etc. El objetivo de este artículo es actualizar la información y describir las clasificaciones más utilizadas para valorar la evidencia en el ámbito de la salud, analizando sus principales diferencias y aplicaciones para que el usuario pueda elegir la que mejor se adapte a sus necesidades y tomar de este modo decisiones sanitarias basando su práctica en la mejor evidencia disponible. Se realizó una búsqueda sistemática de la literatura en las bases de datos PubMed y MEDLINE y en los buscadores Google, Yahoo e Ixquick. Se obtuvo una gran cantidad de información referente a niveles de evidencia y grados de recomendación, para finalmente resumir la información de 11 de las propuestas más utilizadas en la actualidad (CTFPHC, Sackett, USPSTF, CEBM, GRADE, SIGN, NICE, NHMRC, PCCRP, ADA y ACCF/AHA), entre las que destaca la del GRADE WORKING GROUP, incorporada por alrededor de 90 organizaciones nacionales e internacionales, tales como la World Health Organization, The Cochrane Library, American College of Physicians, American Thoracic Society, UpToDate, etc. y a nivel local por el Ministerio de Salud, para generar guías de práctica clínica. There are multiple proposals and classifications that hierarchize evidence, which may confuse those who are dedicated to generate it both in health technology assessments, as for the development of clinical guidelines, etc. The aim of this manuscript is to describe the most commonly used classifications of levels of evidence and grades of recommendation, analyzing their main differences and applications so that the user can choose the one that better suits your needs and take this health decisions basing their practice on the best available evidence. A systematic literature search was performed in PubMed and MEDLINE databases and in Google, Yahoo and Ixquick search engines. A wealth of information concerning levels of evidence and degrees recommendation was obtained. It was summarized the information of the 11 proposals more currently used (CTFPHC, Sackett, USPSTF, CEBM, GRADE, SIGN, NICE, NHMRC, PCCRP, ADA y ACCF/AHA), between which it emphasizes the GRADE WORKING GROUP, incorporated by around 90 national and international organizations such as the World Health Organization, The Cochrane Library, American College of Physicians, American Thoracic Society, UpToDate, etc.; and locally by the Ministry of Health to create clinical practice guidelines.