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ObjectivesThe aim of this paper is to describe the development, implementation and evaluation of a flexible living approach to maintaining NICE’s long-term effects of COVID-19 (LTE) guideline and monitoring the uncertain evidence base of this condition.Study Design and SettingThe NICE COVID-19 team reviewed its practical experiences of establishing a living approach to developing and maintaining the LTE guideline, including initial development, maintenance and eventual transition to a lower intensity model. The methods and processes were described narratively over the first 2 years of the guideline’s lifespan. This was combined with quantitative data on emerging and cumulative evidence over the period to chart the evidence landscape.ResultsFollowing publication, the initial timepoint-based update process evolved into a flexible living approach with remote topic expert engagement.Experts engaged with the new process with a 64% response rate to the online surveys.Emerging evidence increased rapidly following publication [11,405 studies assessed in 2021 and 13,181 in 2022] and was captured by continuous surveillance. There were no urgent triggers for updating from the studies identified in 2022 via the living approach, saving considerable resources over the timepoint based approach which would commit resources to planning and convening expert panel meetings.A total of 184 studies with a potential future impact were summarised to capture the cumulative evidence base. Experts highlighted ongoing research and implementation issues which have further informed surveillance of the guideline.After a sustained period without triggers for updating, the living approach was restricted to the highest priority areas with surveillance of ongoing studies.ConclusionThis paper illustrates a flexible living approach taken to a novel condition with an evolving evidence landscape. Currency of some living guidelines can be maintained without the need for frequent updating.Highlights: What is new?In an unpredictable pandemic context, novel conditions with uncertain aetiology, diagnosis, management and prognosis demand a flexible living approach to surveillance of initial recommendations, even where triggers for updating remain infrequent.Monitoring cumulative evidence with potential future impact is important for high priority areas lacking a strong evidence base.In guidelines with previous scheduled updates, transition to a more reactive ‘trigger-based’ approach can be both more efficient and productive, while maintaining currency of recommendations through continuous surveillance.Determining when to transition between living and standard approaches to maintaining a guideline is dependent on multiple factors, including intelligence from the health and social care system, ongoing research and government policy.Use of NICE COVID-19 content internationallyOur COVID-19 rapid guidelines and evidence summaries are exempt from our overseas reuse application, licence and fee. This means you can:adopt the guidelines for your own healthcare settingadapt the guidelines by combining them with your own local contenttranslate the resultant outputs.When using content from our COVID-19 rapid guidelines and evidence summaries you must:make all your outputs reusing NICE content freely available to othersacknowledge the use of NICE content, and link to the source content on our websiteonly use the NICE logo if the original NICE guidance publication is used in its entirety without including additional contenttell us how our content has been used by emailingreuseofcontent@nice.org.uk, to support the evaluation and development of our guidance.We cannot accept responsibility or liability for the use of our content in third party outputs.Further information on reuse of content is available on the NICE website.

Background: This review adds to a series of reviews looking at primary medical management options for patients with chronic rhinosinusitis. Chronic rhinosinusitis is common and characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Antifungals have been suggested as a treatment for chronic rhinosinusitis. Objectives: To assess the effects of systemic and topical antifungal agents in patients with chronic rhinosinusitis, including those with allergic fungal rhinosinusitis (AFRS) and, if possible, AFRS exclusively. Search methods: The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 17 November 2017. Selection criteria: Randomised controlled trials (RCTs) with at least a two‐week follow‐up period comparing topical or systemic antifungals with (a) placebo, (b) no treatment, (c) other pharmacological interventions or (d) a different antifungal agent. We did not include post‐surgical antifungal use. Data collection and analysis: We used the standard Cochrane methodological procedures. Our primary outcomes were disease‐specific health‐related quality of life (HRQL), patient‐reported disease severity and the significant adverse effects of hepatic toxicity (systemic antifungals). Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse effects of gastrointestinal disturbance (systemic antifungals) and epistaxis, headache or local discomfort (topical antifungals). We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. Main results: We included eight studies (490 adult participants). The presence of nasal polyps on examination was an inclusion criterion in three studies, an exclusion criterion in one study and the remaining studies included a mixed population. No studies specifically investigated the effect of antifungals in patients with AFRS. Topical antifungal treatment versus placebo or no intervention We included seven studies (437 participants) that used amphotericin B (six studies; 383 participants) and one that used fluconazole (54 participants). Different delivery methods, volumes and concentrations were used. Four studies reported disease‐specific health‐related quality of life using a range of instruments. We did not meta‐analyse the results due to differences in the instruments used, and measurement and reporting methods. At the end of treatment (one to six months) none of the studies reported statistically significant differences between the groups (low‐quality evidence ‐ we are uncertain about the result). Two studies reported disease severity using patient‐reported symptom scores. Meta‐analysis was not possible. At the end of treatment (8 to 13 weeks) one study showed no difference and the second found that patients in the placebo group had less severe symptoms (very low‐quality evidence ‐ we are very uncertain about the result). In terms of adverse effects , topical antifungals may lead to more local irritation compared with placebo (risk ratio (RR) 2.29, 95% confidence interval (CI) 0.61 to 8.62; 312 participants; 5 studies; low‐quality evidence) but little or no difference in epistaxis (RR 0.97, 95% CI 0.14 to 6.63; 225 participants; 4 studies, low‐quality evidence) or headache (RR 1.26, 95% CI 0.60 to 2.63; 195 participants; 3 studies; very low‐quality evidence). None of the studies found a difference in generic health‐related quality of life (one study) or endoscopic score (five studies) between the treatment groups. Three studies investigated CT scan ; two found no difference between the groups and one found a significant decrease in the mean percentage of air space occluded, favouring the antifungal group. Systemic antifungal treatment versus placebo or no treatment One study (53 participants) comparing terbinafine tablets against placebo reported that there may be little or no difference between the groups in disease‐specific health‐related quality of life or disease severity score (both low‐quality evidence). Systemic antifungals may lead to more hepatic toxicity events (RR 3.35, 95% CI 0.14 to 78.60) but fewer gastrointestinal disturbances (RR 0.37, 95% CI 0.04 to 3.36), compared to placebo, although the evidence was of low quality. This study did not find a difference in CT scan score between the groups. Generic health‐related quality of life and endoscopic score were not measured. Other comparisons: We found no studies that compared antifungal agents against other treatments for chronic rhinosinusitis. Authors' conclusions: Due to the very low quality of the evidence, it is uncertain whether or not the use of topical or systemic antifungals has an impact on patient outcomes in adults with chronic rhinosinusitis compared with placebo or no treatment. Studies including specific subgroups (i.e. AFRS) are lacking.

Based on a breakout session held at the 33rd UKSG Conference, Edinburgh, April 2010 Case studies from the Universities of Leeds and York, together with the experiences of some libraries in the United States and Europe, are used to help demonstrate the range of purchasing options currently available to libraries. The advantages and disadvan- tages of routine title-by-title purchasing of e-books ‘just in case’ are examined, the emerging patron-driven ‘just in time’ model is explored, and the value of large publisher and aggregator e-book packages in com- parison to individual purchases is assessed.

Liver function tests are routinely performed in women as part of a battery of investigations to assess severity at admission and later to guide appropriate management.To determine the accuracy with which liver function tests predict complications in women with preeclampsia by a systematic review.We conducted electronic searches without language restrictions in (1951-2010), (1980-2010) and the Cochrane Library (2009).Primary articles that evaluated the accuracy of liver function tests in predicting complications in women with preeclampsia were chosen. Data was extracted by two reviewers independently. A bivariate model estimated area under the curve, sensitivity and specificity.There were 13 primary articles including a total of 3 497 women assessing maternal (30 2×2 tables) and fetal (19 2×2 tables) outcomes. For predicting adverse maternal outcome, the point estimates of specificity were70% in 18 tables with 0.79 (95%CI 0.51, 0.93). For predicting adverse fetal outcomes the specificity of the test was70% in 2×2 tables. Sensitivity of the test was poor for both maternal and fetal outcomes.In women with preeclampsia, function tests performed better in predicting adverse maternal than fetal outcomes. The presence of increased liver enzymes was associated with an increased probability of maternal and fetal complications, but normal liver enzyme levels did not rule out disease, as specificity was often higher than sensitivity.

Maternal symptoms such as severe headache, nausea and vomiting, visual disturbances and epigastric pain have been associated with complications in women with preeclampsia.To determine the accuracy of maternal symptoms in predicting complications in women with preeclampsia by systematic review.We searched MEDLINE (1951-2010), EMBASE (1980-2010), the Cochrane Library (2009) and the MEDION database.Studies which evaluated the accuracy of symptoms in women with preeclampsia for predicting complications were selected in a two-stage process. Information was extracted by two independent reviewers. We summarized accuracy with a bivariate model estimating sensitivity, specificity and area under the curve.Six primary articles with 2573 women were included. The area under the curve for predicting complications for headache, epigastric pain and visual disturbances was 0.58 (95%CI 0.24-0.86), 0.70 (95%CI 0.30-0.93) and 0.74 (95%CI 0.33-0.94). The sensitivity and specificity of the symptoms in predicting adverse maternal outcomes were respectively as follows: headache 0.54 (95%CI 0.27-0.79) and 0.59 (95%CI 0.38-0.76); epigastric pain 0.34 (95%CI 0.22-0.5) and 0.83 (95%CI 0.76-0.89); visual disturbances 0.27 (95%CI 0.07-0.65) and 0.81 (95%CI 0.71, 0.88); nausea and vomiting 0.24 (95%CI 0.21, 0.27) and 0.87 (95%CI 0.85, 0.89).The presence of symptoms is more useful in predicting complications in preeclampsia compared to their absence in excluding adverse events.

Background Proteinuria is one of the essential criteria for the clinical diagnosis of pre-eclampsia. Increasing levels of proteinuria is considered to be associated with adverse maternal and fetal outcomes. We aim to determine the accuracy with which the amount of proteinuria predicts maternal and fetal complications in women with pre-eclampsia by systematic quantitative review of test accuracy studies. Methods We conducted electronic searches in MEDLINE (1951 to 2007), EMBASE (1980 to 2007), the Cochrane Library (2007) and the MEDION database to identify relevant articles and hand-search of selected specialist journals and reference lists of articles. There were no language restrictions for any of these searches. Two reviewers independently selected those articles in which the accuracy of proteinuria estimate was evaluated to predict maternal and fetal complications of pre-eclampsia. Data were extracted on study characteristics, quality and accuracy to construct 2 × 2 tables with maternal and fetal complications as reference standards. Results Sixteen primary articles with a total of 6749 women met the selection criteria with levels of proteinuria estimated by urine dipstick, 24-hour urine proteinuria or urine protein:creatinine ratio as a predictor of complications of pre-eclampsia. All 10 studies predicting maternal outcomes showed that proteinuria is a poor predictor of maternal complications in women with pre-eclampsia. Seventeen studies used laboratory analysis and eight studies bedside analysis to assess the accuracy of proteinuria in predicting fetal and neonatal complications. Summary likelihood ratios of positive and negative tests for the threshold level of 5 g/24 h were 2.0 (95% CI 1.5, 2.7) and 0.53 (95% CI 0.27, 1) for stillbirths, 1.5 (95% CI 0.94, 2.4) and 0.73 (95% CI 0.39, 1.4) for neonatal deaths and 1.5 (95% 1, 2) and 0.78 (95% 0.64, 0.95) for Neonatal Intensive Care Unit admission. Conclusion Measure of proteinuria is a poor predictor of either maternal or fetal complications in women with pre-eclampsia.

There are nearly a quarter of a million ENT publications listed in MEDLINE alone and the knowledge within our field continues to accumulate at an increasing rate. Many factors influence publication and the production and dissemination of new knowledge. But the direction of research effort does not always reflect clinical need. A variety of external factors are implicated including-but certainly not limited to-funding, corporate interest and market forces, the political climate, tenacity and resourcefulness of special interest groups, and even fashion. Little detailed information on the current state of knowledge within otolaryngology has been available.

Background Pre-eclampsia is one of the largest causes of maternal and fetal mortality and morbidity. Hyperuricemia is often associated with pre-eclampsia. Objective To determine the accuracy with which serum uric acid predicts maternal and fetal complications in women with pre-eclampsia. Study design Systematic quantitative review of test accuracy studies. Search strategy We conducted electronic searches in MEDLINE (1951–2004), EMBASE (1980–2004), the Cochrane Library (2004:4) and the MEDION database to identify relevant articles. A hand-search of selected specialist journals and reference lists of articles obtained was then carried out. There were no language restrictions for any of these searches. Selection criteria Two reviewers independently selected the articles in which the accuracy of serum uric acid was evaluated to predict maternal and fetal complications of pre-eclampsia. Data collection and analysis Data were extracted on study characteristics, quality and accuracy to construct 2 × 2 tables with maternal and fetal complications as reference standard. Summary likelihood ratios for positive (LR+) and negative LR(−) test results are generated for various threshold levels of uric acid. Main results There were 18 primary articles that met the selection criteria, including a total of 3913 women and forty-one 2 × 2 tables. In women with pre-eclampsia, a positive test result of uric acid greater than or equal to a 350-μmol/l threshold predicted eclampsia with a pooled likelihood ratio (LR) of 2.1 (95% CI 1.4–3.5), while a negative test result had a pooled LR of 0.38 (95% CI 0.18–0.81). For severe hypertension as the outcome measure, the LRs were 1.7 (95% CI 1.3–2.2) and 0.49 (95% CI 0.38–0.64) for positive and negative test results, respectively, and for caesarean section the LRs were 2.4 (95% CI 1.3–4.7) and 0.39 (95% CI 0.20–0.76). For stillbirths and neonatal deaths the respective LRs were 1.5 (95% CI 0.91–2.6) and 0.51 (95% CI 0.20–1.3). For the prediction of small-for-gestational-age fetus, the pooled LRs were 1.3 (95% CI 1.1–1.7) and 0.60 (95% CI 0.43–0.83) for positive and negative results, respectively. Author's conclusion Serum uric acid is a poor predictor of maternal and fetal complications in women with pre-eclampsia.

A delegate’s view of the UKSG seminar on e-books – business models, usage and marketing, held at the British Library, London, 9 November 2005.

Background Pre-eclampsia is associated with several complications. Early prediction of complications and timely management is needed for clinical care of these patients to avert fetal and maternal mortality and morbidity. There is a need to identify best testing strategies in pre eclampsia to identify the women at increased risk of complications. We aim to determine the accuracy of various tests to predict complications of pre-eclampsia by systematic quantitative reviews. Method We performed extensive search in MEDLINE (1951–2004), EMBASE (1974–2004) and also will also include manual searches of bibliographies of primary and review articles. An initial search has revealed 19500 citations. Two reviewers will independently select studies and extract data on study characteristics, quality and accuracy. Accuracy data will be used to construct 2 × 2 tables. Data synthesis will involve assessment for heterogeneity and appropriately pooling of results to produce summary Receiver Operating Characteristics (ROC) curve and summary likelihood ratios. Discussion This review will generate predictive information and integrate that with therapeutic effectiveness to determine the absolute benefit and harm of available therapy in reducing complications in women with pre-eclampsia.