Thomas Piggott

BackgroundDifferent therapeutic strategies are available for the treatment of people with relapsing‐remitting multiple sclerosis (RRMS), including immunomodulators, immunosuppressants and biological agents. Although each one of these therapies reduces relapse frequency and slows disability accumulation compared to no treatment, their relative benefit remains unclear.

ObjectivesThis article describes considerations for addressing intransitivity when assessing the certainty of the evidence from network meta-analysis (NMA) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Intransitivity is induced by effect modification, that is, when the magnitude of the effect between an intervention and outcome differs depending on the level of another factor.Study Design and SettingTo develop this GRADE concept paper, the lead authors conducted iterative discussions, computer simulations, and presentations to the GRADE project group and at GRADE working group meetings. The GRADE Working Group formally approved the article in July 2022.ResultsNMA authors can have a higher or a lower threshold to rate down the certainty of the evidence due to intransitivity, which depends on the extent of their concerns regarding the …

In an Editorial, 1 The Lancet Neurology stressed that approval by WHO of the Multiple Sclerosis International Federation (MSIF) and WHO Collaborating Centre Bologna application for the addition of diseasemodifying treatments (DMTs) to their essential medicines list (EML) would be a crucial first step towards equitable access to appropriate treatment options for multiple sclerosis globally. WHO has since announced its landmark decision to include, for the first time, treatments for multiple sclerosis in their EML, filling an important gap to address the large global burden of multiple sclerosis and lending support to global advocacy efforts, especially in low-income and middle-income countries (LMICs). 2 WHO listed three of the DMTs proposed in the application: rituximab, cladribine, and glatiramer acetate. These medications offer different modes of action but are not the only effective therapies for multiple sclerosis, as …

ObjectivesGuidelines and essential medicine lists (EMLs) bear similarities and differences in the process that lead to decisions. Access to essential medicines is central to achieve universal health coverage. The World Health Organization (WHO) EML has guided prioritization of essential medicines globally for nearly 50 years, and national EMLs (NEMLs) exist in over 130 countries. Guideline and EML decisions, at WHO or national levels, are not always coordinated and aligned. We sought to explore challenges, and potential solutions, for decision-making to support trustworthy medicine selection for EMLs from a Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group perspective. We primarily focus on the WHO EML; however, our findings may be applicable to NEML decisions as well.

Essential medicine lists (EMLs) are important medicine prioritization tools used by the World Health Organization (WHO) EML and over 130 countries. The criteria used by WHO’s Expert Committee on the Selection and Use of Essential Medicines has parallels to the GRADE Evidence-to-Decision (EtD) frameworks. In this study, we explored the EtD frameworks and a visual abstract as adjunctive tools to strengthen the integrate evidence and improve the transparency of decisions of EML applications. We conducted user-experience testing interviews of key EML stakeholders using Morville’s honeycomb model. Interviews explored multifaceted dimensions (e.g., usability) on two EML applications for the 2021 WHO EML–long-acting insulin analogues for diabetes and immune checkpoint inhibitors for lung cancer. Using a pre-determined coding framework and thematic analysis we iteratively improved both the EtD framework and the visual abstract. We coded the transcripts of 17 interviews with 13 respondents in 103 locations of the interview texts across all dimensions of the user-experience honeycomb. Respondents felt the EtD framework and visual abstract presented complementary useful and findable adjuncts to the traditional EML application. They felt this would increase transparency and efficiency in evidence assessed by EML committees. As EtD frameworks are also used in health practice guidelines, including those by the WHO, respondents articulated that the adoption of the EtD by EML applications represents a tangible mechanism to align EMLs and guidelines, decrease duplication of work and improve coordination. Improvements …

BackgroundThis study presents the prevalence of burnout among the Canadian public health workforce after three years of the COVID-19 pandemic and its association with work-related factors.MethodsData were collected using an online survey distributed through Canadian public health associations and professional networks between November 2022 and January 2023. Burnout was measured using a modified version of the Oldenburg Burnout Inventory (OLBI). Logistic regressions were used to model the relationship between burnout and work-related factors including years of work experience, redeployment to pandemic response, workplace safety and supports, and harassment. Burnout and the intention to leave or retire as a result of the COVID-19 pandemic was explored using multinomial logistic regressions.ResultsIn 2,079 participants who completed the OLBI, the prevalence of burnout was 78.7 …

Background and ObjectivesThe World Health Organization Model List of Essential Medicines has led to at least 137 national lists. Essential medicines should be grounded in evidence-based guideline recommendations and explicit decision criteria. Essential medicines should be available, accessible, affordable, and the supporting evidence should be accompanied by a rating of the certainty one can place in it. Our objectives were to identify criteria and considerations that should be addressed in moving from a guideline recommendation regarding a medicine to the decision of whether to add, maintain, or remove a medicine from an essential medicines list. We also seek to explore opportunities to improve organizational processes to support evidence-based health decision-making more broadly.MethodsWe conducted a qualitative study with semistructured interviews of key informant stakeholders in the …

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected seniors living in congregate living settings. The evolving surveillance context has led to novel use of wastewater surveillance to monitor levels of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in these settings. This study presents a pilot of upstream congregate living wastewater surveillance of SARS-CoV-2 for the detection of COVID-19 outbreaks and the effects of early public health interventions. We monitored localized wastewater SARS-CoV-2 levels from four congregate living settings March 15, 2021 to October 1, 2022 and correlated these levels with suspected and confirmed COVID-19 outbreaks determined by other methods. We identified five wastewater signals that correlated with confirmed outbreaks and three wastewater signals that did not correlate with subsequent outbreaks. In the five confirmed …

Background Misinformation poses a serious challenge to clinical and policy decision-making in the health field. The COVID-19 pandemic amplified interest in misinformation and related terms and witnessed a proliferation of definitions. Objective We aim to assess the definitions of misinformation and related terms used in health-related literature. Methods We conducted a scoping review of systematic reviews by searching Ovid MEDLINE, Embase, Cochrane, and Epistemonikos databases for articles published within the last 5 years up till March 2023. Eligible studies were systematic reviews that stated misinformation or related terms as part of their objectives, conducted a systematic search of at least one database, and reported at least 1 definition for misinformation or related terms. We extracted definitions for the terms misinformation, disinformation, fake news, infodemic, and malinformation. Within each definition, we identified concepts and mapped them across misinformation-related terms. Results We included 41 eligible systematic reviews, out of which 32 (78%) reviews addressed the topic of public health emergencies (including the COVID-19 pandemic) and contained 75 definitions for misinformation and related terms. The definitions consisted of 20 for misinformation, 19 for disinformation, 10 for fake news, 24 for infodemic, and 2 for malinformation. “False/inaccurate/incorrect” was mentioned in 15 of 20 definitions of misinformation, 13 of 19 definitions of disinformation, 5 of 10 definitions of fake news, 6 of 24 definitions of infodemic, and 0 of 2 definitions of …

This protocol outlines a scoping review with the objective of identifying and exploring planetary health considerations within existing health guidelines and health technology assessments. The insights gained from this review will serve as a basis for shaping future Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidance on planetary health.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected seniors living in congregate living settings. The evolving surveillance context has led to novel use of wastewater surveillance to monitor levels of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in these settings. This study presents a pilot of upstream congregate living wastewater surveillance of SARS-CoV-2 for the detection of COVID-19 outbreaks and the effects of early public health interventions. We monitored localized wastewater SARS-CoV-2 levels from four congregate living settings March 15, 2021 to October 1, 2022 and correlated these levels with suspected and confirmed COVID-19 outbreaks determined by other methods. We identified five wastewater signals that correlated with confirmed outbreaks and three wastewater signals that did not correlate with subsequent outbreaks. In the five confirmed outbreaks, the wastewater signal was detected 2–10 days (median, five days) prior to confirmation of the outbreak by case testing. This pilot demonstrates upstream sampling for SARS-CoV-2 in wastewater may effectively detect outbreaks prior to their detection through symptomatic case testing and could support a balanced approach to outbreak response in congregate living settings, leading to increased wellbeing of these residents.

Background and ObjectivesOur objective was to develop an extension of the widely used GIN-McMaster Guideline Development Checklist and Tool for the integration of quality assurance and improvement (QAI) schemes with guideline development.MethodsWe used a mixed-methods approach incorporating evidence from a systematic review, an expert workshop and a survey of experts to iteratively create an extension of the checklist for QAI through three rounds of feedback. As a part of this process, we also refined criteria of a good guideline-based quality indicator.ResultsWe developed a 40-item checklist extension addressing steps for the integration of QAI into guideline development across the existing 18 topics and created one new topic specific to QAI. The steps span from ‘organization, budget, planning and training’, to updating of QAI and guideline implementation.ConclusionThe tool supports integration …

An evidence-based approach is considered the gold standard for health decision-making. Sometimes, a guideline panel might judge the certainty that the desirable effects of an intervention clearly outweigh its undesirable effects as high, but the body of supportive evidence is indirect. In such cases, the application of the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach for grading the strength of recommendations is inappropriate. Instead, the GRADE Working Group has recommended developing ungraded best or good practice statement (GPS) and developed guidance under which circumsances they would be appropriate.Through an evaluation of COVID-1- related recommendations on the eCOVID Recommendation Map (COVID-19.recmap.org), we found that recommendations qualifying a GPS were widespread. However, guideline developers failed to label them …

We thank Dr. Giordano for his response to our article “Supporting Bill S-206 protects Canadian children from violence” and agree that we do not wish to turn “loving parents into criminals”.[1]Criminalization of parents is neither the intent nor an anticipated consequence of Bill s206. Instead, we see this proposed legislation is a step toward altering societal norms around the use of physical force in child-rearing. In our article, we presented the evidence on the link between adverse childhood events, including violence in childrearing, and adverse outcomes later in life.[2]

Background: The ongoing coronavirus disease 2019 (COVID-19) pandemic has necessitated novel testing strategies, including the use of rapid antigen tests (RATs). The widespread distribution of RATs to the public prompted Peterborough Public Health to launch a pilot RAT self-report tool to assess its utility in COVID-19 surveillance. The objective of this study is to investigate the utility of RAT using correlations between RAT self-report results and other indicators of COVID-19.Methods: We investigated the association between RAT results, PCR test results and wastewater levels of nmN1N2 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genes (to infer COVID-19 levels) using Pearson's correlation coefficient. Percent positivity and count of positive tests for RATs and polymerase chain reaction (PCR) tests were analyzed.Results: The PCR percent positivity and wastewater were weakly correlated (r= 0.33, p= 0.022), as were RAT percent positivity and wastewater nmN1N2 levels (r= 0.33, p= 0.002). The RAT percent positivity and PCR percent positivity were not significantly correlated (r=-0.035, p= 0.75). Count of positive RATs and count of positive PCR tests were moderately correlated (r= 0.59, p< 0.001). Wastewater nmN1N2 levels were not significantly correlated with either count of positive RATs (r= 0.019, p= 0.864) or count of positive PCR tests (r= 0.004, p= 0.971).Conclusion: Our results support the use of RAT self-reporting as a low-cost simple adjunctive COVID-19 surveillance tool, and suggest that its utility is greatest when considering an absolute count of positive RATs rather than percent positivity due to reporting bias …

Background Integrating shared decision making between patients and physicians and incorporating their values and preferences in the development of clinical practice guidelines (CPGs) is of critical importance to optimize CPG implementation and treatment adherence. This applies to many debilitating diseases, including hypercalcemia of malignancy (HCM). Objective Evaluate patient and physician values, preferences, and attitudes to better inform CPGs to treat HCM in adults. Methods We followed a mixed-methods approach. We conducted a systematic review using 5 databases to identify studies reporting on patient and physician values, costs and resources, feasibility, acceptability, and equity regarding HCM treatment. We also gathered data from different countries on the cost of multiple treatment modalities. We collected data on outcome …

BackgroundIt is evident that COVID-19 will remain a public health concern in the coming years, largely driven by variants of concern (VOC). It is critical to continuously monitor vaccine effectiveness as new variants emerge and new vaccines and/or boosters are developed. Systematic surveillance of the scientific evidence base is necessary to inform public health action and identify key uncertainties. Evidence syntheses may also be used to populate models to fill in research gaps and help to prepare for future public health crises. This protocol outlines the rationale and methods for a living evidence synthesis of the effectiveness of COVID-19 vaccines in reducing the morbidity and mortality associated with, and transmission of, VOC of SARS-CoV-2.MethodsLiving evidence syntheses of vaccine effectiveness will be carried out over one year for (1) a range of potential outcomes in the index individual associated with …

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected seniors living in congregate living settings. The evolving surveillance context has led to novel use of wastewater surveillance to monitor levels of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in these settings. This study presents a pilot of upstream congregate living wastewater surveillance of SARS-CoV-2 for the detection of COVID-19 outbreaks and the effects of early public health interventions. We monitored localized wastewater SARS-CoV-2 levels from four congregate living settings March 15, 2021 to October 1, 2022 and correlated these levels with suspected and confirmed COVID-19 outbreaks determined by other methods. We identified five wastewater signals that correlated with confirmed outbreaks and three wastewater signals that did not correlate with subsequent outbreaks. In the five confirmed outbreaks, the wastewater signal was detected 2–10 days (median, five days) prior to confirmation of the outbreak by case testing. This pilot demonstrates upstream sampling for SARS-CoV-2 in wastewater may effectively detect outbreaks prior to their detection through symptomatic case testing and could support a balanced approach to outbreak response in congregate living settings, leading to increased wellbeing of these residents.

Background Hypercalcemia of malignancy (HCM) is the most common metabolic complication of malignancies, but its incidence may be declining due to potent chemotherapeutic agents. The high mortality associated with HCM has declined markedly due to the introduction of increasingly effective chemotherapeutic drugs. Despite the widespread availability of efficacious medications to treat HCM, evidence-based recommendations to manage this debilitating condition are lacking. Objective To develop guidelines for the treatment of adults with HCM. Methods A multidisciplinary panel of clinical experts, together with experts in systematic literature review, identified and prioritized 8 clinical questions related to the treatment of HCM in adult patients. The systematic reviews (SRs) queried electronic databases for studies relevant to the selected questions. The …

Contexte: La pandémie actuelle de maladie à coronavirus 2019 (COVID-19) a nécessité de nouvelles stratégies de test, y compris l’utilisation de tests antigéniques rapides (TAR). La large distribution des TAR au public a incité le Bureau de santé de Peterborough à lancer un outil pilote d’autodéclaration des TAR, afin d’évaluer son utilité dans la surveillance de la COVID-19. L’objectif de cette étude est d’examiner l’utilité des TAR en utilisant les corrélations entre les résultats de l’autodéclaration des TAR et d’autres indicateurs de la COVID-19.Méthodes: Nous avons étudié l’association entre les résultats des TAR, les résultats des tests PCR et les niveaux de gènes à coronavirus 2 du syndrome respiratoire aigu sévère nmN1N2 (SRAS-CoV-2)(pour en déduire les niveaux de COVID-19) dans les tests dans les eaux usées en utilisant le coefficient de corrélation de Pearson. Le pourcentage de positivité et le nombre de TAR et de réaction en chaîne de la polymérase (tests PCR) positifs ont été analysés.Résultats: Le pourcentage de positivité des tests PCR et dans les tests dans les eaux usées étaient faiblement corrélés (r= 0, 33, p= 0,022), tout comme le pourcentage de positivité des TAR et les teneurs en nmN1N2 dans les tests dans les eaux usées (r= 0, 33, p= 0,002). Le pourcentage de positivité des TAR et le pourcentage de positivité des tests PCR n’étaient pas significativement corrélés (r=-0,035, p= 0, 75). Le nombre de TAR positifs et le nombre de tests PCR positifs étaient modérément corrélés (r= 0, 59, p< 0,001). Les teneurs en nmN1N2 dans les tests dans les eaux usées n’étaient pas significativement corrélées avec le nombre de …