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      American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy

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          Abstract

          <div class="section"> <a class="named-anchor" id="d3098998e317"> <!-- named anchor --> </a> <h5 class="section-title" id="d3098998e318">Background:</h5> <p id="d3098998e320">Venous thromboembolism (VTE) complicates ∼1.2 of every 1000 deliveries. Despite these low absolute risks, pregnancy-associated VTE is a leading cause of maternal morbidity and mortality. </p> </div><div class="section"> <a class="named-anchor" id="d3098998e322"> <!-- named anchor --> </a> <h5 class="section-title" id="d3098998e323">Objective:</h5> <p id="d3098998e325">These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and others in decisions about the prevention and management of pregnancy-associated VTE. </p> </div><div class="section"> <a class="named-anchor" id="d3098998e327"> <!-- named anchor --> </a> <h5 class="section-title" id="d3098998e328">Methods:</h5> <p id="d3098998e330">ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations. </p> </div><div class="section"> <a class="named-anchor" id="d3098998e332"> <!-- named anchor --> </a> <h5 class="section-title" id="d3098998e333">Results:</h5> <p id="d3098998e335">The panel agreed on 31 recommendations related to the treatment of VTE and superficial vein thrombosis, diagnosis of VTE, and thrombosis prophylaxis. </p> </div><div class="section"> <a class="named-anchor" id="d3098998e337"> <!-- named anchor --> </a> <h5 class="section-title" id="d3098998e338">Conclusions:</h5> <p id="d3098998e340">There was a strong recommendation for low-molecular-weight heparin (LWMH) over unfractionated heparin for acute VTE. Most recommendations were conditional, including those for either twice-per-day or once-per-day LMWH dosing for the treatment of acute VTE and initial outpatient therapy over hospital admission with low-risk acute VTE, as well as against routine anti-factor Xa (FXa) monitoring to guide dosing with LMWH for VTE treatment. There was a strong recommendation (low certainty in evidence) for antepartum anticoagulant prophylaxis with a history of unprovoked or hormonally associated VTE and a conditional recommendation against antepartum anticoagulant prophylaxis with prior VTE associated with a resolved nonhormonal provoking risk factor. </p> </div>

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          Most cited references185

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          2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism.

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            Systems for grading the quality of evidence and the strength of recommendations I: Critical appraisal of existing approaches The GRADE Working Group

            Background A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations. Methods Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches. Results There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered (effectiveness, harm, diagnosis and prognosis). None of the systems was considered usable for all of the target groups we considered (professionals, patients and policy makers). The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised. Conclusions All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings.
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              Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise.

              Although several tools to evaluate the credibility of health care guidelines exist, guidance on practical steps for developing guidelines is lacking. We systematically compiled a comprehensive checklist of items linked to relevant resources and tools that guideline developers could consider, without the expectation that every guideline would address each item. We searched data sources, including manuals of international guideline developers, literature on guidelines for guidelines (with a focus on methodology reports from international and national agencies, and professional societies) and recent articles providing systematic guidance. We reviewed these sources in duplicate, extracted items for the checklist using a sensitive approach and developed overarching topics relevant to guidelines. In an iterative process, we reviewed items for duplication and omissions and involved experts in guideline development for revisions and suggestions for items to be added. We developed a checklist with 18 topics and 146 items and a webpage to facilitate its use by guideline developers. The topics and included items cover all stages of the guideline enterprise, from the planning and formulation of guidelines, to their implementation and evaluation. The final checklist includes links to training materials as well as resources with suggested methodology for applying the items. The checklist will serve as a resource for guideline developers. Consideration of items on the checklist will support the development, implementation and evaluation of guidelines. We will use crowdsourcing to revise the checklist and keep it up to date.
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                Author and article information

                Journal
                Blood Advances
                Blood Adv
                American Society of Hematology
                2473-9529
                2473-9537
                November 27 2018
                November 27 2018
                November 27 2018
                November 27 2018
                : 2
                : 22
                : 3317-3359
                Article
                10.1182/bloodadvances.2018024802
                6258928
                30482767
                b54845db-0989-4677-bdac-4d198789ab8d
                © 2018
                History

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