In our biomechanical model, we found a significant positive correlation between extensometer micromotion and parasagittal crack area derived from reconstructed CT images . Correlations with transverse and frontal plane crack lengths were not significant. Histologic fatigue damage was not significantly correlated with crack dimensions determined by CT or extensometer micromotion. Bones with parasagittal crack area measurements above 30 mm2 may have a high risk of crack propagation and condylar fracture in vivo because of crack micromotion. In conclusion, our results suggest that CT could be used to quantify subchondral fatigue crack dimensions in racing Thoroughbred horses in-vivo to assess risk of condylar fracture. Horses with parasagittal crack arrays that exceed 30 mm2 may have a high risk for development of condylar fracture.Articular stress fracture arising from the distal end of the third metacarpal bone (MC3) is a common serious injury in Thoroughbred racehorses. Currently, there is no method for predicting fracture risk clinically. We describe an ex-vivo biomechanical model in which we measured subchondral crack micromotion under compressive loading that modeled high speed running. Using this model, we determined the relationship between subchondral crack dimensions measured using computed tomography (CT) and crack micromotion. Thoracic limbs from 40 Thoroughbred racehorses that had sustained a catastrophic injury were studied. Limbs were radiographed and examined using CT. Parasagittal subchondral fatigue crack dimensions were measured on CT images using image analysis software. MC3 bones with fatigue cracks were tested using five cycles of compressive loading at -7,500N . Crack motion was recorded using an extensometer. Mechanical testing was validated using bones with 3 mm and 5 mm deep parasagittal subchondral slots that modeled naturally occurring fatigue cracks. After testing, subchondral crack density was determined histologically. Creation of parasagittal subchondral slots induced significant micromotion during loading ( Parasagittal fracture of the condyles of the third metacarpal/metatarsal bone (MC3/MT3), or condylar fracture, is common in Thoroughbred and Standardbred racehorses and is often identified as part of a syndrome of fetlock breakdown injury. Some of these injuries are catastrophic and require euthanasia of the horse Over the last 30 years, various etiologies for condylar fracture have been proposed. These theories fall into three main categories: first, accidental injury from mechanical overload Functional adaptation is readily detectable by 4 months of race training Currently, there are differing opinions in the field regarding the etiology of fetlock breakdown injury in the racing Thoroughbred. The causative mechanism is likely complex and involves all of the joint structures, the third metacarpal or metatarsal, the proximal sesamoids, and the proximal phalanx. Very little is known about the mechanical stability of the fatigue cracks in the subchondral bone plate that precede development of a condylar stress fracture. It is likely that condylar stress fracture is preceded by cracks in the subchondral plate that become sufficiently severe to permit development of micromotion at the high joint loads associated with training or racing. Therefore, knowledge of the relationship between crack dimensions determined by cross-sectional imaging and crack micromotion at high load may facilitate early identification of horses that are at high risk of condylar stress fracture. Ultimately, this knowledge could help reduce the incidence of serious or catastrophic injuries at the racetrack.Multiple imaging methods relevant to the distal limb are available to the equine clinician. Radiography is inferior to computed tomography (CT) and magnetic resonance imaging (MRI) for identification of pathologic features in subchondral bone and articular cartilage, such as fatigue cracks in the subchondral bone plate The objective of the present study was to develop an ex-vivo biomechanical model in which subchondral crack micromotion at high loads could be measured in distal MC3. We then used this model to determine the relationship between subchondral crack dimensions measured using CT and crack micromotion. We hypothesized that subchondral crack micromotion would be commonly detectable in the distal end of the MC3 bone in Thoroughbred racehorses at joint loads that model racing activity. Such a result would suggest that athletic Thoroughbred horses commonly train and race with incipient condylar stress fracture and are vulnerable to fracture propagation during athletic activity. A secondary objective was to study detection of fetlock joint abnormalities by CT imaging.www.equineline.com) for horses with parasagittal subchondral cracks that were tested mechanically.Thirty-six pairs of entire distal forelimbs and 4 individual limbs from 40 Thoroughbred racehorses that died or were euthanatized for reasons unrelated to the present study were given for use in this work Fig. 1. DR radiographs of the metacarpophalangeal joint of each limb specimen were made using a single dorsopalmar radiographic view  to determine whether fractures of the MC3 bone, proximal sesamoid bones or proximal phalanx were present. Limbs were excluded if a fracture of the MC3 bone was present.CT imaging was performed at high-resolution using 0.625 mm contiguous slices . CT images were reconstructed in the sagittal, transverse, and frontal planes using a 64-bit Dicom viewer . CT images were examined for evidence of pathological changes, including the presence of subchondral sclerosis, fractures, defects in the joint surface, and parasagittal fatigue cracks within the condylar grooves. The presence of palmar osteochondral disease (POD), initially referred to in the literature as traumatic osteochondrosis After CT imaging, all soft tissue was removed from each MC3 bone. The shaft was cut with a band saw in the mid-diaphysis, 12 cm proximal to the dorsal articular margin of the distal end of the bone. The second and fourth metacarpal bones were removed. The articular surface at the distal end of the bone was photographed and the articular cartilage and remaining soft tissues were then digested using 0.15–0.2 M sodium hydroxide at 37°C. The solution was changed as needed every 1 to 3 days. Once the soft tissues were removed, bones were fixed in 70% ethanol and additional photographs of the distal articular surface were made. Severity of the parasagittal crack arrays was graded using a visual analogue scale as previously described To study subchondral crack micromotion at high loads associated with athletic performance, we developed a non-destructive MC3 bone-loading model. An isolated single bone model was chosen for this work because of the high compressive load used for mechanical testing. Each bone was potted in an aluminum cylinder that was 10 cm long using epoxy . An 8 mm hole was drilled in the proximal end of the potted bone and the surrounding cylinder approximately 2 cm from the end of the cylinder, perpendicular to the long axis of the bone and the joint surface, and a stainless steel pin was inserted for additional stability.Bone specimens without detectable CT lesions in the condylar grooves were used to validate the biomechanical model. Holes, 1.25 mm in diameter, were drilled at the distal palmar aspect of the sagittal ridge and 1 mm abaxial to the condylar groove in the same oblique frontal plate to span the region-of-interest. The potted bone specimen was then positioned in a custom jig Fig. 3. −2Crack micromotion was measured using a materials testing system  under load control. Before the mechanical test, each bone was pre-loaded at 100 N. Five cycles of compressive load of 7,500 N were then applied to the condyle abaxial to the extensometer at 0.1 Hz. This load was selected based on biomechanical modeling of fetlock joint loading After an initial baseline testing, an artificial slot was created in the palmar region of the condylar groove using a high-speed rotary tool with a circular diamond wheel, 0.6 mm thick  to model a naturally occurring parasagittal array of fatigue cracks. Lateral and medial condyles were randomly assigned to slots that were either 3 mm or 5 mm deep and approximately 18 mm long in a dorsopalmar direction. Mechanical testing was then repeated.Bone specimens that were found to have macroscopic parasagittal crack arrays in the condylar groove after cartilage digestion and corresponding lesions detectable on CT cross-sectional images were also tested biomechanically. In order to separate pre-existing fatigue cracking from artifactual damage induced by mechanical testing, a bulk-staining method was used After mechanical testing, 1.1 mm thick oblique frontal sections of the distal end of each MC3 bone were prepared using a diamond saw. Sections were cut in a proximodorsal distopalmar plane to pass through the palmar crack array in the condylar groove Bone sections were examined for condylar groove cracking t test for paired data, as appropriate, were used to analyze pathological change in the lateral and medial joint regions. The correlative relationships between measurements of fatigue crack dimensions on CT images and extensometer micromotion and subjective and objective measures of pathologic change in the joint surface were examined using the Spearman Rank test. Baseline micromotion for bones with naturally occurring fatigue cracks was determined from extensometer measurements of all condyles without fatigue cracks evident on CT examination (n = 14 condyles). A mean baseline extensometer reading was subtracted from the mean micromotion value for each bone before analysis. The Spearman Rank test was also used to determine whether a correlative relationship existed between athletic history  and fatigue crack dimensions measured by CT. A similar analysis was performed for crack micromotion measured by mechanical testing, and subjective and objective measurement of pathologic change.The Shapiro-Wilk test was used to determine whether data approximated a normal distribution. To validate the ex-vivo bone-loading model, baseline extensometer motion was subtracted from extensometer motion recorded after slot creation. Because data did not approximate a normal distribution, the Wilcoxon Signed Rank test was used to determine whether data for each slot group differed from a theoretical median of zero (no extensometer displacement). Distribution of condyles between groups was examined using the Chi-squared test. The Wilcoxon Signed Rank test or the Student's p<0.05. Fatigue cracks with a probability estimate >0.8 for micromotion 15% above baseline were considered clinically relevant.The relationship between fatigue crack micromotion from mechanical testing and crack dimensions was also examined using logistic regression. Extensometer micromotion was coded as 1 – motion is >15% above baseline, or 0 – ≤15% above baseline for condyles without CT evidence of subchondral fatigue cracks from the pool of bones with naturally occurring fatigue crack arrays. 15% above baseline was arbitrarily chosen to create a conservative assessment of crack micromotion within the statistical model. Horse identity and the presence or absence of a proximal sesamoid bone fracture were included as variables in the logistic regression model. For crack measurement methods with significant results in the logistic regression model, postestimation was used to determine probability of a positive outcome for each CT measurement. Results were considered significant at DR radiographs were made of 76 forelimbs Fig. 1. Metacarpophalangeal joint osteoarthritis was seen in three limbs, and evidence of rupture of the intersesamoidian ligament  was seen in one limb. Lateral condylar fracture was also seen concurrently with a comminuted fracture of the proximal phalanx in one limb.Sixty-one bones were examined via CT imaging see . Of thosThe distal end of the MC3 bone was examined in 57 limbs, after exclusion for MC3 fracture (15 limbs) and absence of CT lesions (4 limbs) Fig. 1. Wear lines were identified on the cartilage of the distal end of 24 MC3 bones (42%)., p<0.05). Severity of subchondral fatigue damage assessed by subjective scoring was not significantly correlated with crack dimensions measured on reconstructed CT images or extensometer micromotion during mechanical testing.Results are summarized in , p<0.05).POD was identified in 67 of 114 condyles (59%) after cartilage digestion. Abnormality in the cartilage overlying the subchondral bone lesion was evident in 50 (75%) of these condyles , 7. Of tIn the 3 mm slot group, there were 22 condyles  analyzed from 19 MC3 bones. In the 5 mm slot group, there were 24 condyles  analyzed from 20 MC3 bones. Three condyles did not yield interpretable data and were excluded due to fracture of the bone during biomechanical testing. Six other condyles were excluded because of failure of extensometer data collection Fig. 1.p<0.001), with median values of 0.008 mm and 0.038 mm, respectively. Micromotion was significantly increased in the 5 mm slot group when compared with the 3 mm slot group (p<0.001)  Fig. 8.MC3 bones from 24 limbs were used for mechanical testing. Of the 48 condyles, 6 did not yield interpretable data and were excluded because the bone sustained a fracture during mechanical testing. Iatrogenic fractures did not propagate from the condylar groove, and affected either the potted region of the bone shaft (n = 2) or the region of the condyle in direct contact with the actuator (n = 4). Four other condyles were excluded because of failure of extensometer data collection. Mechanical data were acquired for the remaining 38 condyles Fig. 1. R = 0.32, p<0.05). Correlations with transverse and frontal plane crack lengths were not significant. Similarly, correlations with volumetric and surface measurements on 3D reconstructed images were not significant. All CT measurements were significantly correlated with each other . When extensometer motion data were transformed into a binary format, we found a significant relationship between crack dimensions on CT and the presence of fatigue crack micromotion . Comparisons of other CT measurements with baseline-corrected crack micromotion were not significant. The presence of a proximal sesamoid fracture was not significantly correlated with subchondral crack micromotion and was not a significant factor in the logistic regression model.Micromotion 15% above baseline was detected in 18 of 38 condyles (47%) Fig. 9. 2. Specimens with parasagittal crack area measurements above this value had a probability of >0.8 that crack micromotion in our biomechanical model would exceed baseline +15% and be deemed clinically significant  in the limbs of three different horses had parasagittal fatigue cracks in the condylar groove with a parasagittal crack area measurement that exceeded 30 mmificant ,5,7Mean ± standard deviation N.Cr/B.Bd was 0.62±0.34 and 0.55±0.32 respectively for the lateral and medial condyles; severity of histologic fatigue damage was not significantly different between lateral and medial condyles. Severity of histologic fatigue damage was not significantly correlated with crack dimensions measured on reconstructed CT images or extensometer micromotion during mechanical testing. Examination of the oblique frontal bone sections after mechanical loading did not reveal any evidence of crack extension from mechanical testing. One or two unstained cracks were identified in the articular surface of the condylar groove in 6 of 38 condyles after mechanical testing.Mechanical data were obtained for 38 condyles from 22 limbs of 18 horses. Of these 18 Thoroughbreds, a racing history was available for 15 animals. The study group was comprised of 7 females and 8 males consisting of 5 stallions and 3 geldings. The median age was 4 years old (range of 2 to 8). Median number of career starts was 12 (range of 0 to 46). Seven horses were racing on dirt and 4 on turf. One horse never raced. Athletic history was not available for the other three horses. There were no significant correlations between athletic history and the magnitude of parasagittal fatigue crack dimensions from CT imaging of the distal end of the MC3 bone. Similarly, there were no significant correlations between athletic history and detection of crack micromotion. Subjective scoring and histomorphometric assessment of parasagittal subchondral fatigue damage, but not severity of POD, was significantly correlated with horse age and athletic activity Table 4.2 may have a high risk for development of condylar fracture; based on our results it is likely that fatigue crack arrays exceeding these dimensions are exposed to micromotion during high speed running and are, therefore, vulnerable to catastrophic crack propagation Collectively, past observations suggest that condylar stress fractures arise from site-specific accumulation of fatigue damage in the subchondral plate of the distal end of the MC3/MT3 bone During initial screening with DR, we found that condylar fracture was present in 14% of limbs of the Thoroughbred horses in this study. This observation is similar to other epidemiological studies that suggest that condylar stress fracture is commonly associated with catastrophic injuring in racing Thoroughbreds The lesions we identified on examination of the articular surface before and after cartilage digestion were similar to earlier studies Previous work from our laboratory suggests that cross-sectional imaging, particularly with CT, is superior to digital radiography for lesion identification in the fetlock joint of racing Thoroughbreds The appearance of parasagittal subchondral crack arrays in the condylar grooves of the MC3 joint surface was quite variable using CT imaging. Subchondral cracks surrounded by radiolucency may have a greater area or volume than cracks with more clearly defined margins. This is likely important, as stressed volume is thought to be an important factor in the pathogenesis of stress fracture CT imaging was also able to identify POD in a large proportion of the condyles studied. However, not all POD lesions seen on examination of the subchondral plate after cartilage digestion were evident with CT imaging. The main reason for this discrepancy is that those POD lesions not identified on CT imaging were mostly a discoloration of the palmar condyle area, and not a bony defect. Ten of 24 limbs in the naturally occurring crack group were affected by POD, potentially complicating measurement of subchondral crack motion during mechanical testing. In specimens with this lesion, care was taken to place the extensometer needle axial to the POD lesion. By doing so, any POD-associated micromotion should not be included in the motion measured by the extensometer. Although subchondral bone cracks and POD are different clinical entities, they have a similar etiology and both represent fatigue injury to the joint surface To validate our ex-vivo model, we measured micromotion before and after creation of parasagittal slots of two different depths in the palmar region of the condylar groove. Data from this initial experiment supported the validity of our biomechanical model and yielded micromotion values that approximated the values obtained from bones with naturally occurring fatigue crack arrays. Loading conditions for the model were based on earlier studies 2 are likely to experience substantial crack micromotion under high joint loads, based on our regression analysis. This result was identified in 7.9% of horses, suggesting that a large number of Thoroughbreds racing in the United States are vulnerable to condylar stress fracture during racing.We found evidence of fatigue crack micromotion in 47% of condyles, suggesting that a large proportion of racing Thoroughbreds may experience some degree of crack micromotion in vivo. This is an important observation, since it is unlikely that articular fatigue damage will heal well clinically in the face of ongoing instability from habitual training and racing. Horses with parasagittal crack areas that exceed 30 mmIn this experiment, extensometer motion was detected in condyles without detectable subchondral crack arrays. This is likely a consequence of the large compressive load that was applied to the joint surface during testing to model weight-bearing during high-speed running. Rotational motion and creep of some of the bones inside the potting cylinder was noticed during the mechanical testing and there was a tendency for some degree of extensometer drift during the five loading cycles of each test. To account for this limitation, mechanical data were baseline-corrected before statistical analysis. Further, we chose to only consider crack micromotion as relevant when it increased ≥15% above baseline. As there is no established model to determine what amount of motion is truly relevant, this value was chosen arbitrarily as a conservative approach to data interpretation. Development of an improved method for measurement of crack motion during mechanical testing may be help improve precision of mechanical testing in future work.Histomorphometric quantification and severity scoring of subchondral cracking were significantly correlated with horse age and number of race starts, suggesting that accumulation of MC3 subchondral fatigue injury is related to habitual athletic activity. Cumulative cyclic loading of the fetlock is influenced by accumulation of racing starts as well as high-speed timed workout. Another important component of fetlock loading history is the frequency of these events, which can significantly influence risk of a catastrophic musculoskeletal injury in vivo scenario was our use of frozen limbs collected from catastrophically injured racing Thoroughbreds. Limbs were thawed for DR and CT imaging and then refrozen until further dissection, digestion, and basic fuchsin staining. It is possible that post-mortem change and freeze-thaw effects could have influenced our results. Such effects are likely relatively small in a high load biomechanical model. Furthermore, all specimens tested were treated in a similar manner. Removal of the articular cartilage was necessary to appreciate the subchondral crack array in the condylar grooves. Another limitation is that we studied an isolated single bone model with our mechanical testing. Therefore, our study does not address the role of the first phalanx in loading of the distal MC3 bone. It is likely that the articulation between the proximal phalanx and the metacarpus and the loading pattern resulting from this is of importance in the pathogenesis of condylar fracture. Although currently unknown, this interaction, as well as the forces placed on the condyles by the adjacent soft tissues structures  probably plays a role in the formation and propagation of these fractures. Our goal was to isolate one portion of the bone that is of known importance in condylar fractures to estimate crack micromotion during direct loading via the articulation between the condyle and the sesamoid. While of great importance, addressing the roles of other anatomical structures is outside the scope of this study, but relevant to future work. The presence of a proximal sesamoid fracture was not significantly related to detection of crack micromotion in our model. Although actuator placement modeled the position of the proximal sesamoid during mechanical testing, in-vivo loading of the distal MC3 bone by the proximal sesamoid may be different. This may explain the iatrogenic fracture that occurred in some bones during testing. Finally, athletic history was obtained from a relatively limited number of horses. Additional epidemiological work is needed to comprehensively understand the relationship between habitual athleticism and fetlock injuries, such as accumulation of MC3 subchondral fatigue damage.A limitation of this project in accurately modeling an The current design of equine CT scanners requires general anesthesia, which limits the use of CT as a diagnostic modality for equine athletes in race training. However, CT scanning of the foot in the standing horse using a gantry in a horizontal orientation has been performed In conclusion, condylar stress fractures are common in Thoroughbred racehorses. Parasagittal arrays of fatigue cracks in the subchondral plate of the condylar grooves of the distal end of the MC3 bone are readily detectable by CT. Our results suggest that measurement of crack area on reconstructed parasagittal CT images is a predictive marker for crack micromotion at joint loads associated with high-speed running. Consequently, this parameter may prove to be a useful predictive marker for condylar fracture risk in longitudinal in-vivo studies of Thoroughbred racehorses. Improved determination of fracture risk promises reduction in serious injuries during racing and better clinical management of horses with incipient condylar fracture. Furthermore, such knowledge promises improved understanding of the epidemiological relationship between habitual athletic activity and fetlock breakdown injury.


Significant resources are invested in the production of research knowledge with the ultimate objective of integrating research evidence into practice. Toolkits are becoming increasingly popular as a knowledge translation (KT) strategy for disseminating health information, to build awareness, inform, and change public and healthcare provider behavior. Toolkits communicate messages aimed at improving health and changing practice to diverse audiences, including healthcare practitioners, patients, community and health organizations, and policy makers. This scoping review explores the use of toolkits in health and healthcare.Using Arksey and O’Malley’s scoping review framework, health-based toolkits were identified through a search of electronic databases and grey literature for relevant articles and toolkits published between 2004 and 2011. Two reviewers independently extracted data on toolkit topic, format, target audience, content, evidence underlying toolkit content, and evaluation of the toolkit as a KT strategy.Among the 253 sources identified, 139 met initial inclusion criteria and 83 toolkits were included in the final sample. Fewer than half of the sources fully described the toolkit content and about 70% made some mention of the evidence underlying the content. Of 83 toolkits, only 31 (37%) had been evaluated at any level .Toolkits used to disseminate health knowledge or support practice change often do not specify the evidence base from which they draw, and their effectiveness as a knowledge translation strategy is rarely assessed. To truly inform health and healthcare, toolkits should include comprehensive descriptions of their content, be explicit regarding content that is evidence-based, and include an evaluation of the their effectiveness as a KT strategy, addressing both clinical and implementation outcomes. Each year, considerable human and financial resources are devoted to the development of research knowledge in various sectors of health . The ultimate objective on the research continuum is to integrate research evidence into practice to inform and improve health outcomes. To this end, efforts in the rapidly developing field of knowledge translation (KT) have focused on bridging research to practice. Knowledge translation efforts in health strive to ensure that knowledge users are aware of and use research evidence to inform health and healthcare decision-making . In otheA range of KT strategies have been used with varied effectiveness to increase awareness and utilization of research evidence in health, including but not limited to printed educational materials , educational meetings , educational outreach , local opinion leaders , audit and feedback , and reminders (patient or encounter specific prompts). KT strategies can also be tailored, taking into account identified barriers to change, and/or multifaceted, which capture interventions having two or more components . DespiteMost of the reviews included in Bero et al.’s systematic review identified modest improvements in performance resulting from these common KT interventions . GeneralThe vision of mapping which KT strategies are effective for which audiences and in what contexts remains elusive. The field is in need of more detailed guidance on how to best share research evidence in a way that promotes and enables its use. Some of this guidance is emerging from taxonomies of KT strategies developed recently to facilitate greater consistency in strategy naming, definition, level of detail and specification of the target user in research on KT strategy effectiveness, with the ultimate goal of enhancing the synthesis and application of findings across a body of research ,6. ConteEducational meetings and materials tend to be the most widely used KT strategies in health and healthcare ; they arEducational materials are often packaged as “toolkits”. Coined in the 1980’s, the term ‘toolkit’ has been widely used for decades. As in other fields, no definitive toolkit format has been established in the context of health. The term has been used to describe the bundling of a combination of educational materials including templates, instruction sheets, literature reviews, videos, and posters, presented in a variety of formats . Toolkits have been used to inform and improve health behaviors for diverse audiences, including health practitioners, patients, community and health organizations, policy makers, and for the public. Toolkits have gained popularity as a KT strategy, particularly in health, and the Internet has provided fertile ground for toolkit dissemination. For example, a recently completed study of evidence-based interventions to increase booster seat use lends itself to dissemination in a web-based toolkit format for multiple target audiences that are highly likely to access information on the Web .Given the pervasiveness of toolkits to disseminate health evidence and change practice, it is important to map the evidence for their effectiveness to inform decisions about their potential use. To this end, the present study focuses on toolkits as a KT strategy. We conducted a scoping review of published and grey literature to identify how toolkits have been operationalized, and to describe their content, evidence underlying their content, format, and evidence of effectiveness. Our focus was on toolkits that were developed to disseminate health information, as well as change healthcare provider behavior . As is the purview of scoping reviews, we sought to assess whether sufficient research is available to warrant a more traditional systematic review on health toolkits and, where gaps are noted, to issue recommendations for future research on toolkit development and effectiveness. This type of review is appropriate given the emerging nature of evidence on toolkits and the absence of syntheses on this topic .The review followed Arksey and O’Malley scoping review framework  and the How Schools Can Help Students Recover from Traumatic Experiences is an online toolkit designed to support schools that want to help students recover from traumatic experiences such as natural disasters, exposure to violence, abuse or assault, terrorist incidents, war and refugee experiences [While no single definition of the term toolkit has gained wide acceptance, for the purposes of this review ‘toolkit’ was defined as the packaging of multiple resources that codify explicit knowledge, such as templates, pocket cards, guidelines, algorithms, summaries, and that are geared to knowledge sharing, educate, and/or facilitate behavior change. For example, eriences . The tooThe review sought to assess the scope of toolkits available in the field of health and healthcare, so search terms were relatively broad. Electronic databases and websites were searched by a library and information scientist. The research team compiled a broad list of terms pertinent to health and healthcare. These terms were used by the library scientist in various combinations to search electronic databases of peer-reviewed and grey literature. Searches were limited to English language publications from 2004 to 2011. Papers were included if they reported on toolkits used for disseminating health information and informing and/or changing healthcare provider behavior. Given the goal of mapping how toolkits have been used as a KT strategy, study design was left unspecified. The following electronic databases were searched: MEDLINE, PsychINFO, CINAHL, ERIC and those available in Scholar’s Portal. Common terms across all databases included health education and health promotion. Each database contained unique relevant terms used to create search strings. The term ‘toolkit’ was included as a keyword as it is not used in the controlled vocabulary for these databases. The following headings were used in combination with ‘tool kit’ or ‘toolkit’ to create search strings: health education, health promotion, consumer health information, preventative health services, information resources, child safety, passenger safety, patient safety, health programs and educational programs.Grey literature was searched using Scirus (now retired), a scientific search engine that searches journals as well as websites. The search terms included toolkit or tool kit, health, child, pediatric, youth. Searches were limited to the following subject areas: medicine, psychology, social and behavioral sciences and sociology.Source selection was carried out in two stages. Figure In stage 2 of the scoping review all included and undecided sources were located and reviewed in full. Initial exclusion criteria were again applied and new exclusion criteria emerged; development of exclusion criteria during the review stage is a unique feature of scoping reviews and differentiates scoping reviews from systematic reviews . Given tTwo reviewers independently read all 139 sources identified for full review, with the exception of one article that could not be located. The reviewers periodically conferred on inclusion or exclusion criteria. Conflicting decisions (n = 7) were resolved through reviewer discussion, culminating in the inclusion of 83 sources.Two reviewers independently abstracted the following data from each source: toolkit format, toolkit topic (as specified by the toolkit authors), target audience(s) , toolkit content, evidence underlying toolkit content, KT goal of the toolkit, whether toolkit had been evaluated, evaluation approach, evaluation design, evaluation outcome. A unique aspect of our review was a focus on whether the toolkit content was evidence-based, which we assessed based on information provided by the authors. Publication details and abstracted data were subsequently transferred to a detailed spreadsheet, and authors met to discuss and synthesize the findings. During meetings, the authors reviewed the information extracted from the sources and organized it into larger categories determined through group consensus discussions.Of 253 citations initially identified, 139 met initial inclusion criteria and 83 toolkits were included in the final sample. Among the 83 toolkits, the majority (n = 68) were identified in journal articles, and 15 toolkits were located online in their entirety with no related peer-reviewed publication.Toolkit topics were categorized as clinical, general health and safety, developmental and mental health, technology-related, advocacy, politics, and cultural awareness  were directed at healthcare practitioners, such as physicians and nurses  were designed to inform practice change  targeting healthcare practitioners. Educating or sharing knowledge and informing were the main KT goals for 40 (48%) toolkits  and typically the target audience was parents, caregivers and school staff. Finally, informing policy and decision-making was the KT goal for 10 (12%) toolkits .Toolkit content was well described in only 36 (43%) of the sources reviewed , and found that 72% included some mention of the evidence supporting the toolkit, while the remaining 28% made no reference to evidence. The type of evidence underlying the development of the 60 toolkits varied widely. Here, evidence took the form of literature scan/reviews (n = 31), qualitative data , expert panels (n = 13), and evidence-based guidelines (n = 14). Toolkits supported by evidence from randomized controlled trials were much less common (n = 3). Toolkits were sometimes supported by multidisciplinary specialists’ discussions, theories or conceptual frameworks, best-practice approaches, reviews of institutional documentation, national reports, and observations of existing practices. Most toolkits relied on a combination of these sources and none of the toolkits specified the evidence base underlying each individual toolkit element; if they were supported by evidence, this was not made clear in the source.High School Coaches’ Assessments, Intentions to Use and Use of a Concussion Prevention Toolkit [We also examined whether (1) toolkits as a whole were evaluated relative to their purpose or KT goal, and whether (2) toolkit components were evaluated for specific outcomes. Information regarding evaluation of the toolkit either as a whole or for its components was only available for 31 of the 83 toolkits. Importantly, none of the online toolkits included information about toolkit effectiveness. Table  Toolkit , which cToolkit for New Parents [Where possible, information was collected regarding the type of evaluation conducted on the toolkit: process , and outcome . For instance, the  Parents , designeProper Exercise and Nutrition Toolkit planned to incorporate it into their practice [Safety of the Land Toolkit designed to increase rural children’s knowledge about safety [Diabetes Literacy and Numeracy Education Toolkit designed to improve glycemic control and self-efficacy in patients with diabetes [With respect to overall outcome evaluation, the majority (n = 21) of evaluated toolkits reported that the toolkit was satisfactory, useful, or resulted in an intention to change practice. For instance, 92% of the nurses who received and tried out the practice . Resultst safety ) and moddiabetes ). In theToolkits as a KT strategy have popular appeal, particularly given the ease with which they can be disseminated on the Internet in an engaging and multimodal manner to a wide variety of audiences. This study set out to scope the literature on toolkits in health and healthcare, to explore their breadth of topic, format, target, content, underlying evidence and their effectiveness as KT strategies. The majority of toolkits focus on clinical and general health and safety topics such as disease prevention and care, oral health, and end of life care. Toolkits permeate both published and grey literature and tend to be targeted to healthcare practitioners, although many also target community-based knowledge users, health decision makers and policy makers. Toolkit content was adequately described in fewer than half of the sources reviewed. Although about 70% of the sources mentioned the evidence underlying the toolkit content, there was a wide range of variability in what constituted this evidence. The most commonly used sources of evidence included literature review findings, qualitative data, expert panels, and practice guidelines. Of the 83 toolkits included in the study, only 31 had been evaluated in any way. Among these, the majority focused on the effectiveness of the toolkit as a whole, and, very rarely, on the effectiveness of the individual components. Among evaluated toolkits, outcomes were generally positive related to their intended KT goal.To our knowledge, this is the first scoping review on toolkit use in health and healthcare. Our findings indicate that there is sufficient research on this topic to warrant a full systematic review. In addition, the findings reveal several knowledge gaps which can inform how to best share research evidence in a way that optimizes its use. First, evaluation findings suggest toolkits can be an effective KT strategy, but more systematic evaluations are needed to capture impacts beyond intention to use or user satisfaction, which were the most commonly employed indicators of outcome. Systematic evaluations of toolkits that aim to change knowledge, attitudes, practice and, where applicable, patient outcomes, are crucial for understanding their full impact on health practice and behavior, and ultimately strengthen their utility. This finding aligns with results from the Cochrane review on the use of educational materials to change the practice of healthcare professionals and patient outcomes . This gaSecond, comparisons of toolkits with other KT strategies using comprehensive designs will help us to elucidate the contexts in which toolkits are useful and the relative advantage of this type of KT strategy. Toolkit research must also include full documentation of the toolkit materials, a limitation noted in 60% of the sources reviewed herein. This is informative for toolkit development, assessing toolkit feasibility and effectiveness, and comparisons to other toolkits and KT educational approaches. Finally, given that toolkits aim to translate knowledge, it is essential to make explicit the type and quality of evidence that is being translated and that underlies each component within the toolkit; in other words, the evidence on which the toolkit elements are based.We harken back to the conclusion of an earlier review  that notWe note two limitations. First, we reviewed toolkits developed prior to 2011 and it is likely that other toolkits have been published in the last three years. This presents an opportunity for other authors to extend the review when conducting a more systematic review. Additionally, findings are limited to studies published in English. Despite these limitations, this scoping review presents a comprehensive profile of toolkit use in health and healthcare, and contributes to advancing knowledge in the field of KT. Addressing the above noted gaps in future research has the potential to optimize the effectiveness of toolkits as a strategy to share knowledge and change practice.Toolkits are proving to be desirable, accessible, and useful but they lack scientific rigor with respect to the evidence underlying their content, and evaluation of their overall effectiveness. To the extent that toolkits are focused on practice or behavior change, it is imperative that they be supported by research evidence, which was not the case for all toolkits included in this review. Furthermore, fewer than half the toolkits identified as relevant for this review included any evaluation of the toolkit at any level. Moreover, if we are to develop confidence in the ability of toolkits to change practice and/or behavior, we must evaluate and accumulate evidence of their impacts. Only then can we be certain we are behaving ethically, supported by evidence, and with the knowledge that the toolkit is both effective and a defensible investment of time and resources.1References included in the scoping review [g review -95.


For several decades, music has been used more and more frequently and consciously as a mean of care to reduce or stabilize symptoms and/or complications arising therefrom. This has been the case with several diseases, including chronic and degenerative ones  , the presence of a therapeutic setting, and also the ability to define targets and therapeutic strategies of intervention with adequate awareness and the possibility to verify the therapeutic results achieved.From a careful analysis of the scientific literature different applications that make use of music can be identified: music therapy interventions , music listening  and general music-based interventions.Music therapy interventions in the scientific culture of the discipline are characterized by a relational component, which is considered essential, and by the presence of a qualified music therapist. In these cases, the treatment is therefore mediated by the presence of a therapist that uses applicative models based on psychological and/or neuroscientific theories. In the first case the reference is to the active techniques  and receptive ones  that aim at reducing psychological symptoms or complications arising therefrom, and at increasing relational and communication skills  , but can also be listening experiences in which the music turns out to be an excuse to stimulate verbalization, memories or to encourage of relaxation.In Table From the literature analysis some key points and recommendations emerge that can promote the development of music therapy: first of all the need to use appropriate research methodologies to assess the effectiveness of interventions, focusing on randomized controlled trials and controlled clinical trials; moreover the need to define the interventions  by promoting the use and spread of these effective non-pharmacological approaches, which are indeed applicable in several areas of health care, at low cost and without side effects.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


With an annual prevalence of 0.9–2.6%, posttraumatic stress disorder (PTSD) is very common in clinical practice across Europe. Despite the fact that evidence-based interventions have been developed, there is no evidence on their implementation in clinical practice and in national psychiatric training programmes.The Early Career Psychiatrists Committee of the European Psychiatric Association conducted a survey in 23 European countries to explore implementation of evidence-based interventions for PTSD and training options.n=19, 82.8%). However, psychological interventions were much less widespread. For example, psychoeducation was widely available in 52% of the countries (n=12), cognitive-behavioural therapy in 26.2% (n=6), and specific trauma-focused techniques were rarely available. Training on PTSD was part of the official training in 13 countries (56.5%), predominantly in the form of theoretical seminars.The findings indicate that pharmacotherapy was available in the majority of the participating countries (Overall, this survey indicates that the treatment for PTSD is largely focused on pharmacotherapy, with psychological evidence-based interventions poorly available, especially outside specialized centres. Poor implementation is linked to the lack of official training in evidence-based interventions for psychiatric trainees across Europe. Posttraumatic stress disorder (PTSD) is frequent in the general population. In recent European surveys, lifetime prevalence rates of 1.9%  often encounter PTSD patients in their clinical practice. Psychologists and allied professionals in the USA reported that their training in the treatment of PTSD was not sufficient to meet the needs in clinical practice  how often they had contact with PTSD patients in their clinical practice; (2) whether evidence-based interventions were available in the majority of centres in their country; and (3) whether training options in PTSD treatment were included in training curricula and if so, in what form.To this end, a questionnaire was developed by members of the ECP committee of the European Psychiatric Association (EPA-ECPC) and members of its research task force. The questionnaire was developed during three online sessions attended by psychiatric trainees from seven European countries. The questionnaire was in English. It consisted of two large categories of interest: the availability of evidence-based interventions (eight questions) and the availability of training in evidence-based treatment options in each country .n=15, 65.2%) with a mean age of 32.3 years (SD=3.7). They were either psychiatric trainees  or ECP . The majority of respondents  reported seeing at least one patient with PTSD in the previous month, whereas eight participants (34.8%) reported seeing one in the previous week. National guidelines for treatment were available in 11 countries (47.8%). Their impact on practice was considered as “high” in only four countries . Availability of evidence-based interventions for PTSD treatment is summarized in n=10, 43.5%), discussion of clinical cases , individual supervision , group supervision  and continuing medical education (CME) courses . The reasons for a poor implementation of evidence-based practice reported by experts (more than one answer was possible) were: lack of funding , lack of expertise in the country , poor recognition and identification of trauma-related disorders by psychiatrists  and problems with organization of mental health care . Four experts did not report problems in implementation in their countries .Experts from 23 out of 35 countries completed the survey . Of thesThe data gathered by national experts represent a snapshot of the current provision of evidence-based treatments for PTSD and of their presence in national training curricula in European countries. Our findings emphasize the need for strategies to increase the availability of evidence-based interventions for PTSD in European countries. Pharmacological interventions were the most frequently available type of treatment for PTSD across European countries. This is not surprising given that psychopharmacology is an integral part of psychiatric training. Although psychoeducation was widely available in more than 50% of the countries, CBT and other specific interventions were most often provided only in specialized centres. A wider availability of training options for evidence-based treatment outside specialized centres was given mostly in a few Western European countries  with the exception of Serbia. A lack of funding and lack of expertise in the countries were the most common reasons given for lack of implementation of evidence-based practices. Even when training was available in national training curricula, it was mainly based on theoretical seminars. In only 30% of the countries, CME initiatives on PTSD treatment were offered. These findings echo previous studies, which emphasize major differences in psychiatric training curricula across Europe  with a high prevalence of responses from eastern European countries (14 out of 23). Moreover, as one expert per country answered the survey and we had to rely on the expertise of the respondents, results may have been biased. Yet, surveys of nationally appointed experts are commonly used to obtain representative data (Kuzman et al., Strategies to increase the availability of evidence-based interventions for PTSD across European countries are needed. Ensuring that the highest standard of training on PTSD treatment is part of national psychiatric curricula is an important component of these strategies. Lack of trained professionals may reduce the likelihood of PTSD detection and limit the provision of evidence-based treatments to specialized centres.Click here for additional data file.Click here for additional data file.Click here for additional data file.Click here for additional data file.


Over many years, a number of academic/community partnerships have worked independently to develop, evaluate, and bring to scale participant-centered, evidence-based self-management, and health promotion programs offered in community settings for older Americans. Many of the programs developed by these partnerships have since become critical pieces of the infrastructure that supports older adults with chronic health conditions. Indeed, community-based self-management support is an integral component of the Chronic Care Model  illustraThe EBLC is currently a group of 11 individuals representing a total of 19 evidence-based programs  as well as four leaders from organizations providing multiple evidence-based programs . EBLC members are employed by community-based organizations, foundations, healthcare systems, universities, and governmental entities and have been directly involved for many years in the development, evaluation, and scaling of their individual programs as well as implementation through community-based organizations. The individual program developers met informally for several years and in 2012 formed the EBLC. Over the past year, community-based organization leaders responsible for implementing multiple evidence-based programs were asked to join and be part of the council.All the programs represented by EBLC program developers meet the Administration for Community Living’s (ACL) criteria for highest level of evidence . In addiPerson Centeredness – individuals are actively involved in programs and making a difference.Effectiveness – evidence-based programs focus on outcomes/results.Collaboration – multi-sector, multi-organizational and interdisciplinary .Equity and access – social justice, respect of diversity.Sustainability.Together, the council represents more than 200 combined years of experience in developing, evaluating, scaling, implementing, and sustaining evidence-based self-management programs. All of the programs have proven effectiveness in published randomized controlled trial research and all programs have been brought to scale. The mission of the EBLC is to increase delivery of evidence-based programs that improve the health and well-being of diverse populations. The EBLC is committed to the following values:The EBLC has accomplished several important tasks, including: (1) performed an initial mapping of all agencies  offering any of the 19 programs as well as which programs are being offered by each agency; (2) completed a telephone survey of 15 of the agencies offering two or more programs to identify facilitators and barriers to implementation of multiple EBPs and approaches to support scaling up these programs; (3) participated in federal meetings with the ACL, the National Council on Aging Self-Management Alliance and others; and (4) held four in-person strategic planning meetings as well as smaller subcommittee meetings and bi-weekly phone calls.status quo is no longer acceptable. As the demand for programs has increased, program infrastructures have, for the most part, not grown to meet the new demands. Each program developer has experienced challenges to keep up with increasing expectations for planning, training, and technical support, while working within the confines of their parent organization and maintaining affordability for community-based organizations. Community-based organizations have had their own set of challenges in sustaining these programs. To bring the true promise of these programs to scale, there needs to be an integration of infrastructures, and a one-stop-shop to build and to assist implementing organizations.The EBLC believes that our community care system has now reached a stage where the Facilitate the effort to identify a minimal set of common data points for all programs, which can be used to evaluate dissemination, reach and outcomes both within and across programs,Efficiently, feed a public-facing website by providing unduplicated and jointly maintained data on organizations providing EBP trainings and workshops.Offer the potential for significant gains in efficiency for program owners, who can combine information about organizations providing or interested in providing EBPs and can eliminate duplication of communications and common workflow processes .Offer the potential for significant gains in user-friendliness for organizations providing or interested in providing EBPs, by providing a single gateway to the programs (including the common website) through which adoption research, readiness assessment, licensing, and training can be handled for one or multiple programs at a time.The focus of the EBLC going forward will be to improve coordination and efficiency around marketing, technical assistance , training, and licensing and fee structures. An EBLC website is also being developed to improve access to tools and information in each of these areas. A shared data management platform is being expanded to include all programs in the EBLC. This platform will:The EBLC’s vision for the future is an ever increasing number of adults engaged in evidence-based programs that inform, activate, and empower them to improve their health and maintain independence. These programs will be embedded in a permanent, sustainable infrastructure –a national network supported by the EBLC’s technical assistance in implementation and dissemination, training, marketing, licensing, and evaluation. Bringing years of experience and expertise in disseminating participant-centered, evidence-based self-management, and health promotion programs in communities nationwide, the EBLC is poised to help many more organizations with limited resources effectively address population health challenges.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health  panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.


Evidence mapping is an emerging tool used to systematically identify, organize and summarize the quantity and focus of scientific evidence on a broad topic, but there are currently no methodological standards. Using the topic of low-calorie sweeteners (LCS) and selected health outcomes, we describe the process of creating an evidence-map database and demonstrate several example descriptive analyses using this database.The process of creating an evidence-map database is described in detail. The steps include: developing a comprehensive literature search strategy, establishing study eligibility criteria and a systematic study selection process, extracting data, developing outcome groups with input from expert stakeholders and tabulating data using descriptive analyses. The database was uploaded onto SRDR™ (Systematic Review Data Repository), an open public data repository.Our final LCS evidence-map database included 225 studies, of which 208 were interventional studies and 17 were cohort studies. An example bubble plot was produced to display the evidence-map data and visualize research gaps according to four parameters: comparison types, population baseline health status, outcome groups, and study sample size. This plot indicated a lack of studies assessing appetite and dietary intake related outcomes using LCS with a sugar intake comparison in people with diabetes.Evidence mapping is an important tool for the contextualization of in-depth systematic reviews within broader literature and identifies gaps in the evidence base, which can be used to inform future research. An open evidence-map database has the potential to promote knowledge translation from nutrition science to policy.The online version of this article (doi:10.1186/s12874-015-0105-z) contains supplementary material, which is available to authorized users. Evidence mapping is an emerging tool to systematically and comprehensively identify, organize and summarize the distribution of scientific evidence on a broad topic , 2. It cevidence map, scoping review and systematic map, are widely used within evidence mapping, yet there are some differences between them [There are currently no methodological standards for evidence mapping . As desceen them . Nonetheeen them , 4, 13.In this paper, we describe the process and methodology of creating an evidence map database, using the topic of low-calorie sweeteners (LCS) and selected health outcomes of interest as a worked example. We also demonstrate several example descriptive analyses by using data in the LCS evidence map to help identify potential gaps and future research directions.Seven steps were used to construct a LCS evidence-map database: 1) Identify the Scope of the Evidence Map; 2) Define the Roles and Responsibilities of Different Parties: Stakeholder Panel and Research Team; 3) Develop a Comprehensive Search Strategy; 4) Establish Study Eligibility Criteria and a Systematic Study Selection Process; 5) Carry Out Abstract Screening and Selection; 6) Carry Out Data Extraction; and 7) Classify Outcome Categories. Details are described as follows.The initial scope of work was developed by the sponsor of this project in a request-for- proposals. The following five areas of research regarding the potential health effects of LCS were all considered and included: 1) energy sensing by the brain; 2) gut hormones that may influence energy homeostasis; 3) satiety and preference for taste; 4) eating behavior; and 5) body weight and composition. It is important to note that, aside from their initial feedback on our funded research proposal, the sponsor was not involved in the later refinement of the work scope or the process of creating the evidence-map database other than providing a list of selective citations for cross-referencing purposes.A diverse stakeholder panel was recruited across eight areas of expertise: one physician, two dietitians, three policymakers, a research funder, academic researchers from five different fields, two representatives from the food industry, one journalist and one lay person. The panel served as a steering committee to guide the research team through the process of building the LCS evidence-map database. Specifically, the stakeholder panel helped refine the search strategy, finalize study eligibility criteria and define outcome groups for evidence map analysis and charting. Data screening, collection and analyses were performed by the research team. The research team included a methodologist with expertise in conducting and leading systematic reviews and meta-analyses, two team members with graduate-level epidemiology training and a research coordinator.The research team collected key search terms from previous reviews and systematic reviews on relevant topics to formulate the initial search strategy –16. The The research team used an iterative process to establish study eligibility criteria, with input from the stakeholder panel collected via webinars and online surveys. After 2 iterations, the stakeholders and research team decided that for studies to be included, they needed to be: 1) randomized or non-randomized, controlled, clinical trials or prospective cohort study designs, which are considered the strongest study designs for causal inferences; 2) investigating orally administered, FDA-approved LCS or LCS that are generally recognized as safe (GRAS); 3) reporting at least one health outcome within the five categories in our scope of work; 4) an English publication; and 5) human subjects research. Articles with study populations including adults, children, adolescents, pregnant women and infants greater than 6 months old were included, whereas studies in cancer patients and cancer outcomes were excluded because the project scope includes only FDA-approved LCS that have passed FDA’s toxicological safety assessment as food additives, which includes assessment for cancer risks. A search of systematic reviews and meta-analyses was also conducted in addition to the main search for reference-mining purposes.n = 11,830) were single-screened due to the large number of abstracts and budgetary constraints. Abstracts with a “yes” or “maybe” label were both included in step 1 of the evidence map and the full-text articles of these abstracts were retrieved for full-text screening. Citations with a “no” label were saved for record. Because of the single screening process, it is possible that a few abstracts were mistakenly rejected during this screening phase. In an effort to ensure all key studies were included, all included citations were cross-referenced with the reference list of relevant systematic reviews and meta-analyses. In step 2 (full-text screening), we followed the predefined study eligibility criteria (Table n = 571) of the original citations were screened in for full-text review. Each full-text article was screened by one reviewer, and the screening decision of the first reviewer was then confirmed or disputed by a second reviewer. Discrepancies were resolved through consensus among all research team members.The titles, abstracts and keywords of all identified articles were screened using Abstrackr™, an open source, web-based, citation screening tool . The resThe research team extracted data on a customized extraction form shared via Google Drive to facilitate collaboration among research team members and allow for simultaneous data entry. The minimal data to collect for an evidence-map database are the information related to the PI(E)COS . The extraction form for the LCS evidence-map database was designed to collect the following data from each study: study design characteristics , study population characteristics , study interventions/exposures and comparisons , outcome information , the aim or hypothesis of the study and funding source of the study. The extraction form was designed and finalized by the research team lead, who has expertise in evidence-based research and methods. The evidence-map database was uploaded onto SRDR™, an open public data repository, and a database codebook is included in the supplemental material  and Microsoft Excel.The original search on MEDLINE® from inception to June 2014 yielded 12,830 citations. The supplemental search including terms recommended by the stakeholder panel yielded 4440 additional citations. In total, 17,270 relevant citations were screened. After title and abstract screening, 571 articles were included in full-text screening. Our final LCS evidence-map database included 225 studies, of which 208 were interventional studies and 17 were cohort studies. The literature search and study selection process are summarized in Fig. 2 (range: 16.1–42.3 kg/m2). The mean age was 31 years old (range: 8–73 years old). Fifty-seven percent of the trials were randomized cross-over trials and 28 % were randomized parallel controlled trials. Eleven percent of the trials were non-randomized crossover or parallel trials. More than half of the trials (60.1 %) were acute studies, defined as less than 1 day in study duration. Among the 17 cohort studies, the BMI (mean of the means) was 23.6 kg/m2 (range: 16.2–27.4 kg/m2). There were 6 studies conducted on children and 11 on adults. The mean age was 32 years old (range: 2–84 years old) with an average sample size of 15,430 subjects   were done in adults, 51 % of the study populations were male and 140 (68 %) of the studies included only healthy subjects with no known diseases. The mean sample size was 48 subjects (range: 2–732 subjects) and the mean BMI across studies was 25.6 kg/mStudies in the evidence-map database can be summarized using the outcome categories described earlier. Among the 208 intervention studies identified, 84 studies reported appetite-related outcomes, 75 studies reported energy sensing-related outcomes, 35 studies reported body weight or body composition outcomes, 62 studies reported dietary intake-related outcomes and 76 studies reported glycemic outcomes. All 17 cohort studies reported body weight or body composition outcomes. Table A cumulative frequency chart of the number of publications by outcome categories was produced to show the cumulative publication growth over time. As shown in Fig. A scatter plot is often used to identify relationships or patterns. A bubble plot is a variation of a weighted scatter plot, which was used here for the purpose of identifying research gaps. A bubble plot can graphically present multiple categorical data on study characteristics in a single, two-dimension chart by displaying the evidence-map data according to specific, special locations defined by the x-axis and y-axis, as well as according to the color, shape or size of bubbles. In the construction of the bubble plot using data in the LCS evidence-map database, the unit of the analyses was the individual study. One study could be included multiple times in an analysis because each study could report multiple outcomes of interest.In the example bubble plots Figs.  and 4, sIn the second example, bubble plot data points are grouped and plotted according to population health status and outcome categories. The plot is further stratified by two types of intervention and comparison designs: 1) LCS versus sugars (or vice versa) or 2) LCS versus other non-sugar comparisons (or vice versa) Fig. . This exIt is important to note that the research gaps identified by the bubble plots do not necessarily equate to research needs. Besides the quantity and quality of the existing studies, the importance, desirability, feasibility, and potential impact of research gaps need to be considered to determine the research needs. For example, while a research gap exists regarding LCS vs. sugar intakes in diabetic populations, experts in this area would need to determine if there is a further need, given that individuals with diabetes need to limit their added sugars intake. The LCS evidence map database and analyses presented here were an integral component of a Future Research Needs (FRN) assessment project. The stakeholder panel in this project was assembled to provide input for the FRN project according to a framework for stakeholder engagement in patient-centered outcome research to identify research needs in the broad field of LCS and potential health-related outcomes .This paper reviewed the components of an evidence map and described the steps in the process of constructing a LCS evidence map as a worked example. The methodology presented to create the evidence map is replicable and helps readers understand the steps required to build a comprehensive database. These steps can be applied to create an evidence-map database for any research topic of interest. We have applied the same methodology to create two other evidence-map databases–one on the health effects of added sugars and another on fiber , 20. TheOur LCS evidence-map database has several limitations. Due to limited resources, only the Medline® database was searched; thus the evidence-map database cannot be the sole source of data when used as the basis for a systematic review. We encourage future evidence map projects to include databases such as EMBASE, Cochrane, Scopus and other databases deemed appropriate to the research question. With more databases searched, it is expected that the number of abstracts and full-text articles to be screened will rise substantially. Hence, it is important to evaluate the project feasibility by looking at the number of search hits at the beginning of the project. Regardless of the comprehensive search strategy, it is likely we missed studies that did not include key LCS or outcome terms in the abstract or keywords. Our effort in addressing this limitation included cross-referencing studies cited from published LCS systematic reviews with our database, as well as conducting several supplemental searches to include additional key search terms. Furthermore, it is important to note again that evidence maps do not include quality (risk of bias) appraisal of the included studies. Thus, there can be a high volume of poor quality research and more research is still needed despite this high volume. There is a growing interest in engaging stakeholders in evidence synthesis processes for the potential benefits of improving relevant, enhancing quality, and increasing dissemination and uptake of evidence-based findings . In thisEvidence mapping is a replicable evidence-based approach to identify, collect and evaluate the characteristics of published studies. The methodology is systematic and requires less time and effort than a systematic review to achieve an understanding and distribution of evidence. Evidence mapping can also be used to identify both research gaps, as well as areas of opportunity for systematic reviews. An open evidence-map database has the potential to promote knowledge translation from nutrition science to policy. To achieve this ultimate goal, continuous updating, data quality control and validation would be required.


The increased demand for evidence-based practice in health policy in recent years has provoked a parallel increase in diverse evidence-based outputs designed to translate knowledge from researchers to policy makers and practitioners. Such knowledge translation ideally creates user-friendly outputs, tailored to meet information needs in a particular context for a particular audience. Yet matching users’ knowledge needs to the most suitable output can be challenging. We have developed an evidence synthesis framework to help knowledge users, brokers, commissioners and producers decide which type of output offers the best ‘fit’ between ‘need’ and ‘response’. We conducted a four-strand literature search for characteristics and methods of evidence synthesis outputs using databases of peer reviewed literature, specific journals, grey literature and references in relevant documents. Eight experts in synthesis designed to get research into policy and practice were also consulted to hone issues for consideration and ascertain key studies. In all, 24 documents were included in the literature review. From these we identified essential characteristics to consider when planning an output—Readability, Relevance, Rigour and Resources—which we then used to develop a process for matching users’ knowledge needs with an appropriate evidence synthesis output. We also identified 10 distinct evidence synthesis outputs, classifying them in the evidence synthesis framework under four domains: key features, utility, technical characteristics and resources, and in relation to six primary audience groups—professionals, practitioners, researchers, academics, advocates and policy makers. Users’ knowledge needs vary and meeting them successfully requires collaborative planning. The Framework should facilitate a more systematic assessment of the balance of essential characteristics required to select the best output for the purpose. The increased demand for evidence-based health policy in recent years has provoked a parallel increase in diverse evidence-based outputs designed to translate knowledge from researchers to policy makers and practitioners, yet matching users’ specific knowledge needs to the most suitable output, while essential, can be challenging.We have developed an evidence synthesis framework classifying 10 distinct evidence synthesis outputs under four domains: key features, utility, technical characteristics and resources, in relation to six primary groups of users—professionals, practitioners, researchers, academics, advocates and policy makers.We propose a process for matching users’ knowledge needs with an appropriate evidence synthesis output, using essential characteristics to consider when planning an output—Readability, Relevance, Rigour and Resources.When used in combination, the framework and process should facilitate a more systematic assessment of the balance of essential characteristics required to select the best output for the purpose and help knowledge users, brokers, commissioners and producers decide the best ‘fit’ between ‘need’ and ‘response’.hybrid of both , advocates , policy makers, administrative and managerial professionals, and practitioners. . Each of these groups requires knowledge for different purposes . EvidencThis study aims to contribute to an understanding of different users’ knowledge needs and how they can be met through matching them with relevant evidence synthesis outputs. The objectives are to identify: different evidence synthesis outputs and their distinguishing features; as well as issues to consider when planning the development of an evidence synthesis to match users’ knowledge needs.We have created an evidence synthesis framework describing the features, benefits and limitations of outputs, based on a literature search, and consultations and interviews with experts in the field of synthesizing research for policy and practice. This framework should benefit both commissioners and producers of synthesis outputs—including knowledge brokers, who are responsible for deciding which type of output will best meet the needs of the evidence users they support.The scope of this study is the wide range of diverse evidence synthesis outputs, which encompasses, but is not exclusive to systematic reviews. Much of the existing literature focuses on methodologies to analyse quantitative and/or qualitative studies that are variants of systematic reviews, e.g. A four-strand literature search, described below, was conducted to ascertain what research exists that contributes to answering the study objectives. Using the methodology for a systematic review was not feasible because of the nature of the documents on which the literature search was based. Such documents, for policy makers and a general audience are not generally found in databases of academic peer-reviewed articles. Nevertheless, the methodology we used followed parameters which were intended to make it systematic.The first strand of the literature search was a search of five bibliographic databases of peer-reviewed journal articles: Embase, Global Health, Medline, Social Policy & Practice and Web of Science. Based on the number of relevant articles from particular journals identified in the database search, the second strand was a hand search of three peer-reviewed journals that were considered particularly relevant: Systematic Reviews Journal; Journal of Health Services Research & Policy; and BMC Medical Research Methodology. The third strand was a search for relevant grey literature using Google. This was not exhaustive, but was as comprehensive as possible, representing five leading organizations involved in producing evidence syntheses: the UK Department for International Development (DFID), the Overseas Development Institute, INASP , the UK Economic and Social Research Council (ESRC) and the International Initiative for Impact Evaluation (3iE). DFID’s Research for Development (R4D) database was also searched.evidence synthesis  AND methodology.A second search of the bibliographic databases was then undertaken using the search terms (expert opinion OR consensus statement) AND policy making.The inclusion criteria for the literature search were that articles were written in English and were either review or discussion articles. The initial search terms used for the first two strands of the literature review were:Supplementary data 1 are available at HEAPOL online). Twelve documents were considered to meet these objectives. The fourth strand of the literature search was to use a snowball technique to identify further documents from the references cited in these 12 documents, as well as two key documents identified by the expert panel we consulted, bringing the total number of relevant documents to 24. Once the search results were compiled using Endnote, the titles and abstracts (or executive summaries) of all records were appraised and 49 were considered to be relevant. Given the small number of documents, one researcher read all 49 in full and made a decision as to whether or not they met the study objectives of identifying different types of evidence synthesis, or highlighted issues to consider when planning the development of an evidence synthesis to match users’ knowledge needs (Supplementary data 2 are available at HEAPOL online). Prior to the literature search, a discussion guide was devised to focus phone and face-to-face meetings with four of these experts. It included identifying the need for evidence syntheses, the value of a question-based evidence synthesis, the value of synthesized evidence versus expert opinion, sound examples of typologies of evidence syntheses and different types of evidence synthesis outputs and their relative validity.Experts in synthesis designed to get research into policy and practice were also consulted to hone issues for consideration and ascertain key studies. We consulted with a panel of eight experts, from diverse backgrounds, with experience of producing evidence syntheses. They were selected purposively because they represented the various types of expertize needed to produce such outputs and included a leading research scientist involved in knowledge translation, health system researchers, advocacy and communications specialists and representatives from large organisations that regularly produce evidence synthesis outputs, and advisers to policy makers  evidence summaries prepared as part of a collaborative project between the Champlain Local Health Integration Network and the University of Ottawa, funded by Canadian Institutes of Health Research, were not initially developed with a predetermined primary research question, user feedback suggested it would provide ‘clarity and direction’ ’. While there are a limited number of databases available to help guide such searches, e.g. Open Grey, these are not exhaustive and often have a basic search function. A clear statement of the issue might be a more suitable starting point . This helps determine a feasible and relevant scope for the synthesis output within the time available. Building on Thomson’s concept, Four Rs fit into a process for matching information needs with appropriate evidence synthesis outputs: once the need for synthesized evidence has been established, an acceptable balance between the Four Rs is agreed and used to make an objective assessment of the types of evidence synthesis outputs, to help identify the most appropriate output.Considering the three Rs should help secure a credible, timely and appropriate output that meets users’ needs. Relevance often relates to the particular context in which evidence synthesis outputs are to be used . Such fahybrid output that offers a peer-reviewed synthesis of recent scientific evidence with practical information for policy makers and practitioners  were beyond the scope of this study. Nevertheless, this study addresses the needs of a wide range of users. An assessment of the in-depth knowledge needs of other audiences may require some adaptation of the framework.Furthermore, while it was beyond the scope of this study, the use of the framework in conjunction with the process for identifying knowledge users’ information needs with an evidence synthesis output, would benefit from being pre-tested and pilot tested with different groups of knowledge users. Although the process currently suggests equal weighting is given to considerations of rigour, relevance, readability and resources, we would expect that different groups of policy and decision makers might emphasize different components in different contexts. For example, the primary concern for academic stakeholders might be rigour, while policy makers might consider readability and relevance to be of primary importance, and practitioners might prioritize relevance. The emphasis given to each component might lead to the adaptation and development of the framework, in order to increase its utility to different user groups.Users’ knowledge needs vary and meeting them successfully requires collaborative planning. The Framework describes the various evidence synthesis outputs identified and the process for matching users’ information needs with an appropriate output. It is intended to offer a more systematic way for users, commissioners and producers to establish a common understanding of users’ knowledge needs, and the essential characteristics to be considered when matching those needs with the most suitable output, given the resources available.Further work would help to address the limitations of this study, such as taking the knowledge needs of other audiences into account.