Purpose: Andrological diseases have an important social and economic impact as they cause a serious impairment of the quality of life of the affected patient. Epidemiologically, the impact of these disorders is progressively increasing, as demonstrated by the ever-growing prevalence of male infertility. This evidence justifies the rapid development of research in andrology that the scientific community has undertaken in recent decades. This study aims to evaluate the productivity index of the main andrological topics studied and reported in the literature. Methods: The total number of published articles was extracted from the Scopus database by entering the following keywords and mesh terms: “Male Infertility”, “Erectile Dysfunction”, “Premature Ejaculation”, “Male Hypogonadism”, “Testicular Tumors”, “Prostate Cancer”, “Prostatic hyperplasia”, “Prostate hyperplasia”, “Prostatitis”, “Prostate inflammation”, and “Male Accessory Gland Infections”. Furthermore, a list of the top 50 researchers sorted by productivity was created for each topic. For male infertility, a further search was performed by combining the search term “male infertility” with the above-mentioned terms. Thus, a list of the top 30 authors in order of productivity was also extracted. The graphs were created using Excel. Results and Conclusions: As could be expected, we observed that prostate cancer and male infertility were the two most investigated topics, followed by benign prostatic hyperplasia and erectile dysfunction, whose prevalence is set to increase given the progressive aging of the population. Less investigated is the inflammation of the accessory sexual glands. In conclusion, this study provides a ranking of the main andrological topics investigated in the literature, also presenting the top list of the most productive authors for each one. Endocrine disorders represent an important cause of morbidity and mortality that significantly impact quality of life. In particular, among endocrine diseases, disorders of gonadal function have an epidemiological impact second only to that of metabolic disorders . It is aSince the field of andrology covers diverse and wide-ranging topics, we have decided to focus our attention on diseases with the highest prevalence and the greatest impact on the quality of life of affected patients.Therefore, a thorough search was performed on the Scopus database by entering the following keywords and mesh terms: “Male Infertility”, “Erectile Dysfunction”, “Premature Ejaculation”, “Male Hypogonadism”, “Testicular Tumors”, “Prostate Cancer”, “Prostatic hyperplasia”, “Prostate hyperplasia”, “Prostatitis”, “Prostate inflammation”, and “Male Accessory Gland Infections”.For these topics, the total number of published articles was evaluated, and then, using the Scopus function that allows the subdivision of articles by author, the list of the top 50 researchers sorted by productivity was extracted. As far as male infertility is concerned, a further search was carried out by inputting combinations of the following keywords: “Male infertility AND varicocele”, “Male infertility AND male hypogonadism”, “Male infertility AND diabetes”, “Male infertility AND prostatitis”, “Male infertility AND prostate inflammation”, “Male infertility AND male accessory gland infection”, “Male infertility AND testicular cancer”, “Male infertility AND sperm DNA fragmentation”, “Male infertility AND FSH treatment”, and “Male infertility AND obesity”. As for the first search, the total number of articles was evaluated, but in this case, a list of the top 30 authors in order of productivity was extracted. The graphs were created using Excel.The list of the main andrological topics in order of productivity is shown in Immediately after prostate cancer, the topic that would seem to be most investigated is male infertility, which, unlike other topics  has its origins in more recent research, but for which interest from the scientific community has grown exponentially.The form of male sexual dysfunction that has seen the highest number of publications is erectile dysfunction, which is also the third most investigated topic. However, it is possible to observe that in the last 10 years, there has been a rapid growth in the number of publications compared to the past 20 years. Conversely, premature ejaculation is one of the least investigated andrological topics.A similar trend of rapid growth over the past 20 years can also be observed for male hypogonadism, which ranks sixth on this list. The inflammatory aspect, on the other hand, although it is one the topics that was studied in the past, when andrology was not yet considered a branch with its own identity, has been less investigated, with only 13,042 articles found when the term “prostatitis” was input and even fewer when the terms “prostatic inflammation” and “male accessory gland infections (MAGI)”  were useThe analysis of the researchers in order of productivity in terms of individual topics is shown in Regarding the sub-research on male infertility, we observed that the largest number of articles was concerned with the association between male infertility and genetics. In particular, it can be seen from In fourth place were publications on male infertility and testicular tumors, followed by publications that correlated the main metabolic diseases, DM and obesity, to infertility. In particular, for these last two subtopics, interest has increased especially in recent years and research trends seem to demonstrate that the interest in the association between dysmetabolism and infertility will progressively increase. Again, the association between infertility and inflammation has been studied the least .The analysis of the researchers in order of productivity on the individual topics of this sub-research is shown in Despite the significant impact of andrological diseases and although male infertility is a global health problem, considerable progress is still needed regarding the management of these diseases, especially in the area of male reproductive health . This arOur research strategy identified male infertility as the second most investigated topic in andrology. This is likely due to the significant global impact of infertility, as mentioned above. In particular, the rapid growth of research in the field of male infertility would appear to correlate directly with the rapid improvement in the genetic study of this condition. In fact, 1/6 of the publications on male infertility seem to be related to genetic aspects, which therefore appear to be the most investigated subtopics. This is probably due to the introduction of next-generation sequencing techniques in the last twenty years, which have made it possible to identify a large percentage of genes involved in the pathogenesis of non-obstructive azoospermia and infertility hitherto identified as idiopathic ,13. ProbThe association between tumor and infertility is another close relationship that we found. In particular, it is known that the treatments that are carried out to cure neoplastic diseases damage fertility . HoweverIn the context of male infertility, we found that the most studied association is with varicocele. In fact, although in general the varicocele topic is among the least investigated in the andrological field, most of the publications that include it studied its relationship in association with male infertility. Not by chance, varicocele is considered the most common correctable cause of male infertility, and a recent meta-analysis confirmed that varicocele repair is able to improve conventional sperm parameters compared to untreated controls . The extOur search strategy subsequently highlighted that hypogonadism, another condition closely associated with infertility, has been extensively studied. Indeed, hypogonadism has a considerable impact on the quality of life of the individual and on fertility, as suggested by the fact that in 75% of infertility cases, a primary testicular dysfunction is present . However6 would seem to be a model capable of predicting with high accuracy the presence of SDF. All of this evidence explains why SDF is a hot topic in andrology today [Our results also noted that among the most studied associations was that between male infertility and SDF. Consequently, the extensive literature that has been published over the years led the World Health Organization in 2021 to introduce the SDF test as a test to be requested under certain circumstances for a better assessment of the fertility status, giving this test a diagnostic value and not only value in scientific research . Howevergy today .Much less investigated are the inflammatory aspects and their impact on fertility. In our opinion, this result is quite surprising given the high prevalence of inflammatory diseases on the male population. Indeed, 5–40% of men suffer from MAGI . FurtherFinally, our results showed wide attention to scientific research on two other highly prevalent andrological conditions: BPH and ED. Regarding the former, attention from the scientific community is not surprising, since BPH has a very large impact on the quality of life of the patients who suffer from it. In fact, in 2017, it was estimated that the years lived with disease attributed to BPH/lower urinary tract syndrome were 2,247,334, compared to 843,226 for prostate cancer. This impact is expected to increase considering the progressive aging of the general population . SimilarOur study has some limitations. First, the search was performed on a single database, although Scopus was the database that produced the most results after keyword entry compared to others, such as PubMed or Web of Science . AnotherAndrological diseases have a significant social and economic impact and compromise the quality of life of affected patients. Undoubtedly, the extensive research in this area has led, over the years, to a better understanding of the pathophysiological mechanism of these diseases and the clinical management of patients suffering from them. However, much remains to be done. Indeed, the progressive increase in age will lead to an ever-higher prevalence of some of these diseases . Similarly, for male infertility, much remains to be understood about the pathophysiological mechanisms underlying this condition and its correct management. Surprisingly, the inflammatory diseases of the male accessory glands appear to be less explored, despite their impact on the quality of life of affected patients and other associated andrological conditions. Our study provides a global overview of andrological research to date, revealing which topics are most investigated and which authors have contributed most to the research on each topic.


Microfilariae parasites are common in tropical regions, and some species are reported as potentially zoonotic. The diagnosis of filarial infection in dogs by cytology or hematologic techniques showed lower sensibility and specificity, which may result in misdiagnosis. Thus, molecular techniques seem to be an alternative to identifying and detecting microfilariae infections. On the other hand, lymphoma is one of the main tumors in domestic animals, with a high prevalence in domestic canines. This study aims to report a mixed infection with microfilariae in a dog with lymphoma, emphasizing its diagnosis and the possible role of this infection in the development of the neoplasia.An 8-year-old male mixed breed dog was referred to consultation due to the presence of lethargy, recumbency, skin ulceration lesions, nonspecific pain manifestations, emesis, myoclonus in the left temporalis muscle, and seizures. Routine blood and biochemistry tests were normal, and cytology of the skin evidenced a microfilariae infection. The dog died due to a cardiorespiratory arrest, and tissue sampling was done for histopathology and molecular analysis at the necropsy examination.Acanthocheilonema reconditum. Histopathology of the spleen and liver revealed a diffuse lymphoma composed of blast cells and large lymphocytes, distributed diffusely in the parenchyma and surrounding the vasculature. In the skin, microfilariae were seen in some superficial capillaries.Skin lesions were related to a microfilarial pyogranuloma related to A. reconditum and Dirofilaria immitis in a dog with a lymphoma and its molecular detection. To the knowledge of the authors, this is the first report of a mixed microfilariae infection in a tumor of a dog and highlights the use of molecular techniques, i.e., polymerase chain reaction, for an accurate diagnosis.This study describes a microfilariae mixed infection with  Several species can be found, including Dirofilaria immitis,Dirofilaria repens (Dirofilariinae subfamily), Acanthocheilonema reconditum, Amphiachyris dracunculoides, and Cercopithifilaria spp., (Onchocercinae subfamily) [D. immitis has been detected by immunochromatography and ELISA [A. reconditum are scarce [Filarial worms can infect canines as the definitive host; they belong to the order Spiruridabfamily) . Discrimbfamily) –4. In Cond ELISA . Howevere scarce .On the other hand, lymphoma  is one of the most common tumors in dogs, with an annual incidence estimated to range between 13 and 114 per 100,000 dogs at risk . The mulD. immitis and A. reconditum in a dog with lymphoma is described along with its diagnosis by cytological, histopathological, and molecular methods.In human patients, the coexistence of neoplasia and filarial organisms has been described, mainly in endemic areas, but the cause is under discussion –11. The An 8-year-old male mixed breed dog was referred to consultation by his owner due to lethargy remaining in recumbency, skin ulceration lesions, nonspecific pain manifestations, emesis, and myoclonus in the left temporalis muscle. Fifteen days before the consultation, the dog was treated with phenobarbital and B complex due to the presence of seizures, which persisted even after treatment. Since the patient previously presented coughing episodes, the presence of hemoparasites was considered.Upon physical examination, physiological constants were within reference values, and the patient ate and drank water normally. In addition, complete hemogram analysis, serum biochemistry, skin cytology, and a canine distemper virus (CDV) antigen rapid test  were performed. For skin cytology, imprints were made from the ulcerated areas by lifting the scar and imprinting it with the slide, allowing it to dye and stain with Wright .g for 5 min. Morphological characterization was performed in a binocular microscope  at 5× and 10× magnification for the Woo test and 100× for the smear.Due to the suspicion of hemoparasites, a Woo test and a blood smear that was stained with Wright were performed. First, canine whole blood was transferred to capillaries without heparin, and then the end of the tube was heat-sealed and centrifuged at 13,700×The patient did not show any alteration in the hemogram, and it was negative for the CDV test; however, due to its symptoms, it was decided to keep the patient under observation and start a pain treatment with multimodal analgesia  at night. The next morning, the patient showed no improvement; thereby, tramadol was administered. Despite the treatment, the patient died due to cardiopulmonary arrest. A necropsy examination was carried out, and samples from the liver, spleen, kidney, urine, brain, cerebellum, cerebrospinal fluid, and skin were collected for histopathology and molecular diagnosis. All the procedures, including sampling collection, followed the guidelines for research ethics and animal welfare based on resolution number 8,430/1,993 and law 84/1,989 and fulfilled the guidelines for animal care and use in clinical research and teaching.® Tissue DNA Kit  following the manufacturer’s instructions. The quality of the extracted DNA was verified by spectrophotometry  and amplification of canine beta actin (ACTB). Detection of microfilariae was performed by amplifying ribosomal RNA (rRNA) 5.8s-ITS2-28s, using primers flanking conserved areas of the gene. To discriminate between filarial species, the cytochrome oxidase C subunit 1 (COX1) gene from D. immitis and A. reconditum was amplified  gene were used  was extracted from tissue samples using the E.Z.N.A.mplified . To idenere used .® DNA Polymerase , gDNA sample (1 μl) and distilled and deionized water (14.85 μl). Amplification was performed in a thermocycler  with a first denaturation cycle for 3 min at 94°C, followed by 35 cycles of denaturation at 94°C for 30 sec, annealing at specific temperatures  was carried out using a reaction volume of 25 μl, composed of 5× standard reaction buffer (5 μl), 1.5 mM dNTPs (2 μl), primers forward and reverse , 0.15 μl of OneTaqeratures  for 30 sPCR amplicons were revealed by horizontal agarose gel electrophoresis (2%), stained with Hydragreen , at 100 volts for 40 min using the MyGel Mini electrophoresis chamber , and visualized through the ENDURO GDS™ gel documentation system  under ultraviolet light.A. reconditum. The morphological characteristics of the parasites observed in the Woo test were similar, including a cephalic region and a filiform ending. In addition, progressive and stationary movements were observed.In the cytology of ulcerative lesions of the skin of the right hindlimb, a hemorrhagic background with neutrophil predominance, the presence of macrophages, and the absence of bacteria were noted . LikewisHistopathological analysis of the spleen revealed a diffuse lymphoma composed of round cells, blast cells, and large lymphocytes, distributed diffusely in the parenchyma and surrounding the vasculature, megakaryocytes, hemosiderophages, and plasma cells were also evidenced . The neo.Skin showed marked dermal interstitial and perianexal fibrosis and a mild multifocal leukocyte infiltration with the presence of lymphocytes, plasma cells, and scarce neutrophils distributed in some pilosebaceous and epitrichial units and the superficial capillaries . MicrofiACTB gene was amplified from all samples (data not shown) with a size of approximately 497 bp, indicating adequate gDNA quality. 5.8s-ITS2-28s rRNA was amplified to determine the possible species of microfilariae in the canine patient, with similar amplicon sizes for D. immitis and A. reconditum (COX1 fragments corresponding to each filarial species, it was shown that the kidney, spleen, brain, and blood samples presented genetic material of A. reconditum and that the skin, lung, and liver samples presented a coinfection of A. reconditum and D. immitis (conditum . By ampl immitis .Filariasis is a worldwide parasitic disease affecting both domestic and wild animals as well as humans, and it is necessary to differentiate among etiologic agents for epidemiologic surveillance . LaboratMicroscopic techniques allow the identification of microfilariae in the blood . Knott’sD. repens, D. immitis, and A. reconditum described by McCall et al. [A. reconditum infection differs from that for heartworm, it is crucial to distinguish between the two [COX1 was used to identify the diversity of filarial species [D. immitis and A. reconditum found in this patient is consistent with other studies that have reported coinfection of filarial worms [In this study, the microscopic findings matched those of l et al.  and Otral et al. , and difl et al. ,15. Therl et al. . In addi the two . In the  species , and 5.8al worms ,17–19, iwsp gene from the endosymbiont bacterium Wolbachia spp. was negative, excluding the presence of this microorganism, like Ionică et al. [In our study, the detection by amplification of the ă et al. . The DNAAcanthocheilonema reconditum is a species that generally does not require treatment; therefore, its identification prevents inappropriate medical treatment. All heartworm-infected dogs, however, have the potential to infect people, making them a public health concern [A. reconditum in pets may justify treatment to reduce potential transmission to humans [ concern ,20. Thero humans .Schistosoma haematobium eggs in the wall of the urinary bladder and Schistosoma japonicum eggs in the wall of the large intestine is responsible for squamous cell carcinomas, and Opisthorchis and Clonorchis can cause cholangiocarcinomas [D. immitis and A. reconditum in this organ. The presence of these parasites in the neoplastic spleen could be explained by several mechanisms, including their transmigration, lymphatic blockage due to scarring, inflammatory damage, trauma, or stasis, as well as neovascularization that favors parasite concentration in the tumor [The presence of rcinomas . In the rcinomas , which hrcinomas . In the he tumor . Howeverhe tumor ,10–21, che tumor  demonstrA. reconditum DNA was detected in the spleen, and there was no evidence of the parasite in the cytology or histopathology of the spleen, highlighting the need to implement molecular techniques.In most cases, microfilariae are not found directly in the tumor under the microscope . In our A. reconditum and D. immitis in a dog with a lymphoma. They highlighted the relevance of molecular techniques in diagnosis and the studies about the role of parasites in the development of neoplasia.This study showed for the first time, using molecular methods, a microfilariae mixed infection with


Their article is an important contribution to the body of research promoting KT. In this commentary we reflect on the convergences and differences between the concepts of ‘sustaining’ and ‘institutionalizing’ KT, highlighting domains and processes related to the institutionalization, providing an analysis of KT landscape in Brazil and making a case for the need to increase countries’ routine use of evidence.In their study of sustaining knowledge translation (KT) practices, Borst et al found that this process is an interplay of: ( Country-owned KT infrastructures and mechanisms are key to implement an equitable COVID-19 recovery process, increase country resilience against the current and future crises, and address societal challenges in ‘peace’ times. It has become clear, though, that capacities, productive relation and partnerships between researchers, policy-makers and other stakeholders, just as trusted mechanisms, need time to be in place before a crisis hits.4 The unprecedented evidence climate presented by the COVID-19 pandemic provides a unique window to promote knowledge translation (KT) and evidence-informed health policy-making (EIHPM).6 Despite the increased international recognition and efforts to promote the systematic and transparent use of evidence in policy and practice, KT initiatives continue to be frequently linked to externally funded, time-bound projects disconnected from local needs and ownership. As a consequence, KT practices are susceptible to being discontinued once projects come to an end, leading to an investment loss for the organizations involved and jeopardizing the achievement of set public health goals. translating, contexting, and institutionalizing.5 Realizing the need to identify means by which countries are guided in maintaining their KT work, Borst et al conducted a critical interpretive synthesis, exploring both the meaning and processes of sustaining evidence-to-policy activities. The resulting conceptual framework is a valuable contribution to the body of research literature: three main processes were identified as constituting the sustainment KT process:7 For years, WHO with its Evidence-informed Policy Network (EVIPNet) has been promoting Member States’ capacity in KT and EIHPM by providing training workshops and developing, jointly with its partners, cutting-edge KT approaches and tools to empower countries and strengthen their leadership in formulating and implementing health policies embedded in sound evidence. In 2021, to accelerate processes towards more mature KT institutionalization, EVIPNet developed a new global roadmap for supporting evidence into policy and action. It was launched in the form of a call for action at the WHO Evidence-to-Policy Summit.8 Departing from the same line of reasoning as Borst and colleagues, the World Health Organization (WHO) has recently developed an institutionalization checklist for its Member States relying on domains and processes for institutionalizing EIHPM.9 to assess the country’s KT landscape and identify the institutional niche for and mechanisms to establish national knowledge translation platforms (KTPs), no concrete Guidance was available to countries for the implementation of more strategic and comprehensive KT institutionalization processes towards better health policies. Both the article and the checklist contribute greatly to this: while Borst and colleagues outline conceptually the (re)creation of KT systems, the WHO approach provides clear steps towards its institutionalization, aiming that governments can indeed routinize the use of evidence in health policy-making. Before that, beyond supporting the conducting of an EVIPNet situation analysis In the following we will briefly describe how the work of Borst et al and of WHO complement and mutually enrich each other to provide a more comprehensive view of sustaining and institutionalizing KT. We will first try to entangle the concepts of sustainment and institutionalization, secondly, outline the domains and processes identified on KT institutionalization efforts, providing the example of Brazil as a case study of how the concepts developed by Borst et al and by WHO can be associated in a country’s analysis, and finally focus on a call to action for increasing countries’ resilience against future crisis.6 In the context of KT, both concepts aim to promote the routinization of evidence-to-policy activities to ensure that policy processes are regularly informed by relevant knowledge while relying on strategic linkages and exchange between policy-makers, researchers and other stakeholders, and making the activities last.6 Importantly, both concepts also need to be seen as being a process, ie, a set of ongoing activities, just as an outcome. Reflecting the latter, WHO suggests defining KT institutionalization as a7: The conceptual separation between institutionalization and sustainability reveals itself as difficult, with the terms often used synonymously.Process and outcome of (re-)creating, maintaining and reinforcing norms, regulations, and standard practices that, based on collective meaning and values, actions as well as endowment of resources, allow evidence to become – over time – a legitimate and taken-for-granted part of policy-making.”6 “Institutionalization relies on building relationships and interactions between those stakeholders that produce research evidence, and how they connect, interact and network with the ones who will use this knowledge. It is also affected by institutional capacities to conduct the processes and uphold the standards.”10 “6 In other words, while sustainability can be seen as the umbrella concept under which institutionalization is featured, sustainment and institutionalization both aim for the similar outcomes in terms of securing the permanence of activities and the related durability of societal benefits such as the achievement of the Sustainable Development Goals. Although one could argue that with its focus on longevity and duration, the concept of sustainability omits to consider how much a practice is actually built-in to a society and enshrined in its structures, rituals and beliefs, a range of authors  argue that institutionalization is an important phase instrumental to achieving sustainability.5 relying on the identification of key institutional and contextual factors contributing to institutionalizing and promoting the longevity of KT at country level. WHO supplements the ‘factor’-centred approach by providing guidance on how countries can initiate and advance their journey of KT institutionalization, including how the proposed institutionalization factors can be enhanced.6 Despite the similarities in terms of goals and outcomes, the approaches taken forward by the work of Borst et al and WHO considerably differ. While Borst et al promote a practice-centred perspective, WHO has focused with its work on what the authors call a ‘factor’-centred approach,, understood as encompassing both the transformation of knowledge and the creation of engagement processes and connections between the producers and users of research. The process of translation in Borst and colleagues’ framework goes hand-in-hand with the contexting of KT practices, meant as the day-to-day work of actors constructing contexts that are conducive to reproducing KT practices.5 Borst and colleagues’ article and WHO share a similar definition of KT6 While WHO’s work does not explicitly feature KT practices, the domains and process frameworks point out the need for actorial efforts and the continuous, pro-active reproduction and adaption of practices to advance the institutionalization agenda. This includes the continuous reproduction and strengthening of the domains just as the routinization both of KT processes and of policy-makers regular requesting evidence, enabled by the institutionalization domains. The domains framework, in a nutshell, combines six conceptually distinct, but interlinked domains that offer guidance to KT actors seeking to improve the institutionalization of their efforts: “ 1) Governance – wide range of rule-making and steering-related functions, including institutionalized structures, mandates or platforms that span the boundaries between research and policy; 2) Standards and routinized processes – tools and protocols, as well as institutional memory and documentation processes, to ensure minimum standards and high-quality KT products and processes; 3) Leadership and commitment – strong charismatic leadership and champions who have the ability to affect the long-lasting adoption of EIPM directly, through allocation of resources  and indirectly, through encouragement, support, and mentorship; 4) Resources and capacity-building/strengthening – availability and development of human, financial, material and information resources. Having a critical mass of people, within and outside of the organization, skilled in applying KT routinely and consistently, and throughout time; 5) Partnership, collective action and support – extent to which stakeholders interact in the “organizational field,” providing a mechanism for continued engagement and involvement of multiple stakeholders for the same cause, joint problem-solving, identification of resources for ongoing KT, and continued technical support; and7 6) Culture – basic values, assumptions and beliefs that are considered valid and are being disseminated and promoted as daily practices. These allow for a common understanding of what KT is, what value it can bring about and what is to be expected in terms of activities and benefits.”7 Actorial efforts become even more pronounced in WHO’s process framework of KT institutionalization. Indeed, institutionalization, to be understood as a non-linear process comprising of the phases of pre-institutionalization, semi-institutionalization, re-institutionalization and, potentially, renewed de-institutionalization, is relying on a constant negotiation and reproduction of practices shaping the institutional landscape and contexts over time. Conscious steps need to be taken to influence the general discourse, legitimize practices, and mobilize both material and immaterial assets to effect change at the beginning of the institutionalization process, or maintain the status quo through the reproduction of social order and standardized, habitualized behaviours once a mature stage of institutionalization has been reached. In March 2022, members from Instituto Veredas, a Brazilian evidence center, applied the WHO checklist while presenting the national evidence ecosystem to an international community of practice. From the practice-centred approach of Borst and colleagues, the idea of KT as (re-)building of networks by creating connections between places of knowledge production and utilization resonates with the Brazilian experience, due to ongoing efforts related to the institutionalization of EVIPNet Brazil and the Brazilian Coalition for Evidence. Also, the double-meaning of ‘context,’ highlighted by Borst et al as an environment to which the KT practice needs to be attuned to and as a concrete set of facilitators and barriers, was useful to characterize how KT institutionalization changes in a country with so much local diversity such as Brazil. From the WHO domains and processes, it was possible to frame the country as having reached an institutionalization stage in the Leadership and Partnership domains. Despite having some KTPs embedded in governments, Brazil still is in the semi-institutionalization stage in the Governance, Resources and Standards domains, especially when moving away from the health sector. Finally, the COVID-19 pandemic sparked debates that fostered the Culture domain, which is still very much in the pre-institutionalization stage. From this comprehensive reflection on the national context, Instituto Veredas alongside the Brazilian Coalition for Evidence designed an early-career introductory course and mentorship on KT for researchers who are gender and race-diverse and focus on evidence for social policies to the North and Northeast regions of Brazil. This capacity-strengthening initiative was launched on June 2022 as a measure to improve the underserved domains of culture and human resources, reflecting a direct combination of the practice and factor-centred approaches to KT institutionalization.6 We agree with Borst and colleagues’ suggestions of further empirical studies to understand what actors do to create, amend, or dismiss institutions, and how they interact and shape the KT context.5 To scale-up KT institutionalization, case studies and a pilot testing of the WHO institutionalization checklist are required. In addition, further research is needed to fully understand the complex interrelations and system equilibrium between the six institutionalization domains as some domains may be more relevant in certain sociopolitical and cultural context than in others.2 We urge governments, intergovernmental organizations and other key stakeholders, such as bi-/multilateral donors and foundations, to join our efforts so as to the routine use of evidence in decision-making becomes the norm and a meaningful difference to national policy-making and the lives of people can be made. The most pressing step now it to mobilize political commitment and investments to put in place the national, regional and global implementation plans for KT institutionalization. Not applicable. TK is employed full-time with WHO, working in the fields of research, evidence and policy. LdSB had a consultancy contract with WHO on institutionalizing EIHPM. TK contributed to the conception, writing and formatting of the commentary, LdSB contributed to the writing and reviewing of the commentary. All authors read and approved the final manuscript. The authors alone are responsible for the views expressed in this paper and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.[1] EVIPNet’s website: https://www.who.int/initiatives/evidence-informed-policy-network[2] According to EVIPNet, a KTP “is an organization or network that brings together the worlds of research and policy” (p. 6).11 A KTP develops strategies to better understand a particular policy issue; harvest, synthetize, package, disseminate and broker local and global evidence to inform policy development and implementation among stakeholders; and strengthen KT capacities of researchers, policy-makers and other stakeholders.11[3] WHO defines KT as “the exchange, synthesis, and effective communication of reliable and relevant research results. The focus is on promoting interaction among the producers and users of research, removing the barriers to research use, and tailoring information to different target audiences so that effective interventions are used more widely” (p. 140).12


We discuss how presence is a way of restoring human beings’ relational and dialogical nature. To inform a different perspective on relational ethics, we also discuss how accompaniment refers to the clinician’s awareness of the human condition and its existential limits.In this paper, we offer a phenomenological and hermeneutical perspective on the presence of clinicians who care for the suffering and dying patients in the context of end-of-life care. Clinician presence is described as a way of (1) being present to the patient and to oneself, (2) being in the present moment, and (3) receiving and giving a presence (in the sense of a gift) End-of-life careconnection and being. However, is such ethics promoted today? Contemporary healthcare models fit into the framework of biomedical thinking and its positivist paradigm, concerned with capitalist efficiency, standardization, and control  and to maintain their relationships . Given this complex goal, palliative care is the responsibility of several clinicians from different backgrounds . The concept of ent Wood . The phient Wood . As we sof something. In other words, the consciousness does not exist by itself, it is directed towards objects and persons. In the work of Husserl . The fact that human existence is made of possibilities puts us, according to Heidegger, in a state of endless questioning, mainly because the utmost possibility is death. Time, therefore, reveals the ambiguity of human life: the future is both existence and finitude  and given conditions . In Heidegger’s opinion, this background represents an inherited tradition over which one has no control but must detach to unveil their conditions of existence  The Grondin . These t Grondin .encounter based on the fusion of two different traditions or horizons . But as Heidegger and Gadamer argued after Husserl, this transformation is limited. This means that presence is related to finitude, in the sense that clinicians can reach presence only if they keep in mind the finitude of human existence and the limits of human understanding. Also, presence is related to finitude because death directly calls for the deployment of presence  being present to oneself and the other, (2) being in the present moment, and (3) receiving and giving a presence (in the sense of a gift).direction and the quality of attention  and time (now) where the self and the other can meet. We refer here to presence as being in the present moment. The hermeneutic phenomenology approach invites us to live the present in the perspective of the past and the future. For example, there is a connection between presence and the dimensions of past and future when the clinician receives the patient’s story (which is part of the patient’s narrative identity) but also when the clinician is attentive to the history of his or her relationship with the patient, which includes an attention to the expansion of the clinical encounter. Thus, being in the present moment refers less to a fixed temporality than to an attention to the instability and the expansion of our experiences, which compels to be attentive to the ways in which the relationship with the patient changes (deepens) over time and with each encounter.to do—do more, all the time, more quickly  with an unusual passivity (slowness) because only then could they receive something from the patient  and be touched by it. As presence with the patient deepens, time seems to slow down and space seems to open up , but also by the time limit that comes with the fast pace of the healthcare system (the clinician tries to find time to open and deepen the relationship). The clinician’s responsibility is to respond to the ethical injunction of being present to the other and cultivate their relationship despite its limits.In addition, the clinical encounter and the meaning that emerges from it are neither continuous nor fixed once and for all. The encounter is a brief event of meaning Gadamer . The consuffering with the other. The patient’s suffering may be unsubstitutable and unspeakable, yet the patient’s demand (for connection and meaning) is limitless . Denizeau . An undeThis concluding section illustrates the important issue of human powerlessness in end-of-life accompaniment through the case of Mrs. K, whom we have met before her death. Mrs. K was a fifty-year-old woman with advanced thyroid cancer. She had been admitted to palliative care after an acute respiratory distress syndrome followed by a tracheostomy. She was unable to communicate verbally due to the tracheostomy, so writing was the only way for the care team and her family to connect with her. Mrs. K’s relatives were very uncomfortable seeing her suffering and knowing that she was dying, especially since her tracheostomy. They were not often at the bedside, and when they were, they felt helpless and useless, which affected their ability to be present. Therefore, our role with Mrs. K was to offer a kind of presence that her relatives could not provide, due to their own suffering. Although the topic of this article is not the clinician’s meeting with the family, we can mention here that our role with the relatives was to help them better understand what they were experiencing and to validate their feelings of powerlessness.The clinical encounter between Mrs. K and us was based on presence. First, Mrs. K initiated a relational movement with her demand for relationship and meaning—her demand took the form of apparent suffering, looks, cries, and written words/questions. Our role as clinicians was to recognize Mrs. K as a suffering person and to respond to her demand by cultivating presence, that is, by becoming present to ourselves and to her, by being in the present moment, and by allowing her to give (teach) us something. We invited Mrs. K to enter into presence with us, by inviting her to become more attentive to her own experience as well as to our relationship, which was an implicit way of encouraging her to adopt a phenomenological attitude. Our concern was to create the opportunity for Mr. K to awaken her consciousness and to enter into an authentic encounter, so that she could better understand what it was like to experience the end of her life, here and now. Over the course of two sessions, Mrs. K shared with us her fear of dying of respiratory failure. More deeply, she expressed anxiety about the reality of her decline and saw no meaning in life. We came to understand that severe illness had shattered her sense of identity, and created an existential crisis. She had always seen herself as an active woman, in control of her personal and professional life, and the end of her life appeared dramatically inconsistent with her life up to that point.do, but it was still possible to be there with her. So we set a new therapeutic goal: to be in contact with the powerlessness of the patient and our own powerlessness. We opened a dialogue in silence with Mrs. K. With her consent, we touched her hands and her hair. Over the days, we established what appeared to be a ritual: we sat at her bedside and stroked her hair, a gesture that led her to allow herself to cry (which she was not able to do otherwise in front of her family) and to fall asleep.Before the third session, Mrs. K’s health condition deteriorated. Medical tests showed the development of brain metastases. Rapidly, Mrs. K lost the use of her right hand which affected her remaining ability to communicate with others. At the same time, Mrs. K also began to refuse medication. The therapeutic impasse seemed obvious at first, as it seemed impossible to put into words the patient’s suffering and alleviate it through medication or conversation. The silence of the dying patient was particularly difficult for the care team and the family to tolerate because it underscored their powerlessness. Faced with this situation, we had to focus even more on our intentionality and trust in the non-medical quality of presence. There was not much to The case study suggests that a dialogue took place with Mrs. K  because we trusted the effect of presence. Because we intentionally focused our attention on the patient and, more broadly, on the human existential conditions we shared with her, we offered her the possibility of a meaningful dialogue, that is, a more active participation in life and a new meaning, at a time when action and meaning were precisely limited. Returning to Ricoeur’s  definitiThis paper offers a phenomenological and hermeneutical perspective on the presence of clinicians who care for suffering and dying patients, using an original perspective on relational ethics in healthcare. This theoretical reflection helps to conceive how end-of-life accompaniment depends on the clinician’s experience of the human condition. Presence is a way of being and connecting with oneself and the other, restoring the relational and dialogical nature of human beings. The very condition of a patient-clinician encounter produces connection and meaning. Another contribution of this paper is to emphasize how the clinician can embody a particular presence to offer resonance in the face of suffering and death. If the vulnerability of the dying patient may be obvious, that of the clinician is often forgotten and disregarded. Therefore, this article contributes to filling a gap in the current literature on the clinicians’ work with patients. More broadly, accompanying patients on their way to death appears to be a way to respond in a more appropriate manner to the essential question of human suffering. It is through medical humanities that we may hope to find, on the one hand, a different kind of remedy to our modern relation to suffering and, on the other hand, a different response to patients’ suffering.Although this paper emphasizes the ethical significance of accompaniment, it does not leave aside the limits of clinician presence. The suffering patient may have a difficult relationship with the world and others, and this existential situation can complicate the care relationship and even imply a loss of reciprocity. Being present appears even more difficult in today’s hyper-organized societies that tend to speed things up and push us toward insensitivity Rosa . Conside


Background: Clinical practice guidelines make recommendations based on the best available evidence. Proper management and disclosure of financial conflicts of interest (FCOIs) are necessary for trustworthy clinical practice guidelines. This study evaluated the prevalence of FCOIs and quality of evidence underlying the American Diabetes Association (ADA) guidelines.Methods: Using the Open Payments Database (OPD) between 2018 and 2020, we examined the research and general payments to all authors of the Standards of Medical Care in Diabetes, 2021. The quality of evidence and tone of recommendations were assessed and the associations between the two were evaluated by logistic regression analysis.Results: Of the 25 guideline authors, 15 (60.0%) were United States (US)-based physicians eligible for the OPD search. Eight (32.0%) and 12 (48.0%) received one or more industry payments one year and three years prior to the guideline publication, respectively. The median total payments (interquartile range) per author were $33,262  in 2020 and $18,053  in 2018-2020. One author received a research payment of over $10,000 undeclared. Of 471 recommendations, 61 (13.0%) and 97 (20.6%) were supported by low-quality evidence and expert opinions, respectively. Also, 439 (93.2%) recommendations had a positive tone. The lower quality of evidence tended to recommend positively with an odds ratio of 1.56  without reaching statistical significance.Conclusion: A minority of the guideline authors received industry payments from the healthcare industry, and declared FCOIs were mostly accurate. However, the ADA FCOI policy required the guideline authors to declare their FCOIs for one year before publication. A more transparent and rigorous FCOI policy is needed in the ADA guidelines. Transparency in the management of financial conflicts of interest (FCOIs) and making recommendations based on the best available evidence are the two foundations necessary for developing evidence-based clinical practice guidelines . FCOIs pAdditionally, clinical guidelines often made recommendations based on low-quality evidence such as expert opinions and case studies -18. Of tHere, we evaluated FCOIs of the diabetes guidelines issued by the American Diabetes Association (ADA), using the US Open Payments Database, the federal payment disclosure database. Furthermore, we assessed the quality of evidence supporting the recommendations.This study aimed to assess the prevalence of FCOIs and the quality of recommendations of the ADA guideline for diabetes. We considered all guideline authors and recommendations in the Standards of Care in Diabetes, 2021, as this was the latest version of the ADA guidelines for diabetes at the time of the study (November 2021). As the ADA guideline disclosed authors’ FCOIs from the past one year and the latest payment data from the Open Payments Database was 2020, we considered all authors of the ADA guideline for diabetes care published in January 2021. Names of authors, quality of evidence, and self-reported conflicts of interest (COIs) were extracted from the guideline. We collected all categories of payments made to ADA guideline authors from the Open Payments Database between January 2018 and December 2020, as many societies require guideline authors to declare their COI for the past three years ,20. PaymThen descriptive analyses were performed on the payment data. Payments per author were calculated based on authors receiving a payment each year, as in other studies ,21-25. TThis study was approved by the Ethics Committee of the Medical Governance Research Institute . Informed consent from the study participants was waived, as this study only analyzed publicly available databases. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.Of the 25 guideline authors, 15 (60.0%) were US-based physicians eligible for the Open Payments Database search  and 97 20.6%) were supported by low-quality evidence and expert opinions, respectively, while 29.3% were based on high-quality evidence including well-controlled multicenter clinical trials and meta-analyses. Also, 439 (93.2%) recommendations had positive tones (Table 0.6% wereThis study elucidated eight 32.0%) ADA guideline authors had FCOIs with industry and FCOIs were majorly consistent with payment data in the one year before the guideline publication. Only one author failed to self-report FCOI. Many previous studies showed that there were widespread financial conflicts of interest between guideline authors and the healthcare industry in most specialties ,19,27-372.0% ADA However, in the past three years, more than 50% of the guideline authors had FCOIs with industry, which was a deviation from the US Academy of Medicine’s trustworthy guideline standards . The IntBesides FCOI, greater than one-third of clinical practice guideline recommendations were based on low-quality evidence with almost all positive tones. Importantly, recommendations supported by lower-quality evidence might encourage more intervention. When high-quality evidence was not available, experts’ opinions and consensus-based recommendations were made. However, expert-consensus-based recommendations gravitate towards discordant recommendations than evidence-based approaches . AdditioThis study included several limitations. First, we could not exclude the possibility of errors in the Open Payments Database, as some previous studies  with mucA minority of the guideline authors received industry payments from the healthcare industry one year before the guideline publication. These authors’ declared FCOIs were mostly accurate. However, the ADA FCOI policy set a shorter period for authors’ FCOI declaration than other global FCOI policies. More than 50% of the guideline authors had FCOIs three years before the publication. A more transparent and rigorous FCOI policy is needed in the ADA guidelines.


N = 109) and confederates worked on an individual task with a dividing wall obstructing their view of each other. When the mobile phone of the experimenter was missing from an adjacent room at the end of the session, all participants confirmed that the confederate had not left the room. After several days, participants returned to the lab for a second session. They were asked to confirm their corroboration, orally and in writing, after learning that the confederate either had been identified from a photograph or was present on camera footage. A control group received no evidence. In this second session, written  alibi corroboration was weaker in the incriminating evidence conditions (47%) than the no-evidence condition (81%), as hypothesized. Unexpectedly, corroboration was equally strong in the camera and identification evidence conditions. As expected, alibi corroboration was stronger in session 1 than in session 2 for both camera (89% and 31–46%) and identification evidence conditions (86% and 31–49%). The current findings provide first evidence that camera footage and eyewitness identification testimony can bear on the availability of exculpatory alibi evidence in court and emphasize the need to document incidents of evidence contamination.The present field experiment investigated how alibi witnesses react when confronted with camera footage or identification testimony that incriminates an innocent suspect. Under the pretext of a problem-solving study, pairs of participants ( However, how context information can shape a witness’s perception and decision-making in providing a stranger with an alibi is poorly understood. Here, we study how identification evidence and camera footage evidence can affect a witness’ willingness to provide an alibi to a stranger.Wrongful convictions can originate from flawed incriminating evidence and the absence of exculpatory evidence. Providing an alibi to someone is one such powerful piece of exculpatory evidence that can be lost because of context information. More specifically, although irrelevant for the task at hand, context information has the power to bias the evaluations of (forensic) evidence. For instance, consider a fingerprint or handwriting expert who becomes aware of a suspect’s confession. Although the confession itself should be irrelevant to the expert’s evaluation, knowledge of it increases the likelihood of interpreting non-matching fingerprints  or handwA growing body of literature shows the significant impact of context information on the decision-making of forensic experts. Numerous studies have demonstrated that forensic evaluators, such as fingerprint and DNA analyst, odontologists and radiologists, can be influenced by extraneous context information –6. For eAnother line of research suggests that context information may not only affect evaluations of evidence but also the evidence itself. For example, when eyewitnesses received information that the suspect confessed, they often changed their lineup identification decision to align with the confession , even ifconvictingtheinnocent.com) lists 156 cases of innocent convictions in which the defense presented an alibi as innocence defense. Whereas we cannot infer from the available case descriptions why these alibis were not believed, we do know that in John Kogut’s case, for instance, alibi witnesses withdrew their support when the police told them that the suspect had confessed ) and DNA , camera footage , and fingerprint analysis  the most reliable, ts(21/20) ≥ 8.55, ps < .001, ds ≥ 1.87, for the three comparisons with showup. Participants’ sorting order confirmed this finding (we report reversed scores for ease of interpretation): again, showups scored lowest , whereas DNA , fingerprint , and camera footage analysis  scored highest, ts(20) ≥ 9.20, ps < .001, ds ≥ 2.00, for the three comparisons with showup. A majority of participants thought that these methods would be used in case of a theft .Participants considered showup evidence the least reliable  as more elastic type of evidence and fingerprint analysis as less elastic type of evidence. We did not consider DNA because it would be difficult to convince participants that a DNA test had actually been conducted. However, following pilot testing, it became clear that participants would not believe that we actually conducted fingerprint analyses, either. We therefore used camera footage as less elastic type of evidence. This choice is supported by research in the elasticity of evidence that shows that camera evidence is considered less elastic than identification testimony , 19, Expn = 37, 36, and 36. The strength of alibi corroboration in session 1  and session 2  and the differences between them  served as dependent measures. We also measured participants’ beliefs that the confederate did not leave the room and that she was guilty of the theft.We used a mixed 3 (type of evidence: no evidence vs. camera footage vs. identification testimony) x 2 (time of measurement: session 1 vs. session 2) design. Type of evidence was a between-subjects factor and time of measurement a within- subjects factor. The sample sizes of the three evidence conditions were The procedure was based on Marion et al. . Fig 1 sThe experimenter greeted the participant and the confederate and provided them with consent and demographic data forms. As a cover story, the experimenter informed them that the study tested how different sleeping patterns related to performance on individual and dyadic problem-solving tasks. The experimenter used her smartphone to schedule session 2 with each of them and left it on top of a desk. After setting a time and date, the experimenter led both the participant and the confederate to a different lab (lab Y), leaving her phone on the table in the first lab (lab X).When entering lab Y, the confederate made sure to sit in the chair close to the door, so that the participant would sit on the spot that was equipped with a heart-rate monitor. The experimenter then mentioned a “pilot study” they were currently running “on the physiology of problem-solving” and asked the participant if it was okay to attach them to the monitor using a finger clip. The confederate would also agree, but the experimenter would ask the participant if they minded, because they were closer to the device.The experimenter then provided the pair with the dyadic problem-solving tasks. The experimenter then exited the lab but left the door open, mentioning that it could get quite hot in the lab. The confederates who were blind to the experimental conditions, acted politely, but not overly friendly or likeable towards the participant (cf. ). The coAfter seven minutes, the experimenter returned, handed out the individual problems and told the pair to work on their own. She also put a dividing wall between the two, so they could not see each other and so that the participant could not see the door. When exiting the experimenter left the door open. The confederate made some noises throughout, such as clicking a pen and moving in her chair to create the impression that leaving the room would have been difficult, but not impossible for the confederate.Another seven minutes later, the experimenter returned and, to support our cover story, provided two sleep questionnaires , 21 and Session 2 took place about 3–6 days later as an individual session . To maintain the cover story, the experimenter provided the participant with a new set of individual problem-solving tasks and three questions about the quality of their sleep in the previous night. When the experimenter returned, she announced completion of the experiment. She then mentioned that she had not found her phone after session 1, that she suspected it had been stolen, and that she had to fill in an incident report form. The experimenter explained that she knew that the participant could not have taken the phone because they had been attached to the monitor the whole time, but that she suspected the confederate.In the identification condition, the experimenter added that another researcher who used the lab across had seen someone enter lab X and had identified the confederate as being that person from a photograph fetched from Facebook. In the camera condition, the experimenter stated that she had asked security to look at the camera footage from lab X and that she had seen the confederate enter and exit the lab. However, because the camera was directed at the door she could not see whether the confederate took the phone.not at all) to 10 (definitely). In the end, the experimenter asked participants not to share information with others about the study, debriefed the participant, and provided the consent form for the use of their audio recordings. Session 2 took about 20 min.The experimenter presented the incident report form, read the form with the participant and asked the participant to sign the form as a witness. The experimenter stressed that the confederate had denied stealing the phone. The experimenter then orally enquired whether the participant could still confirm that both participants had been in lab Y during the whole session. If the participant confirmed, the experimenter asked him or her to sign. If the participant did not confirm, the experimenter asked if they wanted to change the statement. Participants would then amend the statement at their own discretion and sign it. Finally, participants estimated how strongly they believed that the other participant did not leave the room and that the other participant was guilty of the theft on a scale from 1 ? Three different versions were used through the course of the experiment to introduce novelty for the confederates from time to time. The individual tasks in session 1 consisted of 20 anagrams. The individual tasks in session 2 consisted of 20 word association problems.The dyadic/individual tasks were difficult; I enjoyed working on the dyadic/individual tasks).In line with the cover story, participants answered questions regarding the problems they had solved earlier  and dropped item 3 and 7. The remaining items were The other participant was friendly/ likable/ agreeable/ approachable; I would ask the other participant for advice ; I would like to be friends with the other participant; The other participant was similar to me; and The other participant was knowledgeable. Participants rated these items on a scale from 1 (strongly disagree) to 5 (strongly agree). We combined the responses into one confederate likability scale by summing up the answers (Cronbach’s α = .88). The score can range between 9 and 45.ty Scale . We adapThis two-page bogus form with the university header, contained two sections and was similar to the form used by Marion et al. ?; Did you find it odd that you were the only one hooked up to the heart monitor?; Did you believe the phone was stolen? Participants in the identification and camera conditions additionally received questions about the believability of the evidence.Participants answered questions that prompted whether they had believed the cover story: strong , modest , or weak . Oral and written statements provided in session 2 were coded analogously, with the additional categories: no corroboration  and weak incrimination . Two coders independently coded the strength of corroboration for 173 randomly selected corroboration statements from session 1 and 2 . Disagreements were resolved in discussion. Cohen’s κ across all those statements was κ = .80, p < .001, and κ = .75 for oral statements in session 1, κ = .82 for oral statements in session 2, and κ = .74 for written statements in session 2, ps < .001.Participants’ oral corroboration statements in session 1 were coded as being corroboration but some doubts) and corroboration levels 1 and 2 (no corroboration) for comparing alibi corroboration in session 2 (hypotheses 1a/b). Because the new scale is ordinal rather than continuous, we opted for multinomial regression analyses, because this method is more suited for our data than the pre-registered analyses of variance (ANOVA).Inspection of the data revealed extreme skewness. In session 1, the vast majority of participants (87.9%) scored 5 on the corroboration scale, 8.4% scored 4, and 3.7% scored 3. Session 2 revealed greater dispersion in the scores, with a smaller majority scoring 5  and a small minority scoring 1 . The overall distribution remained very skewed . Therefore, deviating from the pre-registration but similar to Marion et al.  vs. 0 (absence of strong corroboration). Although this deviates from the pre-registration, this is again analogous to Marion et al. ) and the belief that the confederate was guilty of the theft was low . These ratings did not differ as a function of type of evidence, Fs ≤ 0.77, ps ≥ .466, ηp2s ≤ .014, lending no support to hypotheses 3a and 3b.Hypothesis 3a predicted that participants’ belief that the confederate did not leave the room would be stronger in the no-evidence than the camera and identification conditions. Hypothesis 3b predicted that participants’ belief that the confederate was guilty of the theft would be weaker in the no-evidence vs. the camera and identification conditions. Across conditions, participants generally believed that the confederate did not leave the room  and that corroboration would decrease, compared to alibi witnesses’ initial corroboration statement (hypothesis 2a).Our results support our hypotheses for written alibi corroboration. Written alibi corroboration statements were significantly weaker in the incriminating evidence conditions (47.2%) than the no-evidence condition (81.1%) in session 2 (hypothesis 1a). Furthermore, compared to the initial corroboration statement in session 1, strong alibi corroboration occurred significantly less often in written alibi statements when participants received incriminating evidence , whereas written alibi corroboration remained equal in strength in the no-evidence group .Oral alibi corroboration in session 2 did not differ as a function of evidence condition, contrary to hypothesis 1a. This was because, in line with hypothesis 2a, strong oral alibi corroboration occurred less often in session 2 (30–53%) than session 1 85–89%) across all evidence conditions and not only in the incrimination conditions. These findings extend earlier reports that demonstrated the damaging effect of context information on the availability of exculpatory alibi evidence , 12, the5–89% acrsaid during the conversation with the experimenter  and the statement participants eventually signed (written corroboration) in session 2 separately. Across all evidence conditions, strong oral alibi corroboration occurred less often than strong written alibi corroboration. That means, participants displayed skepticism about the innocence of the confederate in speaking with the experimenter, but when it came down to the formal reporting and signing of a written statement that matched their doubts, participants were not ready to do so. Possibly, participants empathized with the experimenter and conformed with her suggestion in the direct conversation with her. However, they may have considered the costs and consequences of withdrawing their support for the alibi or making an accusation in written as too high, also because they had confirmed the alibi with some confidence just days earlier. Participants’ hesitation for changing their written statement matches the finding that participants generally believed that the participant had not left the room and had not committed the theft, and–contrary to hypotheses 3a and 3b –these beliefs were not moderated by type of presented evidence.Another interesting finding concerns the effect of formal status on corroboration. We coded what participants We also tested the hypothesis that the elasticity associated with different types of evidence moderates the effect of context information , 19. Bascoherence effect [The present findings could be seen through the lens of constraint-satisfaction , 28 and,e effect . At a neIn legal decision-making, probative evidence  tends to assimilate other uncertain, ambiguous, and conflicting elements  as to accord with the evidence . In the evaluation of evidence, but also on the very availability of exculpatory evidence [The current findings have important implications for our understanding of the genesis of wrongful convictions. Thus far, we knew that investigator and confirmation bias can corrupt evidence , resultievidence , 12. Theconvictingtheinnocent.com). Thus, the absence of (corroborated) alibi evidence may well result from a combination of the effects of context information on alibi witnesses and investigators.The troubling issue with alibi evidence is that–once shared–context information can contaminate or weaken the memory of the alibi witness (much like new information can contaminate the memory of other eyewitnesses). Thus, an interview with an alibi witness cannot be revised and redone once the alibi witness received the new information. As a result, investigators and legal practitioners likely assign little or no exculpatory weight to the now uncorroborated alibi. This is likely what happened in the cases of Kogut and Laughman  and manyWe can also derive implications for legal procedure and policy from the current study. The corruptive effects of context information on alibi evidence could be mitigated, or avoided altogether, by using blind procedures and recording interactions with alibi witnesses . AdditioType of evidence had a differential effect on the comparison between strength of corroboration in session 1 vs. 2 only when looking at written, but not oral corroboration in session 2. This could be considered a limitation of the alibi-undermining effect of context information. One the other hand, a written alibi statement has formal status and requires a higher level of commitment from alibi witnesses and is therefore most relevant when considering the effect of context information on the availability of alibi corroboration in a real case. Furthermore, alibi corroboration in session 2 differed as a function of type of evidence, regardless of corroboration mode. An interesting line of research worth investigating concerns the question in how far contradictive evidence can undermine the availability of exculpatory evidence other than a corroborated alibi. For example, are there some types of evidence that generally trump other types and is this mostly a question of timing or a combination of both?behavior in a field experiment rather than self-reports of what participants think they might do in a certain situation . We canFinally, a word on generality is appropriate. The current results derive from a western European, academic, mostly Caucasian, mostly female, young sample. Wrongful convictions, on the other hand, often happen to people with lower socio-economic status and people of color. It is possible that the demographics of our sample had an effect on alibi corroboration. Although speculative, there could be a bias to provide a stronger alibi to women than men or to same-race suspects vs. different-race suspects. These are interesting questions that might be addressed in future studies.To conclude, the current study demonstrates that camera footage and identification testimony have the power to undermine the availability and weaken the strength of exculpatory alibi evidence. This is troubling because there are currently no procedures in place to prevent wrongful convictions by loss or devaluation of exculpatory evidence. Avoidance and documentation of possible evidence contamination incidents should be a top priority for those concerned with criminal justice.


To investigate trends in SGLT2i and GLP-1RA use in Australia in the era of increased evidence of their cardiovascular benefits.We used national dispensing claims for a 10% random sample of Australians to estimate the number of prevalent and new users (no dispensing in the prior year) of SGLT2i or GLP-1RA per month from January 2014 to July 2022. We assessed prescriber specialty and prior use of other antidiabetic and cardiovascular medicines as a proxy for evidence of type 2 diabetes (T2D) and cardiovascular conditions, respectively.We found a large increase in the number of prevalent users ; in July 2022 approximately 250,000 Australians were dispensed SGLT2i and 120,000 GLP-1RA. Most new users of SGLT2i or GLP-1RA had evidence of both T2D and cardiovascular conditions, although from 2022 onwards, approximately one in five new users of SGLT2i did not have T2D. The proportion of new users initiating SGLT2i by cardiologists increased after 2021, reaching 10.0% of initiations in July 2022. Among new users with evidence of cardiovascular conditions, empagliflozin was the most commonly prescribed SGLT2i, while dulaglutide or semaglutide was the most common GLP-1RA.SGLT2i and GLP-1RA use is increasing in Australia, particularly in populations with higher cardiovascular risk. The increased use of SGLT2i among people without evidence of T2D suggests that best-evidence medicines are adopted in Australia across specialties, aligning with new evidence and expanding indications.The online version contains supplementary material available at 10.1007/s00228-023-03539-8. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) are two classes of glucose-lowering medicines .Since 2015, clinical trials have also shown these medicines significantly reduce cardiovascular events among patients with T2D and established cardiovascular disease (CVD) or high cardiovascular risk Table . SGLT2i More recent trials have shown protective effects of SGLT2i in other populations, regardless of T2D: SGLT2i significantly decreases re-hospitalisations and cardiovascular deaths among people with heart failure , and redDespite advances in knowledge about the broader cardiovascular benefits of SGLT2i and GLP-1RA, there is limited evidence on trends in the uptake of these therapies among different clinical populations  and presWe therefore used dispensing data from a nationally representative sample of Australians in the period 2014–2022 to: 1) quantify trends in SGLT2i or GLP-1RA use in people with evidence of T2D and/or cardiovascular conditions, and by the specialty of prescriber; 2) quantify changes in characteristics of new users of SGLT2i or GLP-1RA; and 3) describe the uptake of specific SGLT2i and GLP-1RA medicines among new users with evidence of cardiovascular conditions.In Australia, a national healthcare system provides subsidised prescription medicines to all citizens and eligible residents under the PBS . People We used the dispensing records for a 10% random sample of PBS-eligible people . The PBSIn Australia, three GLP-1RA  and four SGLT2i medicines  have been PBS-listed for T2D since mid-2010 and late 2013, respectively. Since then, canagliflozin was delisted by the sponsor in 2015. The PBS-indications were expanded in dapagliflozin and empagliflozin for treating symptomatic heart failure, in January and April 2022 respectively  and prescriber specialty.We reported the characteristics of new users grouped by two-year intervals  and January-July 2022. New users could contribute to multiple time intervals if they met the definition of initiation in each.We reported characteristics at the date of initiation, including age, sex, PBS concessional status and specialty of prescriber . We also identified morbidities using the Rx-Risk Comorbidity Index, which maps 46 morbidities to ATC codes in a 12-month look back period (i.e. 360 days before and including the index dispensing) and calculated a total weighted comorbidity score . We alsoWe selected a subgroup of new users who had evidence of cardiovascular conditions to investigate specific medicines initiated, reporting the monthly percentage of new users initiating each SGLT2i and GLP-1RA medicine.We performed all analyses using SAS version 9.4  and produced figures using R version 4.2.3 .We identified a total of 67,207 prevalent users of either SGLT2i  and/or GLP1-RA  during the study period. The number of prevalent users of SGLT2i substantially increased, from 116 people in January 2014 up to 25,099 in July 2022 Fig.  and 4 anMost new users of SGLT2i or GLP-1RA had evidence of T2D and cardiovascular conditions Fig. . HoweverA relatively small proportion of new users of SGLT2i and GLP-1RA were prescribed these medicines by cardiologists, endocrinologists and nephrologists, with the majority prescribed by GPs or other medical specialists Fig. . HoweverCompared to earlier in the study period, new users of SGLT2i in more recent years tended to be older, with a slightly higher percentage of males and evidence of treatment for heart failure, and lower percentage of concessional beneficiaries and evidence of T2D Table . In 2022We observed substantial changes in the medicines initiated among new users over time with evidence of cardiovascular conditions Fig. . For SGLOur study provides a contemporary perspective on SGLT2i and GLP-1RA use in Australia in the context of increasing clinical evidence of cardiovascular benefits and expanding therapeutic indications for SGLT2i medicines for heart failure. Most new users of SGLT2i and GLP-1RA had evidence of treatment for CVD or CVD risk factors, including T2D. We also observed a rapid increase in the use of SGLT2i among those with evidence of cardiovascular conditions, but not T2D, as well as a rapid increase in prescribing by cardiologists, consistent with the expansion of indications for SGLT2i to include heart failure. In addition, empagliflozin became the most prescribed SGLT2i and dulaglutide or semaglutide the most prescribed GLP-1RA. Accordingly, new users of SGLT2i in 2022 tended to be older, more likely to be male, and have evidence of treatment for heart failure, but not T2D, than in earlier years. Changes in the characteristics of new users of GLP-1RA were less pronounced.Overall, the increasing trends in SGLT2i and GLP-1RA use suggest that clinicians are applying the best available evidence. While the trends of increasing use found in our study are similar to those seen in Australian studies in earlier years , 23, theNotably, the majority of SGLT2i were prescribed by clinicians other than cardiologists, endocrinologists and nephrologists. This is also consistent with prescribing patterns in the US , 15 and Encouragingly, we found that medicines with higher cardiovascular benefits such as empagliflozin  and dulaThe lower proportion of new users with evidence of T2D in recent years shows a tendency for both SGLT2i and GLP-1RA to be used for indications beyond T2D. This was particularly interesting for GLP-1RA, as PBS indications in Australia currently do not support the use of GLP-1RA beyond T2D – inferring the possibility of off-label use for other indications such as weight loss. The higher percentage of female users of GLP-1RA in recent years could similarly be related to the clinical evidence of weight loss of GLP-1RA published in 2021 .Given we used a 10% representative sample of the population, we estimate approximately 670,000 Australians received SGLT2i and/or GLP-1RA during the study period, the majority of whom had evidence of T2D or cardiovascular conditions. Approximately 1.16 million Australians have been diagnosed with T2D, with 60,000 new T2D diagnoses every year . Around As the body of evidence of benefits of SGLT2i and GLP-1RA continues to grow and their indications expand , and so may underestimate SGLT2i and GLP-1RA use. Second, since no information regarding indication for prescribing is available in the PBS data, we derived proxies from dispensing of other medicines, which may be subject to misclassification. Third, there were shortages of some medicines of interest during the study period Table , which mSGLT2i and GLP-1RA use increased substantially in accordance with the increasing evidence of cardiovascular benefits. The use of SGLT2i and GLP-1RA prescribed by cardiologists increased over time, and rapidly increased from 2022 when the therapeutic indication for heart failure was included in the PBS. In recent years, medicines with higher cardiovascular benefits such as empagliflozin and semaglutide accounted for a large percentage of new users with evidence of cardiovascular conditions. This study shows the diffusion of medicines aligns with new evidence and indications and suggests there is potential to further optimise the use of these evidence-based therapies in Australia.Supplementary file1 (DOCX 418 KB)Below is the link to the electronic supplementary material.


Prehabilitation aims at enhancing patients’ functional capacity and overall health status to enable them to withstand a forthcoming stressor like surgery. Our aim was to synthesise the evidence on the cost-effectiveness of prehabilitation for patients awaiting elective surgery compared with usual preoperative care.We searched PubMed, Embase, the CRD database, ClinicalTrials.gov, the WHO ICTRP and the dissertation databases OADT and DART. Studies comparing prehabilitation for patients with elective surgery to usual preoperative care were included if they reported cost outcomes. All types of economic evaluations (EEs) were included. The primary outcome of the review was cost-effectiveness based on cost–utility analyses (CUAs).The risk of bias of trial-based EEs was assessed with the Cochrane risk of bias 2 tool and the ROBINS-I tool and the credibility of model-based EEs with the ISPOR checklist. Methodological quality of full EEs was assessed using the CHEC checklist. The EEs’ results were synthesised narratively using vote counting based on direction of effect.We included 45 unique studies: 25 completed EEs and 20 ongoing studies. Of the completed EEs, 22 were trial-based and three model-based, corresponding to four CUAs, three cost-effectiveness analyses, two cost–benefit analyses, 12 cost–consequence analyses and four cost-minimization analyses. Three of the four trial-based CUAs (75%) found prehabilitation cost-effective, i.e. more effective and/or less costly than usual care. Overall, 16/25 (64.0%) EEs found prehabilitation cost-effective. When excluding studies of insufficient credibility/critical risk of bias, this number reduced to 14/23 (60.9%). In 8/25 (32.0%), cost-effectiveness was unclear, e.g. because prehabilitation was more effective and more costly, and in one EE prehabilitation was not cost-effective.We found some evidence that prehabilitation for patients awaiting elective surgery is cost-effective compared to usual preoperative care. However, we suspect a relevant risk of publication bias, and most EEs were of high risk of bias and/or low methodological quality. Furthermore, there was relevant heterogeneity depending on the population, intervention and methods. Future EEs should be performed over a longer time horizon and apply a more comprehensive perspective.PROSPERO CRD42020182813.The online version contains supplementary material available at 10.1186/s12916-023-02977-6. Prehabilitation is still a relatively new care concept. It aims at enhancing patients’ functional capacity and overall health status through behaviour change  to enablThe potential of prehabilitation is widely recognised. Nevertheless, prehabilitation has not yet been widely adopted by health care systems. Current evidence is still somewhat limited, though much research is still underway to determine the optimal programme types and delivery modalities for different patient populations. Most research activity seems to be in the field of cancer surgery, for example, in an overview of 55 systematic reviews on preoperative prehabilitation, 23 reviews specifically focused on cancer . A likelThe aforementioned overview identified only one systematic review on costs , but thiThe aim of this systematic review was to synthesise the evidence on the cost-effectiveness of prehabilitation programmes for patients awaiting elective surgery compared with usual preoperative care to inform decisions about the implementation of prehabilitation programmes and to guide the design of future rigorous economic evaluations of prehabilitation programmes. More specifically, our objectives were to (1) identify all eligible economic evaluations (EEs), (2) assess their validity and (3) systematically present their characteristics, methods and findings.We followed general methodological guidance on systematic reviews of interventions  as well The systematic review was prospectively registered in PROSPERO CRD42020182813) and we published a protocol . Importa82813 andThe study in- and exclusion criteria are displayed in Table We searched PubMed, Embase and the Centre for Reviews and Dissemination (CRD) Database on 31/08/2021, which are the most efficient combination of bibliographic databases for systematic reviews of EEs . FurtherThe database search strategies consisted of search terms, relating to the population (e.g. ‘preoperative’), the intervention (e.g. ‘exercise’) and study type, i.e. terms to search for economic evaluations (e.g. ‘cost’). Full search strategies for all sources can be found in Additional file Records retrieved from databases were deduplicated, screened and managed using EndNote 20 , USA). After deduplication, a randomly selected 10% sample of all unique records was screened against the eligibility criteria by two reviewers  independently based on their titles and abstracts. Disagreement was resolved by consensus. As agreement was above 80%, the remaining 90% were screened by one reviewer (TR). We retrieved the full-text articles for all potentially eligible studies as well as for relevant systematic reviews, so that their references could be screened. Each full-text article was screened for eligibility by two reviewers independently who noted reasons for exclusion. Disagreements were resolved by consensus and by consulting a third reviewer (WQ). Last, all study reports were mapped to unique studies as the unit of interest. No automation tools were used in the process.Data were extracted into a standardised excel sheet that was piloted by one reviewer (TR). Two reviewers  independently extracted the data of a randomly selected 20% sample of the included completed EEs for calibration. Disagreement was resolved by consensus. As there were no systematic discrepancies, the remaining records were extracted by one reviewer (TR). All outcome data was verified by a second person (JS). We used all documents relevant to the included EEs for data extraction and contacted the study authors via email in case of missing or unclear data. Uncertainties about the methods were only inquired for completed EEs. A reminder email was sent after 2 weeks.A list of all data items and detailed descriptions can be found in Additional file The risk of bias of trial-based EEs was assessed on outcome-level using the Cochrane risk of bias tool 2 (RoB 2)  for EEs The review’s primary outcome was the cost-effectiveness from cost–utility analyses (CUAs) based on direction of effect . Secondary outcomes were the cost-effectiveness from cost-effectiveness analyses (CEAs), cost–benefit analyses (CBAs), cost-minimisation analyses (CMAs) and cost–consequence analyses (CCAs) based on direction of effect. We calculated effect measures when not reported using risk differences for dichotomous outcomes and mean differences or differences in medians for continuous outcomes. Confidence intervals were extracted when reported. All calculated values are marked as such. All outcomes were reported in disaggregated form in natural units and combined outcome measures, e.g. incremental cost-effectiveness ratios (ICERs), where possible.We were unable to perform a meta-analysis because the only EEs that were sufficiently homogenous had an unquantifiable overlap in patient populations –34 or miResults were presented graphically in form of a hierarchical permutation matrix . There wTo address publication bias, we searched comprehensively for ongoing studies and grey literature and followed up on their status by searching for related publications and contacting the named investigators. In addition, we discussed how the effectiveness results from the included EEs compare to those of clinical effectiveness studies on prehabilitation using an overview of 55 systematic reviews and meta-analyses of RCTs by McIsaac et al. 2022 . Our hypThe study selection process is presented in Fig. The characteristics of the 25 completed EEs are displayed in Table Most EEs were published in the last 10 years and came from Europe (10 EEs), Asia (8 EEs) or North America (7 EEs). The EEs covered a wide range of diseases and surgery types that can be broadly categorised as orthopaedic surgery (9 EEs), cancer surgery (8 EEs), mixed major surgery (6 EEs) and other (2 EEs). In 11 EEs, patients had an increased perioperative risk (e.g. old age or frailty). Sample size ranged from 20 to 8830 patients (median 137). The median proportion of women across the EEs was 53%, and the mean or median age ranged from 59 to 78 years, with one outlier (median age 27 years).Characteristics and methods of the 20 ongoing EEs are reported in Additional file Information on the completed and ongoing EEs’ funding and conflict of interest can be found in Additional file Detailed information on the methods can be found study-by-study in Additional file Characteristics of the completed EEs’ prehabilitation programmes can be found in Table The results of the assessment of risk of bias and methodological quality of the included studies can be found in Additional file The methodological quality of full trial-based EEs as judged with the CHEC-checklist ranged from 8 to 15 fulfilled items (of 18 to 19 applicable items) and thus can be considered moderate to low. The credibility of model-based EEs as judged with the ISPOR checklist was acceptable in one EE , insuffiTable Four trial-based EEs , 48, 53 Three model-based and 18 trial-based EEs reported on the secondary outcomes Fig. , i.e. coOverall, 16/25 (64.0%) EEs found prehabilitation cost-effective based on direction of effects, , inThere was a relevant risk of publication bias regarding the included completed EEs. Firstly, the review had initially included 74 study reports belonging to 54 unique studies. However, ten reports referring to nine unique studies were excluded post hoc –85  and programmes  resulting more frequently in benefit. Among the included EEs, there was a high variability in populations, whose underlying diseases and surgeries differed in concept (e.g. restoration in orthopaedic surgery and cure in cancer surgery). It is possible that for orthopaedic patients, the restoring character of the surgery might be the crucial element in the recovery of both groups, although the modalities of prehabilitation may also serve as a conservative therapy option for certain orthopaedic patients, delaying or even eliminating the need for surgery , 53. Of Our review also showed great variability in the programme modalities, ‘dose’  and delivery settings. As a result, the programme costs ranged from below 100 EUR (2020) per patient in six (mainly home-based) EEs , 47, 48 The dose–response relationship of prehabilitation programmes is a crucial aspect for programme effectiveness and depends largely on the length of the preoperative period available for prehabilitation. This again depends on the underlying diseases and how fast these are progressing, i.e. patients with slowly progressing diseases, such as osteoarthritis, can generally wait longer than those with more rapidly progressing diseases, such as most cancer types, who should often be operated within a few weeks following diagnosis . HoweverThe dose of prehabilitation is also determined by the intensity of individual sessions which must be sufficiently high to have an effect while being tolerable for the target population . AlthougSome limitations on review and study level apply. First, we could not perform a meta-analysis but had to resort to narrative synthesis in the form of vote counting based on direction of effects. This synthesis method does not provide any information on the magnitude of effects, nor does it account for the EEs’ sample sizes . Second,Limitations on the study level included the high risk of bias and low methodological quality of the included EEs. However, the exclusion of the two EEs judged to be insufficiently credible/of critical risk of bias only had a small effect on the results. Furthermore, there was a high risk of publication bias associated with trial-based EEs. Trial-based EEs are by nature prone to a specific form of publication bias, namely conduct bias , meaningOwing to the limitations described above, our results should be interpreted with caution. As many EEs were based on prospective trials, decision-makers must also consider the possibility that there was a motivational bias among the participants and that the cost-effectiveness of prehabilitation may be lower under ‘real world’ circumstances. Before implementing prehabilitation into routine care, decision-makers should assess potential barriers and facilitators , 109, whFinally, decision-makers must determine which patient population(s) should receive prehabilitation and establish screening pathways, accessibility to the programme and strategies to ensure sustainability . This inFirst, future research should address the knowledge gaps discussed above, i.e. which populations benefit most and what the optimal prehabilitation programme for those populations is. If a broadly defined population is included in a clinical trial, it is recommended to consider pre-specified subgroup analyses for economic evaluation . To ensuSecond, future research should address the shortcomings of existing EEs. Common issues included inadequate reporting, short time horizons, and the use of limited perspectives. Reporting guidelines are intended to support authors and increase the accuracy and transparency of reporting, but they are frequently used inappropriately, including those for EEs . In our Many EEs had a short time horizon of 1 month or less. However, as argued by Grocott and Ludbrook 2019, ‘it is plausible that improved fitness arising from prehabilitation might have a further lingering positive impact on the need for later care’ . Such anWe plan to update the review upon publication of our own economic evaluation  in 2025/We found some evidence that prehabilitation for patients awaiting elective surgery is cost-effective compared to usual preoperative care. Cost-effectiveness based on direction of effect was more frequently observed for cancer patients, patients with a high perioperative risk and for low-cost (shorter or home-based) programmes. However, the results should be interpreted with caution as most EEs were of high risk of bias and/or low methodological quality, and we suspect a relevant risk of publication bias. Future research should address clinical knowledge gaps surrounding prehabilitation, e.g. which populations benefit most, as well as the shortcomings of existing EEs, e.g. by adopting a societal perspective.Additional file 1: App1. Important changes made to the protocol. App2. Search strategies. App3. Data items. App4. List of excluded studies. App5. Characteristics of ongoing economic evaluations. App6. Funding and competing interest of included economic evaluations. App7. Methods of completed economic evaluations. App8. Methods of ongoing economic evaluations with a published protocol. App9. Description of prehabilitation programmes in ongoing studies. App10. Risk of bias and methodological quality of included economic evaluations. App11. Detailed costs results of included economic evaluations. App12. Results of adherence and safety outcomes. App13. Results of descriptive post-hoc subgroup analyses to explore heterogeneity in cost-effectiveness results.