N = 3103) one from Brazil (Braziln = 2217) and one from Portugal . BAT’s original structure was confirmed, and it achieved measurement invariance across countries. Using both classic test theory and item response theory as frameworks, the BAT presented good validity evidence based on the internal structure. Furthermore, the BAT showed good convergent evidence . In conclusion, the psychometric properties of the BAT make this freely available instrument a promising way to measure and compare burnout levels of Portuguese and Brazilian workers.The Burnout Assessment Tool (BAT) has been gaining increased attention as a sound and innovative instrument in its conceptualization of burnout. BAT has been adapted for several countries, revealing promising validity evidence. This paper aims to present the psychometric properties of the Brazilian and Portuguese versions of the BAT in both the 23-item and 12-item versions. BAT’s validity evidence based on the internal structure  and validity evidence based on the relations to other variables are the focus of research. A cross-sectional study was conducted with two non-probabilistic convenience samples from two countries ( Although the burnout syndrome appeared in the 1970s, it is still a global issue such that the 11th revision of the International Classification of Diseases of World Health Organization (ICD-11) defines it as an occupational phenomenon with risk of harming health . HoweverResearch shows that job demands  are more associated with job burnout, while job resources  are more related to job burnout’s antipode, i.e., work engagement . NowadayThe most widely used instrument to assess burnout is the Maslach Burnout Inventory (MBI) . DespiteTaken together, these criticisms call for an alternative instrument to assess burnout and overcome these flaws using a novel conceptualization of the matter, which has been addressed by the development of the Burnout Assessment Tool (BAT) . The BATn = 43,675), using data from the 6th European Working Conditions Survey 0.080; 0.0840.077; 0.0820.086; 0.0940.051; 0.0590.045; 0.0560.067; 0.0840.082; 0.0860.077; 0.0830.078; 0.0890.088; 0.095[). In terms of reliability, the internal consistency estimates obtained ranged from acceptable to good: work engagement , co-worker support , role clarity , negative change , and work overload .The latent correlations among BAT’s burnout latent factor with other related latent variables were investigated. Regarding the sample from Brazil, the measurement model with burnout-related constructs provided a satisfactory fit to the data when using either BAT-23  and the EAP reliability index. In terms of the Rasch model, the MRCMLM was used in contrast with the unidimensional approach used in BAT’s previous research [The data from Brazil and Portugal provided robust validity evidence for the BAT-23, and the BAT-12 using item response theory  and classical test theory  in conjunction. Satisfactory evidence was obtained based on both the internal structure and the relations to other variables. The current study adds to the already available evidence about BAT’s psychometric properties using the classical test theory, e.g., , and iteresearch . The mulresearch . The mulresearch .The originally proposed dimensionality for BAT-23 and BAT-12 presented a satisfactory fit to the data for both countries without removing items (H1). Such findings are corroborated by samples from other American and European countries, Ecuador using BAT-23 and BAT-12 , and Itaord, ω, and CR) and item theory response estimators .Globally, the evidence of the reliability of the scores in terms of internal consistency obtained by both samples was satisfactory both for second- and first-order dimensions (H2). In fact, only the mental distance dimension of the BAT-12 version with the Portuguese data presented estimates slightly below the desirable the Portuguese workers; nevertheless, those values were acceptable . BAT’s mental distance was the first-order dimension that had the lowest α, and ω in the Ecuadorian version , as did Both versions of BAT had measurement invariance  for countries and sex (H3), allowing mean comparisons for BAT among countries, and sex. BAT-23 presented measurement invariance among seven countries in a previous study by De beer et al. . One of The BAT’s scores’ relation to other variables presented convergent evidence (H4) since all latent correlations’ paths were statistically significant (moderate to strong effect sizes) with the theoretically expected direction for each correlation pair. BAT’s burnout latent scores were negatively correlated with work engagement, role clarity, and co-workers’ support. Positive latent correlations were found among BAT’s burnout latent scores, work overload, and negative change. The latent correlations’ effect sizes were similar among countries. Burnout’s correlation with work overload and burnout’s correlation with role clarity presented the largest difference among countries. The observed latent associations between BAT’s scores and job demands and job resources are in accordance with the findings from research reading other BAT’s versions; for example, the Romanian  and the Both BAT-23 and BAT-12 presented good validity evidence and thus both can be used to measure burnout levels among workers from Brazil and from Portugal. The advantage of using BAT-23 concerns its finer-grained assessment of burnout ; however, if time is a constraint and other measures are being collected, BAT-12 can be a more parsimonious alternative. As the results showed, the obtained raw scores for BAT-12 and BAT-23 presented an almost perfect correlation . Moreover, short-versions of psychometric instruments are preferable since their validity evidence is not compromised with its shorting from the full-length version. The main goal of using a short-version is to reduce the time burden of assessment. Usually, short-versions have lower estimates of reliability than full versions. The BAT-12 results were (in some of the first-order dimensions) slightly lower than the BAT-23 ones, although with no meaningful losses in terms of its satisfactory validity evidence. Practitioners and researchers opting between BAT-23 and BAT-12 will have to balance between time-saving of brevity versus construct content coverage and validity evidence . The BATThe obtained non-probabilistic convenience sample introduces some degree of selection bias. However, probabilistic sampling  is only possible when there is a complete and up-to-date list of the member of the population being investigated ,122, whiThe findings of the current study are based on large samples from two different countries. The obtained findings are promising in terms of the measurement of burnout’s core symptoms. Future research should investigate the version of BAT including the secondary symptoms items for both countries, so as to also compare BAT’s psychometric properties directly with the Brazilian and Portuguese adaptations of other psychometric instruments that measure burnout . It will also be convenient to obtain cut-off values for different levels of burnout; for such a purpose, clinical samples will have to be investigated. Using the receiver operating characteristic (ROC) curve  will allBAT-12 was shown to be virtually equal to BAT-23 in terms of scores, as in terms of validity evidence, representing an equally robust alternative to measure burnout. The decision to use BAT-23 or BAT-12 will be related to the level of detail that one intends to obtain regarding the burnout measurement. BAT’s Brazilian and Portuguese versions are invariant in terms of measurement, allowing for comparisons of means among countries, and between males and females. BAT’s scores presented the expected associations with related measures. The quartiles and mean scores are also provided as the first reference in terms of burnout at the country and sex levels. BAT is a promising instrument and is a viable alternative to measuring burnout in workers from Brazil and Portugal.The data of multi-occupational workers from Brazil and Portugal presented good validity evidence for both BAT-23 and BAT-12, supporting its use to measure and to compare burnout levels among sex and countries. BAT’s scores provided support for the theoretical nomological network of constructs. Both samples’ data fitted well the original structure of BAT-23 and BAT-12 with good reliability evidence. This leads to the conclusion that BAT is a good instrument for practitioners and researchers to measure burnout among different occupations.


The Covid-19 pandemic has demanded modifications to undergraduates’ learning experiences and promised a more challenging scientific world in which they will live. Bespoke evidence synthesis and critical appraisal skills modules are an opportunity to utilize our information-saturated world to our advantage. This program of study made use of a virtual journal club, structured literature searches, scoping review methods and a variety of online research tools to navigate and critique the literature. The program design is here outlined with sample learning objectives and reference to the resources used. The pandemic has led to establishment of new ways to embed scientific literature into the undergraduate medical curriculum. Medical and biomedical science education have a very pressing problem: aside from the ever broader and deeper knowledge base to be mastered by todays’ undergraduate, the problems which these students will face as graduates are increasingly difficult, surrounded by a mounting body of literature of uncertain quality. The Covid-19 Pandemic has been a prime example of this global uncertainty and abundance of conflicting evidence. Future citizens will have to be more comfortable with risk and uncertainty, whilst being literate in assimilating and sifting scientific literature for themselves  offer engagement with open ended questions and increase student engagement, with many choosing to become involved beyond the end of the project Lopatto . After oet al. Blooms’ taxonomy places ‘analysis’ and ‘evaluation’ toward the apex of Educations’ objectives, building on a foundation of understanding and application Bloom . A way tLearning outcomes for the block included:Learn the different types of literature and study design.Critically appraise a paper against a quality checklist.Contribute to group discussions on papers presented by other students.Develop an area of interest within upper respiratory tract microbiology.Summarize some of the key findings within this niche, with comments on any major risk of bias or applicability concerns of the contained articles.et al. et al. Evidence synthesis is the aggregation of relevant scientific literature as it pertains to a precise question. This is a key skill for clinicians whose actions and decisions are based on information. The classic systematic review (the ‘whole truth and nothing but the truth’ on a topic) has been supplemented more recently by scoping reviews and rapid reviews. Scoping reviews search the literature broadly to quantitively summarize the number of papers on a subject over time, and qualitatively outline key themes and gaps within it. Scoping reviews are particularly apt for undergraduates, as quick to perform, and introducing key skills such as defining a research question, literature searching and making inclusion/exclusion criteria decisions (Tricco Learning objectives for the block included:Asking a simple research question.Deciding the scope of the research (inclusion criteria).Establishing the closely related/overlapping topics not of interest (exclusion criteria).Deciding how comprehensive to make the analysis (e.g. whether to include grey literature and how many years of publication).Using scientific databases and evidence synthesis software to collate results.et al. Evidence synthesis has been a valuable source of research projects for students over the Covid-19 pandemic where ‘wet-lab’ and near-patient opportunities have been in short supply. Freely available web apps such as Rayyan QCRI allow students to collaborate asynchronously on a portfolio of articles by excluding papers, assigning labels and applying filters (Ouzzani et al. Undergraduate critical appraisal and evidence synthesis projects can be powerful tools in student engagement. Scientific literature becomes less daunting as students learn to navigate it within a community of practice. Such projects help students identify both methodological strength and potential gaps in the literature: fertile grounds for future clinician–scientists. Their presence as an accompanying thread throughout undergraduate degrees rather than as a temporary project will help engagement with literature become a part of everyday practice (Larsen


Although research on presence in virtual environments has increased in the last few decades due to the rise of immersive technologies, it has not examined how it is achieved in distributed cognitive systems. To this end, we examine the sense of presence on the Martian landscape experienced by scientific team members in the Mars Exploration Rover (MER) mission (2004–2018). How this was achieved is not obvious because the sensorimotor coupling that typically underlies presence in mundane situations was absent. Nonetheless, we argue that the Three-Level model can provide a framework for exploring how presence was achieved. This account distinguishes between proto-presence, core-presence, and extended-presence, each level dependent on being able to respond effectively to affordances at a particular level of abstraction, operating at different timescales. We maintain that scientists' sense of presence on Mars involved core-presence and extended-presence rather than proto-presence. Extended-presence involved successfully establishing distal intentions (D-intentions) during strategic planning, i.e., long term conceptual goals. Core-presence involved successfully enacting proximal intentions (P-intentions) during tactical planning by carrying out specific actions on a particular target, abstracting away from sensorimotor details. This was made possible by team members “becoming the rover,” which enhanced their ability to identify relevant affordances revealed through images. We argue, however, that because Mars exploration is a collective activity involving shared agency by a distributed cognitive system, the experience of presence was a collective presence of the team through the rover. The development of immersive digital technology has created opportunities for interacting with remote or simulated virtual environments across a wide range of domains , Curiosity in the Mars Science Lab mission , and Perseverance in the Mars 2020 mission. Although it is a technologically-mediated activity, ethnographers using open-ended interviews to query scientists about their experiences working with rovers report that team members have a collective sense of presence on Mars : (1) Geology, (2) Mineralogy and Geochemistry, (3) Rocks and Soil, and (4) Atmospherics Squyres, . ScientiDespite the fact that the mission was made up of many individuals pursuing highly specialized tasks, the MER team managed to function in a unified manner to explore Mars. This is a deliberate result of the way the decision-making process was structured by the Principal Investigator Squyres, . AlthougA unity of purpose and complementarity of effort was achieved through consensus-based operations. This is most clearly illustrated in the SOWG meetings, which had a highly ritualized structure designed to produce consensus among science team members. At the start of the meeting, scientists were presented with the “skeleton,” a file that lists all the constraints, including when the rover needed to recharge its batteries, when it had to communicate with Earth based on satellite passes, and what times were available for the science team to request observations. It provided a frame into which all planned activities must fit. Next, the SOWG Chair opened the meeting for discussion, allowing each STG to propose observations. All proposals had to be justified based on their scientific relevance, but had to take into account the “bio-economics” of the rover and the resources available. Any team member could comment on any proposed observation. The back-and-forth discussions ensured observations were relevant to testing hypotheses in the most efficient manner possible. Importantly, the SOWG Chair ensured all team members were satisfied with the plan prior to finalizing it by going around the room asking if each group was “happy” with the plan Vertesi, .complementarity of the functions of the different agents of the sociotechnical system. Cognitive systems can be made up of components with very different properties and functions, provided that they work together to create an intelligent system that functions with a unified purpose, i.e., they provide “collective and complementary contributions to flexible thinking and acting” , the musculoskeletal position of the body and its limbs , as well as input from the external senses (exteroception) as an action is unfolding. According to Damasio .The intentions that underlie core-presence are what Pacherie  calls “pautobiographical self. The autobiographical self is able to set goals not necessarily related to the here and now, ones consistent with narratives that define its identity. It allows us to plan activities and imagine possible future situations. Although the goals are often defined abstractly, they have to reflect possibilities for action in the world as well as our self-narratives.Extended-presence arises when one successfully formulates long term, conceptually-articulated goals. Extended-presence is greatest when those goals are attainable. According to Riva and Waterworth , extendeends, as they involve arriving at a decision about a course of action that will be undertaken. They also prompt practical reasoning about means by generating a plan for achieving the goal in question. The content of shared D-intentions is conceptual, i.e., offering a general description of a type of action to be carried out, and they are formed prior to actions and separate from the situation in which a concrete action will actually unfold. These intentions operate over narrative timescales .The intentions that underlie extended-presence are what Pacherie  calls “dAccording to the Three-Level model, the intentions that underlie the three types of presence form an action cascade. D-intentions generate P-intentions when relevant affordances are identified. P-intentions, in turn, generate M-intentions, though the latter also depend on the details of the environment where the action is taking place. In other words, D-intentions have to dovetail with distal affordances in that it must be possible within the milieu in question to achieve the general goal  assessing the past habitability of Mars by analyzing the geological and chemical features of rocks and soils for evidence of past water activity; (2) studying the Martian climate by analyzing the temperature profile of the atmosphere; (3) identifying the geological history of Mars by examining the role of wind, water, tectonic, and volcanic activity in modifying its surface; and (4) preparing for human missions to Mars by identifying potential resources and hazards Squyres, . AlthougOther essential features of the we-narratives in MER included a commitment to a flattened social hierarchy. Individuals were obligated to be open to revising their beliefs in response to reasoned discussion with others. During planning meetings, MER team members collectively examined each other's views prior to arriving at a decision. True to the flattened hierarchy, discussions did not appeal to authority, seniority, or other factors pertaining to the identity of the members. Instead, the factors that were considered included matters of scientific relevance. Engineering factors were also legitimate issues to discuss during deliberation. This included, for example, the health of the rover and its instruments, and the basic need to keep the rover alive so that the mission could continue.Core-presence is the presence one experiences when actions are effectively carried out on objects, abstracting from micro-movements and specific sensorimotor details. Core-presence arises through the successful enactment of P-intentions. In MER, a P-intention would be, for example, to take an infrared reading by applying the mini-TES tool to a specific soil sample, or using the rock abrasion tool (RAT) to grind the surface of a particular rock. Core-presence involves tracking actions to make sure they are proceeding as intended and involves monitoring for unwanted side-effects. In mundane situations, this happens within an integrative timescale while the action is unfolding. Although in the case of Mars exploration actions were tracked to make sure intentions were fulfilled, the feedback was not available until data was downloaded, thus operating within narrative timescales. In particular, instrument experts analyzed downloaded data from the instruments to verify that the observations were reliable and met scientific requirements , these were mostly for raising awareness of the mission among the public. Scientists and engineers, however, used images to either plan rover movements or to deploy instruments to answer scientific questions. In the case of Mars exploration what images did was extend the affordance space so that opportunities for action by the rovers on Mars would present themselves to team members on Earth. Affordances are possibilities for action provided to us by the environment, and they are defined relative to abilities available in a certain kind of practice, a “form of life”  to develop and test the sequence of commands to be sent each sol .A move in the direction of proto-presence on Mars, however, is offered by the sion see . It runsOnSight is used by scientists to increase understanding of features of the Martian terrain, and by engineers to inform vehicle operation. Nonetheless, although OnSight has come to be widely used by team members on MSL, it has not fully replaced the 2D and 3D imagery. Indeed, most use of OnSight appears to be of short duration  and most of the work is still carried out using the same visualization tools that were employed during the MER mission. This is likely because the immersive display is of lower resolution than computer monitors (Abercrobie et al., Research conducted at JPL suggests Scientists and engineers working on Mars through rovers in MER reported experiencing a collective presence on the Martian landscape through the rovers. Prima facie, this sense of presence is problematic because neither scientists nor engineers experienced the tight sensorimotor coupling that normally underlies the experience of presence in mundane situations (Chiappe and Vu, We were all there, together, through a robot!'.” The feeling of core-presence and extended-presence depended on successfully responding to affordances revealed through images. This was achieved by team members collectively “becoming the rover,” thus absorbing its embodiment with its constraints and abilities.Importantly, the length of the time involved in enacting D- and P-intentions far exceeded those characteristic of mundane situations, and individuals at times complained of the slow pace of the work. They complained that if they were physically present on Mars, they would be able to do in a few minutes what the rovers take a day or longer to accomplish. Thus, the work environment and the structure of the sociotechnical system involved in Mars exploration likely prevented the sort of flow experience that can accompany certain types of interactions with technology (Triberti et al., The model of presence we are advocating for relies on evidence provided by open-ended interviews conducted by participant-observer ethnographers Clancey,  and by tThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.DC and JV contributed equally to the development of the arguments contained in the paper. DC wrote the first draft of the manuscript and its revision. JV provided edits and helped get it ready for submission. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The paper by Kolaski et al.Generating trustworthy evidence is the only way forward for medicine. This was made very clear during the COVID‐19 pandemic, which included issues around rehabilitation.https://www.equator‐network.org/), these cannot compensate for lack of time, thus impairing the system.The bleak picture on the quality of systematic reviews provided by Kolaski et al.An even more devastating issue is the unreliability of clinical practice guidelines that use flawed systematic reviews. In the knowledge translation process, clinical practice guidelines are essential to inform clinicians, health decision‐makers, and patients. Therefore, the methodology used to conduct clinical practice guidelines must be more rigorous than in primary and secondary research papers. Clinical practice guidelines are expensive to produce, are resource‐intensive, and require the involvement of renowned scientists and research teams who must search the evidence and even more importantly, appraise it properly.Finally, Kolaski et al.’s paper


However, both HGC  and FVC health literacy  were associated with fruit consumption. In addition, HGC effect is concentrated among participants who reported low FVC health literacy, especially on overall FVC and vegetables alone. Results are discussed in relation to the beneficial role played by HGC in those particularly vulnerable households who perceived little FVC health literacy. Our results provide insights on novel improved FVC consumption across all population segments. Future research should explore the complex interplay between agricultural policies and educational programs in the design of interventions promoting fruit and vegetable production and consumption.Low fruit and vegetable consumption (FVC) remains a global health challenge. Fostering subsistence agriculture through the production and home-grown consumption (HGC) of fruits and vegetables are seen as potential strategies for improving overall FVC, in particular, for developing countries like India. In addition, educational strategies targeting FVC health literacy are also used. Little evidence has documented a connection between these two strategies. We examine the single and combined influence of HGC and health literacy with regard to benefits from fruits and vegetable consumption. Data were collected from 427 rural households in the state of Odisha, India. Three outcomes were examined: FVC, as well as fruit and vegetables separately. Linear and Poisson regression were used to examine the association among home-grown consumption (HGC), FVC health literacy, and the FVC outcomes. Findings show that HGC, but not FVC health literacy, was directly associated with FVC (β = 0.65, SE = 0.10,  Fruits and vegetables (FVs) are important components of a healthy diet, and when consumed in sufficient levels, it can reduce the risk of chronic diseases, such as diabetes and obesity, cardiovascular diseases, and certain types of cancer –5. The FAmong people living in low- and middle-income countries (LMICs), 78% consume less than the daily recommended FVC , and theDirect linkages between agricultural production and nutrition are created by household decisions regarding the quantity and composition of food production, which are partially reliant on the needs of the household . SurendrBeside the agriculture sector, education and knowledge-based interventions targeting behavior change are often used as a means to improve FVC by increasing health literacy, such as nutrition knowledge, nutritional benefits, dietary guidelines, core food group intake, or specific nutrition education to prevent or manage diseases . For insIndia is the second largest agricultural producer of FVs in the world, accounting for roughly 10 and 15%, respectively, of total global production . TraditiAdditionally, the drivers of eating behaviors, including food choices and consumption, are the results of the complex interplay among sociodemographic, psychosocial, and environmental factors . TherefoAlthough some empirical work from rural India has shown that home-grown fruit and vegetable consumption (HgFVC) can mediate FVC , it is nData were obtained from the baseline survey of an agri-food value chain intervention sponsored by Grand Challenges India . The intThe baseline survey for this study was conducted in four districts of rural Odisha: Kandhamal (I and II), Jharsuguda, Angul, and Nayagarh. The surveys were administered between April and May 2015. Study sites were selected based on existing geographical boundaries, eKutir operational requirements, and consumers' and farmers' voluntary willingness to participate in the evaluation of the program. The following criteria were used to identify rural village sites: (i) high farmer density, (ii) procurement logistics, and (iii) the capacity for hosting a VeggieLite center. Within villages, the number of households selected was proportionate to the village population size. A total of 32 villages with 427 households were selected from the four districts for baseline data collection. Structured questionnaires were administered to participating rural households. The questionnaire included specific modules on (1) household demographic information, (2) cropping pattern and agriculture inputs, (3) fruit and vegetable consumption patterns, and (4) household development and poverty index. Ethical approval was obtained from the Research Ethics Board of McGill University. Informed consent was also collected from all participants.FVC was based on self-reported information from each rural household. To calculate the overall consumption for FVs, rural households were asked to name the top five vegetables and fruits that they had consumed in the past 7 days, as well as the quantity, source, and amount they purchased vs. what they grew at home. As per India's dietary guidelines, potatoes were included as vegetables in the calculations. The amount of five vegetables consumed per household in the past 7 days was summed to calculate the total grams of vegetables consumed per household. The total grams of vegetables consumed per household was then divided by the household size and 7 days, in order to calculate the average grams of vegetables consumed per person per day. To arrive at the average daily servings of vegetables per person, the average grams of vegetables consumed per person per day was divided by 80 . The aveTo capture a driver from the agricultural sector, we measured households' level of home-grown consumption (HGC) following four steps: (1) For each reported vegetable, we calculated the amount that households consumed in total grams as a function of the amount that the household consumed in the past 7 days multiplied by the percentage reported to have come from home-grown production, (2) we divided the household HGC total by the household size, (3) we divided this total by 80 to get the average daily servings of vegetable per person, and (4) we summed the amount of daily servings for the top five vegetables (or fruits) consumed from home-grown production.As for measuring the household health literacy, we asked the participants about their beliefs regarding FVs as a proxy. Using a five-point Likert scale from not very important to very important, participants responded to six items asking, “how important they believe vegetables were for.” The six items were (1) improving your family health, (2) good health and nutrition, (3) your body, (4) your eyes and bones, (5) providing nutrients that your body needs, and (6) enhancing immunity/body fighting against disease. Due to the medium to high correlation between these items (Pearson correlation coefficient range: 0.39–0.61), a composite health literacy score was constructed by the weighted sum of six items. The weights were the standardized scoring coefficients from the first component of a principal component analysis due to 58% of the variability accounting for the first component. High internal reliability justified the use of the composite score . In order to further explore the differential influence of homegrown consumption by the extent of health literacy, we stratified our sample into two groups based on the median value of the composite fruit and vegetable health literacy score for subpopulation analyses.To measure household demand drivers, participants were asked how the following factors affected their decision to purchase FVs: (1) affordability, (2) availability, (3) accessibility, (4) proximity (5) taste (6) easiness to prepare/cook (7) knowledge to prepare FVs, and (8) food safety of FVs. Affordability means people can afford to purchase FVs. Availability is defined as the ability to purchase FVs that the household prefers to eat. Accessibility represents the ability to go to a place where fruits and vegetables are sold. Proximity indicates the nearness of store/place where FVs can be purchased. Indicator responses were on a five-point scale to represent the extent of agreement .Household socio-economic and -demographic characteristics were included as control variables, including area of irrigated land, education level, primary language spoken, social groups, and household food insecurity. The highest level of education completed by the head of household and the area of irrigated land were included as proximal measures for socio-economic status (SES) for this analysis due to the low reliability of self-reported income collected for this study . The prit-test for continuous variables with normal distribution as well as the Wilcoxon Mann–Whitney U-test for continuous variables without normal distribution and chi-square test for categorical variables. Using overall FVC as the main outcome, a multivariable regression model was then built to evaluate the association of home-grown fruit and vegetable consumption (HgFVC) and other drivers with FVC after adjusting all control variables, including eight household demand indicators, area of irrigated land, education, primary language spoken, social group, household food insecurity (Model 1). In Model 2, the interaction term between HgFVC and health literacy was added to Model 1 to examine whether the influence of HgFVC on FVC may vary with health literacy. Following the same modeling process, analyses were conducted separately for average daily servings of (1) vegetables per person and (2) fruits per person. Since the distribution of average daily servings of fruits and vegetables per person, as well as vegetables per person, were close to normal, linear regressions were used for the modeling process. Poisson regression was used for the outcome of average daily servings of fruits per person due to its skewed distribution toward zero servings. Since the interactions between HGC and health literacy for the three outcomes were all significant, subpopulation analyses were conducted to further assess if the influence of HGC and other drivers might differ between the low- and high-health literacy groups. An a priori power calculation shows that based on 15 predictors, and a two-sided significance level of 0.05, 139 participants would provide 80% power to detect a medium effect size f2 of 0.15 by using G*Power 3.1.9.7 software  consumed two or more servings of fruits daily per person, and around 69% of participants consumed zero servings of fruits daily. When comparing between the low- and high-health literacy groups, there were no differences for overall FVC and vegetable consumption (VC) alone, but the high-health literacy group had significantly lower fruit consumption (FC) compared with the lower one.Descriptive analyses are shown in p = 0.008), but the household health literacy was not associated with FVC  after adjusting for control variables. The results also presented the similar findings for VC where VC positively associated with home-grown VC , but not with health literacy . Meanwhile, among the demand indicators, both availability  and accessibility  were both positively associated with VC. As for FC, individuals who consumed more home-grown fruits  also reported higher FC. However, there was an interesting result showing that higher health literacy was specifically associated with less FC . When comparing with VC, there were two different demand drivers associated with FC: taste  and easiness to prepare/cook .The multivariable linear regression results for FVC, VC, and FC are shown in p = 0.02), VC , and FC . According to the subpopulation analyses, HGC was positively associated with overall FVC  and VC  among those who had little health literacy, but not among those who perceived more health literacy   (As shown in Model 2 on  = 0.06) , 4. In c= <0.01) . AdditioThis research examined the single and combined contributions of home-grown consumption (HGC) and FVC health literacy in rural India. The evidence from the current study indicates that higher HGC is associated with higher consumption of fruits and vegetables, which confirms previous evidence on the efficacy of agricultural approaches as a way of increasing FVC by promoting HGC , 21, 22.Evidence has shown that homestead farming contributes significantly to nutrition outcomes in developing countries , 61. ForPrevious studies have treated fruits and vegetables in a similar manner when exploring the drivers of FVC. However, recent studies argue that fruits should be considered separately from vegetables given that drivers could be different, and separate strategies may be needed –71. Our Meanwhile, our findings additionally showed that health literacy could modify the influence of HGC on FVC. Specifically, after stratifying the data into low- and high-health literacy groups, the positive influence of HGC on FVC was demonstrated only in the low-health literacy group. Previous evidence suggests that health literacy is a prominent predictor of FVC , 35, andMeanwhile, the findings also suggest that more vegetable consumption from home grown could increase overall vegetable consumption only among people with low-health literacy. However, the positive impact of home-gown fruit consumption on overall fruit consumption was the same in both low- and high-health literacy groups. Additionally, subpopulation analyses also reveal that differential drivers could be found based on the level of health literacy. These results suggest that when designing an intervention for improving FVC, it would be important to consider differential levels of health literacy among people in order to apply the most appropriate behavioral interventions. For example, knowledge to prepare FVs could have reverse influence on vegetable consumption among low- and high-health literacy groups, and the influence of affordability, accessibility, or knowledge to prepare FVs could be found only in the high-health literacy groups. Different demand drivers in low- and high-health literacy groups may cause different consumption rates of fruits and vegetables among the two groups, as also evidenced by previous studies demonstrating that the determinants of fruit consumption differ from vegetable consumption , 71–74. This study has several limitations. First, the results may not be generalizable to other rural settings since the data were collected in only four districts of rural Odisha. Nevertheless, our main findings of differential drivers and consumption motives that differ by fruit and vegetable consumption literacy level have added further knowledge to fruit and vegetable research. Second, measures of fruit and vegetable consumption, as well as health literacy, are partial. FVC is the most obvious one because no instrument has perfectly captured consumption data—and there are often biases when using self-reported measures. Meanwhile, the measure for health literacy had a similar measurement issue. There are various aspects for health literacy, but the focus of the present study was on perceived health benefit on vegetables due to the limitation on the questionnaire. Third, the data in this study were cross-sectional, and causality should not be directly inferred from the findings in this study.In India, low consumption of fruits and vegetables undoubtedly constitutes one of the country's critical nutritional problems. Although there is an important role for the agricultural and educational sectors in improving FVC, less is known about their direct and indirect relationships to farmers' decisions about fruit and vegetable consumption. This study filled in the gap of the empirical evidence on the potential contribution of agricultural approaches on FVC, as well as the connection between agricultural and knowledge-based approaches. Results indicated that higher home-grown consumption was associated with improving FVC, with one implication being the importance of agricultural programs as representing viable entry points for increasing FVC. Evidence on the contingent relationship between agricultural and knowledge-based programs highlights the multifaceted approaches needed to promote FVC. Therefore, for countries like India, the policy focusing on behavior or educational approach to increasing FVC was not enough, and the effective policy development need to additionally incorporate agriculture aspect, such as home gardening, to construct stronger synergies to act on nutrition-sensitivity agriculture intervention. In addition, further research on elaborating a clear direction of impact pathways, theories of change, or cost effectiveness of nutrition-sensitivity agriculture intervention is needed in order to translate and provide solid evidence to policy makers.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Research Ethics Board of McGill University. The patients/participants provided their written informed consent to participate in this study.Y-HW was a contributor to the study conception, design, data analysis, and wrote the manuscript. CM contributed toward manuscript preparation and revisions. SM and LD contributed toward study conception, design, and data collection. All authors critically reviewed and approved the final manuscript for submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The Journal of Nursing Research, four articles address issues that influence professional identity formation in the nursing profession. Their topics include the effects of education on professional quality of life and health among nurses, the effects of film-based nursing education in developing professional nursing identity among nursing students, the impact of organizational support on practice outcomes in nurse practitioners, and the use of a function-focused interdisciplinary communication framework in a nursing home setting.The nursing profession is evolving rapidly to meet the challenges and opportunities presented by the constant, technology-driven changes in healthcare delivery and the ever-changing landscape of healthcare needs. In this issue of Evidence-based nursing interventions are paramount to the successful development and adoption of evidence-based practices in nursing. Two articles in this issue provide evidence regarding the efficacy of nursing interventions on different groups of nursing clients, including the efficacy of machine-based hand massage in patients awaiting outpatient surgery and the efficacy of auricula acupressure in community-dwelling poor sleepers.Self-management is an important strategy for reducing chronic-disease-related symptom distress and illness burden. Also in this issue, the results of a survey querying the perceived effectiveness of pain self-management strategies in people with migraine headache are reported.While high-quality quantitative studies are needed for evidence-based nursing practice, the qualitative research approach is useful for exploring issues and phenomena that are poorly defined or understood. To this end, the components of empowerment in family caregivers of community-dwelling people with dementia were also explored in a qualitative research study included in this issue.Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.ptsai@tmu.edu.twAddress correspondence to: Pei-Shan TSAI, PhD, RN, Professor, School of Nursing, College of Nursing, Taipei Medical University, No. 250, Wu Xing St., Taipei City 11031, Taiwan, ROC. Tel: +886-2-27361661 ext. 6321; E-mail: Cite this article as:The Journal of Nursing Research, 29(3), Article e147. https://doi.org/10.1097/jnr.0000000000000438Tsai, P.-S. (2021). The varied and multifaceted professional roles of today’s nurses.


Evidence and practice recommendations on the use of transanal total mesorectal excision (TaTME) for rectal cancer are conflicting.We aimed to summarize best evidence and develop a rapid guideline using transparent, trustworthy, and standardized methodology.We developed a rapid guideline in accordance with GRADE, G-I-N, and AGREE II standards. The steering group consisted of general surgeons, members of the EAES Research Committee/Guidelines Subcommittee with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, biostatisticians, and a guideline methodologist. The guideline panel consisted of four general surgeons practicing colorectal surgery, a radiologist with expertise in rectal cancer, a radiation oncologist, a pathologist, and a patient representative. We conducted a systematic review and the results of evidence synthesis by means of meta-analyses were summarized in evidence tables. Recommendations were authored and published through an online authoring and publication platform (MAGICapp), with the guideline panel making use of an evidence-to-decision framework and a Delphi process to arrive at consensus.https://app.magicapp.org/#/guideline/4494.This rapid guideline provides a weak recommendation for the use of TaTME over laparoscopic or robotic TME for low rectal cancer when expertise is available. Furthermore, it details evidence gaps to be addressed by future research and discusses policy considerations. The guideline, with recommendations, evidence summaries, and decision aids in user-friendly formats can also be accessed in MAGICapp: This rapid guideline provides evidence-informed trustworthy recommendations on the use of TaTME for rectal cancer.The online version contains supplementary material available at 10.1007/s00464-022-09090-4. Colorectal cancer affects a substantial proportion of the general population, with a lifetime risk of 4.3% for men and 4% for women . Rectal Rectal dissection is, however, challenging in low-lying tumors and in patients with unfavorable anatomy, such as male and obese individuals. Transanal total mesorectal excision (TaTME) has been developed as an alternative technique, that allows down-to-up dissection of the rectum and perineal dissection of the mesorectum without the need for deep abdominal dissection. It has been hypothesized that this approach may improve the quality of the specimen .TaTME has attracted much attention over the past few years and it has stimulated a debate around its safety and efficacy –10. MoreThe objective of this rapid guideline was to develop reliable, trustworthy, pertinent, evidence-informed recommendations based on state-of-the-art guideline development methodology on the use of TaTME versus laparoscopic or robotic surgery in patients with rectal cancer.The protocol of this rapid guideline is available online . It was https://app.magicapp.org/#/guideline/4767) and in the Appendix; complete datasets are available online [This is an outline of the methodology; more detailed information is provided in MAGICapp , a certified guideline methodologist with vast experience in evidence outreach, synthesis, assessment and guideline development, ; biostatisticians ; and a GRADE external auditor (POV). All members of the steering group disclosed no conflicts, direct or indirect .The guideline panel consisted of four general surgeons, a radiation oncologist, a radiologist, a pathologist, and a patient advocate . The patient advocate resides in the USA and was nominated by the European Patients' Forum, a non-profit umbrella organization of patient organizations across Europe. Panel members watched a short video tutorial outlining the guideline development methodology. The composition of panel members aimed to be representative of different parts of Europe, both genders, different age groups, and academic/non-academic surgical practice. Panel members disclosed no direct nor indirect conflicts . ExternaShould TaTME versus laparoscopic TME be preferred for the treatment of rectal cancer?Should TaTME versus robotic TME be preferred for the treatment of rectal cancer?A protocol was developed a priori by the steering group . The proThe importance of outcomes was rated by the panel members using the GRADE scale . The cla30-day or in-hospital mortality: critical30-day complications Clavien-Dindo ≥ 3 (major morbidity): critical30-day complications Clavien-Dindo ≤ 2 (minor morbidity): importantAnastomotic leakage: criticalCompleteness of TME: criticalDisease recurrence at 2 years: critical5-year overall survival: critical5-year disease-free survival: criticalLow anterior resection syndrome: criticalQuality of life: criticalWe considered the importance of outcomes as follows:The evidence-to-decision framework was set within a fully contextualized approach . An anon30-day or in-hospital mortality: 10 per 100030-day complications Clavien-Dindo ≥ 3 (major morbidity): 10–50 per 100030-day complications Clavien-Dindo ≤ 2 (minor morbidity): 50–100 per 1000Anastomotic leakage: 25 per 1000Completeness of TME: 25–50 per 1000Disease recurrence at 2 years: 25–50 per 10005-year overall survival: 10–50 per 10005-year disease-free survival: 10–25 per 1000Low anterior resection syndrome: 50 per 1000Quality of life: score 5–10 out of 100Under consideration of panel's responses, the following minimal important differences were considered:One strategy was developed for both guideline questions because of their affinity. The databases of Medline, EMBASE and OpenGrey were searched. The search syntaxes are available online .Titles and/or abstracts were screened (first level) and full text articles were scrutinized (second level) to identify eligible studies in duplicate . Inclusion criteria were adult patients with adenocarcinoma of the rectum, TaTME compared with laparoscopic/robotic TME. Exclusion criteria were single incision and open surgery.RoB-2 and ROBINS-I were used for risk of bias assessment in RCTs and cohort studies with a comparative arm, respectively , 23. RelI2 statistic that describes the percentage of the variability of effect estimates that is due to heterogeneity rather than sampling error. We further explored heterogeneity by computing the Q-statistic and the 95% predictive intervals that show the plausible range of effect size values for a future trial. All the analyses were performed in R statistical package version 4.0.3 using the meta package. All statistical analyses were performed independently by the statisticians' group with no involvement of the steering group or panel members.We conducted random effects meta-analyses to quantitatively synthesize the evidence for the guideline questions since we expected much variation in the PICO criteria across studies . We explWe constructed GRADE evidence profiles of certainty for each outcome separately using MAGICapp. The certainty of evidence is determined by the risk of bias across studies, incoherence, indirectness, imprecision, publication bias and other parameters . We usedThe panel discussed the evidence within a GRADE evidence-to-decision framework coordinated by the guideline methodologist using MAGICapp. A formal anonymous Delphi process was carried out to finalize the judgements. A total of two online meetings were required.Based on the evidence-to-decision framework, the panel anonymously voted on the strength and the direction of the recommendations through MAGICapp. There was unanimous consensus on the strength and the direction of the recommendations, whereas minor dissenting opinions on the wording were noted and reported accordingly in this manuscript.Some 822 records and 46 full text articles were screened, out of which 17 met the eligibility criteria. Sixeen studies addressed Q1 –44 and oData on disease-free and overall survival were provided by one study only; local recurrence at 2 years was provided by two studies , 44; howSeveral articles addressed parameters pertinent to the evidence-to-decision framework –53.We suggest TaTME over laparoscopic TME if expertise is available.Weak recommendationRationaleThe panel identified some evidence of benefit in critical outcomes with TaTME and no evidence of harm; nevertheless, the overall certainty of the evidence was very low, primarily due to confounding bias and imprecision of effect estimates, whereas evidence on some critical outcomes, primarily survival outcomes, was very low. Substantial variability in patient values and preferences is anticipated and patient aids might be useful in this context. There is uncertainty around the use of resources, whereas equity might be reduced, due to lack of widespread expertise and longer use of operating room resources, at least during the early stages of implementation. The panel considered the intervention to be acceptable to key stakeholders, whereas feasibility was considered to vary and depend on annual volume of cases and centralization of care. An important parameter which determines the direction of the recommendation is  expertise. External validity of relevant research evidence is determined by the degree of expertise of surgeons and operating room staff. Consensus reports detailing training and considerations on expertise can be found here .See Table We suggest TaTME over robotic TME if expertise is available.Weak recommendationRationaleThe panel recognized that the evidence was very limited to allow assessment of the balance between benefits and harms with confidence. Several panel members suggested that surgeon's expertise plays a vital role and probably affects outcomes, so that both options may be appropriate. Substantial variability in patient values and preferences is anticipated and shared decision making after discussion of surgeon's preference and expertise, and perceived benefits and harms is encouraged. There is uncertainty around the use of resources, which depends on whether robotic-assisted or laparoscopic-assisted TaTME is performed, and on the selection between disposable or reusable instruments for laparoscopic-assisted TaTME. Equity might be reduced, due to lack of widespread expertise and longer use of operating room resources, at least during the early stages of implementation. The panel considered the intervention to be acceptable to key stakeholders, whereas feasibility was considered to vary and depend on annual volume of cases and centralization of care. Consensus reports detailing training and considerations on expertise can be found here .See Table TaTME represents an option for the treatment of low rectal cancer, next to laparoscopic and robotic rectal resection. Although evidence on economic considerations is limited, empirical evidence does not suggest increased overall cost. Centralization of rectal cancer management may be necessary to allow accumulation of experience, which may play a vital role in operative outcomes.Surgeons with experience in TaTME are not advised against performing TaTME in patients with low rectal cancer, as evidence from comparative observational studies which have adjusted for confounders does not indicate increased harm, moreover there is evidence of moderate certainty suggesting lower 30-day mortality and lower rate of recurrence at 3 years.Substantial new evidence is awaited within the next few years, so that surgeons who are not trained in TaTME may not change their practice for the present. Importantly, evidence considered in this rapid guideline derives primarily from centers and surgeons with experience in TaTME; guideline users are therefore advised to exercise caution in extrapolating the evidence summarized herein.Patients can be informed that available evidence suggests similar outcomes between TaTME and laparoscopic TME, whereas 30-day mortality and 3-year loco-regional recurrence may be lower with TaTME if the surgeon has experience with this technique. Furthermore, they may want to discuss expected benefits and potential harms, and their surgeon's experience and preference.There are important gaps in evidence, which are expected to be addressed by future research:TaTME v. laparoscopic TME De novo RCTs may not be necessary, because several trials are currently underway and their results are expected to be published within the next years . Matched cohort studies are needed to address the outcomes major morbidity, 30-day or in-hospital mortality, 2-year recurrence, 5-year disease-free and overall survival, low anterior resection syndrome and quality of life. Importantly, further reports of unmatched cohorts do not contribute reliable information to the body of evidence and may be redundant and potentially misleading. Researchers may want to consider performing analyses that have adjusted for sex, BMI, ASA classification, tumor stage and distance from anal verge, and neoadjuvant chemoradiotherapy. To reach sufficient sample size, multi-institutional collaborations or registry analyses are encouraged. Analyses of male patients, patients who underwent neoadjuvant chemoradiotherapy and level (height) up to which transanal dissection was performed are expected to address the outcomes of TaTME in these subgroups.TaTME v. robotic TME Available evidence is extremely limited and the same research considerations apply here as well. Critical and important outcomes as listed in the Methods section are expected to be addressed.Use of the guideline by EAES members will be monitored through an online survey 2 years after publication. Feedback from target users in the form of email communication, letters to the editor, and comments in social media will be documented to be addressed by future versions.n = 4) or robotic (n = 1) TME, including two mega-trials (planned to recruit > 1000 patients each) [Disclaimer for further information regarding validity.A scoping search of ClinicalTrials.gov, EU Clinical Trials Register, WHO International Clinical Trials Registry Platform, EORTC and ISRCTN registry identified at least 5 ongoing RCTs comparing TaTME with laparoscopic (ts each) –58. CompAn update of this rapid guideline is planned to take place in 2025. However, one could anticipate a change in the direction or the strength of the recommendation when data from cohort studies or registries become available, under the condition that their methodological quality will be high. The EAES Research Committee/Guidelines Subcommittee will keep monitoring new evidence and update this document if such data become published.This rapid review summarizes highest quality evidence and provides evidence-based and trustworthy recommendations on the use of TaTME for low rectal cancer.Supplementary file1 (DOCX 1980 KB)Below is the link to the electronic supplementary material.


The post-mortem interval of human cadavers may be estimated based on insect evidence. In order to identify scientific challenges that pertain to these estimations, I review forensic entomology literature and conclude that research on the development and succession of carrion insects, thermogenesis on cadavers and the accuracy of PMI estimates are of primary importance to advance this field.During death investigations insects are used mostly to estimate the post-mortem interval (PMI). These estimates are only as good as they are close to the true PMI. Therefore, the major challenge for forensic entomology is to reduce the estimation inaccuracy. Here, I review literature in this field to identify research areas that may contribute to the increase in the accuracy of PMI estimation. I conclude that research on the development and succession of carrion insects, thermogenesis in aggregations of their larvae and error rates of the PMI estimation protocols should be prioritized. Challenges of educational and promotional nature are discussed as well, particularly in relation to the collection of insect evidence. Carrion insects living in human cadavers can be highly useful for the estimation of the post-mortem interval (PMI) ,2. MethoA PMI estimate is only as good as it is close to the true PMI. The accuracy of estimation is most important, particularly for the end users of insect evidence. Therefore, the major general challenge for the field is to reduce the estimation inaccuracy. Its sources are related to both the collection and analysis of insect evidence . I dividErrors in the collection of insect evidence are certainly among the most important sources of the inaccuracy in PMI estimation. Death scene samples frequently misrepresent cadaver entomofauna. However, it is difficult to discern how bad these samples usually are and what the consequences of sampling errors are for the estimation of PMI. In most cases insects are collected by law enforcement officers or medical examiners, and rarely by entomologists. In a recent case, insects were sampled by police officers with the medical examiner and independently by entomologists, which enabled—in this paper—the comparison of samples taken by non-experts and experts . The samGuidelines for the collection of insect evidence state that death scene samples should accurately represent cadaver entomofauna, i.e., all life stages of each important species that inhabit a cadaver should be represented in the sample ,9,10. CaLucilia sericata or Calliphora vicina), there are still species that regularly breed in cadavers but for which no dataset has been published  or only single datasets are available . These species should become the hot taxa for forensic entomology research in Europe. The understudied species ought to be identified also for other geographical regions.Most frequently, forensic entomologists estimate the age of immature insects collected on a death scene and use this information as the minimum PMI . The refAnother point that needs our attention is the lack of standards and guidelines for developmental studies in forensic entomology. Several elements of the protocol for such studies were found to affect the quality of the resultant developmental data ,17,18,19There are several forensic reasons to study insect succession on cadavers. First, these studies yield inventories of carrion insects for habitats and geographical locations that form a starting point for any further research in forensic entomology. Such inventories were published for many habitats and locations around the world (recently reviewed in ), but thSecond, succession studies provide reference data on the pre-appearance interval (PAI) and the presence interval (PI) of particular insect taxa. Such data are essential to use insects that colonize cadavers late in decomposition, as their PAI may be longer than the development interval, and to get meaningful PMI it may be necessary to combine insect age with the PAI ,11,103. Third, decomposition experiments using pig cadavers may be useful to validate the PMI estimation protocols . Such exThere are guidelines for decomposition studies in forensic entomology ,114,115.The succession and development of insects on cadavers is largely dependent on the temperature ,128,129.Forensic entomologists frequently use temperature data from the local weather stations. Weather station temperatures can be corrected to adjust them to the peculiarities of a death scene ,133,134.Some authors modelled temperature conditions in parked vehicles , containNecrodes littoralis L. (Silphidae), with evidence that heat is produced within the feeding matrix, which is formed by adult and larval beetles through spreading their exudates over the cadaver surface [The last factor that needs much more of our attention is the insect-driven thermogenesis. It has been discovered and extensively studied in aggregations of blow fly larvae ,151,152. surface . Thermog surface .When large aggregations of fly larvae (with elevated temperature) are present on a cadaver, Charabidze and Hedouin  suggest All insect evidence can be challenging in some cases, and some types are always challenging. The puparia of flies and pupae of beetles are informative pieces of insect evidence, particularly on decomposed cadavers ,11. HoweThe identification of insect evidence is a necessary first step in any analysis. Significant progress has been recently made in this field, with several forensically important fly taxa gaining excellent identification keys for adult insects ,160,161 Necrodes littoralis by means of the quantification of the eye-background contrast, with very encouraging results of the initial validation [It is difficult to estimate the age of the fixed puparia of flies and pupae of beetles. The most promising techniques for aging such evidence consist of the qualitative morphological analyses of the intra-puparial forms of the flies ,35,36. Ilidation . SimilarEmpty puparia  are frequently collected on cadavers with long PMI, and their examination may provide an estimate of the minimum PMI . This tyForensic entomologists developed several methods for the estimation of PMI based on insect development ,181,182 Most of the validation studies in forensic entomology were proof-of-assumptions or proof-of-concept studies . ExperimSimilarly, validations using casework data were infrequent . In ordeThere were surprisingly large differences between the cases. Errors I (differences between the true and estimated PMI expressed as the percentage of the true PMI) ranged from 0 to 83% for the development-based estimates  and fromSummarizing, the protocols for the estimation of PMI based on insect evidence usually lack errors and their validity has been rather poorly demonstrated in a true forensic context. Therefore, validation studies using pig or human cadavers and casework data should be prioritized in forensic entomology. I think this is our greatest challenge.Although the set of challenges elucidated in this article is somehow subjective, I believe that most forensic entomologists would construct similar sets. Some challenges should focus more of our attention, with priority for the resultant research. This applies, in particular, to the validation research, as well as to development and succession research. Studies on thermogenesis in larval aggregations on cadavers should be prioritized as well. There are also highly important challenges of educational and promotional nature. Although we should look for more optimal guidelines for insect sampling on a death scene, and this is a scientific task, improvement in the samples taken by a law enforcement personnel depends equally or even more on the promotion of forensic entomology among its end-users and on the education of the officers or medical examiners that collect insect evidence on death scenes.


There were no significant differences in operative time, anesthesia time, or complications from microsurgery by the same operator. According to the questionnaire survey results, compared with MES, EES had a wider field of view due to its lack of an eyepiece, was easier when loading and unloading instruments into and out of the surgical field, and was more suitable for the simultaneous observation of two fields of view. Overall, 79.2% of surgeons indicated that EES may be better suited than MES to simultaneously observe two fields of view.The use of an endoscope in exoscopic transcranial neurosurgery for skull-base lesions has not yet been investigated. Thus, this study aimed to investigate the advantages, disadvantages, and safety of “simultaneous temporary use of an endoscope during exoscopic surgery” (exo-endoscopic surgery (EES)). Consecutive exo-endoscopic surgeries performed by experienced neurosurgeons and assistants were analyzed. Surgical complications and time were compared with previous consecutive microsurgeries performed by the same surgeon. A questionnaire survey was conducted on 16 neurosurgeons with experience in both “temporary simultaneous use of endoscope during microscopic surgery” (micro-endoscopic surgery (MES)) and EES. EES was performed in 18 of 76 exoscopic surgeries, including tumor removal ( With the advancement of digital image processing technology, the miniaturization of video equipment, and the introduction of high-resolution digital imaging equipment, such as 4 K, 8 K, and three-dimensional 3D) screens to the medical field, there have been increasing reports on the usefulness and safety of exoscopes and heads-up surgery in the field of neurosurgery ,2,3,4. VD screensMicrosurgery in the field of neurosurgery has been performed since the 1950s. The usefulness and limitations of the “temporary simultaneous use of an endoscope during microscopic surgery” ) were not reported until the 1990s; it has been used for deep and back-surface observation of anatomical objects ,11,12,13Previous studies have reported the usefulness of switching to endoscopes when the field of observation is inadequate in exoscopic surgery ,8,17. HoThis observational study aimed to compare the usefulness and safety of EES and MES by examining the following two aspects: (1) comparison of operative time, anesthesia time, and frequency of complications associated with EES and MES performed by the same surgeon for the same period; and (2) questionnaire survey administered to neurosurgeons who had participated in both EES and MES as surgeons or assistants regarding their comparison. One primary surgeon (Y.M.) was in charge of all cases of cerebral aneurysms, whether exoscopic or microscopic. Another primary surgeon (A.M.) was in charge of all cases of auditory nerve tumors, whether endoscopic or microscopic. For surgeries using the exoscope, written consent for the procedure was obtained from all patients using a form approved by the institutional review board of Nippon Medical School Hospital.®, Karl Storz, Tuttlingen, Germany), and Kinevo 900 . Between July 2018 and March 2019, 76 surgical cases were performed using an exoscope.We used the exoscope to replace the surgical MS in hospitals and prepared both the surgical MS  and an exoscope for exoscopic surgery. The following three types of endoscopes were used: ORBEYE , VITOM 3D  and an EndoArm endoscopic holder  were used in all EES. In both exoscopic and microscopic surgeries, the use of an endoscope was left to the surgeon’s discretion.n = 6), anterior circulation cerebral aneurysm clipping (n = 5), meningioma removal (n = 4), transcranial removal of craniopharyngioma (n = 1), transcranial removal of the epidermoid (n = 1), and microvascular decompression for trigeminal neuralgia (n = 1)  . VestibuAll cases of vestibular schwannoma were operated on via the lateral suboccipital approach using EES, and the tumor size was <28 mm. The cases used for comparison were consecutive cases with the same conditions and performed by the same surgeon; tumor sizes were <28 mm. In addition, cerebral aneurysm clipping using an exoscope was <17 mm in all cases, and the cases included frontotemporal craniotomy without concomitant revascularization. The cases used for comparison were also consecutive cases performed by the same surgeon under the same conditions. These case groups were compared in terms of postoperative complications, operative time, and anesthesia time.All cases of cerebral aneurysm clipping by EES were initial operations for unruptured cerebral aneurysms in the anterior circulation. Therefore, only the initial clipping of unruptured cerebral aneurysms in the anterior circulation was selected for comparison. All cases of vestibular schwannoma removal by EES were also initial surgeries performed via the lateral suboccipital approach. Only microsurgical cases under the same conditions were included in the comparison. Patients with neurofibromatosis were excluded from the study. No selection was made based on patient age. Postoperative complications were assessed using the evaluation system used in Japan . After p < 0.05. All analyses were performed using JMP software . The appropriate sample size and power were determined for the statistical analyses. Categorical variables were compared using Fisher’s exact test. The type 1 error was 5% (α = 0.05), the power was 95% (1 − β = 0.95), a p-value < 0.05 was considered statistically significant, and JMP 14.0 software was used for the analyses. Consequently, logistic regression analysis was excluded due to the small sample size. Responses to the questionnaire were rated on a five-point Likert scale as follows: strongly prefer MS, prefer MS, neither agree nor disagree, prefer exoscope, and strongly prefer exoscope. Each of these aspects was rated as follows: the grade “Neither agree nor disagree” denoted “Equal or Incapable” , “Agree to EES” denoted “Superior”, and “Strongly agree to EES” denoted “Clearly superior” (EES is clearly superior to the MES). We attempted to compare the seven questionnaire items with each other and extract the items that were more highly rated. Chi-square test was used for statistical analysis. Next, we divided the questionnaire evaluators into two groups: experienced board certified neurosurgeon and inexperienced non-board certified neurosurgeon, to investigate whether the evaluations differed depending on the experience of the surgeons. Fisher’s exact test was used for statistical analysis. Non-normally distributed continuous variables were compared between groups using the Mann–Whitney U test. Categorical variables, such as the frequency of complications, were compared using Fisher’s exact test. Statistical significance was set at p = 0.018).There were no significant differences in the operative time, anesthesia time, operative complications, or frequency of complications between the EES group or MES group for either aneurysmal clipping or acoustic tumor removal . For vesDetails of the 11 cases of EES are shown in n = 1), epidermoid removal (n = 1), and microvascular decompression for trigeminal neuralgia (n = 1), the surgeons found it difficult to operate with the exoscope and switched to the MS owing to the narrow field of view at depth. However, in two of these cases, the exoscope was used in situations where temporary endoscopic use was necessary. Although this study mainly aimed to evaluate EES, no cases were switched to microscopy while performing EES. In cases of cerebral aneurysm clipping (p = 0.035), simultaneous observation of the two monitors (p = 0.041), and observation of the surgeon’s hand (p = 0.035) were rated statistically significantly higher. The results are shown in Valid responses to the questionnaire survey were obtained from 16 neurosurgeons. The survey items and a summary of the results is provided in We want to emphasize that this study did not to aim to examine the superiority or inferiority of the visual fields of exoscopic surgery and microscopic surgery. Rather, this study aimed to determine whether the exoscope or the MS was superior when used in combination with an endoscope. The light is unidirectional for both the MS and exoscope, and the areas behind and beside the optical axis are difficult to see with either instrument. Thus, it has been recommended to temporarily use an endoscope simultaneously with an MS to expand the field of view. This study demonstrates that the exoscope may be superior to the MS in some aspects that are limited to the temporary use of the endoscope. This study consisted of a limited number of cases, and further investigation involving a larger number of cases is needed. It is also necessary to investigate this subject in terms of different surgical positions and pathologies.The comparison between MES and EES revealed that there was no significant difference in operative time, anesthesia time, or frequency of complications, although surgeons had limited experience with this technique. The survey results indicated that the ease of insertion of the endoscope into the field of view, the simultaneous observation of the two surgical fields, and the ease of viewing the surgeon’s field of view at hand were highly rated. Furthermore, the survey results were not influenced by the level of experience of the neurosurgeons.The surgeons felt that EES provided a wider field of view owing to the absence of eyepieces and the possibility of safely moving surgical instruments, such as bipolar forceps and micro-scissors, and the endoscope itself into and out of the surgical field ,3,6. TheMicro-endoscopic surgery expands the field of view in deeper regions of the body ,10,11; hAll the responses were obtained from neurosurgeons with little experience in exoscopic surgery. However, when analyses were limited to endoscope-assisted surgery, we found that 5.4% of the responses favored the MS, and 79.2% favored the exoscope. However, it should be noted that this result does not indicate that the exoscope is superior to the MS in all surgeries. This study entailed only a comparison between the exoscope and the MS in surgeries using an endoscope. We also observed that the MS was rated relatively higher in terms of ease of preparation in the operating room. This may be partly attributed to the limited experience of the surgeons with exoscopic surgery using an endoscope.We decided to include all assistants in the questionnaire survey instead of limiting it to only the surgeon, the reason being that one of the characteristics of exoscopic surgery is that participants other than the surgeon can observe the surgical field in exactly the same way as the surgeon ,3. This 3D images are becoming increasingly available for both exoscopic ,7,20 andThe survey on the usefulness of this surgery is based on a questionnaire survey. The survey should ideally be based on objective figures, not only on the impressions of the surgeon or assistant. Therefore, as a way of increasing objectivity, it is desirable in the future to classify a large number of cases in different surgical positions and pathologies, and to investigate the operative time and complications.This study had some limitations. First, this is only an initial report, and the number of cases in this study is limited. We searched PubMed for reports on preliminary studies on exoscopic neurosurgery published since 2019 using the search terms “exoscope,” “microsurgery,” and “neurosurgery”. We found seven studies ,24,25,26We report our initial experience with EES. MES and EES had similar operative times and complications. Results of the survey showed that more than 79% of surgeons reported a possible advantage of EES over MES, and the simplicity of preparing for EES was rated low. In the future, the development of a large monitor, capable of simultaneously displaying two screens of 3D images, is anticipated.


There are over 1 million adults with a learning disability in the UK, of whom approximately 20% displaying behaviours that challenge others. Two thirds of people with learning disabilities live in the family home. As they and their family carers age, both are likely to face particular difficulties and stresses, but there is little understanding of their experiences and needs. To address this evidence gap, our main objective is to undertake two rapid scoping reviews that will collectively focus on the health and social care needs, experiences, service interventions and resources of older people with learning disabilities and behaviours that challenge others, and their family carers. Both reviews will focus on issues relating to forward planning and transitions to different care contexts. The study is part of a research project funded by the National Institute for Health Research No.129491.We propose to address the need for evidence via two rapid scoping reviews. We will include published and unpublished (grey) literature, encompassing empirical research, policy and practice guidance and lay resources to support decision-making. We will search multiple electronic databases, hand search references lists, and use expert guidance to identify potential evidence. The following databases were used for research and grey literature: CINAHL; Healthcare Management Information Consortium (HMIC); NHS Evidence; Scopus; Turning Evidence Into Practice (TRIP); Web of Science (WoS); Google (first 5 pages); and Google Scholar (first 5 pages). For RR2, additional intended databases are the Carer Research Knowledge Exchange Network (CAREN) and Social Care Institute for Excellence (SCIE). Two reviewers will independently screen all citations and full-text articles for inclusion. One reviewer will extract data, with an independent review undertaken by the research team. Critical appraisal will depend on the nature of included evidence. Narrative synthesis will be collaboratively developed, with descriptive information presented in tables summarising study characteristics and thematic analysis of findings presented in the main text. Dissemination will be through journal publication, conference presentations and written short-form, easy-read versions of articles and audio-video clips for lay audiences.We will consider the strengths and limitations of our reviews, considering their impact on findings. We will summarise the main findings and provide an interpretation linked to the review questions and objectives. We will consider the implications of our findings for policy and practice, as well as future research addressing the support of older people with learning difficulties and behaviours that challenge others, and their family carers, in the context of transition to different care contexts in the UK.The protocol has been registered as Vseteckova, J., Jordan, J., Tilley, E., Larkin, M., Ryan, S., and Wallace, L. . Transitions for older people with learning disabilities and behaviours that challenge others, and their family carers: a merged protocol for two rapid scoping reviews of evidence. Retrieved from osf.io/jzrn9.The online version contains supplementary material available at 10.1186/s13643-021-01883-3. There are approximately 1,130,000 adults with a learning disability in the UK . Two thiThe consequences of ageing for family carers and the older people with learning disabilities for whom they care are deeply entwined. Both face the challenges typically associated with ageing. In addition, people with learning disabilities are more likely to experience early onset of chronic health conditions such as kidney disease, dementia, constipation and diabetes than their non-disabled peers , 11, whiThe issue of breakdown in support is compounded by a reluctance on the part of family carers to plan for transition, leaving older people with learning disabilities at risk of inappropriate relocation to more intensive supported care , 14, 15.Despite the clear challenges and stresses faced by older people with learning disabilities and behaviours that challenge others and their family carers, we know little about their transition-related experiences and needs. Two systematic reviews addressed people with learning disabilities and behaviours that challenge others, but they focused on younger adults , 30. In To address the above gaps in evidence, we will undertake two rapid scoping reviews. The first (RR1) will address older people with learning disabilities and behaviours that challenge others, with a specific focus on ageing, including issues relating to transition. The second (RR2) will address their family carers, again with a specific focus on ageing and issues relating to transition. Both reviews will encompass literature concerning the health and social care needs, experiences, service interventions and resources of and for both populations.What are the health and social care needs, experiences, service interventions and resources of and for older people with learning disabilities and behaviours that challenge others as they move to different care contexts1in the UK? In line with this question, our objectives are to (1) Identify relevant UK evidence according to key features such as nature, focus, content, target population, design, methodology and findings/outcomes; (2) Systematically integrate this evidence in terms of what it suggests are the health and social care needs, experiences, service interventions and resources of and for older people with learning disabilities and behaviours that challenge others as they transition to different contexts of care; and (3) Use the learning delivered by (2) to consider the status of transition-related care and support for older people with intellectual disabilities and behaviours that challenge others, drawing out implications for how this care and support might be most effectively planned and undertaken to fit with people’s needs and preferences.For RR1 our review question is: What are the health and social care needs, experiences, service interventions and resources of and for family carers2of older people with learning disabilities and behaviours that challenge others as they move to different care contexts in the UK? In line with this question, our objectives are to (1) Identify relevant UK evidence according to key features such as nature, focus, content, target population, design, methodology and findings/outcomes; (2) Systematically integrate this evidence in terms of what it suggests to be the health and social care needs, experiences, service interventions and resources of and for family carers of older people with learning disabilities and behaviours that challenge others as they transition to different contexts of care; and (3) Use the learning delivered by (2) to consider the status of transition-related care and support for family carers of older people with intellectual disabilities and behaviours that challenge others, drawing out implications for how this care and support might be most effectively planned and undertaken to fit with people’s needs and preferences.For RR2 our review question is: The rationale for undertaking rapid scoping reviews of the literature is as follows. Our review questions are inclusive and exploratory in nature, designed to capture a broad range of evidence pertaining to multiple aspects of the health and social care needs, experiences, service interventions and resources of and for older people with learning disabilities and behaviours that challenge others as well as exploring multiple aspects of the health and social care needs, experiences, service interventions and resources of and for the family carers. Scoping reviews seem ideally suited to our requirements, as it allows evidence drawn from diverse sources, which is typically heterogeneous in nature, to be systematically synthesised in terms of its nature, features, and findings/outcomes . Given tSelecTing Approaches for Rapid Reviews (STARR) [This study protocol has been registered in the Open Science Framework (osf.io/jzrn9); it is publicly available for view in the National Institute of Health Research (NIHR) library. It is being reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement  see che. The pla (STARR)  decision (STARR)  and the  (STARR) .The guidance for rapid reviews repeatedly stresses the importance of interaction with the users of the review to ensure it remains relevant and useful , 35. We Given that we aim to scope a broad range of evidence in RR1 and RR2, we will include published and unpublished (grey) literature, including research articles, reports and guidance. Whilst we will include policy and practice guidance, we will exclude discussion papers, position papers, expert opinion pieces, editorials and study protocols as we are interested in the nature of and findings of evidence that can be used to draw conclusions regarding our phenomena of interest.Valuing People White Paper for England and Wales [Valuing People included an explicit focus on the needs of older people with learning disabilities and on the needs of people with behaviours that challenge others. For both reviews, where evidence encompasses countries in addition to the UK, it will be included if the UK specific evidence can be extracted e.g. when we can differentiate between data in primary research findings or we can use UK-only references included in systematic reviews.Within the published research we will include both primary  and secondary (e.g. review) level evidence. Given our time and other resource constraints, we will only include literature written in English. To enhance the relevance of our review findings, we will include evidence made available after 2001, to coincide with the publication of the UK Government’s nd Wales . ValuingTable Table Primary: to identify empirical research which indicates the enablers and barriers  that either facilitate or hinder effective planning for, and execution of, transition of older adults with learning disabilities and behaviours that challenge others in relation to their personal needs;Secondary: to identify resources/tools/models/approaches that provide transition-related information and support to this population.For RR1, we expect the following outcomes:Primary: to identify empirical research which indicates the enablers and barriers  that either support or hinder effective transition planning by carers for this population as they age;Secondary: to identify resources/tools/models/approaches in the literature that engage with, and provide information and support to, this population (and those who care for them) as they age.For RR2, we expect the following outcomes:All database selection, search strategies and searches will be undertaken with the support of a subject specialist librarian. Given the short timescale and consequent need to achieve a balance between sensitivity and specificityFor electronic databases, we will generate search terms . These terms will be combined using the Boolean operators ‘and/or’ and appropriate truncation and phrase symbols to form initial search strategies, which we will pilot against selected key databases. On the basis of this exercise, we will confirm our final search strategies to be used for each of the databases. A draft search strategy for SCOPUS is provided in Additional file Exclude articles/reports etc. that clearly do not meet the inclusion criteriaIdentify articles/reports etc. for full paper review.Electronic search datasets will be imported into Excel and duplicate records removed prior to screening. For RR1 and, separately, for RR2, two reviewers will independently screen all returned titles and abstracts (where available) against the inclusion criteria. Through this process we will:Any discrepancies will be discussed between the reviewers in the first instance and, if necessary, with the wider review team. The emphasis will be on inclusivity at this stage, so that we will retain those articles/reports etc. about which no firm decision can be made on the basis of the titles/abstracts.Full-text copies of potentially relevant articles/reports etc. will be obtained. The record containing the most complete data on any single study/other source of evidence will be identified as the primary source of evidence . Two reviewers will independently review all full texts for RR1, two reviewers will independently review all full texts for RR2. In order to reduce the potential for bias, and to promote transparency and consistency, a standardised tool will be used ; funding/sponsoring organisation; geographical area of the UK; aims and objectives; study/service intervention design; nature of resource; study participants/service intervention population; sample size; study research methods; and, results/findings/outcomes/other content. Additional/amended categories will be confirmed in discussion with the expert advisory group, once the nature of the available evidence is known.Using the final form, one reviewer will independently extract data from included articles / other sources of evidence, separately for RR1 and RR2. The same reviewer (for consistency purposes) will then collate the information from all of the forms onto a series of Excel master sheets. Each sheet will include the information extracted for each category for all included articles/other sources of evidence. Any uncertainty regarding the data to be extracted will be resolved through discussion within the review team. Where data is missing, we will attempt to contact relevant authors. Given our time constraints, if an author is uncontactable after two contact attempts over a 1-month period, we will record the data as “missing”. All completed data extraction forms will be independently reviewed against relevant texts by review team members as a means of checking for gaps and errors.The conduct of critical  appraisal in both scoping and rapid reviews is generally considered optional , 33, 40.Given the broad scope of our research question, the included evidence will be diverse in nature. In both reviews, alongside empirical research findings, our evidence is likely to include policy and practise guidelines relevant to our populations, as well as lay resources to support transition-related decision-making. Such diversity will necessitate a flexible, yet robust, approach to bringing together the body of evidence in its entirety. Although decisions concerning our detailed approach to synthesis can be made only when the precise nature of available evidence is known, it is possible to provide an outline at this stage.For each review, we will include a PRISMA flow diagram , outliniAnalysis will be led by one reviewer for consistency. To promote rigour, early drafts will be shared with the review team, who will provide feedback on fit with the original data, as well as overall sense and insight provided. Successive drafts of the synthesis will be shared with our project advisory group for ongoing discussion, review and refinement. This process will enable the production of analyses, which have benefited from the input of a range of expert knowledge and understandings.We have assembled a research team to collectively undertake the reviews, with designated roles and responsibilities, and so do not anticipate any adverse operational issues in respect of their completion. Practically, we may encounter difficulties in accessing potential sources of evidence in the time frame within which we are operating (a rapid review), but have sought to mitigate these by imposing an explicit approach . As a rapid scoping review, the possibility that we will miss relevant sources of evidence remains. We will make strenuous efforts to capture all relevant sources, not only through our database searching and hand searching of reference lists, but also through the advice and direction from our Project Advisory Group, which is wide-ranging in representation (see below). From our initial scan of the literature, relevant sources of evidence appear limited; it is therefore all the more vital to identify what does exist as a means of identifying gaps as this will enable informed decision-making about future research and the development of practical resources to aid the effective transition.For each RR1 and RR2, we will summarise the main findings . We will consider the strengths and limitations of the included evidence, as these impact on the findings of the review. We will also consider the strengths and limitations of our review methodology, again considering their impact on review findings. We will provide an overall interpretation of review findings with respect to their respective questions and objectives. We will also consider the implications of our findings for policy and practice, as well as future research.All aspects of the reviews will be set out in detailed main publications. This will ensure that the reviews are transparent, reproducible, and could be updated in the future . Due to Expert guidance stresses a need for rapid reviews to be reported clearly and communicated in a way that fits the practical needs and context of knowledge users , 34. BotAdditional file 1. PRISMA-P 2015 Checklist.Additional file 2. Draft Scopus Search Strategy.Additional file 3. RR1: Study inclusion screening form. RR2: Study inclusion screening form.