A40R gene, which encodes a protein with unknown immune function. The innate immune responses triggered by MVA-B ΔA40R in infected human macrophages, in comparison to parental MVA-B, revealed an increase in the mRNA expression levels of interferon (IFN)-β, IFN-induced genes, and chemokines. Compared to priming with DNA-B (a mixture of DNA-gp120 plus DNA-GPN) and boosting with MVA-B, mice immunized with a DNA-B/MVA-B ΔA40R regimen induced higher magnitude of adaptive and memory HIV-1-specific CD4+ and CD8+ T-cell immune responses that were highly polyfunctional, mainly directed against Env. and of an effector memory phenotype, together with enhanced levels of antibodies against HIV-1 gp120. Reintroduction of the A40R gene into the MVA-B ΔA40R genome (virus termed MVA-B ΔA40R-rev) promoted in infected cells high mRNA and protein A40 levels, with A40 protein localized in the cell membrane. MVA-B ΔA40R-rev significantly reduced mRNA levels of IFN-β and of several other innate immune-related genes in infected human macrophages. In immunized mice, MVA-B ΔA40R-rev reduced the magnitude of the HIV-1-specific CD4+ and CD8+ T cell responses compared to MVA-B ΔA40R. These results revealed an immunosuppressive role of the A40 protein, findings relevant for the optimization of poxvirus vectors as vaccines.Development of a safe and efficacious vaccine against the HIV/AIDS pandemic remains a major scientific goal. We previously described an HIV/AIDS vaccine based on the modified vaccinia virus Ankara (MVA) expressing HIV-1 gp120 and Gag-Pol-Nef (GPN) of clade B (termed MVA-B), which showed moderate immunogenicity in phase I prophylactic and therapeutic clinical trials. Here, to improve the immunogenicity of MVA-B, we generated a novel recombinant virus, MVA-B ΔA40R, by deleting in the MVA-B genome the vaccinia virus (VACV)  The acquired immune deficiency syndrome (AIDS) pandemic caused by the human immunodeficiency virus (HIV)-1 is spreading worldwide, with high impact and severity in human health. In spite of active antiretroviral therapy (ART), in 2017, an estimated 1.8 million individuals became newly infected with HIV-1 and 940,000 people died from AIDS-related illnesses worldwide, according to the Joint United Nations Programme on HIV/AIDS. Therefore, the discovery of an effective vaccine against HIV/AIDS that could control the infection and disease progression should be one of the main priorities of the developed world.An effective vaccine against HIV/AIDS should stimulate both humoral and cellular immune responses to multiple HIV-1 viral antigens, including structural and regulatory proteins, and induce strong, broad, polyfunctional, and durable T- and B-cell responses . For exaPreviously, we constructed a recombinant MVA expressing HIV-1 gp120 (engineered to be produced as a cell-released product) and Gag-Pol-Nef  antigens from clade B (termed MVA-B) . MVA-B hA41L, B16R, C6L, K7R, and N2L (either as single deletions or in combination), have been associated with a significant enhancement in the magnitude, breadth, polyfunctionality, and durability of the HIV-1-specific T-cell and humoral immune responses in immunized mice, when compared to parental MVA-B  expressing different HIV-1 antigens have been widely used in several human clinical trials in the last few years, proving that they are safe and immunogenic, inducing HIV-1-specific humoral and cellular immune responses ,67,68. IAmong the different approaches developed to enhance the immune response induced by poxvirus vectors, one promising strategy is the removal of the VACV genes that antagonize the immune system, as the virus genome still contains several genes that interfere with host immune responses ,40. SeveA40R gene and tested its role on antigen-specific immune responses in vivo after deleting the MVA A40R gene in the vector backbone of MVA-B, an HIV/AIDS vaccine candidate that expresses HIV-1IIIB GPN as an intracellular polyprotein and HIV-1BX08 gp120 as a cell-released product from HIV-1 clade B isolate [A40R was controversial. On one hand, it has been proposed that the VACV gene A40R encodes a type II membrane glycoprotein that is expressed early during infection on the cell surface, but is not incorporated into IMV or EEV particles [A40R gene from the VACV strain WR resulted in a modest attenuation after intradermal inoculation of mice, which could perhaps reflect an immunomodulatory role for this protein [In this work we described the immunosuppressive function of MVA  isolate . Previouarticles . These aarticles  and, in  protein . On the  protein . Althoug protein . HoweverA40R gene was generated from the HIV/AIDS vaccine candidate MVA-B (termed MVA-B ΔA40R). It is of note that the amino acid sequence of WR A40 protein differs from MVA A40 protein, in which the last five amino acids at the C-terminus are substituted with another 14 unrelated ones. The results showed that A40R deletion had no effect on virus growth, demonstrating that MVA A40R gene is not essential for VACV life cycle, in contrast to what has been suggested by others [A40R gene was to study the innate immune responses triggered in THP-1 human macrophages infected with MVA-WT, parental MVA-B, and MVA-B ΔA40R deletion mutant. The results showed that, compared to parental MVA-B, MVA-B ΔA40R significantly enhanced the expression of several genes involved in the type I IFN signaling pathway, such as IFN-β, IFIT1, and IFIT2, as well as the viral dsRNA sensor MDA-5, and the pro-inflammatory chemokine MIP-1α, suggesting that MVA A40 protein could have an immunomodulatory role, blocking innate immune responses during virus infection. The enhanced levels of these mRNAs in MVA-WT versus MVA-B were likely due to a suppressive effect mediated by expression of the HIV-1 antigens. Moreover, since it has been described that innate immune responses play a critical role in the control and resolution of HIV-1 infection, providing signals for the efficient priming of the adaptive branch of immune response [Consequently, to evaluate whether the VACV A40 protein has an immunomodulatory role, an MVA recombinant vector lacking the MVA y others . As the y others ,20,23,72response , the enhC6L, C6L-K7R, and A41L-B16R MVA genes), where a pattern of GPN-specific CD8+ T-cell immune responses was mainly induced [To further define whether MVA A40 could impair the immune system in vivo, a DNA prime/MVA boost immunization protocol was performed in mice to compare adaptive and memory immune responses to HIV-1 antigens induced by parental MVA-B and the deletion mutant MVA-B ΔA40R. Results showed that the DNA-B/MVA-B ΔA40R immunization group presented significantly enhanced magnitude of the overall adaptive and memory HIV-1-specific CD4+ and CD8+ T cells expressing CD107a, IFN-γ, TNF-α, and/or IL-2 compared to DNA-B/MVA-B. These results further suggest the immunosuppressive role of MVA A40 protein, as deletions of well-known immunosuppressive VACV genes from MVA or NYVAC vectors expressing HIV-1 antigens have produced similar results ,76,77,78 induced ,20,21, M induced . The bioThe analysis of the gp120-specific humoral immune responses at the adaptive and memory phases showed that DNA-B/MVA-B ΔA40R immunization induced higher levels of total IgG, IgG1, IgG2a, and IgG3 anti-gp120 antibodies than DNA-B/MVA-B. This enhancement in antibodies against gp120 may have been mediated by the increase in innate immune responses and HIV-1-specific CD4+ T helper cells triggered by the MVA-B ΔA40R deletion mutant, and it could be a positive immune parameter, as it has been described that anti-HIV-1 V2-specific IgG1 or IgG3 antibodies are able to drive ADCC correlated with efficacy in the RV144 phase III clinical trial .Moreover, evaluation of the Th1 or Th2 response by analyzing the ratio of IgG2a/IgG1 or IgG3/IgG1 antibodies showed that all the viruses induced higher levels of IgG1 than IgG2a or IgG3 antibodies, indicating a Th2 response. However, MVA-B ΔA40R induced in the adaptive and memory phases a ratio of IgG2a/IgG1 significantly higher than MVA-B , indicating that MVA-B ΔA40R may induce a more pronounced shift towards a Th1 response than MVA-B. According to current thinking, any therapeutic vaccination approach against HIV-1 should stimulate the induction of cytotoxic T lymphocytes (CTLs) and Th1 cells. It has been demonstrated that Th1 cells are more resistant to HIV-1 replication than Th2 cells ,83,84, aA40R gene, and to confirm our previously suggested immunosuppressive role exerted by the MVA A40R gene, a revertant virus termed MVA-B ΔA40R-rev was generated. Due to the lack of detection (using Western blot or immunofluorescence assays) of A40 protein when expressed from its natural locus in MVA or MVA-B viruses, we decided to reintroduce the MVA A40R gene into the HA locus of the MVA-B ΔA40R under the control of a stronger sE/L viral promoter. A similar strategy was used previously to generate NYVAC-based revertant viruses, which allowed us to demonstrate the important role of NFκB activation by VACV in enhancing neutrophil migration and HIV-1-specific T-cell responses [To finally demonstrate that the in vivo effects triggered by MVA-B ΔA40R in immunized mice were due to the deletion of the MVA esponses ,78. Moreesponses . In factesponses  and Ebolesponses , and thiA40R gene at higher mRNA levels (5–7-fold) than MVA-B or MVA-WT, allowing the amplification of the A40 protein signal during viral infection. In the MVA-B or MVA-WT viruses, the protein levels of A40 were very low since the rabbit polyclonal antibody anti-A40 used could not detect the A40 protein by Western blot or by immunofluorescence, while in MVA-B ΔA40R-rev-infected cells the A40 protein was readily detected. This was confirmed by Western blot analysis with a multiplicity of infection (MOI) of 5 PFU/cell. For these experiments, we used the same antibody that was described in the first report of the A40 protein from the WR strain [A40R gene was inserted into the MVA HA locus (A56R gene) controlled by a stronger VACV promoter than its naturally occurring promoter, the MVA A40 protein was clearly detectable by Western blot and immunofluorescence assays using the anti-A40 antibody recognizing the VACV WR A40 protein, indicating that the MVA A40 protein was stable, correctly expressed, and detected in the cell membrane, as previously described with the WR A40 protein [The MVA-B ΔA40R-rev expressed the MVA R strain . The WesR strain . The expR strain  and reinR strain . AlthougR strain  was main protein .A40R gene and of A40 protein, strongly suggest the immunosuppressive function of A40 by blocking the type I IFN signaling pathway.Importantly, the RT-qPCR experiments showed that mRNA levels of IFN-β, IFIT1, IFIT2, MDA-5, TNF-α, MIP-1α, RANTES, and RIG-I in MVA-B ΔA40R-rev–infected human THP-1 macrophages were significantly lower than those induced by MVA-B ΔA40R or MVA-B. However, mRNA levels of the constitutive cellular gene, HPRT, and the heterologous HIV-1 gp120 gene were not affected, suggesting that A40 blocks specifically innate immune sensing genes. The clear decrease in the levels of IFN-β, IFN-induced genes, proinflammatory cytokines, and chemokines induced by the revertant virus MVA-B ΔA40R-rev, expressing high mRNA levels of the MVA Interestingly, the enhancing effect on adaptive HIV-1-specific CD4+ and CD8+ T-cell immune responses observed with MVA-B ΔA40R was restored, in general, to levels similar or lower to those induced by MVA-B when we immunized mice with MVA-B ΔA40R-rev, either in DNA/MVA or in MVA/MVA regimens, further confirming in vivo the immunosuppressive function of MVA A40 protein.A40R gene has an immunosuppressive role, with its deletion enhancing innate immune responses in cell cultures, and adaptive and memory HIV-1-specific CD4+ and CD8+ T-cell and humoral immune responses in vivo, while its overexpression inhibited innate responses in human macrophages and adaptive HIV-1-specific CD4+ and/or CD8+ T-cell immune responses in immunized mice. Thus, deletion of the A40R gene has an immunomodulatory role in VACV infection and ablation of this gene provides an important strategy for the optimization of MVA vectors as vaccines.Overall, our findings revealed that MVA


Steroid-induced osteonecrosis of the femoral head (SONFH) is a devastating orthopedic disease, which seriously affects the quality of life of patients. The study aims to investigate the effects of LncRNA NORAD on SONFH.Human bone marrow-derived mesenchymal stem cells (hBMSCs) were isolated from the proximal femur of patients during routine orthopedic surgery and then cultured with dexamethasone (Dex) and transfected with NORAD overexpression vector, siRNA-NORAD and miR-26a-5p mimics. The mRNA expression of NORAD, miR-26a-5p, OPG, RANK, and RANKL was detected by RT-qPCR. Cell proliferation and apoptosis was measured by CCK-8 assay and flow cytometry, respectively. The protein expression of RUNX2, OPG, RANK, and RANKL was detected by western blot. The dual-luciferase reporter gene assay was performed to confirm the binding between NORAD and miR-26a-5p.NORAD expression was downregulated in SONFH tissues, while miR-26a-5p expression was upregulated. Overexpression of NORAD improved DEX-induced inhibition of proliferation and differentiation, and promotion of apoptosis in hBMSCs, while knockdown of NORAD led to the opposite results. Moreover, NORAD improved DEX-induced inhibition of proliferation and differentiation, and promotion of apoptosis by regulation of miR-26a-5p in hBMSCs.NORAD expression was downregulated in SONFH tissues, while miR-26a-5p expression was upregulated. NORAD improved DEX-induced inhibition of proliferation and differentiation, and promotion of apoptosis by regulation of miR-26a-5p in hBMSCs. Osteonecrosis of the femoral head (ONFH) is characterized by the collapse of the femoral head due to bone cells and bone marrow to be necrotic , 2. At pGC can inhibit the bone formation by affecting bone cell . One stuLong noncoding RNAs (lncRNAs) are RNAs that lack the ability of protein coding and their length are more than 200 nucleotides . In receIn this study, we detected the expression of NORAD and miR-26a-5p in SONFH tissues. In addition, we explored the biological effects of NORAD and miR-26a-5p on cell proliferation, apoptosis, and OPG/RANK/RANKL pathway in hBMSCs. Our findings may provide a new target direction for the treatment and diagnosis of SONFH.Bone marrow samples were obtained from 20 patients with SONFH as well as 20 patients with femoral neck fracture who underwent surgeries between April 2018 and March 2020 at our hospital. According to the Steinberg or University of Pennsylvania system, diagnosis of SONFH was proved by preoperative radiographs and magnetic resonance image (MRI). All patients with SONFH who had a history of taking a greater than 1800 mg of GCs or a long-term glucocorticoid therapy for more than 4 weeks were included, and patients concurrent with cardiovascular diseases, congenital diseases, or tumor-related diseases were excluded in the present study. In addition, patients with femoral neck fracture have no history of GC therapy. All participants were signed written informed consent, and our study was approved by the ethics committee of our hospital.2. For inhibition of differentiation, the cells were treated with different concentration of dexamethasone .Bone marrow aspirates (10 ml) were obtained from the proximal femur of patients during routine orthopedic surgery. The aspirates were resuspended in phosphate-buffered saline (PBS), and then, the cell suspension was injected into a centrifuge tube containing an equal volume of lymphocyte separation solution. After centrifugation for 30 min at 2000 r/min, the mononuclear cells in the white layer were collected and cultured in low-glucose Dulbecco’s modified Eagle’s medium  with 10% fetal bovine serum  and Penicillin-Streptomycin solution  at 37 °C in 5% CO−6 Dex), Dex+Vector [BMSCs were treated with 10-6 Dex and transfected with negative control of NORAD (Vector)], Dex+NORAD (BMSCs were treated with 10−6 Dex and transfected with NORAD overexpression vector), Dex+si-NC [BMSCs were treated with 10−6 Dex and transfected with negative control of NORAD (si-NC)], Dex+si1-NORAD (BMSCs were treated with 10−6 Dex and transfected with siRNA1-NORAD), Dex+Vector+mimics NC (BMSCs were treated with 10−6 Dex and transfected with Vector and mimics NC), and Dex+NORAD+miR-26a-5p mimics (BMSCs were treated with 10−6 Dex and transfected with NORAD overexpression vector and miR-26a-5p mimics) group. NORAD, si-NORAD, miR-26a-5p mimics, and corresponding negative control were synthesized by GenePharma . The transfection was performed by Lipofectamine 2000 (Invitrogen) according to the manufacturer’s instructions. Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) was used to determine the transfection efficiency.BMSCs were divided into control (without treatment), Dex  was used to extract total RNA from tissues and cells. Total RNA was taken for reverse transcription of cDNA by a PrimeScript RT-PCR Kit . Subsequently, RT-PCR was performed by the SYBR Green PCR kit  on ABI 7500 real-time PCR system (Applied Biosystems). The relative mRNA expression was calculated by 2es Table  were synRadioimmunoprecipitation assay (RIPA) buffer  was used to extract total protein from BMSCs. BCA assay  was used to detect the total protein concentration. Equal quantities of protein (30 μg) were subjected to 10% sodium dodecyl sulphate-polyacrylamide gel electrophoresis and transferred onto polyvinylidene fluoride membranes . After being blocked with 5% fat-free milk, the membranes were incubated with primary antibody  at 4 °C overnight. Next, the membranes were incubated with the HRP labeled second antibody  at 37 °C for 1 h. The ECL system  was used to visualize the protein bands, and image lab version 3.0  was used to analyze the intensity of the bands.http://starbase.sysu.edu.cn/index.php), and relevant primers (NORAD-MT and NORAD-WT) were synthesized by Shanghai GenePharma. HEK293 cells were seeded in 96-well plates until grew into about 85% concentration, miR-26a-5p mimics, mimics NC, NORAD-MT, or NORAD-WT were co-transfected into cells by the Lipofectamine 2000 reagent. After transfection for 48 h, Dual-Luciferase Reporter Gene Assay Kit (Beyotime) was used to detect the relative fluorescence intensity.The potential binding site between NORAD and miR-26a-5p was predicted by StarBase  value at 490 nm was measured by a spectrophotometric microplate reader .The proliferation ability of hBMSCs was measured by the Cell Counting Kit-8  assay. Briefly, BMSCs (3 × 104 cell/ml) were seeded in 96-well plates after corresponding treatment. After incubation for 0, 24, 48, and 72 h, cells were incubated with 10 μl CCK-8 solution for 2 h at 37 °C and 5% COCell apoptosis was estimated by Annexin V-FITC/PI Apoptosis Assay Kit . After corresponding treatment, BMSCs were incubated with 10 μl Annexin V-FITC and 5 μl propidium iodide (PI) for 30 min in the dark. Then, the flow cytometry  was used to analyze cell apoptosis.t test was used to analyze the statistical differences between two groups. P value less than 0.05 was considered as statistically significant.All experimental data were expressed as mean ± standard deviation (SD), and GraphPad Prism 7.0 software (USA) was used to perform statistical analysis. One-way ANOVA was used to analyze the statistical differences among three or more groups. Unpaired Student’s P < 0.01). Next, we investigated the effects of Dex  on NORAD expression, proliferation, and OPG/RANK/RANKL pathway in hBMSCs. As presented in Fig. 490 value) by increase in concentration and the time of exposure . The mRNA expression of OPG, RANK, and RANKL was also detected by RT-qPCR. The results showed that the mRNA expression of OPG was decreased, and the mRNA expression of RANK and RANKL was increased in a dose-dependent manner  by RT-qPCR. As shown in Fig. P < 0.01, Fig. P < 0.01), while the protein expression of RANK and RANKL which was increased by Dex was reduced after NORAD overexpression (P < 0.01). Moreover, when NORAD was overexpressed, Dex-induced proliferation reduction was attenuated , but Dex-induced apoptosis increase was attenuated by overexpression of NORAD (P < 0.01).To investigate the role of NORAD in Dex-induced hBMSCs’ osteoblastic differentiation, proliferation, and apoptosis, NORAD was overexpressed in hBMSCs. The results of RT-qPCR showed that NORAD expression was significantly increased when cells were transfected with NORAD overexpression vector, which suggested the transfection was successful (P < 0.01), which suggested the transfection was successful. Additionally, knockdown of NORAD significantly decreased the protein expression of RUNX2 and OPG decreased by Dex . As illustrated in Fig. P < 0.01), while transfection of miR-26a-5p mimics remarkably inhibited these effects (P < 0.01). In addition, as can be seen in Fig. P < 0.05), while these effects were weakened by overexpression of miR-26a-5p (P < 0.05). Taken together, the above findings suggested that NORAD improved Dex-induced inhibition of proliferation and differentiation, and promotion of apoptosis by regulation of miR-26a-5p in hBMSCs.To investigate whether NORAD exerted its effects by regulating miR-26a-5p, NORAD overexpression vector and miR-26a-5p mimics were co-transfected into hBMSCs. As shown in Fig. Bone cells’ death caused by blood circulation disorders lead to the occurrence of ONFH . ONFH is−6, 10−7, and 10−8 M) on NORAD expression and proliferation in hBMSCs and found that Dex reduced NORAD expression and inhibited cell proliferation in a dose-dependent manner. In addition, we also found that overexpression of NORAD improved Dex-induced inhibition of proliferation and promotion of apoptosis in hBMSCs, while knockdown of NORAD led to the opposite results. In short, the above findings indicated that NORAD participated in the development of SONFH.The dysregulation of osteogenesis differentiation is an important pathway in SONFH; thus, BMSCs have become a research hotspot and are considered to be potential in treatment of SONFH . AlthougMicroRNAs  are small non-coding endogenous RNAs, which can bind to the 3′UTR of target mRNAs and change the stability of mRNA or protein translation, thus regulating various physiological process , 42. In Osteoprotegerin (OPG) is a member of tumor necrosis factor receptor family, which has the function of inhibiting osteoclast differentiation and increasing bone density . OPG canNORAD expression was downregulated in SONFH tissues, while miR-26a-5p expression was upregulated. Moreover, NORAD improved Dex-induced inhibition of proliferation and differentiation, and promotion of apoptosis by regulation of miR-26a-5p in hBMSCs. This study may provide a new insight for the treatment and diagnosis of SONFH.


Recognising the influence of context and the context-sensitive nature of quality improvement (QI) interventions is crucial to implementing effective improvements and successfully replicating them in new settings, yet context is still poorly understood. To address this challenge, it is necessary to capture generalisable knowledge, first to understand which aspects of context are most important to QI and why, and secondly, to explore how these factors can be managed to support healthcare improvement, in terms of implementing successful improvement initiatives, achieving sustainability and scaling interventions. The research question was how and why does context influence quality improvement initiatives in healthcare?A realist review explored the contextual conditions that influence healthcare improvement. Realist methodology integrates theoretical understanding and stakeholder input with empirical research findings. The review aimed to identify and understand the role of context during the improvement cycle, i.e. planning, implementation, sustainability and transferability; and distil new knowledge to inform the design and development of context-sensitive QI initiatives. We developed a preliminary theory of the influence of context to arrive at a conceptual and theoretical framework.Thirty-five studies were included in the review, demonstrating the interaction of key contextual factors across healthcare system levels during the improvement cycle. An evidence-based explanatory theoretical model is proposed to illustrate the interaction between contextual factors, system levels  and the stages of the improvement journey. Findings indicate that the consideration of these contextual factors would enhance the design and delivery of improvement initiatives, across a range of improvement settings.This is the first realist review of context in QI and contributes to a deeper understanding of how context influences quality improvement initiatives. The distillation of key contextual factors offers the potential to inform the design and development of context-sensitive interventions to enhance improvement initiatives and address the challenge of spread and sustainability. Future research should explore the application of our conceptual model to enhance improvement-planning processes.PROSPERO CRD42017062135 Spreading and sustaining quality improvement (QI) initiatives in healthcare is a recognised challenge; this research highlights the influence of contextual factors on these efforts.Although the evidence base around context in QI is increasing, there remains limited knowledge and guidance about which contextual factors are most influential. This review explores how, when and for whom context impacts during the improvement journey across healthcare system levels.This is the first realist review of context in QI. The realist approach incorporates theory, research evidence and practical knowledge to facilitate the exploration of the multi-level, multi-faceted nature of context, within complex healthcare settings.Improving health and wellbeing outcomes is a key focus of public sector organisations. Over the last decade, there has been significant effort to utilise quality improvement (QI) within healthcare, as a means of delivering evidence-based care, improving mechanisms of care and clinical outcomes. Quality improvement is the purposive, systematic application of specific methods to improve service configuration or delivery, in order to achieve positive change. Key features are identified as ‘the combination of a ‘change’ (improvement) and a ‘method’ (an approach with appropriate tools), while paying attention to the context, in order to achieve better outcomes’ . Some deDespite such explicit definitions and approaches, QI results are often mixed, unpredictable or demonstrate limited impact , suggestThe definition of context in relation to QI has evolved over time . At its Within the literature, contextual factors are frequently conceptualised as either barriers or facilitators; however, this may be too simplistic . The SQUHealthcare systems are complex and dynamic, and as such, their contextual interactions are not static. Throughout the improvement journey, different aspects of context can assume more or less importance (exerting more or less influence), depending on the type of intervention being implemented, its infancy or maturity, stage of implementation, system level at which it is targeted, and, in the case of multi-component interventions, specific components . ContextUntil relatively recently, improvement and implementation science research paid little attention to context, instead focusing on outcomes, effectiveness and impact. Frequently within research studies, contextual attributes were either not acknowledged, under-reported –18 or viGiven that improvement is an inherently context-dependent social process, taking place in real-world clinical settings , the infIn recent years however, there has been a growing recognition of the influence of context on healthcare improvement efforts , 23, witThis realist review was designed to further theoretical understanding of which aspects of context are important and why, and how these factors can be addressed and managed to support healthcare improvement efforts. The research question was how and why does context influence quality improvement initiatives in healthcare? More specifically, the review aimed to (i) identify contextual factors that influence the implementation, effectiveness, sustainability and transferability of QI initiatives in healthcare; (ii) provide a theoretical explanation of how, why, when and for whom these factors are important; and (iii) provide stakeholders  with a practical, up-to-date evidence base relating to the influence of context.Incorporating theory, research evidence and practical knowledge, realist inquiry is ideal for understanding the issues surrounding implementation in complex healthcare settings. This theory-driven interpretive approach seeks to explain the causes of intervention outcomes and patterns of outcomes and effects, by evaluating knowledge and data from a range of sources . Based oThe starting point for the notion of context in realist review is the four contextual ‘layers’ defined by Pawson et al : individWe followed a template adapted from Pawson : 1) def def1). TThe objective of the first stage was to understand the scope of the review and develop the programme theory. This involved a number of interconnected iterative processes: scoping (exploratory background literature searching); mapping ; and consultation with stakeholders and experts. All aspects of this preliminary work informed the programme theory development. A multi-disciplinary advisory group of academics and improvement practitioners was set up to oversee the review, monitor progress, develop consensus and contribute to theory development and interpretation of findings.In the initial exploratory stage, the review team conducted background searches and consulted with key stakeholders from policy, practice and academia, to map the terrain, refine the research question, and clarify the focus and breadth of the review. This scoping exercise included the identification and scrutiny of key publications examining the role of context in healthcare quality improvement , 34, 35.Involving stakeholders in realist research provides a range of additional perspectives and an ‘expert framing’ of the issues that could contribute to the developing programme theory . InitialFindings from the exploratory search and insights from stakeholders and experts generated a number of potentially relevant contexts. As part of the realist theory development, the key contexts were mapped to the landscape of healthcare QI within Scotland  to produce a provisional ‘context map’ Fig. .Fig. 2HThe provisional context map formed the basis of further stakeholder engagement. Mapping out the quality improvement landscape within Scotland to represent the emergent theory enabled stakeholders to engage in the exploration of potential contexts, mechanisms and outcomes across macro, meso and micro system levels. This process advanced the initial theory into a generalisable programme theory, applicable to a range of improvement settings.Hypothesizing how improvement activity within and between the different contexts was likely to play out in terms of the associated mechanisms and outcomes; we developed a realist programme theory, expanding the provisional context map. The programme theory was our conceptualisation of the healthcare improvement landscape, and the role and influence of contextual factors, representing the interactions between multiple components and multiple levels within a complex system, and illustrating context, mechanism and outcome relationships and the patterns of outcomes and effects. The programme theory, which formed the theoretical framework for the subsequent stages of the review, is summarised in Fig. The realist approach aims to retrieve sufficient evidence to answer the research question and achieve theoretical saturation, as opposed to a fully comprehensive search . Review The search strategy was purposefully broad and driven by the programme theory as it developed and was refined through the course of the review. At the review outset, a number of broad-brush exploratory scoping searches were carried out, yielding a large number of full-text documents, including reviews. During programme theory development, further, mostly informal, searches were conducted iteratively (reflecting the current thinking about the programme theory at each point as it evolved) and additional full-text documents were retrieved and stored, in anticipation of the ensuing stages of the review.These preliminary searches produced a large number of potentially relevant articles. Assessment of these existing documents was carried out prior to further searching; six of these were included in the final synthesis. Once these documents were screened, selected and appraised, further searches were carried out, building on the evidence generated by the preliminary searches, in order to find additional pertinent evidence to further test and refine the programme theory. Although this included electronic database searching, the majority of studies were located by other means, including searches of relevant journals, electronic alerts, and via informal methods including from personal contacts (project team members or stakeholders) or by ‘serendipitous discovery’. Hence, this second search phase identified some additional articles , to test and refine the evolving programme theory; however, the aim was not to be fully comprehensive, but to identify relevant literature sufficient to enable the role of context to be explored.The eligibility criteria was set to include empirical research studies of QI initiatives, in primary or secondary healthcare settings, published in English during the previous 10 years, based in developed, industrialised countries. Quality improvement in healthcare is a relatively new area,  furthereThe realist selection and appraisal process differs from a traditional systematic review. Assessing whether research is fit for purpose according to relevance and rigour is the realist alternative to quality appraisal in a systematic review. Decisions about rigour and relevance were made on the basis of potential contribution(s) of the study either as a whole or a section could make to the review.In a realist review, the unit(s) of assessment is not each included study itself or the intervention it describes, but any sections of the study that are relevant to underlying theory and context-mechanism-outcome evidence. Within a document, different kinds of evidence may be relevant to different aspects of the review or the programme theory . SelectiDocuments were then assessed for methodological rigour , whilst bearing in mind that even methodologically weak studies that would be otherwise excluded by a traditional systematic review may contain potentially valuable ‘nuggets’ of understanding . AssessmData extraction, analysis and synthesis was an iterative process beginning with familiarisation and understanding of each study. Each included study was read and re-read, initially for familiarisation and then to assess its relevance to the evidence relating to underlying theory and relevance to the research questions. Within each document, relevant passages containing key evidence were highlighted, annotated and coded to identify contexts, mechanisms, outcomes and CMO configurations. Documents were also examined to capture explanatory accounts, themes, concepts and any other relevant data that might contribute to theory refinement.‘Bespoke’ data extraction forms were created to capture information from each article on contextual factors, mechanisms and outcomes, along with additional data on QI methodology and implementation. A data extraction template and sample extraction table is available on request from the corresponding author. EC conducted the full data extraction; JA independently reviewed each study; and NG and GM checked a 10% sample for credibility of theory development and refinement and reliability of extraction. Using processes of abstraction and conceptualisation, the reviewers compared and contrasted the evidence, looking for patterns of CMOs across the data that were able to support, contradict or inform the programme theory. Recurring themes were also identified and used to guide the rest of the review process as data extraction and analysis progressed.n = 33) were peer-reviewed articles; two were reports. Most studies were from the UK (n = 16) and USA (n = 8), with the remaining studies from Europe , Canada and Australia. Although a variety of study designs were represented, studies were predominantly qualitative, including two realist evaluations. Five were mixed-methods, and two were embedded in wider studies. One study used a longitudinal design, and two involved secondary analysis. Thirteen studies specifically aimed to explore the influence of context or contextual factors. Others addressed contextual issues indirectly in the form of organisational culture, barriers and facilitators to implementation, or improvement capacity and capability. Nineteen studies used a guiding theoretical model or framework, most commonly PARIHS (n = 5) and MUSIQ (n = 4).Thirty-five studies published between 2010 and 2018 were identified for inclusion (Table n = 22) and the majority of the studies reported macro-level results from across more than one hospital or organisation. The studies involved participants with a wide range of experience, including clinicians, organisation leaders, managers, support staff and internal/external QI facilitators, from a variety of settings. Most of the studies reported on improvement initiatives targeting specific systems or processes, such as the implementation of preventive care practices, care bundles, patient safety practices, evidence-based guidelines, checklists or the redesign of clinical pathways/processes. Other types of QI activities included continuous quality improvement (CQI). A variety of standard QI methods and tools were described across the studies. Eleven studies reported on QI collaborative models. Reporting on QI methodology in a small number of the studies was of poor quality, with a lack of detail on the specific improvement methods used.Secondary care was the most predominant setting , during the stages of improvement. A generalisable theoretical model was then developed to illustrate the interactions between contextual factors, system levels and the various stages of the improvement journey along a trajectory where improvements are planned, implemented, sustained and spread.Within the studies reviewed, context was represented in a variety of ways within the literature, highlighting its dynamic, multi-dimensional and highly variable nature. It was characterised both within and across studies as political, economic, social, inner/outer setting, institutional, organisational and individual. However, context was also strongly intertwined with ‘culture’, both at local and organisational levels , 65, 66.Some studies attempted to define context within a hierarchy of factors , 58, 71.Awareness of the potential impact of implementation contexts and local conditions featured widely in the literature in a range of forms. Context was described both in negative and positive terms: frequently contextual factors were portrayed as barriers and/or facilitators , 50, 69,A ‘context assessment’ process , 71 was In some studies, teams utilised QI methods as tools to help them understand and analyse the complexity of their systems , whereasIn contrast to the design of ‘bespoke’ programmes developed for individual contexts , a process of tailoring to context or ‘adapting’ to achieve fit was described . This acleadership, organisational characteristics, change agents and multi-disciplinary collaboration.Using the programme theory Fig.  as a fraLeadership was a key element in the review programme theory—both within the ‘organisation’ context and as a mechanism to deliver outcomes.Supporting ‘organisation’ as a key context in the programme theory, this domain emerged very strongly from the evidence, broadly reflecting system-level (micro/meso) and individual-level contextual factors. It included organisational structures, processes and human resource functions. Awareness of the potential impact of organisational contexts and local conditions are featured widely in the review and included examples of context assessment. The evidence showed that organisational infrastructure should ideally be supportive of improvement, and a key element identified was organisational ‘culture’, i.e. the history, policies, strategy and governance of an organisation, underpinned by shared vision, beliefs and patterns of behaviour. These core values, attitudes, norms and underlying ideologies shaped the implementation context in multiple ways, alongside the level of organisational ‘QI maturity’. An organisation’s QI maturity was highlighted in a number of studies as being one of the key factors influencing the successful implementation of an improvement initiative.Consistent with the programme theory descriptions of the various roles of individuals as ‘drivers of QI’, leading change within the key ‘stakeholder’ context, the role of change agents was frequently reported in the evidence in a variety of forms, from local champions to external QI experts.Multi-disciplinary collaboration featured very strongly across the included studies, despite playing a lesser role in the programme theory, where it was conceptualised as both mechanism and outcome. Interconnected elements within this domain included professional diversity, relationship building, teamwork and communication; these reinforced other aspects of the programme theory.how, why, when and for whom these contextual domains are important to improvement initiatives are provided in Table These four domains reflected contextual influences at all levels of the system. Examples from the realist exploration of A number of key mechanisms that influenced the delivery of quality improvement initiatives (outcomes) were identified from the literature, supporting the programme theory. The mechanisms were applied to different system levels Table .Table 4The map of the theoretical and conceptual landscape of healthcare QI was redrawn with the integration of tacit knowledge from stakeholders, to produce a broader, more descriptive model Fig. , refininleadership, organisational culture, individual skills and capabilities, organisational capacity and capability, data and technical infrastructure, readiness for change, championship and relationships.Findings from the evidence synthesis further distilled the four domains into eight key contextual factors Table : leadersA generalisable theoretical model Fig.  was deveRecognising that context runs all the way through the improvement continuum, we anticipate that the model could support the examination of contextual factors’ influence at each system level during the stages of an improvement initiative. From pre-planning onwards, this model could enhance the understanding of the QI context, and the dynamic, complex systems within it, whilst acknowledging the variation of contextual factors between settings.We identified four contextual domains that influence the implementation, effectiveness, sustainability and transferability of QI initiatives in healthcare. Further unpacking of these domains led to the distillation of eight key contextual factors, which apply to multiple system levels in varied healthcare settings. This review demonstrates the impact of context across all stages of the improvement journey, from the pre-planning and implementation stages, towards achieving spread and sustainability. Our findings follow Øvretveit et al.’s  view of Within realist reviews, it is common practice to refine the programme theory and CMO configurations (context + mechanism = outcome). The outcomes for this review are reflected as the eight contextual factors within the evidence-informed theoretical explanatory model Fig. , rather The original review programme theory was formed around four main contexts: the national policy context (macro); the organisational context ; the clinical microsystem (where most improvements take place—meso/micro); and the stakeholder context .Review findings strongly identified with the latter three contexts and explored the context in and around interventions at these levels, emphasising the dimensions within the organisational context, with a focus on system levels, reinforcing the notion that most improvement and change is taking place at the micro and meso levels. However, whilst that was the primary focus for the majority of studies, the national or macro context was commonly seen as an overarching contextual influence on QI initiatives. Studies frequently reported that regional or national government policies or national agency directives were behind the initiatives. This illustrates the external contextual influences on organisations and the importance of the organisational characteristics, as key mechanisms working to align and accept the ‘change’ and support the initiative.‘Organisational characteristics’ was identified as one of the four contextual domains, and context assessments were highlighted in the review as a mechanism to gain a greater understanding of internal organisational contextual influences and readiness for change. The key elements within this domain are related to culture and the multiple subcultures that can act both to drive change and to undermine improvement efforts . Lukas eAcross the review evidence, there was a strong focus on the role of leadership in various forms. Within the programme theory, leadership was originally characterised as ‘strong leadership’; this was later revised in light of discussions with stakeholders. They viewed successful leaders as ‘active’ and ‘supportive’ within a high-trust environment where all staff are encouraged to lead improvement, reinforcing the notion of a blended leadership model at different levels of the system—demonstrated in a number of the review studies. Also highlighted was the close interaction between leadership and organisational culture, which in turn influenced improvement leadership and management.This review emphasises the importance of stakeholders  within the improvement process, particularly around the key roles of change agents and champions , 81 in sThe use of a realist approach in this review was a key strength. Input from stakeholders with practical knowledge and experience of quality improvement within healthcare settings facilitated the generation of conceptually rich findings with theoretical depth. Stakeholder input and feedback were incorporated at various stages of the review process, playing an important role in generating the initial CMO configurations and to ‘sense check’ and refine the theoretical framework and the final outputs. This contribution helped to temper the interpretive and potentially subjective nature of realist synthesis and provided validation, adding credibility and grounding the findings in real-world knowledge and experience.A limitation of this review is that a small number of studies were weak in terms of their descriptions of QI methodology and lacked detail on the specific improvement methods or tools used within the study. In a number of studies, the assessment of context was conducted retrospectively rather than prospectively, which is less likely to produce meaningful, transferable findings and avoid recall bias . HoweverFurther, it must be noted that the included literature was predominantly from the acute care sector , based in the USA and UK. Other reviews have demonstrated similarities , 34, 78,who will use it , when it should be used  and what form it should take. This co-development process will enable practitioners to have a greater understanding of the influence of context on quality improvement initiatives and will give researchers an opportunity to evaluate the impact of a more context-sensitive approach to the design and implementation of improvement initiatives, across health and social care, to advance practice and accelerate change.The explanatory theoretical model provides a practical reflection of the current evidence base in relation to the influence of context on improvement activities. As an ‘aide memoir’, it can encourage the contemplation of contextual factors by practitioners, senior staff and policy makers to enhance the delivery of improvement initiatives. The next stage of this work will be to maximise the learning from the study, and to consider the application of the explanatory theoretical model in real-world settings: working with researchers and improvement practitioners, to facilitate the translation of the review findings and theoretical model into practical application. This will involve the consideration and co-development of To our knowledge, this is the first realist review investigating the influence of context in healthcare quality improvement. The use of a realist approach enabled identification of the key contextual factors that influence QI initiatives in healthcare and provides a theoretical explanation of how, why, when and for whom these contextual factors are important to QI initiatives, at different system levels and during the stages of improvement. This review enhances the evidence base around context in QI and addresses the limited knowledge and guidance about which contextual factors to consider.Our explanatory theoretical model reflects that the interplay between improvement interventions and their context is a fluid interaction and as such, each can influence the other directly and indirectly in multiple ways. Working within complex adaptive systems, the model reflects the current evidence base around context and provides practitioners with an informed approach to consider how the influence of these contextual factors will impact within their own setting. The factors are not weighted by importance, as their influence will vary from setting to setting. The model provides a practical ‘aide memoir’ that supports pre-planning conversations at the micro system level, either at the start of an initiative or more importantly when spreading changes from one setting to another that can be applied to multiple settings that are constant state of change.This research has produced the foundations to enhance improvement practices, through the co-development with improvement practitioners and policy makers to advance knowledge and the practical assessment of the role and influence of context in healthcare practice settings.


To critically appraise the quality of published systematic reviews (SRs) of randomised controlled trials (RCTs) in tendinopathy with regard to handling and reporting of results with special emphasis on strength of evidence assessment.Medline from inception to June 2020.All SRs of RCTs assessing the effectiveness of any intervention(s) on any location of tendinopathy.Included SRs were appraised with the use of a 12-item tool devised by the authors arising from the Preferred Reporting Items in Systematic Reviews and Meta-Analyses statement and other relevant guidance. Subgroup analyses were performed based on impact factor (IF) of publishing journals and date of publication.A total of 57 SRs were included published in 38 journals between 2006 and 2020. The most commonly used risk-of-bias (RoB) assessment tool and strength of evidence assessment tool were the Cochrane Collaboration RoB tool and the Cochrane Collaboration Back Review Group tool, respectively. The mean score on the appraisal tool was 46.5% (range 0%–100%). SRs published in higher IF journals (>4.7) were associated with a higher mean score than those in lower IF journals . The mean score of the 10 most recently published SRs was similar to that of the first 10 published SRs . Only 23 SRs (40%) used the results of their RoB assessment in data synthesis and more than half  did not assess the strength of evidence of their results. Only 12 SRs (21%) assessed their strength of evidence appropriately.In light of the poor presentation of evidence identified by our review, we provide recommendations to increase transparency and reproducibility in future SRs. The increasing number of available treatment modalities for tendinopathy can be overwhelming to the treating healthcare professionals.Systematic reviews (SRs) of randomised controlled trials provide the highest level of evidence and guide application of research findings to clinical practice.There are several strength of evidence assessment tools used in tendinopathy SRs.The use of strength of evidence assessment results in data synthesis is associated with confusion and inconsistency.More than half of the SRs did not assess the strength of evidence in their results.Only 21% of SRs assessed their strength of evidence appropriately.Authors who publishing SRs on the management of tendinopathy should become familiar with strength of evidence assessment tools and apply them appropriately in their data synthesis and presentation.We provide recommendations to increase transparency and reproducibility in future SRs.The ever-expanding arsenal of treatment regimes for tendinopathy can be overwhelming to the treating healthcare professional. New treatments continuously emerge and so do research studies that aim to assess their effectiveness. The most powerful tool that evidence-based medicine has to offer remains systematic reviews (SRs) of randomised controlled trials (RCTs), which constitute the highest level of evidence and are therefore often used to inform guidelines and guide clinical practice.1Unlike a narrative review, which is purely a summary of a proportion of  the available studies on a given topic without assessing the quality of the included evidence, an SR is expected to include all the relevant evidence which is comprehensively and thoroughly appraised and presented with qualitative or quantitative syntheses and accompanying strengths of evidence.10.1136/bmjsem-2020-000920.supp1Supplementary dataAssessing the strength of evidence  is closely interlinked with RoB assessment and is a process which is commonly overlooked by many SRs. Together with a meticulous methodology and comprehensive RoB assessment, this is what distinguishes a SR from other types of review articles. Assigning a strength of evidence to a finding is as important as the finding itself. Strength of evidence should accompany every assessed outcome measure within an SR for every assessed follow-up time period.An SR should be transparent and reproducible, and subjectivity should be kept to a minimum.10Our aim was to critically appraise the quality of published SRs of RCTs in tendinopathy, with emphasis on handling and reporting of results and especially assessment of the strength of evidence, which is often overlooked. We provide recommendations for authors of future SRs aiming to optimise data synthesis, reporting and summarising the strength of evidence. The present review is also intended for readers of SRs, who need to critically appraise their quality before reaching conclusions about their findings, and finally it can be used by reviewers and editors of journals when assessing submitted SRs for publication.Eligible articles assessed the effectiveness of any intervention(s) on tendinopathy (any type), identified themselves as an SR and/or meta-analysis and only included RCTs. Reviews including a mixture of randomised studies and other types of studies  and those assessing the effectiveness of interventions on tendinopathy and other conditions were excluded. Only articles published in English were included in patients over 16 years of age. No criteria were used regarding the following parameters: publication date, journal type, type of tendinopathy and intervention, outcome measures and length of follow-up.A literature search was conducted by the first author via Medline in June 2020 with the following Boolean operators in ‘All Fields’: “((systematic review) OR  AND (tendin*) AND (randomi*)). For all eligible articles, the reference lists and PubMed’s ‘similar articles’ list were screened to identify potentially eligible articles that may have been missed at the initial search. The initial search returned a total of 207 articles. After exclusion of non-eligible articles according to our predefined criteria and inclusion of articles identified from reference screening, 57 reviews were included in our appraisal.The included articles were read by the first author and their key characteristics were tabulated in Microsoft Word. Each article was then reread and appraised with regard to the handling and reporting of results based on our prespecified appraisal tool.We developed a 12-item appraisal checklist based on guidance from the PRISMA checklist predominantly, as well as other key documents, namely the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool, the AMSTAR checklist and the Cochrane Collaboration Back Review Group.Item 1: The RoB assessment of each included RCTs, with or without an ‘overall risk’ for each study, needs to be used somehow for summarising the strength of evidence, which is its primary purpose, and this needs to be explained in the methods. This can be through subgroup analyses, for example, only synthesising results of studies with low overall RoB (which is indirectly associated with strength of evidence assessment).Item 2; RoB should be assessed for each outcome measure separately to determine the strength of evidence of the results for that specific outcome measure. Assessing RoB on an outcome measure level rather than a study level becomes particularly important when the study includes patient-reported measures and measures assessed directly by another assessor. With the former, if the participants are not blinded then automatically the assessment of outcome measures cannot be blinded either as the assessor is the participant his/herself. For non-patient-reported measures, regardless of blinding of participants, the blinding of assessment depends solely on whether the assessor (researcher) is blinded or not. If RoB is assessed on a study and not outcome level this should be stated in the methods with a justification . For SRs including one outcome measure only, this item was not scored.Item 3: The principal summary measures for each included outcome measure need to be stated in the methods. For quantitative analyses, where outcome measures are continuous, a justification needs to be provided for the use of (raw) mean differences (MD) and not standardised MD (SMD) and vice versa . Similarly, for dichotomous outcomes, the authors should state in the methods whether OR or relative risks (RR) were used.Item 4: An SR without a meta-analysis should ideally have some quantitative summary measures  to demonstrate the treatment effect of the assessed intervention over the comparator. Where results are pooled only based on direction of effect , this needs to be stated in the methods with a justification. If pooling is not possible and results are only described narratively, the reason should be stated ; in such cases, we question whether the article should be identified as an SR.2 and/or I2 test) and how it was used in data syntheses. Sensitivity and subgroup analyses should also be pre-defined in the methods.Item 5: When meta-analyses are performed, the model used needs to be stated  with a justification and the statistical heterogeneity assessment .Item 8: A statement needs to be included in the section explaining how the authors dealt with missing data, which are usually methodological details of the included studies needed for the RoB assessment and descriptive statistics for quantitative analyses. For both, ideally attempts should be made to contact the authors of the RCTs for retrieval of the missing data and this should be stated. If significant statistical data of included studies cannot be retrieved  these studies should be excluded from quantitative analyses; if variability statistics (SD) are missing, the authors have the option to impute these using data from other RCTs and the imputation method used should be described.Items 9–12: Assigning a strength of evidence to a result is an essential part of an SR and it should be determined separately for each predefined outcome measure at each predefined follow-up time period. By and large this is determined based on the overall quality of the included studies and the extent of consistency of their findings with considerations of other limitations across studies. Regardless of the tool used, which should be included in the methods with a brief description, the authors should clearly describe how data were synthesised with regard to assessing the strength of evidence, stating how RoB assessment was used and what other paramaters/limitations were considered. Excluding the GRADE tool, which has clear instructions on how specific intrastudy (RoB) and interstudy  limitations should be handled, the authors should clarify: (1) whether study quality was determined based on RoB only or whether other parameters were taken into account  with a justification; (2) how consistency was defined . When there is some clinical heterogeneity across studies but not sufficient to preclude pooling of results, this should be accounted for and used as part of the strength of evidence assessment. More specifically, authors should include a statement to show that they have considered/assessed for potential differences in included populations, interventions and outcome measures used across studies and how they think this might affect the strength of the evidence of their results. Finally, a statement in the methods should be included to acknowledge the risk of publication bias and whether it was assessed formally. A funnel plot should be constructed and inspected/accompanied with the appropriate statistical tests  where the results of a considerable number of studies  were pooled. For SRs including one outcome measure only, item 11 was not scored.A mean score was calculated for all appraised SRs. Subgroup analyses included comparisons of mean scores of reviews published in a higher versus a lower impact factor (IF) journal . The latest journal IFs were obtained from the journal’s official website. For journals without an IF, a score of 0 was given. Finally, the mean score of the first 10 published SRs was compared with that of the last 10 published. All comparisons were performed with two-tailed independent samples t-tests in Graphpad Prism V.8. Significance levels were set at p<0.05.British Journal of Sports Medicine (n=6) and the most commonly investigated tendinopathy in isolation was shoulder , followed by lateral elbow (n=10) and patellar (n=8). A total of 10 reviews assessed tendinopathy as a generic condition and assessed the same intervention(s) on more than one location of tendinopathy and two reviews included RCTs of ‘lower limb tendinopathies’. The most frequently assessed intervention in isolation was extracorporal shock-wave therapy (n=10), followed by platelet-rich plasma (n=7), however, several SRs included more than one ‘related’ intervention .A total of 57 articles published in 38 journals were included in our review.11–6710.1136/bmjsem-2020-000920.supp2Supplementary dataThe most commonly used RoB assessment tools in the included SRs were the Cochrane Collaboration toolThe items of our tool with the lowest overall score were item 2  and item 11 , which both relate to whether assessments (RoB and strength of evidence) were conducted on an outcome measure and not study level. Those with the highest were item 6  and item 4 .The mean score of the included SRs on our appraisal tool was 46.5% (range 0%–100%). Subgroup analyses showed that those published in higher IF journals  had a significantly higher mean score than those (n=47) in lower IF journals  . The firHaving critically analysed several published SRs of RCTs in the management of tendinopathy, we found that the results of more than half of the included SRs were presented without an accompanying strength of evidence assessment, which is as important as the results themselves for guiding clinical practice. Additionally, a substantial proportion of results from the included reviews were presented with levels of evidence assigned to them arbitrarily without described and reproducible methods. Our findings imply that the majority of SR authors may not be familiar with conducting a strength of evidence assessment and its practical implementation. The other interesting finding was that half of the reviews that performed an RoB assessment did not make any use of it; we assume this is because they either do not understand the purpose of RoB assessment and they only conducted an RoB assessment knowing that it is a prerequisite for an SR, or they left the interpretation of the link between their RoB assessment and the undetermined strength of evidence open to the reader.As an example of the disparity in assessing the strength of evidence, a recent SR of SRs on the clinical management of tendinopathy summarised all the available evidence concluding that eccentric exercise with or without other treatments is the best available intervention.The widely used PRISMA checklist is regarded as the gold standard for the conduct and reporting of SRs.In the following paragraphs, we provide recommendations for what we believe are the most subjective and poorly understood aspects of an SR, aiming to increase transparency, reproducibility and hence the quality of the SR and the confidence in its findings. According to the National Institute for Health Research, authors should only identify their article as an SR ‘when the account of the search, appraisal and synthesis methods would, in theory, permit the replication of the review by others’.4 8 67 73We highlight once again that an RoB assessment is the most important part of but not exactly synonymous to study quality assessment. Where the strength of evidence assessment tool used relies on study quality , the authors should clarify if they only use RoB assessment as an extension of study quality. Finally, RoB assessment should be performed on an outcome measure level, not a study level, especially when the study includes both patient-reported outcomes and outcomes directly measured by study faculty.We recommend the use of the revised RoB assessment tool recently published by the Cochrane Collaboration (RoB 2) as it is more standardised and reproducible with clear instructions on how it should be used and less subjectivity.All SRs should include pooling of results to make conclusions about an overall treatment effect where clinical heterogeneity allows.82 <50%, random-effects for I2 >50%).2 statistic).2 test is substantial (>75%) despite sensitivity analyses, the meta-analysis should be abandoned.76In the absence of significant clinical heterogeneity, results should be pooled quantitatively where there are two or more studies assessing the same interventions, ideally with pairwise meta-analyses that improve precision.For qualitative reviews, where numerical values of treatment effects cannot be obtained and pooled quantitatively, pooling should be performed based on direction of effect for studies assessing the same interventions, even in the presence of some clinical heterogeneity, which should be recognised and accounted for in the strength of evidence assessment.Data should only be combined for similar, predefined follow-up time periods, that is, short term, mid term and long-term.The two tools most frequently used in our included SRs (Cochrane Back Review Group and GRADE) differ substantially and we advocate the preferential use of one over the other in specific situations.et al state in their original publication that in addition to methodological quality of the original studies, participants, interventions and outcomes should also be taken into account when levels of evidence are attributed to qualitative analyses.73Considering the nature and the intention of these two tools, we recommend the use of the GRADE tool for all SRs where comparisons of interventions include any type of quantitative analyses  and the Cochrane Back Review Group where only direction of effect is used for pooling of results . However, when the Cochrane Back Review Group tool is used, in addition to RoB assessment which should be used to determine the level of evidence for each outcome measure, we recommend using imprecision, indirectness of evidence and publication bias (where appropriate) to downgrade the level of evidence in a similar fashion to the GRADE tool. Besides, van Tulder Neither the GRADE tool nor the Cochrane Collaboration Back Review Group tool come without disadvantages.An SR is no small undertaking and should not make for an easy publication. Future authors who only intend to summarise the available evidence without a comprehensive quality assessment and strength of evidence assessment should strongly consider identifying their reviews as narrative, not systematic. Admittedly, strict word counts and other restrictions from journals undoubtedly have a negative influence on the quality of the published SRs; we, therefore, invite the editors of publishing journals to either loosen restrictions for submitted articles or discuss word counts and accompanying material (tables/figures) with authors on a case-by-case basis. Publication of narrative reviews should also become an option in all publishing journals.In the present review, we have demonstrated that the majority of SRs of RCTs in tendinopathy do not assess the strength of evidence of their results and this can substantially influence their application to clinical practice. In the future, authors implicated in producing and publishing SRs on the management of tendinopathy should become familiar with strength of evidence assessment tools and apply them appropriately in their data synthesis and presentation. Finally, relevant guidance documents should emphasise the importance of strength of evidence assessment and provide more detailed instructions for its conduct to increase consistency and transparency.10.1136/bmjsem-2020-000920.supp3Supplementary data


Nutrition and physical activity policies have the potential to influence lifestyle patterns and reduce the burden of non-communicable diseases. In the world of health-related guidelines, GRADE  is the most widely used approach for assessing the certainty of evidence and determining the strength of recommendations. Thus, it is relevant to explore its usefulness also in the process of nutrition and physical activity policymaking and evaluation.The purpose of this scoping review was (i) to generate an exemplary overview of documents using the GRADE approach in the process of nutrition and physical activity policymaking and evaluation, (ii) to find out how the GRADE approach has been applied, and (iii) to explore which facilitators of and barriers to the use of GRADE have been described on the basis of the identified documents. The overarching aim of this work is to work towards improving the process of evidence-informed policymaking in the areas of dietary behavior, physical activity, and sedentary behavior.A scoping review was conducted according to current reporting standards. MEDLINE via Ovid, the Cochrane Library, and Web of Science were systematically searched up until 4 July 2019. Documents describing a body of evidence which was assessed for the development or evaluation of a policy, including documents labeled as “guidelines,” or systematic reviews used to inform policymaking were included.Thirty-six documents were included. Overall, 313 GRADE certainty of evidence ratings were identified in systematic reviews and guidelines; the strength of recommendations/policies was assessed in four documents, and six documents mentioned facilitators or barriers for the use of GRADE. The major reported barrier was the initial low starting level of a body of evidence from non-randomized studies when assessing the certainty of evidence.This scoping review found that the GRADE approach has been used for policy evaluations, in the evaluation of the effectiveness of policy-relevant interventions (policymaking), as well as in the development of guidelines intended to guide policymaking. Several areas for future research were identified to explore the use of GRADE in health policymaking and evaluation. Contributions to the literaturePolicies in the area of nutrition and physical activity should be based on the best available scientific evidence in order to have the best possible impact.The GRADE approach is a tool to form trustworthy evidence-informed recommendations; thus, it may contribute to improving the process of evidence-informed policymaking. It is already being used in policy evaluation, in evaluations of effectiveness, and in the development of guidelines.This research did not reveal actual policies or formulation processes from governmental bodies so future research should focus on assessing the views of policymakers on the usefulness of GRADE to inform their decisions.According to the most recent report by the Global Burden of Disease study group, non-communicable diseases (NCDs), such as cardiovascular disease, cancer, and type 2 diabetes, accounted for 64.8% of total deaths worldwide in 2017 . SuboptiOn a public health level, policies are important instruments that can be used to change people’s behavior . While tPolicies have the potential to influence lifestyle patterns within a population . CertainTo increase the acceptance and impact of polices, it might be helpful if they adhered to principles widely accepted, for instance, similar to health guidelines, i.e., they should be transparent, structured, and evidence-informed , 13. WitThe Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach and the GRADE Evidence to Decision (EtD) frameworks are important methods for the development and evaluation of recommendations for practice and can therefore also help to make evidence-informed decisions on a population level –17. GRADThe primary aim of this scoping review is to investigate how and to what degree the GRADE approach has contributed to policy development in the context of nutrition and physical activity. To this end, the following steps were taken: (i) an overview of documents using the GRADE approach in the context of nutrition and physical activity policymaking and evaluation was compiled, (ii) methods of applying the GRADE approach  were recorded, and (iii) facilitators of and barriers to the use of GRADE described in the identified documents were identified and explored.This scoping review was conducted according to the methodology of the Joanna Briggs Institute’s (JBI) Reviewers’ Manual 2015 and is reported following the PRISMA  extension for scoping reviews, the PRISMA-ScR Statement  search strategy is presented in Additional file Secondly, an internet-based search through the Google™ search engine and through Google Scholar™ was performed to identify gray literature and different relevant institutions and organizations, such as the Food and Agriculture Organization for the United Nations (FAO), World Health Organization (WHO), World Cancer Research Fund International (WCRF), the National Institute for Health and Care Excellence (NICE), and the Campbell Collaboration. Following this, the types of documents relevant for policymaking and which address dietary behavior, physical activity, and/or sedentary behavior, such as guidelines, reports, or systematic reviews, were searched on the websites of relevant organizations. Documents were found both through the Google search directly and also retrieved from the websites of those organizations and institutions identified in the search.Thirdly, an extensive overview of existing policies including policy evaluations from the NOURISHING-database by the WCRF was considered . Lastly,(i)At least one intervention or recommendation of a policy document targeted the PEN-related outcomes: dietary behavior, physical activity, or sedentary behavior.(ii)Recommendations targeted a population rather than individuals. This means that at least one intervention or recommendation had to fit in one of the following categories: school program , mass media , infrastructure , financial incentive , change of offerings , nutrition labeling, and population education . These categories were established by reviewing a set of pre-identified documents.(iii)Specific measures or action plans  that were or could be implemented by a government or an inter-governmental organization such as the WHO .(iv)In addition to meeting criteria i–iii, GRADE was used to assess the certainty of evidence or the strength of recommendations or reasons for not using GRADE were explicitly noted.Because of the lack of a standard definition of the term “policy” across various areas of health policy and policy decision-making, the current search also aimed to identify documents that might not have used the term “policies” or “policy evaluations.” We focused on documents that described a body of evidence which was assessed for the development or evaluation of a policy, including documents labeled as “guidelines,” or systematic reviews used to inform policymaking . Further(i)Since the GRADE approach is primarily applicable in the context of evidence syntheses within systematic reviews, health technology assessments  or guidelines, surveys, and primary studies  or non-randomized studies (NRSs)) were excluded.(ii)Documents concerning the methodological aspects of policy implementation were excluded.(iii)Documents about interventions that specifically target individuals instead of a population were also excluded.There were three exclusion criteria:First, title and abstract screening was performed by one reviewer (JZ). Only clearly irrelevant references were excluded at this stage. Second, for all potentially relevant references, full-text publications were obtained and checked for final inclusion by two reviewers  independently. Uncertainties were resolved through discussion with a third author (JJM).For included documents, one reviewer (JZ) extracted the following characteristics: name of first author, year of publication, document type, study aim, outcome of interventions , design of primary studies included in the document, policy/intervention(s), target group/study setting, use of GRADE, GRADE ratings for relevant outcomes (including down- and upgrading factors), facilitators, and barriers to apply GRADE. The data extraction form was piloted and proved to be applicable to all types of retrieved documents. Data extraction was verified by a second reviewer (LS).The documents were categorized according to policy evaluation, evidence of effectiveness for policymaking, or a recommendation to guide policymaking , title and abstract screening of 5672 documents was performed, from which 5443 documents were excluded. The remaining 229 documents were reviewed in full-text screening. The eligibility criteria were met by 36 documents which were included in this scoping review . Another 19 documents were retrieved through further reference checking and from the gray literature. After removal of duplicates , systematic review protocols , systematic reviews without meta-analyses , guidelines , an umbrella review , or papers on guideline making . From these findings, 17 documents (47%) were Cochrane reviews (including five Cochrane review protocols). Four documents were international guidelines by the WHO and one guideline by NICE  were published within the last 3 years. Settings of the studies included communities, schools, or workplaces. The majority of recommendations/interventions addressed the general population through various forms of mass media. Furthermore, the included documents examined various combinations of interventions addressing dietary behavior, physical activity, and sedentary behavior, and also combinations of these with other health-related topics. Most of the studies investigated interventions related to dietary behavior alone (39%), followed by physical activity (17%). There was only one study that assessed interventions aiming to diminish sedentary behavior alone (3%), and all other documents (41%) were based on interventions that targeted various outcomes, focusing on multicomponent interventions that addressed general health and aspects such as alcohol or tobacco consumption.The characteristics of the included documents are displayed in Table ironment ). Furtheironment , 53. Docn = 8, [n = 1, [n = 2, [n = 3, [Many of the documents included did not review implemented policies and focused rather on interventions that have the potential to drive policy in the future. Seven of the 36 documents include studies in which the effects of implemented nutrition and physical activity policies were examined, including nutrition labeling , 49, SSBn = 8, , 48, 50) [n = 1, ), docume [n = 2, , 53), or [n = 3, , 32, 42)Table The WHO guidelines were the only documents which, in addition to rating the certainty of evidence for each outcome, also provided the “strength of recommendations” for each recommendation included in the guideline . The reason for this is that Cochrane adopted the GRADE approach for the evaluation of the certainty of evidence in systematic reviews [Almost half of the included documents that used the GRADE approach to assess the certainty of evidence are Cochrane Reviews  that used GRADE. The legislative process underlying policymaking is complex and time-consuming. In addition, there are specific challenges associated with translating empirical findings from the lab into actionable policies in government –69. The This scoping review has several strengths. Firstly, the inclusion criteria and the search strategy planned for this scoping review were broad, including an extensive search of gray literature such as databases of the WHO or the WCRF in addition to more traditional sources. This access to a wide variety of documents in the research field yields a better overview than previously available. Secondly, we performed a rigorous approach to screening and data extraction, which was performed by two reviewers independently. Thirdly, the survey among national policymakers of the European region brought relevant input and insights into this study by giving an idea about the current use of GRADE within policymaking institutions.n = 7) actually examined real policies. In these cases, the authors did not distinguish between the types of included studies, that is, if an intervention was carried out in an experimental/artificial setting or based on a law/regulation. Lastly, a document was included even when only one of the interventions in the review was considered a policy intervention although the majority of the remaining interventions were not. In this case, ratings for the certainty of evidence with GRADE are likely to be higher than for NRSs in real-life settings as it is much easier to conduct RCTs in experimental settings. Limitations of this scoping review in our view are as follows. Firstly, developing a suitable search strategy was challenging. Though the search was systematic and as broad as possible, it proved to be difficult to grasp all the facets of the topic. Secondly, only documents were included in which GRADE was applied or reasons were provided for not using GRADE. A different approach with inclusion of documents that could have applied GRADE but did not do so and a research design enabling an in-depth investigation of policymakers’ views  might have provided further insights into this topic. These approaches would have allowed for a thorough investigation of the extent of evidence use without structured consideration of certainty of evidence and strength of recommendations in policymaking and evaluation. However, this was beyond the scope of this project. Thirdly, a standard definition of the terms “policy” and “health policy” was difficult to determine since various definitions can be found in the literature. Only a few of the included documents  , 80. FurMoreover, beyond the evidence of effectiveness in a given context, public health and health policy decision-makers have to consider numerous additional aspects –85, for This scoping review was the first attempt to shed some light on how the GRADE approach has been used in nutrition and physical activity policymaking and evaluation. In conclusion, we show that the GRADE approach is able to support the processes of health policymaking  and policy evaluation  by facilitating a structured and transparent use of evidence, and that it has already been used in the areas of dietary behavior, physical activity, and sedentary behavior. The aforementioned barriers regarding the use of the GRADE approach have been recognized by the GRADE working group as well, since new tools such as ROBINS-I have been endorsed for the assessment of the certainty of evidence, especially to help decision-makers and policymakers in the area of public health. GRADE is being used as a standard method during guideline development in various institutions, which is an important part in the process of informing policymaking. Nevertheless, our survey shows that GRADE is not being used regularly for actual policymaking. We believe the evaluation of policies should be consistent with standardized methods in order to have the best possible impact on improving health and quality of life, and the GRADE approach could play an important role in this.Additional file 1. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).Additional file 2. Search in MEDLINE via Ovid, 4 July 2019.Additional file 3. Survey among European health policymakers.Additional file 4. WHO – Strengths and recommendations according to GRADE.