Protected areas are a crucial tool for halting the loss of biodiversity. Yet, the management of protected areas is under resourced, impacting the ability to achieve effective conservation actions. Effective management depends on the application of the best available knowledge, which can include both scientific evidence and the local knowledge of onsite managers. Despite the clear value of evidence-based conservation, there is still little known about how much scientific evidence is used to guide the management of protected areas. This knowledge gap is especially evident in developing countries, where resource limitations and language barriers may create additional challenges for the use of scientific evidence in management. To assess the extent to which scientific evidence is used to inform management decisions in a developing country, we surveyed Brazilian protected area managers about the information they use to support their management decisions. We targeted on-ground managers who are responsible for management decisions made at the local protected area level. We asked managers about the sources of evidence they use, how frequently they assess the different sources of evidence and the scientific content of the different sources of evidence. We also considered a range of factors that might explain the use of scientific evidence to guide the management of protected areas, such as the language spoken by managers, the accessibility of evidence sources and the characteristics of the managers and the protected areas they manage. The managers who responded to our questionnaire reported that they most frequently made decisions based on their personal experience, with scientific evidence being used relatively infrequently. While managers in our study tended to value scientific evidence less highly than other sources, most managers still considered science important for management decisions. Managers reported that the accessibility of scientific evidence is low relative to other types of evidence, with key barriers being the low levels of open access research and insufficient technical training to enable managers to interpret research findings. Based on our results, we suggest that managers in developing countries face all the same challenges as those in developed countries, along with additional language barriers that can prevent greater use of scientific evidence to support effective management of protected areas in Brazil. Protected areas are important to conserve biodiversity and maintain a wide range of ecological processes and ecosystem services –3. NeverEffective management of protected areas depends on the application of successful management actions. Selecting the most appropriate management actions requires a sound evidence base, derived from scientific evidence and the experience that managers acquire during their daily work . AlthougThere are many reasons why managers tend not to use scientific evidence , includiUnderstanding the types of evidence managers use to support their decisions, and why, can help to reveal the barriers they face in utilizing the best available evidence. It can also provide insights into how to design strategies to help managers achieve greater access to the evidence most valuable for their decisions. For example, the strategies to support evidence-based conservation would be different if managers have limited access to scientific evidence versus if they have insufficient training to understand the relevant science. Thus, our main contribution is both to provide information on the type of evidence managers from a non-English speaking country use to make decsions and to understand the barriers that may prevent managers from using science more frequently.To understand the use of scientific evidence by protected area managers in a non-English speaking country, we spoke with managers of protected areas in Brazil. Brazil has one of the largest protected area networks in the world  encompasAs one of the first studies to investigate the extent of evidence-based decision making in the non-English-speaking world, we sought to understand: 1) where managers look for information, 2) what drives their choice in looking at these sources, 3) what types of evidence they consider valuable for decisions, 4) what they can access, and 5) which factors most influence the use of science by managers.Brazil has 1,940 protected areas, varying in size, administrative divisions, and protection type . There aWe obtained contact details for 1,040 managers responsible for the day-to-day management of Brazilian protected areas from the Brazilian Ministry of the Environment. These individuals represent the managers responsible for at least one protected area within one of the three different administrative divisions . The protected areas included all protection categories , and about the manager, including his/her level of experience (number of years as a protected area manager), preliminary technical training (whether the manager received any kind of training directed to protected area management), education level , English fluency, and their role in the protected area . We then provided respondents with a list of 21 different sources of evidence  and ask http://lattes.cnpq.br/) and the managers were a sub-sample of the respondents of our main survey. The expert elicitation process was carried out with an online survey. The members of the expert panel were first asked to allocate each of the 21 sources of evidence  − rn)/n, where n is the number of sources and r is the rank of the source n. We called this the “scientific foundation scale” where values close to one indicate a strong scientific foundation  and values close to zero indicate a poor scientific foundation . The median ranks, the final ordering and scores are provided in Next, the experts were asked to rank the information sources by their scientific rigor. The median rank attributed to each source was then calculated and scaled to a value between 0–1 by applying the following transformation: To assess where managers go to find information about management decisions, we grouped sources into the categories of evidence assigned by the expert panel . Then, to determine if there are categories of evidence managers consult most frequently, we used Analysis of variance (ANOVA) to evaluate which types of evidence were reportedly used more frequently. Managers’ responses in relation to the frequency of use were assigned a numeric code ; we usedTo assess the degree to which managers use scientific evidence, were used (ANOVA) to determine whether managers reported difference in the accessibility and importance of different categories of evidence. The coded accessibility scale and importance scores  was usedi is the mean of all m evidence categories and where the values for each evidence category c are the mean product of the use frequency uf by the scientific foundation sf of information source s across all n information sources of that evidence category. These EBMD scores provided us with a measure of how often managers are using the most rigorous evidence in each evidence category when making their decision, which we could then use to evaluate the factors that might explain the uptake of scientific evidence by managers.To understand what influences whether or not managers use scientific evidence, we calculated a metric to indicate the degree of evidence based decision making by each manager (EDBM score). To do this, we combined data on how frequently managers use each of the sources of evidence  with theTo understand which variables contribute to difference in the use of evidence by managers we used a general linear model, testing the mean EBDM scores (response variable) against a range of different explanatory variables. The EBDM scores were subjected to a ¼-power transformation to meet the assumptions of normality and equal variance of residuals required by linear regression. The explanatory variables we tested included characteristics of the manager: their level of experience (years), preliminary technical training, education level, and English fluency. We also assessed the influence of protected area characteristics, such as the geographic location, size, and protection category of the different protected areas. Finally, we tested the influence of the accessibility and perceived level of importance of the information sources as indicated by managers . Next, wWe received 282 responses from managers with a response rate of 27%, of which 233 answered all questions (22% response rate). This is a slightly higher response rate than similar studies on protected area managers  and  and 7] aWhile the accessibility of evidence was a major barrier to the use of scientific evidence for Brazilian managers, we also found that even when accessibility was higher, the use of scientific evidence depended on whether managers had training in how to interpret science. These findings suggest that simply improving managers’ access to scientific journals alone will not increase evidence-based management without parallel efforts to improve the technical capacity of managers. Improved access to evidence for managers could be achieved if governments extended existing infrastructure that supports universities to access research, providing access to search engines  and subscriptions to management relevant journals. However, improving the scientific training of managers may not be in itself be a panacea, with efforts to increase training currently being hampered by high rates of staff turn-over associated with swings in political strategy for protected areas . TherefoIn addition to increasing the scientific literacy of managers as a means to improving evidence-based decision making, the language barrier faced by managers in non-English speaking countries can also be a challenge for these managers understanding the available evidence. English is the international language of science, and this places non-native English speakers at a major disadvantage when accessing and understanding science . InteresThis study provides critical insight into the use of different types of evidence by protected area managers outside English speaking countries. Managers in Brazilian protected areas face many of the same challenges in achieving evidence-based conservation management as managers in Australia , the UK S1 DatasetThe dataset does not contain any data that could be used to identify any human participants in this study and frequency of use of sources is coded as in (CSV)Click here for additional data file.S2 DatasetThe dataset does not contain any data that could be used to identify any human participants in this study and accessibility of sources is coded as in (CSV)Click here for additional data file.S3 DatasetThe dataset does not contain any data that could be used to identify any human participants in this study and importance of sources is coded as in (CSV)Click here for additional data file.S4 DatasetThe dataset does not contain any data that could be used to identify any human participants in this study.(CSV)Click here for additional data file.S1 Fig(PDF)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.S3 Fig(PDF)Click here for additional data file.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S1 Text(PDF)Click here for additional data file.


Depression and anxiety remain under-diagnosed and under-treated in those with neurologic diseases such as dementia or Parkinson’s Disease (PD). Our objectives were to first, to provide a synthesis of high quality guidelines available for the identification and management of depression or anxiety in those with dementia or PD. Second, to identify areas for improvement for future guidelines.We searched MEDLINE, PsycINFO, and EMBASE , grey literature , and bibliographies of included studies. Included studies were evaluated for quality by four independent reviewers the AGREE II tool. Guideline characteristics, statements and recommendations relevant to depression or anxiety for dementia and PD were then extracted. (PROSPERO CRD: 42016014584)8121 citations were reviewed with 31 full text articles included for assessment with the AGREE II tool. 17 were of sufficient quality for inclusion. Mean overall quality scores were between 4.25 to 6.5. Domain scores were lowest in the areas of stakeholder involvement, applicability, and editorial independence.Recommendations for the screening and diagnosis of depression were found for PD and dementia. There was little evidence to guide diagnosis or management of anxiety. Non-pharmacologic therapies were recommended for dementia patients. Most advocated pharmacologic treatment for depression, for both PD and dementia, but did not specify an agent due to lack of evidence.The available recent high quality guidelines outline several recommendations for the management of comorbid depression or anxiety in PD or dementia. However there remain significant gaps in the evidence.The online version of this article (doi:10.1186/s12883-016-0754-5) contains supplementary material, which is available to authorized users. Persons experiencing neurologic disorders, such as dementia or Parkinson’s disease (PD), and depressive or anxiety disorders have poorer outcomes with reduced quality of life, poor functional status and worsened cognition –8.It is estimated that the prevalence of depression in dementia is approximately 25% with anxiety occurring in up to 75% –11. In PDespite awareness of these comorbidities, depression and anxiety remain under-diagnosed and under-treated in those with neurologic diseases , 13–17. Thus, in the setting of PD and dementia, CPGs should enable the appropriate management of depression and anxiety –26. DespThe study protocol follows the recommendations provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)—Protocols Statement  and guidThe literature search was developed in conjunction with an experienced librarian (DL) and was verified independently by a second librarian (HLR), using the Peer Review of Electronic Search Strategies (PRESS) methodology . Any recDatabases included MEDLINE, EMBASE, and PsycINFO. Clusters of terms (controlled vocabulary and key words) were used to search each database; these include dementia, Parkinson’s disease, depression, anxiety and CPGs  function to determine if an article was a guideline. When included, the documents were searched using translated relevant terms; for example, if a guideline pertained to PD in the abstract, the text was searched for depression or anxiety . If those criteria were met, the full guideline was translated and reviewed.The Appraisal of Guidelines Research & Evaluation (AGREE II) tool was used to assess guideline quality . This toEach domain was scored independently by four reviewers, along with the assignment of an overall score. An initial assessment of 5 citations was done and compared across all 4 reviewers . The 4 rDomain scores pooled across the 4 assessors were calculated, as outlined in the AGREE II user manual . The higGuideline characteristics were extracted by one author (ZG) and independently verified by a second author (BM). Items extracted included the primary conditions covered, region/organizations, number of committee members, numbers of references, and sources of funding.Two independent reviewers then extracted relevant recommendations . Specifically, guidelines were searched for any mention of relevant recommendations and supporting text or statements. Three authors reviewed the extracted recommendations . Recommendations were compiled across the guidelines into relevant categories and subcategories, and reported using descriptive statistics including the quality, number of guidelines supporting the statement and subpopulations included. As the evidence in the guidelines is represented by practice recommendations, it was not amenable to meta-analysis. The main output of this systematic review was an appraisal of the quality of all guidelines pertaining to comorbid depression or anxiety in PD or dementia, and a synthesis of the recommendations across the different guidelines. Data were analyzed using STATA 13.1 .n = 218), were not guidelines, or were unrelated guidelines. Other common reasons for exclusion at the full text stage were being out of the date range (n = 33) or a duplicate (n = 35). Excluded citations also included 26 mental health guidelines that did not address PD or dementia. Similarly there were 5 PD and 9 dementia guidelines that did not address depression or anxiety. The dementia guidelines primarily pertained to Alzheimer’s disease, vascular dementia, general dementia care and one referred to Lewy Body Disease. Of these articles, 4 were identified to be summary documents of included guidelines and were used as supplemental material to these included guidelines. Twenty-six CPGs met all eligibility criteria and were evaluated using the AGREE II tool, of which 17 met the quality cut off for inclusion.The database search generated 4441 citations after duplicates were removed, with a further 3681 citations identified from the grey literature , dementia (n = 8) and mental health (n = 4) CPGs (Table n = 2), USA (n = 3), Pan-European (n = 4), UK (n = 2), Scotland (n = 1), Spain (n = 2), South Korea (n = 1) and international (n = 2). The associations or organizations are outlined in Table The 17 included guidelines addressed PD  [n = 1) and the practitioner should consider side effects and drug interactions prior to initiation [n = 3) [n = 2) [n = 1) [Antidepressant therapy is recommended, however there is little evidence to support one agent over another (n = 2) , 39. Additiation . There h [n = 3) , 37, 39. [n = 3) , but not [n = 2) . It is rn = 3) [There is some weak evidence supporting the use of dopamine agonists and monoamine oxidase inhibitors for the management of depression in PD (n = 3) , 39, 40.n = 3) . Howevern = 2) [Other therapies for depression are not well explored in PD. The European Federation of Neurological Sciences (EFNS) concluded there was insufficient data to recommend psychotherapy, electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TCMS) . Other gn = 2) , 39.n = 2), however there is no clear consensus on what tools to use [n = 1) [It is recommended that patients with dementia be assessed for anxiety  [It is recommended that patients with dementia be evaluated and re-evaluated over time for depression (n = 5) –45. As pn = 5) , howevern = 5) .n = 5) in dementia, including the CSDD, GDS or Dementia Mood Assessment Scale (DMAS) [n = 4) [The use of a valid screening tool was recommended for depression case finding (e (DMAS) , 47, 48. [n = 4) , 47, 48.n = 4) such as stimulation oriented, cognitive behavioural, reminiscence, exercise or multi-sensory therapy [n = 6) [n = 1) [n = 1) [n = 6) [n = 1) [n = 2) [n = 1) [n = 1) [Therapy for depression in those with dementia should include a variety of non-pharmacologic options  , 49, 50. [n = 1) . Based l [n = 6) , 49, 50. [n = 2) , 42, cho [n = 1) .This study provides a synthesis and quality assessment of available guidelines for the management of depression or anxiety in PD or dementia. We identified clear gaps in guideline quality and the evidence, which inform future research and knowledge translation.Guidelines that were excluded due to low quality were typically those that lacked explicit development methods, thus ratings across all the domains were low. When examining the AGREE II ratings overall, the lowest rating was in assessing the guideline description of barriers and facilitators, implementation, resource implications, or monitoring/auditing criteria (Domain 5). In fact, few guidelines had discrete sections addressing knowledge translation. The concern about guideline applicability was explored in a 2015 systematic review , which fThe engagement of patients and caregivers was notably absent in CPG development. This process is important, as it is aimed at improving implementability, by ensuring the recommendations are comprehensive, adaptable and applicable to the target group and have an open process . Given tThere is an overall lack of recommendations related to the diagnosis or treatment of anxiety in either PD or dementia. This stems from the fact there is little evidence on how to approach the assessment. One guideline suggested the use Hospital Anxiety and Depression Scale for dementia, but they did not provide diagnostic accuracy information or suggestions for implementation . There iGuidance for depression was present in a higher proportion of guidelines. Despite this, there is variability in the reporting of levels of evidence and recommendations (Additional file It is clear that screening for depression with a validated tool in PD is recommended, although evidence varies , 38. It Recommendations surrounding non-pharmacologic therapy were few, stating there was insufficient evidence for the use of psychotherapy, ECT or TMS , 39, 40.Depression in dementia was more frequently addressed. However, these recommendations also had varied guideline and evidentiary support. Guidelines supported the evaluation of depression in dementia, but evidence ranged from high quality to good practice points –45. CommInterestingly, the issue of evaluating for suicide risk was raised in two guidelines with divergent recommendations , 46. OneThere are stronger recommendations for non-pharmacologic treatment in dementia than in PD, outlining several options , 47, 48.There is a well-recognized issue with heterogeneity in the terms used to refer to guidelines . For ourGiven the burden of comorbid mental illness in dementia and PD, it is key that we understand clearly the current knowledge base so we can improve care for these populations. This study provides a synthesis and quality assessment of the relevant guidelines. By synthesizing the recommendations, we identified areas of knowledge that are potentially ready to be translated into practice but also clear evidence gaps. This data was further evaluated in a subsequent study by stakeholders in focus groups to understand the other barriers and facilitators to the use of guidelines. This was to inform and help develop a comprehensive knowledge/end-user focused plan for addressing these gaps.


The main goals of spleen preserving surgery are control of peroperative bleeding and maintaining the spleen’s function postoperatively. Several techniques of spleen preserving surgery have been described. This report presents a new technique to perform partial splenectomy. We performed this partial splenectomy with a bipolar radiofrequency (RF) device in a 21 years old woman with a splenic cyst, with almost no peroperative blood loss. The incidence of splenic cysts is low. A difference is made between primary cysts which are congenital or parasitic (rare in Western countries) and secondary cysts, being posttraumatic in origin or due to splenic infarctions or infections .Partial splenectomy for benign disease of the spleen has an immunologic advantage above total splenectomy, because preserving a part of the spleen prevents the risk of a perilous postsplenectomy sepsis -4. NeverThe current report presents a technique for spleen preserving surgery using a new disposable bipolar RF device developed for liver resection by professor Habib from the Imperial college in London.A 21 years old woman, with no medical history  presented with nagging pain in the upper left abdomen. Ultrasound showed a large cyst, of which the origin was not clear. Subsequently computed tomography scanning showed a cyst localized in the upper part of the spleen, 11 × 8.5 cm in size . There wUnder general anaesthesia a left subcostal laparotomy was performed with the patient in supine position. The spleen was fully mobilized. The technique used for this partial splenectomy was similar to that described for liver resection. In brief, after mobilization of the spleen, an intended line for division of tissue was first drawn on the spleen capsule by electrocautery, 1 cm away from the cyst. Using the disposable bipolar Habib 4X sealer  the upper part of the spleen including the cyst was coagulated along the resection line introducing the sealer perpendicularly into the spleen . The proThe postoperative course was prosperous with a minimal decrease in haemoglobin and there was no need for blood transfusion. The patient was discharged home on the 6th postoperative day and 3 weeks post surgery the patient was functioning normally without any complaints. The histopathologic diagnosis was an epidermoid cyst.Partial splenectomy has an immunologic advantage above total splenectomy. However there is a risk for peroperative bleeding. When a safe operative technique is used, this has to be the treatment of first choice in benign splenic disease.Radiofrequency ablation seems a useful technique to perform partial splenectomy , 11. MorAt present, partial splenectomy with the disposable bipolar Habib 4X sealer seems to be the most simple and safest method to perform spleen preserving surgery.


The Motivational Interviewing target Scheme (MITS) is an instrument to assess competency in Motivational Interviewing (MI) and can be used to assess MI in long and brief consultations. In this qualitative study we examined two sources of the Unified Model of Validity, the current standard of assessment validation, in the context of General Practice. We collected evidence concerning response process validity and content validity of the MITS in general practice. Furthermore, we investigated its feasibility.Assessing consultations of General Practitioners and GP-trainees (GPs), the assessors systematically noted down their considerations concerning the scoring process and the content of the MITS in a semi-structured questionnaire. Sampling of the GPs was based on maximum variation and data saturation was used as a stopping criterion. An inductive approach was used to analyse the data. In response to scoring problems the score options were adjusted and all consultations were assessed using the original and the adjusted score options.Twenty seven assessments were needed to reach data saturation. In most consultations, the health behaviour was not the reason for encounter but was discussed on top of discussing physical problems. The topic that was most discussed in the consultations was smoking cigarettes. The adjusted score options increased the response process validity; they were more in agreement with theoretical constructs and the observed quality of MI in the consultations. Concerning content validity, we found that the MITS represents the broad spectrum and the current understanding of MI. Furthermore, the MITS proved to be feasible to assess MI in brief consultations in general practice.Based on the collected evidence the MITS seems a promising instrument to measure MI interviewing in brief consultations. The evidence gathered in this study lays the foundation for research into other aspects of validation.The online version of this article (doi: 10.1186/s12909-017-1052-7) contains supplementary material, which is available to authorized users. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion” . MI is wIn the Netherlands, GPs see their patients on average four times a year  which prValidated instruments are needed to assess the quality of MI. To assess MI skills in GP residents, an instrument is required that is feasible in the GP-setting and from which valid conclusions can be derived. Widely used instruments like the Motivational Interviewing Skill Code (MISC)  and the The Motivational Interviewing Target Scheme (MITS)  was deveThe MITS has been thoroughly constructed. The developers strived for incorporating all the essential behaviours of MI in global items. They considered descriptions provided by the founders of MI and MI-assessment instruments. This resulted in definitions that described the core constructs of MI behaviour. Subsequently they tested if the behaviour could be observed in practice samples and received feedback from MI-experts. If necessary, the core constructs were adjusted after consensus discussions .This method of developing the instrument contributed to the validity of the MITS as described in the Unified Model of Validity, the current standard for assessment validation , 18. In In the present qualitative study we investigated several aspects of the feasibility of the MITS in general practice and collected evidence concerning content and response process validity. Concerning content validity, we examined the extent to which the items of the MITS cover the full spectrum of MI. According to Cook et al.  responseWe collected response process evidence by analysing the test users’ (in this study: the assessors) considerations during the assessment process. This provided information on how well assessors’ responses align with the intended construct.To become a GP in the Netherlands, registered medical doctors enrol in a 3-year program combining education at one of the eight institutes (1 day a week) and work in a training practice under supervision of a GP. We conducted this study at the GP Specialty Training Program at the Academic Medical Centre (AMC) of the University of Amsterdam. In year three of the GP-training, MI forms part of the doctor-patient communication training . Under supervision of a psychologist who is experienced in MI, trainees discuss consultations they recorded in practice. Assessment of consultations in which MI is used is part of their exam.We selected 11 GPs and GP-traineesMaximum variation sampling was used to obtain a diverse group of respondents. GPs were selected based on age, gender, nationality and former experience as these aspects are supposed to be related to the quality of communication . From evData on validity evidence and feasibility were gathered by way of a semi-structured questionnaire and by notes made during evaluation meetings of the assessors that took place after every 2–3 assessments. The assessors filled out the semi-structured questionnaires during the scoring process. All data were coded and categorized. Data saturation was used as a stopping criterion and was reached when no new codes or categories occurred.During the first evaluation meeting the assessors discussed problems they came across while using the score options. In response to these scoring problems in the first part of the study (the first phase), the score options were adjusted. Subsequently, all consultations were rated both with the original and the adjusted score options (second phase).In the MITS , MI-consno MI-consistency) till 4 (very high degree of MI consistency).The assessment procedure is described as follows: a sample set should be composed of recordings of complete individual MI sessions  and preferably accompanied with a transcript. The assessor views and/or listens to all recordings and reads the transcripts in its entirety. Subsequently, the score options that best describe the holistic impression of the observed behaviour will be selected for every target. The mean score of the targets determines the final score ranging from 0  during three 3-h sessions spread over 3 months. During the training the scores of three consultations were discussed until consensus was reached on the interpretation of the targets and the rating. After this training, the assessors continued to discuss their ratings during the evaluation meetings in order to maintain or improve the inter-rater agreement.We requested participants to hand in 2–3 video recordings of consultations with patients on behaviour change. It was not required that the participants consciously applied MI. The recordings were stored on a secure server at the AMC.Three assessors assessed one consultation of each participant, seven with and four without a transcript. The consultations were viewed once and it was allowed to pause the recording to take notes. If the assessors were not sure about their initial rating, they could watch the video a second time. If they wanted to change their initial ratings, they added new ratings, keeping the initial ratings on record. During this process they filled out a semi-structured questionnaire  and information on familiarity with MI (Did you read about MI? What did you read? Are you trained in MI? How many hours?)The assessors answered questions concerning the characteristics of the consultation, the feasibility of the MITS to assess brief consultations and its usefulness in the GP setting Table . They noAn inductive approach was used. Two authors (RO and MV) categorized the comments made by the assessors independently. After a consensus discussion the categories were slightly adapted. A descriptive analysis of the ratings of the MITS was made. Microsoft Excel (14.1.0) was used to organize the data.After 27 assessments (9 out of 11 consultations rated by three assessors) data saturation was reached. Table The assessors encountered the following problems concerning the score options during the first phase of the study.“The score matches ‘substantially’ but not ‘more than adequately’ ”. (Assessor 2)According to the assessors the adverbs used to describe one score option Table  did not majority of the time”).Furthermore, the assessors had different views on the meaning of some descriptions  and the same findings resulted in different ratings. Therefore they looked for less ambiguous adverbs. This resulted in four qualitative adverbs , which were included in the adjusted score options Close to the former theme are ‘missed opportunities’. The difference is that the practitioner does not fail to use the target behaviour but within the target behaviour obvious chances are unused. We added the possibility to score ‘missed opportunities in the adjusted score options. A reactions on this adaptation is:c.MI / target-inconsistent behaviourMI-inconsistent behaviour is not mentioned in the original score options. This caused problems when the target behaviour was performed well during the majority of the time but some MI/target-inconsistent behaviour was shown as well. It was not clear what the impact of the MI/target-inconsistent behaviour should be on the scoring. To solve this problem, we added ‘target-inconsistent behaviour’ to the score options (See Table “It is clear that the score cannot exceed a ‘2’ because of target-inconsistent behaviour”. (Assessor 1).A quote on this adjustment was:In the second phase of the study, all consultations were scored with the original and the new score options. The semi-structured questionnaires Table  yielded Time spent on the assessment by the assessors and the use of transcriptsDuring the first assessments it took the assessors 75–120 min to watch the whole consultation, to code the MI-part and answer the questionnaire . They preferred to watch (parts of) the consultations twice but after 5 assessments, they did this only occasionally. After 5 assessments, if the assessors used a transcript of the consultation and took notes, it took about 30 min to assess 10 min of MI. Without transcript the assessment total coding time increased by approximately 10–15 min as recordings were paused more often and more notes were written down.b.Assessing short fragments spent on behaviour changeTwo assessors found it difficult to give a global rating to target 3 (empathy) when the part of the consultation on behaviour change was short (2.3 min), the third assessor found it difficult to rate targets 1–7 in this case. It turned out that in this consultation little MI was used. In another short MI-part (2.5 min) the assessors had no difficulties to rate the targets. The difference was that MI was explicitly used in this consultation.c.The length of the descriptions of the targets“An evocative style should be maintained throughout the interview. The practitioner assists the person to articulate arguments in favour of change and ideas about how change could be achieved, and does not attempt to overtly persuade the person. Change talk is encouraged and consolidated.”The descriptions of the targets of the MITS are comprehensive and divided over ‘summary’, ‘definition’ and ‘elaboration’ see Fig. . The lenRepresentativeness of the MITS for the entire spectrum of MIThe assessors agreed on the completeness of the targets of the MITS to assess all components of MI concerning the desirability to change and on the fact that the core concepts of MI are very well reflected in the targets. However, in general practice more attention should be paid to the follow-up of the consultation as discussing behaviour change in one consultation might be insufficient to achieve long-term behaviour change.“By not paying attention to the follow-up, the practitioner possibly diminishes the chance that the patient will actually take steps” (Assessor 3).b.Clarity and distinctiveness of target descriptionsMost parts of the targets are clear and distinguishable. The assessors’ interpretation of the targets was discussed and consensus on how to distinguish between targets was recorded. This yielded agreements to facilitate decision-making Table .Table 8EWhen rated with the original score options (ranging from 0 to 4), from the mandatory targets (target 1–7), target 3 (empathy) and target 5 (independence) had ratings from 1 to 4 and were not distributed over the full range of the five-point scale, while the other targets were. When rated with the adapted score options, target 3 (empathy) and target 7 (navigation) had ratings from 1 to 4. All other ratings were distributed over all five score options.From the optional targets, only target 8 (contrasts) was not distributed over all score options but only over 2 and 3  and over 1 and 2 in the adjusted score options. This optional target was rated in only five of the 27 assessments.In this qualitative study, the MITS turned out to be a feasible instrument to rate MI in GP consultations. Additionally, in terms of the content validity, one of the sources of validity according to the Unified Model of Validity Table , the MITConsultations of GPs are brief and behaviour change has to be discussed among other topics. Nevertheless we found that in all but one consultation all mandatory targets could be scored, even when little time was spent on behaviour change. Only if during this short time spent on behaviour change, little MI was used, not all targets could be scored.Assessing more consultations (30–45 min) at once and giving one holistic impression for every target, which was the original intention of the developers, seems difficult. Even when the assessors assessed only one consultation they needed to check their notes or watch the recording again in order to score the targets. For summative assessment and research purposes we would recommend scoring consultations separately and calculate the average. This will probably contribute to the inter-rater reliability  and is consistent with the use of other communication assessment tools in post-graduate education , 24 .Initially, the assessors needed a considerable amount of time to assess the consultations. Familiarity with the MITS reduced the scoring time substantially. The suggestions provided in this study about unequivocal scoring instructions and shorter descriptions of the targets might facilitate decision-making as well. The duration of the assessment became within the range of other reports on scoring duration . AlthougMITS users are supposed to have a thorough understanding of MI. This seems inherent to global assessment. Ilgen et al.  noted thIn this studied we analysed themes, wording and format of items of the MITS and the actions and thought processes of the assessors (including scoring) according to the Unified Model of Validity.Burt et al.  noticed Another strength of the MITS is that the rating is not constricted to a certain part of the consultation; as the assessors did not know when the change topic would be discussed, they watched the whole consultations. This generated important information. GPs frequently behaved differently when they consciously applied MI. For instance, they supported patients’ autonomy in only that part of the consultation when they where talking about “lifestyle change” but not in other parts where it could have been done as well. In the MITS, these inconsistencies can be reflected in the ratings. There are probably several reasons for the fact that GPs did not integrate the MI-skills in parts of the consultations where they could have been used as well. Often, GPs learn MI during educational programs and from guidelines or books that address smoking cessation. As a result, they might be less focused on the use of MI in other contexts. They also might find it difficult to use MI in other situations or they just don’t know the broad range of health behaviour in which MI can be used. The fact that most consultations in this study were also on smoking cigarettes might support this assumption.The targets of the MITS consist of a variety of descriptors; summaries, definitions, and elaborations Fig. . Some ofThe authors chose to restrict the targets to observable MI behaviour. However, we added ‘missed opportunities’, ‘wrongly unused’ behaviour and ‘MI-inconsistency’ to the score options as the assessors felt that they otherwise could not assess the quality of MI in a proper way. The addition of ‘MI-inconsistency’ is in line with earlier research findings , 9 that Although the MITS covers the core aspects of MI, in the GP setting we would recommend to add ‘discussion of the follow-up’ to target 9. Examples include: asking permission to discuss the behaviour change in the future, refer the patient to another care provider or discussion of the implementation of the intended steps.Several aspects possibly reduced the diversity of the consultations. First, although MI can be used for all kinds of behavioural change most consultations were about smoking cessation: in seven out of nine consultations this was the case. Although this could have affected the range of skills used during the consultations in general, we do not think that this applies to the MI-skills. Moreover, the MITS is a global intrument and the targets are suitable to measure MI for all kinds of health behaviour.Second, even though we emphasized that any consult addressing behavioural change could be handed in by the participants, irrespective of the quality of MI performed, it might have been that participants were inclined to hand in their ‘best consultation’. If this were the case, this would have reduced the range of MI-proficiency. Third, all data were derived from one institute, which might also have been at the expense of the diversity. However, despite these possible restrictions with respect to the diversity of the consultations being assessed, the data showed that for almost all targets all answering options were being used.An additional limitation is that we changed the procedure and assessed every consultation instead of giving our impression of all consultations at once. This may have been at the expense of the holistic impression but matches the way in which communication assessment tools are used in GP-training and facilitates giving feedback to trainees.The MITS is a carefully constructed instrument representing the broad spectrum and current understanding of MI and its global nature is in line with the view on how to assess complex communication skills in brief consultations, in which providers have only short time to apply MI. With some adjustments, the MITS seems a valuable tool to assess the quality of MI in general practice.Now that we found evidence for content and response process validity, further research should focus on the other sources mentioned in the Unified Model of Validity, namely: ‘internal structure evidence’ (reliability and factor structure), ‘relations to other variables’ (correlation with other instruments) and evaluation of intended and unintended ‘consequences’ of assessment with the MITS.


Introduction: Gilles de la Tourette Syndrome (GTS) is a childhood-onset hyperkinetic movement disorder defined by the chronic presence of multiple motor tics and at least one vocal tic and often complicated by co-morbid behavioural problems. The pharmacological treatment of GTS focuses on the modulation of monoaminergic pathways within the cortico-striato-thalamo-cortical circuitry. This paper aims to evaluate the efficacy and safety profiles of pharmacological agents used in the treatment of tics in patients with GTS, in order to provide clinicians with an evidence-based rationale for the pharmacological treatment in GTS.Method: In order to ascertain the best level of evidence, we conducted a systematic literature review to identify double-blind randomised controlled trials of medications in GTS populations.Results: We identified a large number of pharmacological agents as potentially effective in improving tic symptoms. The alpha-2 agonist Clonidine is amongst the agents with the most favourable efficacy-versus-adverse events ratio, especially in patients with co-morbid attention-deficit hyperactivity disorder, although effect sizes vary evidence-based studies.Discussion: Our results are in line with the findings of uncontrolled open-label studies. However, most trials have low statistical power due to the small sample sizes, and newer agents, such as Aripiprazole, have not been formally tested in double-blind randomised controlled trials. Further research should focus on better outcome measures, including Quality of Life instruments.


It should benoted, however, that adherence to them varies widely, and that some doctors haveconcerns that these instruments characterize a rigid or simplified practice of medicine.Therefore, the appropriate implementation of health care guidelines is of great interestto national organizations, professional societies, health care providers, policy makers,legal field of medicine, patients and the public. Given the importance of the theme,several tools have been developed to assess the credibility of existingguidelines,3 However, there was a lack of discernment regarding threeimportant concepts4 in the intention ofthe departments that integrate the SBC to carry out guidelines: a) "Guideline" - a termthat should be reserved for the document that formally summarizes the evidences in theareas of diagnosis and therapeutics of pathologies; b) "Communication" (or"Standardization") shall be used for manuscripts reporting the laboratory methodologyand definitions of clinical outcome and, c) "Clinical Guidance" (or "Positioning") -which should be used for official printouts that provide expert advice on challenges inpatient management.Since 1992, the Brazilian Society of Cardiology (SBC) has systematically publishedguidelines on the most relevant themes of the specialty.It is imperative that the documents issued by SBC should be presented with adequatetitration and background to avoid confusing the reader in the differentiation of termsand, consequently, disinterest in reading them. Therefore, the main objective of thispublication is to establish in a simplified and objective way, the meaning of theseterminologies, aiming to standardize the issuance of Guidelines, Communications andGuidances by SBC.These documents aim to address a particular topic  of recognized clinical interest, for which there are no (or unlikely toexist) evidence of substantial quality or, especially, those from randomizedclinical trials. These documents are complementary to the guidelines and areprepared by a team of professionals with established experience in the subject.5 In general, theguidelines contained in these documents are anchored in the best evidence available;however, often incorporate the personal opinion of specialists.As an example, we could cite the use of direct anticoagulants in pregnantpatients.6 Unlike a guidance document, a guideline addresses a topic wherethere is evidence of moderate to high quality, usually from randomized trials with asatisfactory number of members, to convey the most appropriate clinicalpractices.Clinical guideline consists of systematically developed assertions to assist healthprofessionals and patients in making decisions about the most appropriate form ofhealth care under specific conditions.2In its elaboration, a process is used to summarize the evidences  and to provide a standardized method to express the degrees ofrecommendations with their respective levels of evidences. To produce a guideline,it is recommended that a rigorous checklist of 146 items be followed.Therefore, these documents rarely address medical practice where evidence is scarce.They are designed to support decision-making processes in patient care; its contentis based on a systematic review of clinical evidence.7Therefore, it is a useful tool available to SBC departments.These devices differ from those listed above since they address topics primarilyfocused on the standardization of clinical, laboratory and research methodologies.As an example, we could cite the Subcommittee on Anticoagulation Control of theInternational Society of Thrombosis and Hemostasis to measure the anticoagulantactivity of factor Xa inhibitors.The movement toward evidence-based health care has been rising rapidly in recentyears, motivated by clinicians, policymakers and managers concerned about thequality, consistency, and cost of health care.Thus, the above-mentioned documents, based on standardized best practices, providedthey are written in a practical and objective manner, may be able to promoteimprovements in the quality and consistency of health care.


There are few examples of sustained nationally organised, evidence-informed clinical guidelines development processes in Sub-Saharan Africa. We describe the evolution of efforts from 2005 to 2015 to support evidence-informed decision making to guide admission hospital care practices in Kenya. The approach to conduct reviews, present evidence, and structure and promote transparency of consensus-based procedures for making recommendations improved over four distinct rounds of policy making. Efforts to engage important voices extended from government and academia initially to include multiple professional associations, regulators and practitioners. More than 100 people have been engaged in the decision-making process; an increasing number outside the research team has contributed to the conduct of systematic reviews, and 31 clinical policy recommendations has been developed. Recommendations were incorporated into clinical guideline booklets that have been widely disseminated with a popular knowledge and skills training course. Both helped translate evidence into practice. We contend that these efforts have helped improve the use of evidence to inform policy. The systematic reviews, Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches and evidence to decision-making process are well understood by clinicians, and the process has helped create a broad community engaged in evidence translation together with a social or professional norm to use evidence in paediatric care in Kenya. Specific sustained efforts should be made to support capacity and evidence-based decision making in other African settings and clinical disciplines. Evaluations of district hospital  level care for children and newborns conducted by WHO in multiple countriesIn Pocketbook of Hospital Care for Children,In 2005 the Cochrane Collaboration and the UK’s National Institute for Health and Care Excellence had been established for only 13 and 6 years, respectively, and the WHO had no specific procedures to incorporate research into the guideline development process Initial reviews eg, refs  were useWith increasing use of the guidelines and based on feedback from an emerging group of ETAT+ instructors, demand for their revision grew. The first revision was undertaken in 2010 . This inEfforts to revise guidelines in 2013 were prompted by publication in late 2011 of a large East African trial, with results that contradicted prevailing thinking on fluid management of very sick children.The process of translating this evidence into policy changed considerably in 2013 . Three tThe model for guideline development in 2013 was used again in 2015. For childhood pneumonia uncertainty in the global evidence examined in 2010Initial efforts in 2005 at review of evidence and its translation to policy through discussion and building consensus  had limitations by the standards emerging at the time.Technical and procedural improvements were made over time . These iIn 2010 specific efforts were made to evaluate preferences for or effects of different forms of presenting evidence from systematic reviews.Limitations remain however. Currently mechanisms for patient engagement in the policy process and data on costs and formal cost-effectiveness analyses are largely absent in many LICs. We suspect, as in Kenya, that there is often no structured process for identifying local priority topics in LIC. Often (and appropriately) global issues may drive the process or as in Kenya it may be somewhat reactive, drawing on informal communication from policy makers, the agenda of technical partners or researchers. Despite these limitations the model that has evolved in Kenya uses internationally defined good practice, to the extent that is feasible, and is probably one of the most structured and participatory approaches to national guideline development in a LIC in Sub-Saharan Africa. The process has provided the platform for a complete cycle of decision making spanning a request for better evidence,It is not enough to make even well-informed decisions. These must be linked to a clear plan for disseminating guidance and ideally ensuring such new guidance can rapidly reach those providing and receiving health worker training.Box 1A credible guideline process will probably require at least two or three individuals who are familiar with the technical process of systematic review and use of the GRADE approach. This small team can help present and explain the evidence to a guideline panel so it is formally and critically discussed (a process that in itself builds ownership). Ideally one person should have more specific training in clinical epidemiology. Joining a team undertaking a formal Cochrane review, taking short courses in review methodology, and building links with the growing international community involved in evidence synthesis and evidence-informed decision making can provide a useful training for this small team while helping link them to a wider community of practice.Beginning with a set of specific target conditions and an identified guidelines user group may help focus efforts. We tackled care for common, acute conditions aiming to define first-line treatment strategies. Doing this we were able to build on existing international efforts to improve ‘case management’. By targeting most junior providers, we were not attempting to replace expert opinion which may have resulted in resistance to guidance, but to standardise practice in those with little training. An initial country effort might only tackle one or two pressing guideline questions as a demonstration of the process and its value.Identifying topics for guideline development where concerns already exist about routine practice and outcomes, where there is uncertainty about the value of a new technology or treatment, or where new research findings raise questions about existing practice may help create demand for consensus in the professional community and provide opportunities for initiating a guideline development process.Engaging appropriate stakeholders is clearly important from the start. Those involved in the decision making should have the authority and credibility to support any guideline’s claims to be a national  recommendation. Government, professional associations, academic institutions and potentially regulatory bodies may thus need to be involved. At the same time it is important to engage those involved in frontline practice. A guideline panel of 16–20 seems adequate to span all these groups. They must be given a real opportunity to discuss the evidence and reach consensus. By providing well-written reading materials and with skilled facilitation, 1 day seems sufficient to discuss a single topic in detail even when panellists themselves have little experience in evidence appraisal and use.Possible lessons for other LIC embarking on this journey are summarised in In conclusion, our report contributes to a relatively small literature exploring the process of national guideline development in LIC.


Overall Abstract: The superiority of clozapine for treatment refractory schizophrenia was, until very recently, seen as one of the few unshakeable truths in psychiatry. But the pre-eminence of clozapine has recently been called into question by meta-analyses. What are we to make of the fact that meta-analyses of clinical trials, supposedly the pinnacle of evidence based medicine, fail to show an effect which seems clearly evident to most clinicians, and on which many of our guidelines are based? Have we believed in a fairytale for the past three decades? Or do biases in RCTs and methodological limitations of meta-analyses explain the results? These questions will be discussed by Dan Siskind.Another way to address the question of efficacy is to examine the pharmaco-epidemiological evidence using population-based registers. Jari Tiihonen will present data from his seminal studies of mortality and readmission rates under clozapine treatment versus other antipsychotics, as well as other data. These data seem to show powerful positive effects of clozapine at the population level. Furthermore, more recent evidence suggests a role for clozapine in reducing rates of violent offending, with new data presented for the first time by Vishal Bhavsar.Finally, despite clinical guidelines recommending the use of clozapine, the actual rates of clozapine use are much lower than expected, with large regional and international variations. There is evidence that the burden of blood monitoring deters physicians from prescribing clozapine. Yvonne van der Zalm will present new data from a cluster randomised trial testing the efficacy and safety of an intervention to increase rates of clozapine prescribing by employing nurse practitioners trained in the initiation and monitoring of clozapine.John Kane, author of the first, seminal RCT of clozapine in 1988, will lead the discussion.


The uptake and use of clinical guidelines is often insufficient to change clinical behaviour and reduce variation in practice. As a consequence of diverse organisational contexts, the simple provision of guidelines cannot ensure fidelity or guarantee their use when making decisions. Implementation research in surgery has focused on understanding what evidence exists for clinical practice decisions but limits understanding to the technical, educational and accessibility issues. This research aims to identify where, when and how evidence and knowledge are used in orthopaedic decision-making and how variation in these factors contributes to different approaches to implementation of clinical guidance in practice.We used in-depth case studies to examine guideline implementation in real-life surgical practice. We conducted comparative case studies in three English National Health Service hospitals over a 12-month period. Each in-depth case study consisted of a mix of qualitative methods including interviews, observations and document analysis. Data included field notes from observations of day-to-day practice, 64 interviews with NHS surgeons and staff and the collection of 121 supplementary documents.Case studies identified 17 sources of knowledge and evidence which influenced clinical decisions in elective orthopaedic surgery. A comparative analysis across cases revealed that each hospital had distinct approaches to decision-making. Decision-making is described as occurring as a result of how 17 types of knowledge and evidence were privileged and of how they interacted and changed in context. Guideline implementation was contingent and mediated through four distinct contextual levels. Implementation could be assessed for individual surgeons, groups of surgeons or the organisation as a whole, but it could also differ between these levels. Differences in how evidence and knowledge were used contributed to variations in practice from guidelines.A range of complex and competing sources of evidence and knowledge exists which influence the working practices of healthcare professionals. The dynamic selection, combination and use of each type of knowledge and evidence influence the implementation and use of clinical guidance in practice. Clinical guidelines are a fundamental part of practice, but represent only one type of evidence influencing clinical decisions. In the orthopaedic speciality, other distinct sources of evidence and knowledge are selected and used which impact on how guidelines are implemented. New approaches to guideline implementation need to appreciate and incorporate this diverse range of knowledge and evidence which influences clinical decisions and to take account of the changing contexts in which decisions are made.The online version of this article (10.1186/s13012-018-0771-4) contains supplementary material, which is available to authorized users. Across the world, policymaking organisations exist to produce clinical guidance and recommendations for healthcare, which are based on scientific evidence. In the UK, these organisations are the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) , 2. TogeIn 2014, a review of systematic reviews explored factors which influence guideline implementation and uptake . The finThere is a need for empirical research which examines a wide range of contextual characteristics influencing the uptake and use of clinical guidelines. This includes the professional and environmental factors which have been described previously, but also requires a description of the local practice context and wider healthcare sector in sufficient detail to facilitate more effective guideline implementation. Therefore, the aim of this research was to identify where, when and how evidence and knowledge are used in healthcare decision-making and how variation in these factors contributes to different approaches to implementation of clinical guidance in practice.Achieving effective guideline implementation reflects not only the people involved, but also their professional roles, their positions in the organisation and the epistemic communities to which they belong , 11. ProPreserving clinical autonomy and medical judgement by these professional groups is also recognised as important, particularly when guidelines challenge traditional practices , 14. In A mixed methods systematic review has identified various sources of evidence and knowledge which influence decision-making within orthopaedic surgery . The finEnhanced implementation of guidelines is an unexplored area of research in the highly professionalised, intensely networked group that is orthopaedic surgery. This study provides an in-depth understanding of decision-making using clinical guidance. It generates a unique perspective on the challenges of translating research into clinical practice and moves away from the approach of assessing compliance or auditing guideline uptake. A key part of understanding complex problems, such as where, when and how evidence and knowledge are used in practice, requires examining the values, beliefs and norms of individuals who are responsible for making decisions in context. This complements a broader investigation of an organisation’s capacity to support clinical guideline implementation and of other contextual factors within the healthcare sector which influence the use of knowledge and evidence in practice.We examined the implementation of an example of NICE guidance within orthopaedic surgery, to identify similarities and differences in the way this type of evidence is used in practice. In 2014, NICE released updated guidance on hip implants for total hip replacement for end-stage arthritis  who conducted or facilitated joint replacement surgery, i.e., we sampled purposively aiming for heterogeneity of professional background, level of training and years in practice. Snowball sampling enabled us to follow direct recommendations from participants. We aimed to explore guideline implementation from all perspectives, so we also invited administrators and managers involved in guideline implementation and in the decisions made for patients undergoing hip replacement surgery.We selected a combination of qualitative methods including document analysis, observation and interviews. One author (AG) was responsible for all data collection in each of the cases. Data collection remained systematic and transparent, and decisions were recorded in case summaries. We continued data collection until no new information was obtained and theoretical saturation within each case was reached . Within Document analysis involved collection of key organisational documents such as clinical pathways describing structured multidisciplinary plan of care and hospital protocols . It could equally be any other type of evidence or knowledge, interacting with, for example, a surgeon’s training and formal education (micro) or the contingencies of practice such as the structure of the hospital (meso).Comparison across cases was essential to look beyond the initial impressions and see the findings through multiple lenses. We framed our cases according to their general approach to decision-making and how guidelines were implemented in each hospital. The differences in decision-making contributed to variation from the codified evidence contained in guidelines across all three cases. The analysis revealed that the individuals, groups and organisations in each case had a distinct approach to decision-making. The approach was dependent on how the 17 types of knowledge and evidence interacted, changed and were used in orthopaedic practice. Guideline implementation was contingent and mediated through the distinct contextual environments, which were subject to forces of the regulatory environment.formal codified knowledge contained in clinical guidelines and what guidelines set out to achieve in the healthcare sector. The surgeons working in case A took a population perspective on clinical decisions. The culture, norms and political influence of the sector acted on case A in a positive fashion, as surgeons working here valued the processes and aims of generating clinical guidelines and the goals of NICE as an organisation. Surgeons were accustomed to answering questions using a larger population frame of reference and suggested that they “may subconsciously be following NICE guidance” (Junior surgeon) as it was indoctrinated in the organisational knowledge and processes. One surgeon states that “NICE guidelines help you look at cost effectiveness and evidence a lot more than you would think about in normal daily practice as an individual orthopaedic surgeon” (Consultant surgeon).Case A was an academic centre located within a trauma and orthopaedic department. More than the other two cases, case A appeared to have a positive view of the managerial knowledge. This was reflected in case A’s extensive protocol documentation compared to the other two cases (17 versus 4 and 2). Each protocol was linked to a piece of clinical guidance or an internal evidence summary which had been produced by medical librarians. The implementation process was described by the Chair of the Guideline Committee:We started monitoring NICE implementation in the trust in 2011/12 when we set up the NICE implementation group…when NICE issues their guidance, I forward a list to the NICE administrator who would send it out to lead clinician in orthopaedics…If it’s a clinical guideline, or quality standard…there’s recommendations in there, and a form of a baseline assessment with the recommendations in…they (the clinician) have to indicate if we’re compliant or not. (Hybrid surgeon)Case A had the most advanced and formalised guideline implementation processes i.e., their individual surgeon factors). We consider that this was due to their departmental focus on research (apprenticeship style training) and academic output developed through training and formal education in Evidence Based Medicine (EBM), and beliefs regarding the importance of NICE and the EBM approach. A quote from a surgeon illustrates this:“We do try as much as possible to follow the basis of evidence...So the typical patients would be where we would need to use evidence. There is not much of a dilemma about someone with end stage osteoarthritis as the guidance shows the pathway that they should take.” (Consultant surgeon)The surgeons in case A demonstrated a distinctly different trend in their confidence and appreciation of clinical guidance  and thresholds established by the Orthopaedic Device Evaluation Panel in the UK (macro).The distinct approach to decision-making in case A was ‘pragmatic EBM decision-making’, where the traditional approach to evidence-based decision-making recommended in clinical guidelines was suitable, but not sufficient for their practice. Surgeons in case A acknowledge traditional EBM and focused on pragmatic EBM. This practice-based approach to EBM considered the important point that knowing what to do, how to do it, and the likely outcome of an orthopaedic intervention described in NICE guidelines were only part of the knowledge picture which had to fit into the ever changing context of practice. However, the structure and location of the hospital. The binary characteristics reflect the two distinct hospital locations in case B. By name, the hospitals were one Trust; however, the day-to-day operations and decision-making practices were separated and distinct. Each hospital location in case B had their own way of doing things  and staff acted protectively to maintain them. The ‘it depends approach’ signifies the participants views that what happened in practice depended on which of the two case B hospital sites they were located at when the decision was made.Case B was a small hospital Trust split between two geographical sites. Case B demonstrated an ‘“it depends” approach to decision-making produced by the binary characteristics of the Trust’; this was bought about by external evidence created by regulators was not regarded as important. Formal codified evidence in NICE guidelines was not valued by the clinical staff. Guidelines were often considered in a negative light and considered to be the responsibility of hospital administrators and managers . Described by a hospital board member below:“I think NICE guidance is very much just seen as another layer of administration for clinicians. If no one’s looking at whether you’re following NICE guidance or not they just sit on a shelf, unless you have a very active team of clinicians who take this on board. But that’s not a consistent.” In case B, socialisation and association with colleagues when making clinical decisions:“NICE are not being proactive enough, I would say, in terms of making recommendations on prostheses and they could do a lot more. There is very little sort of robust evidence to guide practice so you rely on other peoples’ anecdotal experience and normal practice to help guide what, what works and what doesn’t” (Consultant surgeon)The negative value attached to NICE and guidelines was echoed by the surgeon in the quote below, in which they demonstrate the importance of evidence of external regulation did not appear to be valued and hence implementation was haphazard, as described by a hospital administrator:I send (guidance) out to the General Manager and then they will send it to the most appropriate person. We used to meet to discuss if we were compliant…but now we send a questionnaire out…so they have to do is tick ‘Yes’ and ‘No’ but they do not always respond. (Administrator)Within the organisational processes, guidelines were not considered an important part of practice in case B. Compliance to NICE guidelines as professional hierarchy in the two orthopaedic departments within the Trust. The individual surgeon factors and the differing characteristics and processes of the two groups of surgeons headed up by opinion leaders meant that guideline implementation across the organisation was difficult. The distinct groups struggled to work together and share organisational knowledge because the specific contexts that clinicians were socialised into differed. For example, evidence from implant manufactures carried greater weight in one location compared to the other. The socialisation and association with colleagues reflected the behaviour and norms that guided or regulated the action and decision-making of individuals at case B.What mattered for implementation in case B was the dynamics of organisational change and leadership enacted through evidence from the managerial knowledge emerging from elsewhere in the Trust. They were also resistant to pressure from external policymakers and evidence from regulators. This divide across professional boundaries compounded by the professional hierarchy and cultural norms of the sector made guideline implementation challenging. Nevertheless, knowledge and evidence generated through managerial and organisational knowledge was present in the wider hospital organisation:Finally, case C was an orthopaedic department located in a teaching hospital. In case C, ‘socialised decision-making was prominent and evidence was discretionary’. The orthopaedic department in case C was closed to the influence of administrators and We have standard operating procedures for NICE, which encourage [surgeons] to write their own action plan (Trauma & Orthopaedic Manager)managerial and organisational knowledge enacted through processes attached to NICE guidelines and governance belonged in the managerial and administrative domain, not within surgical staff. Surgeons reported having “never seen” the organisation’s NICE process (Consultant surgeon). This is reflected in the observation note below:NICE was rarely noted as an influential factor in the day-to-day activities of surgeons. Surgeons I spoke to were unaware their hospital had a NICE process, they would respond “do we have one?” “I’ve never seen it”. (Observation note)However, observations of practice revealed that socialisation and association with colleagues. Surgeons possessed resilient experiential knowledge built up over time as the majority had been working in this hospital for their entire careers and were relatively separate from ‘outside’ knowledge. Formal codified evidence in clinical guidelines had to compete with the complex social systems that existed in the hospital. For example, case C was a referral centre which specialised in performing complex hip replacement revision surgery. In this context, clinical guidelines appeared to be less important because the approaches, techniques and implants needed to perform hip revisions were specialist (the innate feel of surgery) and therefore not included in guideline recommendations. One surgeon noted “NICE, is irrelevant. They don’t tell me anything I NEED to know” (Consultant surgeon). The specialist surgeons working in case C referred to a standard hip replacement operation as “boring” and, hence the work of other surgeons “on the treadmill” who are outside of their community or social system (Consultant surgeon). In this sense, guidelines were not valued or applicable to their specialist work. The informal experimental knowledge and informal experiential evidence built up over time appeared to take precedence in clinical decision-making processes and therefore restricted guideline implementation of guidelines for this group of surgeons. These dominate types of knowledge and evidence were grounded in the experience of surgical work in practice and legacy knowledge about the organisational functions which surgeons developed as a consequence of working there for a long period of time.Clinical practice decisions were made using knowledge and evidence gained through In orthopaedic surgery, clinical guidelines are an important part of practice as they not only help guarantee safety and encourage quality improvement but also ensure that NHS resources are used appropriately . The aimIn fulfilling our aim, we discovered 17 different types of knowledge and evidence which were used in orthopaedic surgery. During our case comparison, it became clear that the dynamic selection, combination and use of each type of knowledge and evidence influenced the implementation and use of clinical guidance in practice. At the time of study, none of the cases could definitively provide evidence to demonstrate that they were accessing, using and monitoring guideline recommendations. We examined implementation of guidelines by individual surgeons, groups of surgeons and the Trusts as a whole. Interestingly, implementation could differ between these levels.In the context of orthopaedic surgery, the process of privileging different types of knowledge and evidence in the context of surgery resulted in three distinct approaches to decision-making in orthopaedic surgery. These include ‘pragmatic EBM decision-making’ (case A), where NICE guidelines failed to deliver all the knowledge and evidence needed to make clinical decisions when organisational context restricted surgeon choice. An ‘“it depends” approach produced by the binary characteristics’ of case B linked to the professional hierarchy of surgeons working in separate geographical locations and ‘socialised decision-making’ where evidence was discretionary due to the strong influence of socialisation and informal knowledge sharing between surgeons in case C.formal codified evidence because it originated outside of orthopaedics and did not contain the micro sources of knowledge and evidence  that were considered more important for surgeons’ decision-making. However, the culture and norms of EBM, identified in case A, demonstrate that it was possible to positively influence guideline implementation. Consideration of the power of professional hierarchies is vital, as surgeons working at the top of the hierarchy, such as clinical leaders can restrict or diminish the influence of mangers and policymakers. Organisational constraints linked to financial restrictions, regulation and procurement-influenced implementation and a lack of focus on clinical guidelines in orthopaedic practice. The presence of organisational processes and protocols could not ensure what guidelines were valued and used. What was more important is what evidence and knowledge transferred from surgical colleagues and professional societies.The similarities and differences between the three approaches generate key contextual dimensions specific to guideline implementation in orthopaedic surgery. These reflect the relationship between guideline implementation and knowledge and evidence that is actually used in orthopaedic practice. Orthopaedic surgeons in our study held ambivalent or negative attitudes towards clinical guidelines. They did not privilege this It is likely that many of the 17 types of knowledge and evidence identified in this research would not have been discovered without the structured, comparative case study approach used in our study. One of the aims of our research was to go beyond reports in the previous guideline implementation literature –9, 37. IWe have demonstrated that guideline implementation and subsequent evidence-based practice were not always possible or preferable in the three cases. Comparative case study analysis revealed dynamic contextual differences and variation in practices and processes between the three hospitals. For example, some surgeons had strict limits placed on the orthopaedic implants they could order within their hospital. This restricted their implant decisions. However, this varied across the cases and differences were found in implant selection practices and processes. This variation had a direct impact on the uptake and use of evidence in practice and demonstrates the problems of effectively implementing standardised guidance in surgery. One of the aims of clinical guidance is to reduce unjustified variation in practice, but we found that this was not achievable or appropriate in all contexts.Our findings encourage more research into how to engage individuals and groups of healthcare professionals to consider the content of clinical guidelines and how it might add to their decision-making processes. The overarching view that guidelines are the responsibility of managers and administrators demonstrates a lack of ownership of the guideline in general in orthopaedics. Also, in the context of orthopaedics, our findings provide insight into approaches to knowledge mobilisation targeted at communities of practice as an area for investigation and improvement. Improvements in the uptake and use of NICE guidance in orthopaedic practice will require the development, presentation and dissemination of evidence-based guidelines in surgery to be better tailored to the orthopaedic community.. The way in which evidence and knowledge interacted with context produced variation in the extent to which guidelines are implemented and used in orthopaedics.The key strength of our research is the use of case studies to examine the context of guideline implementation. In achieving our aim, we were able to discover and explain the gap in implementation of clinical guidelines in orthopaedics. Uptake and use of guidelines, even when grounded on the findings of empirical research including gold standard randomised controlled trials, were not guaranteed in practice. This suggests that well-developed guidelines are necessary but not sufficient to achieve the goals of policymaking organisations such as NICE and Scottish Intercollegiate Guidelines Network (SIGN). Case study methods allowed us to describe the decision-making context in detail. This method has provided a greater depth of description of the evidence and knowledge sources than have been outlined in previous literature, for example, expanding the tacit-explicit-group-individual categorisationsA second strength of our research is the use of multiple data sources  to study the same phenomena. The combination of methods facilitated us to overcome the weaknesses that emanate from selecting a single method to study the complex process and practice of guideline implementation . We triaOur study has limitations. The direct observation of healthcare professionals in their practice may have driven a change to ‘good’ or ‘better’ behaviour by participants; a phenomenon known as observer bias . To ensuOver the last 20 years, there have been significant changes in the way policy-making organisations such as NICE create and disseminate guidance to improve health and social care. What appears to have remained constant is the way in which codified knowledge in guidance is produced with an assumption that a linear ‘push’ fashion will ensure that it is received and acted on by clinicians working in healthcare organisations. The findings of our study reconfirm and extend our knowledge of the limits of this approach for improving the use of guidance and for reducing variation in practice for orthopaedics.In this study, we have raised the issue of whether NICE guidelines are ever likely to be appropriate for the field of orthopaedics. This is due to the wide range of knowledge and evidence identified as influential to decision-making, coupled with the differences in guideline implementation across the structural levels. However, we do not consider that the evidence contained in guidelines is inappropriate. Instead, the ways in which knowledge and evidence were privileged differently by individual practitioners, groups of surgeons and organisations meant that guidelines were rarely accessed as a beneficial evidence source. Surgeons were not concerned about what guidelines recommended. What was important was their definition of knowledge and evidence and how this interacted with understandings of knowledge and evidence in their group and wider organisation. In this study, ‘one size’ guidance could never ‘fit all’ the surgeons’ requirements and therefore, the guidance had limited value in their specific circumstances.Nevertheless, evidence in guidelines represents best practice, and NICE and SIGN must produce recommendations for healthcare. We have provided evidence to suggest that the current modes of transfer and implementation are ineffective. Changes could be made to the process of guideline creation, dissemination or even regulation to move towards effective knowledge mobilisation. For example, a more inclusive process of involving clinicians in guideline development would be welcomed. The current system relies on clinicians being aware of guideline updates, rather than being enabled to actively volunteer their contributions. Targeting the orthopaedic community through professional meetings, networks and clinical leaders would communicate the need for involvement and increase discussion about new guidelines in contrast to the current process of one-way dissemination by policymakers.Regulation was a valuable mechanism as it achieved a desired outcome for achieving targets and controlling the behaviour of the surgeons. However, moving towards regulation as the norm did not appear to be a desirable option for most of the professional groups in this study. Knowledge and evidence from external regulators did not hold the same positive status achieved by the knowledge and evidence emanating from colleague and professional networks. Restricting the discretion and authority of clinical professionals by increasing regulatory power would not be recommended. Instead, interventions which take advantage of the positive knowledge mobilisation between orthopaedic colleagues are encouraged, as they may improve the sharing of evidence-based practice.Improvements need to be made to how healthcare professionals working in hospitals see and think about evidence from guidelines in combination with other knowledge and evidence sources. Improvement interventions are required to help users of guidance identify ‘where they are at’ in their decision-making processes. Clinical guidelines were often unable to provide a solution to a decision problem; therefore, it is important to understand what other types of evidence and knowledge are available or used by others. Practitioners need to acknowledge the difference between certain types of knowledge as positive or negative to patient care. Where possible, those working in healthcare should focus on reducing undesirable types of evidence and knowledge present in their organisation. This could be an area for improvement work. However, surgeons in this study were often unaware of or ambivalent about the consequence of their decisions because processes were not open, transparent or subject to feedback loops.Healthcare practitioners could take a more transparent approach in understanding the evidence that is driving their decisions and how guidelines may fit into the picture. This will facilitate practitioners in deciding whether guideline recommendations are appropriate in their context. If not, other knowledge sources such as clinical experience could take precedence and be shared, explained and understood, rather than frowned upon by managers and administrators and recorded as an organisational risk. Practice-based knowledge was rarely shared between the professional groups in this study. Encouraging open decision-making processes might enable those on all sides of knowledge boundaries to understand and accept why certain options are chosen and actions are taken, especially if they vary from guideline recommendations.The research aimed to explore guideline implementation through the application of comparative case studies which investigate the use of NICE clinical guidelines in decisions made in elective orthopaedic surgery in the NHS. The results of our study highlight the range of complex and competing sources of evidence and knowledge which influence the work practices of healthcare professionals. Case study analysis revealed three distinct styles of orthopaedic practice which represent the ways in which 17 types of knowledge and evidence were used during decision-making. The way in which evidence and knowledge were selected and used impacted on how guidelines were implemented in the orthopaedic speciality. Findings from the case comparison reflect the complexity of evidence-based decision-making in the highly professionalised organisationally regulated context of surgery. Our results could be used to guide the development of implementation interventions that are grounded in the findings of this study. New approaches to implementation need to appreciate and incorporate the diverse range of knowledge and evidence which influences clinical decisions in orthopaedics and to take account of the changing contextual situations in which decisions need to be made.Additional file 1:An example of a NICE guidance recommendation. Technology appraisal guidance [TA304] . Total h