Management of patients with severe traumatic brain injury (sTBI) is highly variable and inconsistently aligned with evidence derived from high-quality trials, including those examining intravenous fluid resuscitation and use of decompressive craniectomy surgery. This study explored the barriers and facilitators of general and specific evidence-based practices in sTBI from the perspectives of stakeholder clinicians.This was a qualitative study of semistructured interviews conducted with specialist clinicians responsible for acute care of patients with sTBI. Interview analysis was guided by the Theoretical domains framework (TDF), and key themes were mapped to relevant TDF behavioral domains.Ten neurosurgeons, 12 intensive care specialists, and three trauma physicians from six high-income countries participated between May 2020 and May 2021. Key TDF domains were environmental context and resources, social influences, and beliefs about consequences. Evidence-aligned management of patients with sTBI is perceived to be facilitated by admission to academic research-oriented hospitals, development of local practice protocols, and interdisciplinary collaboration. Determinants of specific practices varied and included health policy change for fluid resuscitation and development of patient-centered goals for surgical decision-making.In choosing interventions for patients with sTBI, clinicians integrate local environmental, social, professional, and emotional influences with evidence and associated clinical practice guideline recommendations. This study highlights determinants of evidence-based practice that may inform implementation efforts and thereby improve outcomes for patients with sTBI.The online version contains supplementary material available at 10.1007/s12028-022-01551-x. Traumatic brain injury (TBI) is a global health problem: the worldwide annual incidence is 69 million, of which 5.48 million cases are severe TBI (sTBI) , 2. OutcA higher quality of clinical evidence has been associated with increased likelihood of implementation , 12. Of The determinants of evidence-adherent practice in acute sTBI, and of the above practice behaviors specifically, have not been explored from the perspective of treating clinicians. Such enquiry is important to identify factors that determine practice variability and is an essential precursor to developing active implementation strategies aimed at reducing evidence–practice gaps , 20. FurThis study aimed to identify factors that influence the adherence to evidence in the interdisciplinary acute management of patients with sTBI, with focus on choice of resuscitation fluids and decisions to perform surgery to treat intracranial hypertension, from the perspective of medical practitioners responsible for sTBI care.This was a qualitative study using in-depth semistructured interviews. Approval was obtained from the Monash University Human Research Ethics Committee (project number 23614). This report adheres to the Standards for Reporting Qualitative Research .The investigators were intensive care clinician researchers , with experience in the clinical management of TBI, and a knowledge translation researcher (PB). All investigators had research experience in international clinical studies in neurotrauma and critical care. Interview participants were hospital specialist clinicians responsible for the acute hospital care of patients with sTBI. During their stay in the ICU, clinical decisions regarding patients with sTBI are usually made by intensive care specialists and neurosurgeons, with input from trauma specialists. Therefore, clinicians from these disciplines were identified using purposive sampling from the professional networks of the investigators. Geography and academic affiliation may influence uptake of evidence; we aimed to recruit clinicians from Australian and international hospitals with comprehensive neurotrauma services.Consistent with a qualitative research paradigm, sample size was not predetermined. Sampling continued until no new qualitative themes emerged from three consecutive interviews .Participants received an invitation and explanatory statement by email and were asked if they were willing to participate in an interview lasting 30 to 45 min. Agreement to participate and acknowledgment of the explanatory statement implied consent. Single one-on-one interviews were conducted by the lead author (DG) via videoconference  with all but two participants, who requested in-person interviews. Interviews were recorded and transcribed verbatim using professional transcription services . Checked transcripts were imported into NVIVO 12  to manage data and facilitate analysis.Initial open interview questions explored clinicians’ perceptions of the general determinants of evidence-based practice in sTBI, with focused prompt questions to explore the contribution of CPGs and hospital protocols . Interview content then shifted to the two specific practices shown in randomized controlled trials to alter patient-centered outcomes: namely, fluid resuscitation and decompressive craniectomy for intracranial hypertension. Follow-up prompt questions explored the influence of key clinical trials pertaining to these interventions. The final area explored interdisciplinary dynamics and potential sources of bias between professional groups. The interview guide was developed by investigators with expertise in clinical content (DG and DJC) and qualitative and knowledge translation research (PB). Questions were piloted with two clinical staff, and the interview framework was updated.Consistent with previous published approaches , in thisUsing NVIVO®, one investigator (DG) performed open thematic coding and recoding of transcripts in an iterative back-and-forth process. Statements by different participants with similar or related underlying ideas (including statements expressing the opposite belief regarding influence of the same factor) were collected in thematic groups within relevant TDF domains. For example, statements regarding the influence on practice of hospital protocols would be grouped under a theme of ‘Local resources’ within the ‘Environmental context and resources’ domain (Supplementary Tables S1–S3). Emergent themes were subsequently tested for applicability, validity, and consistency. Themes coded to more than one domain were cross-indexed. After three interviews were coded, coding was reviewed with a second investigator (PB).A domain was considered salient if associated themes were identified consistently by participants or were deemed of high impact on clinical practice by researchers or participants, or if there was a combination of these features.Between April 2020 and May 2021, twenty-five medical specialists participated in semistructured interviews: ten neurosurgical specialists, 12 intensive care specialists, and three trauma specialists. Participants worked at eight different hospitals that receive and manage patients with sTBI in six high-income countries. All but one hospital had comprehensive neurosurgical services on-site. Participants were predominantly male (84%) and White (80%), of variable age (76% aged 36–55), and working in metropolitan areas (92%). Most were from Australia (76%), and half were from a single academic center (Table Each of the practice areas discussed had their own pattern of influencing factors (Supplementary Tables S1–S3). The following is a summary of findings. Illustrative quotations from the transcripts are shown in Table The key general factors thought to influence clinical practice in management of patients with sTBI were grouped within six theoretical domains (Supplementary Table S1).On the basis of reported experience and observations, participants from all disciplines stated that practice was more likely to be evidence aligned in academic university-affiliated hospitals than nonacademic hospitals. Hospital characteristics cited as facilitators included presence of subspecialized staff, established internal processes of interdisciplinary engagement and quality improvement and engagement with clinical trial networks.All clinicians perceived local institutional practice protocols to facilitate consistent evidence-based practice and in some cases, more so than widely disseminated CPGs, such as those produced by the BTF. Others cited the benefit of local protocols in providing pragmatic evidence-based guidance to nonspecialist bedside staff without requiring them to have in-depth knowledge of TBI literature.Clinicians of all disciplines noted that audit of practice to identify any evidence–practice gaps was an essential prerequisite to motivating improvement.Several clinicians felt strongly that local participation in clinical research was associated with implementation of evidence; they reasoned that the interventions tested at their institutions would be relevant to the local patient case-mix, championed by local investigators, and, therefore, readily adopted. Additionally, local research engagement reflects attention to contemporary evidence even beyond those interventions investigated in locally championed studies.Accreditation by specialist bodies and changes in government policy were highlighted as potent enablers of evidence-based practice. Participants in North America stated that linking accreditation of trauma hospitals with specific elements of the BTF guidelines had improved practice.Several intensive care clinicians noted that harmful medications and procedures may remain available despite recommendations against their use and that it should be relatively straightforward to make them less available.Social influences related to interprofessional relationships were highlighted by most participants as important determinants of practice. These were frequently cited in association with hospital and environmental characteristics.Many clinicians favorably cited collaborative, interdisciplinary activities  and management of critically ill patients with TBI as a potent enabler of evidence-aligned care, noting that different specialty groups brought different knowledge and skills. Several participants noted that such collaboration was dependent on a culture of positive, respectful engagement. Advocacy of key opinion leaders was also acknowledged as a driver of practice change and adoption of evidence.Multiple participants expressed nihilism about currently available treatments, stating that research has not improved outcomes for patients following TBI and that the best approach is to avoid causing additional harm with potentially dangerous or overly invasive interventions.Others cited anecdotes of satisfactory patient outcomes following non-evidence-aligned practice to justify such practice or highlight persistent knowledge gaps. Improvements in commonly used but short-term metrics, such as normalization of intracranial pressure or reduced length of stay in ICU, were also cited as possible perverse incentives for non-evidence-aligned therapies. To counter this, performance and audit metrics should align with patient-centered outcomes that include long-term functional recovery rather than short-term physiological markers or surrogate end points.Participants from all specialties opined that current practice, particularly neurosurgical practice, can be dogmatic and based on outdated evidence. Clinicians perceived themselves and others to be averse to change, particularly in situations in which new knowledge conflicted with established paradigms. Treatments were more likely to be adopted if they fitted an accepted model of TBI pathophysiology compared with treatments with mechanisms that were less understood but were nevertheless proven to change outcomes.The simplicity and ease of implementation of interventions tested in clinical trials was perceived to be associated with their rapid adoption, and vice versa. Clinicians noted that this could also be a barrier to evidence-based care, wherein ready availability of harmful treatments enables their inappropriate use. These observations overlapped with themes mapped to environmental context and resources.Neurosurgeons and ICU and trauma specialists perceived different but overlapping areas of responsibilities for patient care: neurosurgeons did not participate in early in-hospital resuscitation of patients, including fluid resuscitation, whereas ICU specialists perceived that intracranial procedures were exclusively the responsibility of neurosurgeons. All groups felt shared responsibility for overall quality of patient care.Several neurosurgeons and one ICU specialist observed that most neurosurgeons did not subspecialize in management of TBI, preferring to concentrate on other areas. However, neurosurgeons who delegated responsibility for patient management were perceived to be a potential barrier to evidence-aligned care.Nearly all participating clinicians reported and/or demonstrated knowledge of the pathophysiology of TBI sufficient to appreciate the rationale for different CPGs and usually referred, by name, to the BTF guidelines.However, these CPGs were not consistently held to be facilitators of optimal practice. Several clinicians perceived available CPGs to be inadequate to facilitate best practice, and many presented reasoned judgments for why they may be barriers to evidence-based practice.The underlying evidence was held to be insufficiently robust or poorly generalizable because of methodological concerns, therefore justifying alternative management. The variable pathophysiology and complexity of TBI was cited as an indication for personalized care on the basis of an individual patient’s characteristics rather than strict adherence to evidence-based guidelines. Some noted the delays between publication of the evidence and subsequent CPGs as a cause for persistent non-evidence-based practice. Finally, the BTF guidelines were held to be rigorously evidence focused at the expense of being nonpragmatic, for example, in not providing stepwise guidance on management of intracranial hypertension because of a lack of high-quality comparative data.Others held more favorable views on the CPGs as facilitators of evidence-based practice, citing their value in providing instructions for clinicians without in-depth knowledge of underlying science and clinical trial evidence. Additionally, guidelines were held to be a baseline standard against which actual practice could be audited and deviations interrogated.Following discussion of determinants of neurotrauma practice in general, interview questions focused on the two treatments shown to be potentially harmful: fluid resuscitation with albumin and surgical decompressive craniectomy.Key factors reported to influence the choice of intravenous resuscitation fluids following sTBI were grouped within the following theoretical domains (Supplementary Table S2).Restricting availability of potentially harmful fluids was seen as being the most effective mechanism of preventing their administration and rapidly improving practice. Such restriction was reported to have been achieved in some hospitals by charging a high price per unit and by a change to blood bank policies to require consent for administration of blood-derived products, including albumin. Reduced availability would reduce the risk of unknowing clinicians inadvertently prescribing albumin.With few exceptions, in response to open questions on determinants of intravenous fluid choice, participants of all disciplines cited the physiological impact of different intravenous fluid types rather than impacts on patient-centered end points of clinical trials, such as survival or functional recovery.Participants demonstrated or expressed awareness of evidence regarding the use of albumin that was in keeping with their scope of practice. In practice, neurosurgeons are not involved in fluid resuscitation of patients, and several acknowledged this was outside their knowledge base. Among ICU specialists, several worked in countries where albumin is not readily available, so they reasoned they had little motivation for exploring this evidence. However, some participants in countries where albumin is available were similarly unaware or noted that albumin was not used frequently but were uncertain why. There was greater awareness among intensive care clinicians with clinical research experience or academic appointments.Key factors thought to influence the practice of using decompressive craniectomy to reduce intracranial pressure were grouped within the following theoretical domains (Supplementary Table S3).Participants’ responses regarding decompressive craniectomy were commonly informed by synthesizing the results of key trials. Clinicians commonly inferred that decompressive craniectomy is an intervention of last resort, only considered after the full range of nonsurgical therapies have failed. Participants held that decompressive craniectomy improves intracranial pressure while acknowledging that it may also increase the number of severely disabled survivors. For this reason, it was felt that use of decompressive craniectomy should be reserved for those with the best chance of neurological rehabilitation: generally younger people and those without preceding functional impairments. Some clinicians emphasized reduction of intracranial pressure (a widely accepted surrogate marker of brain injury and treatment target) as the reason to perform decompressive craniectomy, irrespective of high-quality evidence showing harm.Cultural context was noted to be an important factor in deciding whether to perform life-sustaining surgeries with the expectation that the patient may survive with debilitating disability. Clinicians noted that within some ethnic or religious communities, human life is considered sacred in any condition, meaning there is a default to active intervention even in situations in which clinicians might consider the prognosis unfavorable.Despite being cognizant of the risk of poor outcomes, participants from all disciplines (particularly neurosurgeons) reported emotional pressure to perform decompressive craniectomy surgery when presented with a patient with refractory intracranial hypertension. This pressure was both external (from families or other clinicians) and internal (a human bias toward active intervention).With few exceptions, discussions with relatives or friends of the patient to determine their values were reported to be essential in deciding therapies. If a family expressed the view that a patient would not wish to survive with severe disability, this may prompt clinicians to advocate for less invasive  therapies. Some clinicians noted that families may struggle to incorporate the complexity and uncertainty of management and may advocate for decompressive craniectomy to be performed in the belief that the more invasive therapy is more likely to result in improved outcome.Given the complexity of decision-making, clinicians from all groups reiterated that collaborative interdisciplinary discussions at a senior level were essential to decide the most appropriate management for individual patients. Although decompressive craniectomy can only be performed by neurosurgeons, both they and ICU specialists perceived that they share responsibility for decisions regarding surgery. In some regions this has shifted over time such that greater responsibility now rests with the ICU. One academic neurosurgeon noted favorably that few patients have refractory intracranial hypertension if nonoperative therapies are used appropriately; therefore, decompressive craniectomy is rarely indicated and the evidence is rarely applicable.In this qualitative exploration of stakeholder clinicians’ perceptions of the acute management of sTBI, we found that in determining practice, evidence-based recommendations are integrated with local environmental, social, professional, and emotional influences. Our study builds on previous findings that adherence of neurocritical care practice to evidence is a function of factors related to institutions, clinicians, and the guidelines themselves , 25, 26.The health care environment is a potent facilitator of evidence-based sTBI practice in general through different mechanisms at different levels  depending on the practice behavior. Among the sampled clinicians, organizational culture promoting interdisciplinary academic activities  and presence of key opinion leaders were consistently cited as facilitators of evidence-based practice, and interdisciplinary conflict arising from inadequate collaboration was seen to be a barrier. These findings are consistent with previous studies of clinicians’ perceptions of enablers of guideline-based acute hospital care in neurotrauma and antenatal settings , 27 and Evidence-based fluid resuscitation practice in TBI can be achieved with changes to the policy environment. Restricting availability of albumin is relatively uncomplicated given that safer alternatives exist with fewer barriers to administration. Fluid resuscitation practice in critically ill patients has changed in response to evidence , but in Enabling evidence-aligned use of decompressive craniectomy is more complex, with influential factors intersecting multiple TDF domains. A decision whether to offer decompressive craniectomy is usually made at a time of emotional stress for families and clinicians, when nonoperative treatment has failed to treat intracranial hypertension and patients are at immediate risk of dying. Few participants explicitly prioritized high-quality clinical evidence comparing patient-centered end points over lower-quality evidence. Although participants demonstrated knowledge within expectations for their specialty groups, at times their awareness of established models of TBI pathophysiology and the likely physiological impacts of specific therapies overrode or appeared to compete with adherence to evidence-based CPG recommendations. Consistent with previous findings, this was particularly true if the mechanisms of the recommended intervention were inconsistent with the clinician’s existing knowledge . CliniciPrevious studies suggest that adherence to CPGs is enhanced when clinicians have confidence that the recommendation will produce the desired outcome . Nearly This study has several notable strengths, including sampling of clinicians from multiple specialties involved in the care of patients with sTBI, interviews conducted by a content expert, and analysis of influential factors using a validated theoretical framework by content experts and an experienced knowledge translation researcher. Our study is unique in exploring the interdisciplinary dynamics associated with acute management of sTBI and in examining determinants of two specific practices. Our study also has some limitations. We used the TDF predominantly in the analysis of responses rather than in the development of the interview guide; assignment of responses to TDF domains was post hoc, but this approach allowed for analysis according to dominant, unprompted themes. The clinicians were predominantly sampled from a single Australian academic neurotrauma center, with potential for unconscious or confirmation bias to influence perspectives. Although participants ranged in age and breadth of experience, the factors they identified are relevant to the circumstances in which they were sampled and may not be relevant with changes in practice, environment, and evidence. These issues, as well as the limited racial and gender diversity of respondents, potentially limit the generalizability of our results.In a sample of predominantly Australia-based specialist clinicians, factors influencing management decisions and the implementation of key evidence-based practice recommendations for sTBI were identified. Academic organizational culture, resources, and interdisciplinary collaboration were determinants that facilitated evidence-based practice. Fluid resuscitation practice could potentially be improved with health policy changes, whereas an explicit focus on patient-centered treatment goals could direct optimal surgical practice. This study highlights determinants of evidence-based practice that may inform tailored implementation efforts in similar settings and thereby improve outcomes for patients with sTBI.Supplementary file 1. Interview guide for clinicians involved in acute management of severe traumatic brain injury.Supplementary file 2. Table S1. Factors perceived generally to influence practice in severe traumatic brain injury; Table S2. Factors perceived to influence practice in fluid resuscitation of patients with severe traumatic brain injury; Table S3. Factors perceived to influence practice of surgical decompressive craniectomy in patients with severe traumatic brain injury.Below is the link to the electronic supplementary material.


Traditional Chinese medicine splenogastric diseases (TCMSDs) are equivalent to digestive system diseases in modern medicine. The forms of clinical evidence of TCMSDs include clinical trials, such as randomized controlled trials (RCTs) and systematic reviews (SRs). SRs mainly rely on manual operations and have the shortcomings of time consumption and low efficiency; therefore, they cannot meet the needs of rapid clinical decision-making. It is urgent to establish a new and smart form of a database to support the progress of SRs.  We searched and screened all TCMSD RCT reports, in both Chinese and English, and extracted them into meta-evidence through predesigned structural Microsoft Excel tables. All meta-evidence was imported into an online clinical meta-evidence collection and management system after data quality checking. The meta-evidence database of traditional Chinese medicine (TCM) splenogastric disease (MED-TCMSD) was then tested as a backend of an automatic meta-analysis system.  A total of 405 cases of TCMSD RCTs were processed into meta-evidence. The most common diseases were stomach stuffiness disease, epigastralgia, and chronic atrophic gastritis. Banxiaxiexin decoction and its modifications were the most used interventions. More than half of the cases employed TCM in conjunction with regular therapeutics. The top reported outcomes included clinical effects, adverse events, and TCM syndromes. The MED-TCMSD worked well as a part of the automatic meta-analysis system.  We developed and tested a new form of clinical evidence, meta-evidence, for automatic SR and fast evidence-based decision-making. As an example of the MED, the MED-TCMSD can improve the production and updating efficiency of the evidence of TCMSDs. The methods of constructing the MED-TCMSD can be further applied to the development of MEDs of other diseases. H. pylori infection-related diseases. Chen [Traditional Chinese medicine splenogastric diseases (TCMSDs) are a variety of diseases and symptoms that are related to gastrointestinal functions. Their clinical incidence rate is relatively high. For example, the prevalence of functional dyspepsia in China is 7%–41%, the prevalence of irritable bowel syndrome in China is 5%–25% , Chinesees. Chen  construces. Chen  establises. Chen  developees. Chen , 15. TheEvidence-based medicine (EBM) databases can be classified into four types : clinicaIn this study, we explored a kind of clinical evidence database that is highly standardized and structured to meet the needs of automatic systematic reviewing. We named it the meta-evidence database (MED). It is pre-extracted and stored in a machine-readable data format. We constructed a MED of TCM splenogastric disease (MED-TCMSD) and implemented it in a fast evidence-based decision-making system based on ASRs to test its functions and advantages.The literature databases that we referred to were four Chinese databases  and four English databases , Web of Science, and Ebsco Medline). Each database was searched separately for TCM splenogastric disease randomized controlled trials (RCTs) without any time limitations. The search terms were RCT, randomized controlled trial, and a group of specific disease names. We identified 12 TCM diseases corresponding to TCM splenogastric disease: epigastralgia, acid regurgitation, epigastric upset, stomach stuffiness disease, vomiting, hiccup disease, dysphagia disease, regurgitation disease, abdominal pain, diarrhea disease, constipation disease, and dysentery.The inclusion and exclusion criteria followed the patient/population, intervention/exposure, comparison/control, outcome, and study design (PICOS) rule . The incThe screening process was carried out independently by two researchers in three steps: (1) Search results were imported and automatically screened in NoteExpress software to remove the duplicates; they were rechecked manually. (2) The abstracts of the papers were examined carefully according to the selection criteria. Most exclusions were carried out for reasons in this step. (3) The last step was to check all the remaining full texts to make the final inclusion. Two authors completed the screening independently and cross-checked the results for correctness.A standardized extraction table can facilitate the extraction of data. We created a data sheet for extraction based on Microsoft Excel powered with Visual Basic for Applications (VBAs). The extraction tables of the clinical evidence were designed for data collection, which can be imported into the database in the batch mode. The VBA code built in the table can enable basic data inspection and verification of the input data. Each study was assigned a unique number to identify while storing and citing. The full texts (PDF) of the included studies are attached for reference.Based on the characteristics of RCTs, the extraction table contained six sections: general information, evidence sources, clinical data, trial design, grouping and interventions, and outcomes. (1) The general information section has 10 fields, such as evidence ID, evidence status, creation time, evidence name, clinical trial register number, data editor, and reviewer. (2) The evidence sources section has 24 fields, such as source type, article title, journal source, author information, author institution, contact information, grant number, and DOI and full-text path or link. (3) The clinical data section has 23 fields, such as diagnosis (both TCM and Western medicine), sample size, age and gender, course of the disease, inclusion criteria, and exclusion criteria. (4) The trial design section has 19 fields, such as study type, randomization type, blindness type, observation time, and risk of bias factors . (5) The grouping and intervention section has 27 fields, such as group name, sample size of each group, age and gender of each group, observation/control type, name of intervention/drug, dosage form, administration, single dose, frequency of administration, and duration of intervention. (6) The outcome section has 19 fields, such as outcome name, endpoint/change value, direction of effect, result data, and data type (continuous or binary). Clinical data extraction requires clinical knowledge of TCM; hence, we trained data extractors before starting the work. We also employed two experienced reviewers to check all input data to ensure completeness and correctness.th Revision of the International Classification of Diseases (ICD-11) [Regarding standardization of the names of diseases, the names of TCMSDs and those of Western medicine were not unified and did not allow us to form a correspondence map. To create a unified standard, the names of diseases diagnosed by TCMSDs were used to frame the names of diseases diagnosed by Western medicine. With reference to the “11(ICD-11) , Classif(ICD-11) ,” we buiMySQL  is an opThe initial search returned 25,831 papers: 8,428 in Chinese  and 17,403 in English : 834, Web of Science Core Collection: 7,298, and Ebsco Medline: 8,241). Duplicates were filtered by NoteExpress and manually, resulting in 4,734 papers remaining for the next stage. The inclusion and exclusion criteria were applied to the titles and abstracts of the remaining, and 3,118 papers remained for full-text examination. We downloaded them and read their full text carefully, and finally, 1,600 papers of TCMSDs were included. As the main purpose of this paper was to verify the construction of the meta-evidence database, we chose the most recent five years of RCTs  for meta-evidence extraction.A total of 405 cases of TCMSD meta-evidence were collected with Excel tables and imported into the MED.In the 405 cases of TCMSDs, the TCM diagnoses were mainly stomach stuffiness disease (125), epigastralgia (103), diarrhea disease (35), and constipation disease (18). These four TCM diagnoses accounted for 69% of all the included meta-evidence. The top five TCM syndromes were syndrome of Yang deficiency in the spleen and stomach (36), syndrome of cold and heat complex (16), syndrome of dampness and heat in the spleen and stomach (15), syndrome of spleen and stomach deficiency (15), and syndrome of disharmony of the liver and stomach (13). By comparing Western medicine diagnoses to TCM diagnoses, we found that the distribution was relatively uniform, and the top five occurrences were chronic atrophic gastritis of unknown etiology (65), functional dyspepsia (63), chronic superficial gastritis of unknown etiology (53), localized epigastric pain (33), and diarrhea (21) .TCM treatments were mainly herb medicines and Chinese patent drugs, such as banxiaxiexin decoction and its modifications, weifuchun tablets. Weiyan decoction, ziyinyangwei decoction, yiweishengjin decoction, etc., are also occasionally used in clinical use. They are usually combined with Western medicines of gastrointestinal motility drugs and prokinetic agents, such as domperidone, omeprazole, and mosapride citrate tablets .For TCMSDs, most of the included studies employed add-on tests (211 articles) or positive drugs as control (182 articles). Placebo control (3 articles), dose control (3 articles), and blank control (2 articles) were less common. (1) With respect to add-on trials, the patients both in the intervention group and control group were treated with the same baseline therapeutics, and the patients in the intervention group were further treated with TCM interventions. (2) Regarding positive controls, patients in the intervention group were treated with TCM, and those in the control group were treated with an effective routine approach.The outcomes of RCTs of TCMSDs include clinical efficacy measures , safety measures , and prognosis measures . (1) Clinical efficacy measures are quantitative indicators that can objectively describe the clinical treatment effects of interventions. (2) TCM syndrome scores can evaluate the severity and function of the human body. (3) Prognostic measures can reflect the development of disease recovery and outcome after intervention .https://www.pymeta.com/cdss/). The fast EBM decision-making system, namely the TCM clinical evidence auto-analysis and visualization platform, was designed for rapid  clinical and health decision-making . This system includes the MED, automatic meta-analysis, machine-based evidence-labeling, and result visualization modules, in which the MED has the key role of auto-SR support. Based on the TCM splenogastric disease meta-evidence, this platform allows an interesting and different process of SR  Only five years of TCMSD RCT data were included in this sample database. We plan to process the remaining literature in the future. (2) All the extraction work of the meta-evidence was completed by experienced researchers, which consumed substantial manpower and time resources. We are searching for efficient and sustainable solutions, such as computer-aided technologies and crowdsourcing collaboration to replace the current, inefficient manual methods.Rapid decision-making based on automatic SR techniques is an interesting direction of evidence-based medicine development. ASR techniques need to be supported by more efficient databases than the classical forms of EBM databases . Our new EBM database is highly standardized, structured, and machine-readable, which precisely meets all the requirements of ASRs. A sample of this kind of database, MED-TCMSD, was completed, which has a key role in the ASR and rapid decision-making system. We believe that the meta-evidence approach is a good solution for ASR databases, and the method of constructing MED-TCMSD can be further applied in the development of MEDs for other diseases.


Active recreation contributes to child and adolescent physical activity, however, factors affecting uptake are poorly understood at the systems level. The aims of this study were: (1) to use systems analysis methods to understand youth active recreation in Victoria, Australia, (ii) identify potential system leverage points to enhance active recreation, and (iii) explore stakeholder views of systems analysis methods for informing practice and policy decision-making.Phase 1: Umbrella review of systematic reviews (2013–2018), synthesising evidence for correlates, determinants and intervention evidence for promoting active recreation. Phase 2: Development of three systems models (ActorMap and two ActivMaps), depicting active recreation actors/organisations, correlates, determinants and intervention evidence. Phase 3: Development of causal loop diagrams (CLDs) and identification of leverage points based on the Action Scales Model. Phase 4: Model feedback via stakeholder interviews .From the literature, 93 correlates and determinants, and 49 intervention strategies were associated with child and adolescent active recreation; the majority located at a social or individual level. Ten potential system leverage points were identified in the CLDs, which differed for pre-schoolers versus children and adolescents. Only time outdoors (an event leverage point) emerged for all age groups. Changes to the built and natural environment  as a complete domain was a key structural leverage point for influencing active recreation in children and adolescents. Subject matter experts and stakeholder interviews identified 125 actors operating across seven hierarchical active recreation system levels in Victoria. Stakeholder interviews identified 12 areas for future consideration and recommendations for practice/policy influence.Our findings underscore the need for dynamic models of system behaviour in active recreation, and to capture stakeholder influence as more than a transactional role in evidence generation and use. Effective responses to youth inactivity require a network of interventions that target specific leverage points across the system. Our models illustrate areas that may have the greatest system-level impact, such as changes to the built and natural environment, and they provide a tool for policy, appraisal, advocacy, and decision-making within and outside of government.The online version contains supplementary material available at 10.1186/s12966-022-01292-2. The physical and mental health benefits of physical activity are well-established , 2 and yhttps://sport.vic.gov.au/our-work/participation/active-recreation#:~:text=Active%20recreation%20is%20leisure%20time,living%2C%20active%20transport%20and%20sport). Nonetheless, irrespective of the potential opportunities of these settings and activities; school-based interventions show only modest positive effects on physical activity [Schools are recommended as a target setting for intervention , due to activity  and orgaactivity . Whilst activity .. The lack of consistent positive effects of interventions has been attributed to many different factors . To datpractice . Limitatpractice ), yet thpractice . Notwithinteract  and how influencers in a given context . ActorMaps are a type of system map that depicts how individuals and organisations are interrelated in a system, and are useful for identifying opportunities to improve or intervene in the system via stakeholders. AcciMaps are an accident analysis method that is used to retrospectively analyse the multi-layered interactions between events, decisions and outcomes [Systems approaches are fundamental for understanding complexity of health behaviours , and a soutcomes . CLDs aroutcomes . They caoutcomes  may exisThe relationship between determinants of active recreation and subsequent intervention strategies has important policy implications in terms of which interventions governments and other physical activity stakeholders should target, and the complexity of approaches required to achieve population level change. Systems approaches can provide a starting point for stakeholders to develop well-informed health promotion strategies , 34, andThe aims of this study were threefold. Firstly, to use systems analysis methods to understand the active recreation system for pre-schoolers, children and adolescents (herein referred to as children and adolescents) in Victoria, Australia. Secondly, to identify potential system leverage points using the Action Scales Model , and thiPhase 1: Umbrella review of systematic reviews to identify correlates, determinants, and intervention evidence for promoting active recreation among children and adolescents (January–February 2019). Phase 2: Development of ActorMap and ActivMap systems models to depict active recreation actors, correlates, determinants and intervention evidence; based on input from subject matter experts (ActorMap) and review findings (ActivMaps) (March 2019). Phase 3: Development of CLDs (April–August 2019) and identification of leverage points based on the Action Scales Model [Phase 4: Model feedback via stakeholder interviews (September 2019). Figure The study involved four iterative phases. es Model  , using a combination of free text terms and medical subject headings. Search strings were developed in consultation with a research librarian  is placed at the ‘International’ level of the hierarchy as the WHO primarily targets global health issues, even though the WHO would also influence the second level of the hierarchy, ‘government and government departments’. The initial ActorMap was later refined during stakeholder interviews in Phase 4.An initial ActorMap was drafted by three subject matter experts , to provide an overview of the actors  that share responsibility for active recreation internationally, nationally and in Victoria. This is particularly important in Victoria, as promotion of active recreation is a key strategy to increase population physical activity, health and well-being. Approximately $1 billion AUD has been invested into the Victorian sport and active recreation system by the state government, since 2014 . SubjectTwo AcciMaps (herein referred to as ‘ActivMap(s)’ as relevant to the physical activity/active recreation context of this study) were then drafted using results from the umbrella review Phase 1), with factors also organised against the seven levels of Rasmussen’s Risk Management Framework . The CLDs depict the variables influencing active recreation that were identified from literature searches (Phase 1), colour coded in the CLD based on the level of influence (Phase 2). Connections between variables in the CLDs illustrate the relationships between correlates and determinants (positive and negative), which we determined via the subject matter experts and stakeholder feedback (described in Phase 4). To identify potential leverage points, we used the Kumu software to identify CLD variables that were highly connected based on the ‘indegree’ (no. of inbound links), ‘outdegree’ (no. of outbound links) and ‘betweenness centrality’ (no. of times an element lies on the shortest path to another), and aligned them to the four levels of within the Action Scales Model [Using the content from the two ActivMaps, two CLDs were produced using Kumu relationship mapping software (2019)  were recruited to participate in an online or in-person interview. Participants represented state and national government bodies, advocacy groups, as well as independent organisations, with expertise in health, planning, education, policy, sport, and disability. Interviews lasted between 60 and 90 min and were conducted by JS; CS and SC independently took notes. Interviews were conducted either online via Zoom teleconferencing software or face-to-face. The systems models were displayed on the screen during the interview, for participants to review and discuss. For face-to-face interviews, the maps were displayed on a screen and printouts of the maps were provided. The interviewer described the content of the maps, and explained the colour coding of the variables and arrows on display. All participants were asked: 1) if any variables/factors/actors in the maps were missing or that they disagreed with, 2) if any interactions in the maps were missing or that they disagreed with, 3) what they thought was most likely to influence population levels of physical activity, and 4) whether they would be likely to use systems approaches/a system dynamic modelling tool as part of future decision making. As the interview data comprised stakeholder feedback on visual aspects and content of the models, a structured interview script was not required. Formal qualitative analysis was therefore not appropriate in this instance , rather, notes from interviews were summarised by CS and SC into ‘key areas’ for future consideration when using systems approaches for practice and policy decision-making. Stakeholders were invited to review and confirm their recorded feedback post interview.Stakeholder interviews were conducted to refine and validate all systems models Figs. , 4 and 5n = 10); Government and government departments (n = 19); Regulatory bodies, advocacy groups and industry associations (n = 44); Local government, education, sport and health (n = 16); Social environment (n = 20); Individual (n = 3); and, Built and natural environment (n = 13). A majority of the actors were located at the regulatory body/advocacy/industry group level .Figure n = 23), five key areas were identified that stakeholders felt either had not been captured in the ActorMap  or negative influence  on youth active recreation. Whilst stakeholders recognised that it was not the purpose of this study to capture these relationships, it was something they recommended is included for future research.within government – that needed to be identified and depicted in Fig. Engagement structures and coordinating mechanisms that existed between multiple levels of government were identified. For example, whilst local government had a more direct impact on ground-level delivery, there were government coordinating mechanisms at a state level - many of which were informal networks Based on the hierarchical levels used in Fig. Stakeholders discussed the many limits of relying only on the published peer-reviewed literature, and that systems models should include grey literature to capture activities ‘on the ground’. This was described as essential if the maps were to be useful in decision making, and that dynamic, as opposed to static, models would be an improved way of depicting the system. Stakeholders also discussed that policy documents  should be reflected in the ActorMap as an influence, as they perceived this as something that influenced the system in the same way an ‘actor’ would.to what extent do state and federal government care about active recreation?” and “is there policy alignment between different levels of government regarding this topic?”. Critically, stakeholders were emphasising that responses to these questions reflect the nuances of policy influence on active recreation in Victoria, and these aren’t captured within the ActorMap. They described that not all actors are equal. Despite that the actors have been positioned in Fig. Example questions raised during interviews included “The literature search identified 93 correlates and determinants, and 49 intervention strategies, associated with child and adolescent active recreation. Literature identified included studies with typically developing children and adolescents, and children and adolescents with a disability. Figures n = 93) of active recreation , social environment (n = 28), individual (n = 35), and built and natural environment (n = 21). In total, 62 were positively associated with child and adolescent physical activity (coloured green) and 31 were negatively associated (coloured red)  than pre-school and early childhood aged children (n = 30) or children with a disability (n = 7).For pre-schoolers, children and adolescents, correlates and determinants n = 9 of activent n = 2. In totan = 49) , social environment (n = 13), individual (n = 19), and built and natural environment (n = 8). In total, 22 strategies led to improvements in physical activity (coloured green), 15 resulted in no change (coloured orange), 11 reported null results (coloured beige), and one was negative (coloured red)  than pre-school and early childhood aged children (n = 18). There were no active recreation intervention strategies from the umbrella review identified for children with a disability.Intervention strategies n = 9 Fig. 4n = 49  were acknowledged, stakeholders discussed that these factors were essential to depict a true systems model of active recreation. For example, variables, such as ‘access’, were insufficient in isolation and the nuance of factors mediating ‘access’ (such as family socioeconomic status) were required in order to capture the complexity of behaviour.Expanding definitions of the variables in the map was recommended to improve interpretability. Stakeholders discussed the challenges of the methodology capturing something complex and finding a balance between simplifying the information to retaining its richness. An interactive version of the map that allowed for an expansion of variables was suggested.Stakeholders refined the language and terminology used in the map, to reflect language appropriate to the Victorian practice/policy context .For Fig. Strength of the evidence underpinning the intervention variables in Fig. Stakeholders discussed this with particular reference to how the model captured rural and regional areas of Victoria. Some of the intervention evidence appeared relevant to primarily metro areas . Whilst they acknowledged that the models depicted what was published in the literature, this raised discussion about the state-wide applicability of the models.Stakeholders provided many examples in their local jurisdiction that aligned with the intervention evidence in Fig. Figures The number of variables and their connectivity in the CLDs differed between review evidence for pre-schoolers Fig. , and chin = 5 leverage points) and children and adolescents (n = 6 leverage points). Leverage points corresponded to all four levels of the Action Scales Model [n = 1, individual level n = 6, social environment n = 3, and local government, education and health n = 1)  Table .Table 2AFor example, a potential individual-level leverage point corresponding to ‘Events’ in the Action Scales Model, includes influencing youth time spent outdoors Table . Among pThe purpose of this study was to explore the active recreation system in Victoria, Australia, using multiple systems analysis methods; ActorMap, ActivMap and CLDs. Feedback from key stakeholders was used to validate and refine all systems models developed in this study, providing key recommendations on ways these methods can be used in the future to assist with practice and policy decision-making. The current methods present a contribution that is distinct from a traditional evidence synthesis, and that applies systems analysis methods that have been used in safety  domains  to assesDespite calls for systems approaches to physical activity promotion , to our Our findings raise important questions regarding the real-world relevance of current evidence for youth active recreation with the broader active recreation system in practice. It reiterates the benefit of and need for systems approaches to changing physical activity environments and promoting active behaviours and policy actions , which iThe CLDs demonstrate that determinants are not equal in their potential effect on the system. The connectivity between variables in the CLDs Figs.  and 6 diIn contrast, although a child’s motor skill level is positively associated with active recreation , and iCoverage of active recreation evidence also differed across population subgroups. More correlates and determinants were identified for typically developing children and adolescents, than pre-school and early childhood aged children or children with a disability, and there were no intervention strategies in the umbrella review identified for children with a disability. Strengths of a systems approach is that the needs of all groups, including vulnerable groups, are addressed for equitable health improvement. However, the implication of these findings is that these key actors (government/industry) and areas of influence related to active recreation remain ‘untapped’, as we lack evidence of their impact and how to intervene. Greater awareness of the complex interactions between the worldviews, perceptions and agendas of key stakeholders is considered necessary to increase impact and sustainability of population-based physical activity interventions . ImproveOptimising those types of variables that have interconnectedness with others in a system, and targeting them as ‘leverage points’ , may ben = 125) highlights the breadth of influencers in the active recreation system, and potentially how challenging it may be to leverage or influence these different actors to achieve collective change or reduce duplication of effort. Understanding the power of actors and how they exercise it, has been shown to influence policy implementation [Stakeholder feedback was generally positive and supportive about the use of systems models as a tool to inform decision making. For example, despite the limited effectiveness of mass media campaigns at increasing population physical activity levels , many stentation  and systentation , and phyentation .Stakeholders also discussed that policy documents  should be reflected in the ActorMap, as they perceived this as something that influenced the system in the same way an organisational or individual actor would. Whilst the inclusion of non-human actors (such as policy documents) in ActorMaps has previously been demonstrated , it was Major strengths of this study are the combined use of multiple systems approaches to understand active recreation, and involvement of stakeholders to refine the models for practice relevance and provide recommendations for future applicability. By including both published evidence for influences on active recreation, with the perspectives  of key actors in the system; we were able to study the extent that research evidence translates to individuals’ experiences of practice.However, the study is not without limitations. The scope of this project required that the data underpinning the models was based on physical activity literature published within a five-year period, which included an umbrella review of published systematic reviews. The review was conducted between January 2013 to July 2018 and there is the possibility that some evidence may have been missed due to our search parameters. For example, we found that dog walking had no relationship to active recreation based on the included review , and yetFuture research, which incorporates evidence for the mediating and moderating relationships of factors within a dynamic systems model, including influences between actors , would improve our understanding of active recreation and the potential outcomes of leveraging different parts of the system on population physical activity. Due to the timings of data collection, we were unable to obtain stakeholder feedback on the potential leverage points we identified. However, future research that captures stakeholder reflections on the relevance and appropriateness of leverage points, would potentially strengthen their translatability into practice. In addition, it was also beyond the scope of this project to incorporate the views of young people into the research process. Consulting with the target population has the potential to enhance the feasibility of active recreation strategies identified and inform the appropriateness of any recommendations; this should be a focus for future work. Our analysis boundaries meant we did not incorporate influences between actors across systems, or, for example, whether these influences were distal or negative. This created perceived limitations of the models among stakeholders. Models which incorporate this or include a simulation component  would pInfluences on child and youth active recreation participation are demonstrably complex and interrelated. Systems analysis methods offers a way to move beyond the cause-effect models that have been embedded, historically, in physical activity promotion research. Our findings underscore the need for dynamic models of system behaviour in active recreation, and the need to capture stakeholder influence as more than a transactional role in evidence generation and use. Multiple combinations of interacting factors influence active recreation participation in different contexts, with leverage points spanning all levels of system influence. Effective responses to youth inactivity require a network of interventions that target specific leverage points across the system. Our models illustrate areas that may have the greatest system-level impact, such as changes to the built and natural environment, and they provide a tool for policy, appraisal, advocacy, and decision-making within and outside of government.Additional file 1. Online databases and search strings.Additional file 2. Reviews of correlates, determinants, and interventions for child and adolescent active recreation.


Upper gastrointestinal hemorrhage (UGIH) is defined as hemorrhage originating from the gastrointestinal tract proximal to the ligament of Treitz. The causes of UGIH include esophagitis, gastritis, peptic ulcers, Mallory–Weiss syndrome, and cancer. However, a rare cause of UGIH, such as an accessory spleen, may lead to serious complications if left untreated and can sometimes be very difficult to diagnose preoperatively.An 18-year-old man was admitted to the Department of Gastroenterology of our hospital due to “repeated black stool for 2 months with aggravation, accompanied by hematemesis for 9 days.” He denied any history of hepatitis, trauma, or surgery.Laboratory evaluation revealed severe anemia . Computed tomography revealed a mass measuring 127 mm in its largest dimension, located in the upper left abdomen, with varicose veins in the gastric fundus. Moreover, distended blue–purple tortuous veins were observed by gastroscopy in the gastric fundus. We believed the mass was likely an abnormally proliferating accessory spleen; however, the causes of severe anemia and gastrointestinal hemorrhage were unknown.After discussion in a multidisciplinary conference, the mass was completely resected laparoscopically, and the subserosal veins in the gastric fundus were sutured using absorbable threads.After the surgery, the patient recovered uneventfully without any complications. Clinicopathological examination showed that the mass was chronic congestive splenomegaly. Gastrointestinal hemorrhage secondary to an abnormally proliferating accessory spleen was confirmed as the diagnosis. Laboratory evaluation revealed hemoglobin at 12.1 g/dL 2 months after surgery. At the 12-month follow-up, the patient showed no recurrence of gastrointestinal hemorrhage.UGIH caused by accessory spleen is extremely rare. This entity should be considered in differential diagnosis of gastrointestinal hemorrhage. Surgical intervention is necessary for timely diagnosis and treatment in case of gastrointestinal hemorrhage in critical clinical situations. Common risk factors for UGIH include high-dose nonsteroidal anti-inflammatory drug use, anticoagulant use, and old age. The causes of UGIH include esophagitis, gastritis, peptic ulcers, Mallory–Weiss syndrome, and cancer. However, a rare cause of UGIH, such as an accessory spleen, may lead to serious complications if left untreated and can sometimes be very difficult to diagnose preoperatively. The spleen, which is fundamental for the hematological and immune system, is derived from mesenchymal cells of the dorsal mesentery. At the fifth week of embryonic development, an accessory spleen may form if the embryo spleen bud is not fully fused or if a single cell is separated from the body of the spleen. An accessory spleen is a congenital defect, 1 to 3 pieces, about 1.0 cm in diameter, normally located in the left upper abdomen, around the normal spleen. Abnormally enlarged accessory spleen may be found after splenectomy with or without hypersplenism. Preoperative diagnosis for an accessory spleen, whose location could vary, remains challenging, especially in emergencies. Here, we present a rare case of UGIH caused by an abnormally proliferating accessory spleen without trauma or splenectomy in medical history.Upper gastrointestinal hemorrhage (UGIH) is defined as hemorrhage originating from the esophagus, stomach, or duodenum.An 18-year-old man was admitted to the Department of Gastroenterology of our hospital due to “repeated black stool for 2 months with aggravation, accompanied by hematemesis for 9 days.” The patient presented melena 2 months ago without obvious inducement, and the specific amount was unknown. No abdominal pain, acid reflux, abdominal distension, dizziness, fatigue, chills, fever, and other symptoms were noted. Nine days before admission, hematemesis occurred for unknown reasons. The volume was small, about 10 mL, and there was little blood in the saliva. One day before admission, the patient had unexplained hematemesis twice with a large amount of about 500 mL, vomiting bleeding clot, and defecated blood 3 times with a volume of about 800 g, accompanied by symptoms of dizziness and fatigue. No acid reflux, abdominal pain, abdominal distension, consciousness disorder, chills, fever, cough, expectoration, urgent urination, odynuria, and other symptoms were observed. Laboratory evaluation revealed severe anemia . Computed tomography showed a mass measuring 127 mm in its largest dimension, located in the upper left abdomen, with varicose veins in the gastric fundus (Fig. The mass was completely resected laparoscopically, and the subserosal veins in the gastric fundus were sutured using absorbable threads. During surgery, we found that the mass was closely related to the gastric fundus but separated from the pancreas, mesentery, and bowels. The distended tortuous veins of the mass were connected to the gastric fundus. The liver was soft, with no manifestation of cirrhosis and no ascites in the abdominal cavity Fig. B. The sm usually located at the tail of the pancreas and the splenic hilum but occasionally in the greater omentum and gastrointestinal tract. The location of the splenic tissue is often inconsistent with that of the congenital accessory spleen, and multiple sites may be involved. In contrast with a congenital accessory spleen, ectopic spleen implantation refers to the autologous transplantation of splenic tissue after splenectomy following trauma or other causes. This occurs in 67% of patients with splenic rupture and splenectomy. An accessory spleen is clinically crucial in some locations. When an accessory spleen is situated in another site, it may mimic some tumors, such as pancreatic and adrenal tumors. An accessory spleen is relatively common; however, it is rarely the cause of UGIH and severe anemia. In some cases, gastric splenosis may cause upper gastrointestinal bleeding, which is challenging to diagnose and is only incidentally found under most circumstances. While postoperative histopathologic examination is still the gold standard, fine magnetic resonance imaging and enhanced computed tomography scans may be useful in accessory spleen diagnosis.An accessory spleen includes isolated splenic tissue outside the normal spleen, It was also considered that the abnormally proliferating accessory spleen compressed the branches of the splenic vein, which could have caused the dilation and rupture of veins in the gastric fundus. After the accessory spleen enlarged further, its demand for blood supply increased, and, at the same time, the blood vessels entering and leaving the accessory spleen became enlarged. Because the blood supply of the abnormally proliferating accessory spleen came from the arteries of the greater curvature of the gastric body, its veins also directly returned to the submucosal vascular network of the greater curvature and the gastric fundus. Venous blood flow increased with the progressive enlargement of the accessory spleen, leading to the tortuous expansion of local blood vessels under the gastric fundus mucosa. The venous bulbs in the gastric fundus eventually ruptured, leading to UGIH. This possibility should be considered in differential diagnosis of gastrointestinal hemorrhage. Surgical intervention is necessary for timely diagnosis and treatment in the case of gastrointestinal hemorrhage in critical clinical situations.In the present case, the accessory spleen proliferated spontaneously in the presence of the normal spleen, and the cause was unknown. This was likely the cause of severe anemia in the patient 3 years prior to the study, or anemia was the cause of splenomegaly.Usually, an accessory spleen is not uncommon in clinical practice and does not cause serious problems. However, the abnormally proliferating accessory spleen in this case caused severe anemia to the point of shock symptoms. This case shows that the causes of severe anemia and gastrointestinal hemorrhage are diverse and complicated. The abnormally proliferating accessory spleen may be a possible cause, and clinical attention is warranted to distinguish it.Conceptualization: Yuanjun Liu, Enrong Ran.Investigation: Yi Dai, Fan Xiao, Shuang Liu.Supervision: Yakun Wu, Enrong Ran.Writing—original draft: Yuanjun Liu.Writing—review & editing: Yuanjun Liu, Yi Dai, Fan Xiao, Shuang Liu, Yakun Wu, Enrong Ran.We would like to thank the Department of Pathology, Suining Central Hospital for providing pathological images.


Four categories were identified: learning evidence; communicating science; evidence-based practice; and developing skills. The successful implementation of evidence-based practice education resulted in students who understand its importance and use it competently. Further research should explore the skills developed by nurses involved in similar projects and their contribution to an EBP culture.The development of true evidence-based practice requires that practitioners have the knowledge and skills to research, analyze, and use evidence. These skills must be acquired in pre-graduate training. The objective of the present study was to analyze the contributions of students’ participation in knowledge translation projects to clinical practice for evidence-based learning. This was a qualitative, descriptive, and exploratory study that used focus groups. Scripted interviews were administered. The design of the study included five phases and took place in the partnering institutions of the Safety Transition Project, involving fifteen participants. The study was authorized by the Research Ethics Committee. The data were analyzed following the steps encoding the categories, storage and recovery, and (3) interpretation and using computer software (WebQDA Evidence-based practice (EBP) is recognized as key to improving the quality of health care , increasHowever, a literature review showed that nurses are not implementing EBP at levels considered desirable and recommended by scientific and international organizations  that are responsible for issuing guidelines for health settings ,4,5. SomThe exponential increase in nursing research, with the resulting increase in its dissemination, has not been accompanied by the same rate of implementation in clinical practice settings . AlthougThe use of knowledge in health is not a recent concern among researchers because of the delay in the introduction of the results of research in some clinic areas, justified by some authors because of methodological and ethical issues, scientific rigor, project execution capacity, research funding challenges, lack of an EBP culture among the organizations ,7,8,9, aInternationally, EBP is recognized as a crucial element for the education of all health professionals . HoweverRecent studies have reinforced that nurses are not well prepared to apply EBP  and thatConsidering that this is an appropriate recommendation that guides health professionals in clinical practice , we agreThe development of EBP competencies implies the acquisition and consolidation of a minimum set of attributes, knowledge, skills, and attitudes . ClinicaIn Portugal, we have a knowledge translation (KT) project for the clinic that involves nursing students. From the dialogue between our experience and the literature review, the research question of this study emerged: What is the perception that nursing students have about the contribution of their participation in KT projects for the learning and development of EBP skills?In light of the above, the objective of this study was to analyze the contributions of student participation in projects of knowledge translation to clinical settings for evidence-based learning.This was a qualitative, descriptive, and exploratory study that used focus groups (FGs) as a method to answer the following research question: “What do nursing students learn about EBP when participating in knowledge translation projects during their professional integration internship?”. The study design consisted of five phases : planninThis methodological option is justified because: (1) the literature review demonstrated that there are few studies about the participation of undergraduate nursing students in research projects; (2) the uniqueness of the experience that was provided to students justified exploring its contribution to EBP learning; and (3) focus group discussions are the preferred method when descriptions, meanings, opinions, and reflections are the sources of knowledge about a phenomenon or a specific situation or issue . Focus gTo achieve the objective of the study and increase its depth, two FGs were carried out with two different groups of participants who shared the same experience of undergoing the last internship of the undergraduate nursing program.The study took place in the partner institutions of the Safety Transition (ST) Project, which is a knowledge translation program that involves a partnership between a hospital, a nursing school, and a primary health care service in the region of Lisbon and the Tagus Valley in Portugal.The ST Project is based on a simultaneous process of problem solving, training, research, and action, in which the primary purpose is the use of knowledge translation to solve the problems of different hospital inpatient services, increasing the knowledge of and empowering patients and their families in the process of transitioning from the hospital to the community. The project establishes communication circuits that promote continuity of care, reducing readmissions after hospital discharge and promoting rehabilitation and insertion in the community ,20.Over the course of this project, students can be integrated into hospital inpatient services  or into primary health care services, where the last semester-long undergraduate nursing internship takes place.The choice to involve students is based on the consensus that achieving a high level of EBP learning requires investing in quality clinical practice environments and improving the clinical experiences of students, not least because the clinical settings and situations of patients are becoming increasingly complex, requiring a higher level of scientific skills .The participants were selected from among the students involved in the ST Project in the second semester of the 2018/2019 academic year. Similar to other qualitative methods, FGs rely on intentional samples. Therefore, participants are selected based on the possibility of generating the most productive discussions . To be iThe number of participants was established a priori according to the ideal number of participants defined by the same authors, between five and ten participants ,18. At tThe literature review was crucial for structuring the interview script, which was organized around the following question: How has being involved in the Safe Transition Project contributed to your learning? Based on this initial question, the researchers were able to taper the discussion down to more specific questions . Both thThe data collection sessions were video-recorded and took place at the school of nursing, in a room organized for this purpose, creating a comfortable environment that fostered participation, prevented interruptions, and ensured confidentiality ,18.In the e-mail sent to students and at the beginning of the focus group, participants were informed about the objectives and rules of participation, including estimated duration (75 min), avoiding early dropouts at the start of the group discussions . At the The role of the moderator is key in this phase , not onlThe choice of a co-moderator was in line with the recommendations of Krueger and Casey and was designed to increase the rigor of the process. The moderate mission was to develop discussion and keep it going. The co-moderate mission was to help the moderator manage the recording equipment, be aware of the conditions and logistics of the physical setting, respond to unexpected interruptions, and take notes on the group discussion .The recording was watched twice before being transcribed by one of the researchers present in the FGs so that they could “visualize” what had occurred in the group. The findings were analyzed according to the steps defined by Bloor, Frankland, Thomas, and Robson : (1) enc®, Ludomédia, Aveiro, Portugal), which helped organize and analyze the findings and increased the rigor of the process. Coding was carried out by the researcher who transcribed the recordings of the FGs, and then it was validated by the research team.The data were analyzed using computer software  in both FGs .The research phases were rigorously conducted and validated by the entire team so that the results accurately represented the participants’ experiences. After coding the findings, they were returned to the participants for their validation, ensuring the credibility of the study. Confirmability was guaranteed by the communication that took place during the coding process, by the literature, among the team, and by an expert who evaluated the codes that emerged from the findings. Transferability was demonstrated by the depth of the analysis, the methodological description, and the presentation of the results, which increase the likelihood of the findings being significant in other similar contexts.This study was authorized by the Ethics Committee of Hospital Vila Franca de Xira (Protocol number: 09/2019 HVFX). The institutions involved have a formalized partnership protocol that authorizes research. All ethical and formal principles were respected, from authorization for the students to integrate the project as an extracurricular activity, to the ethical issues inherent in the development of research. All participants were assured of the anonymity and confidentiality of the data.Since this was an extracurricular activity that took place simultaneously with a clinical internship resulting in a final grade, the FGs were only carried out after the participants had received their grades for that curricular unit to minimize the effect of “socially desirable” responses.Eight students participated in FG 1 and seven students in FG 2. They were mostly women (12), and most had carried out their internship in the hospital setting (14) .In response to the question about EBP learning based on their participation in the ST Project as part of their professional integration internship, 192 registration units (UR) emerged in the participants’ discourse, organized into four categories: learning evidence (n = 94); communicating science (n = 22); evidence-based practice (n = 55); and developing skills (N = 21) .Evidence is a complex concept associated with the generation (production), synthesis, transfer, and implementation of knowledge for health care. Learning evidence associates the need to acquire knowledge about the different phases but also to develop skills to apply it in the clinic.In relation to the category “learning evidence,” the participants indicated that being involved in the project had given them the opportunity to look up research articles, read them, and evaluate the quality of publications, i.e., level of evidence. This opportunity to read science was mentioned in statements such as:I think it’s something that was complemented, better than reading 100,000 articles and being overwhelmed was reading and seeing how they could be applied in practice, i.e., verifying the applicability of what we looked up and what was researched, so it no longer was just an article but something with a result, a solution of interest.In conversations with colleagues who were from other institutions, I realized that they did not use the databases with the same rigor as we did. Research and quality analysis of the articles was important for us to appraise their quality and verify what they actually presented in terms of evidence. Furthermore, I stopped accepting everything as fact or correct, when they tell me “it’s done this way” I always ask why and the basis behind it.We end up wanting to continue, we do the research, apply the findings, see the results and want to keep going.The opportunity to search databases and read scientific articles was recognized as important for the promotion of a scientific and/or technical culture. This type of reading stimulates the cognitive and sensory processes of perception, curiosity, and motivation to analyze the contribution of results to the development of research projects, contributing to the meaning of research for problem-solving.Learning how to read and evaluate scientific articles is accompanied by the possibility of synthesizing evidence by developing systematic or integrative literature reviews:Literature reviews based on the scientific method were a great lesson, not only in how research is conducted, but what I struggled with most, which was evaluating the quality of the research. Before this internship we searched for articles and if they were in the school database, we assumed they presented evidence. Here we learned that it is much more than that, we had to separate the wheat from the chaff, I think that’s the proverb, we had to verify the quality of the studies and the levels of evidence (…) reviewing the literature allowed us to theoretically substantiate the evidence that supports the project and not just that, (…) it helped us improve our follow-up consultations, including the instruments used to evaluate patients.The enormous quantity of existing research justifies the need to synthesize evidence, and professionals can play an important role in this process, or in its use, as the end consumers of science. This synthesis is a challenge and future professionals should develop skills in this area. The students indicated that they developed attitudes that favored this type of learning and research and synthesis skills.In relation to theoretical-practical integration, the FGs revealed the students’ perceptions that the experience had contributed to the integration of theoretical and practical knowledge:There were things that I saw in practice but that I better understood in theory, and there were things in theory that I understood better once observing them in practice.I actually mentioned this to my colleagues, I was able to observe the practice and I was able to understand the applicability of that, of our work. In that respect, the internship was very good, and for me, it was very gratifying to see that we were doing things that we knew were being applied.For me, it helped narrow the gap between theory and practice. It might seem strange to say this, but often we complain that the content in school is too theoretical and little applied in practice, there are huge gaps, but this experience allowed us to grasp the theory and apply it to practice.The relationship between theory and practice is a recurring issue in nursing education, often based on a duality, which, as is clear in the participants’ discourse, is based on a separation between ways of doing and ways of thinking. The gap between theory and practice was reduced because the project allowed students to introduce knowledge into the clinical setting.This theoretical-practical integration contributes to evidence-based clinical decision-making. The future nurses emphasized the following positive points:This experience has allowed me to see what EBP is very concretely, EBP requires research, method, palpable results, it’s not a philosophy of opinions, it involves concrete results obtained through rigorous research processes, which is very important, and this is how it has benefitted me, through the effective understanding of EBP, it is the result of things that are well done and that have been reached in a right and correct way and… that’s it! In my opinion, we talk a lot about evidence without knowing very well what it is.’It allowed us to develop what we were working on further, and throughout this work, there was always a bridge between what was reality and what maybe was science, that we could be doing more, that there was positive evidence about how to do it and this contributed to our reflection about maybe what little things could make a difference in our practice.In school, we learn the ideal, what has to be done, but when we arrive in clinical practice, there are so many challenges, lack of time, or resources, both human and material, and we end up seeing that there is a lot that is not mentioned in school, in terms of the difficulties we will face as professionals and how to resolve them, school doesn’t talk much about this, everything is very ideal.Negotiating decisions as a team, clarifying the intention behind decisions, anticipating outcomes, reflecting about actions, and problem-solving capacity all contribute to EBP learning and certainty.Learning about evidence is also achieved through opportunities given to students to transfer their knowledge into the clinical setting, which was expressed by the participants as follows: What I mean is that we have an idea of the evidence and that it is used in clinical practice, but in reality it’s still hard to support everything with evidence, even when guidelines come out determining that things should be done a certain way, practices are hard to change, it is ongoing work, almost baby steps.We studied this in theory and with the work developed we were able to transfer it into practice. We even saw how some providers worked in other countries in order to adapt it to our reality, based on what is written about whether the outcomes are suitable to people’s needs.I understand that people would like to do this, but these things take time and this project showed me that it takes not only time, but also a methodology determining what has to be done, as my professor used to say, you can’t introduce evidence with a magic wand, you need a structured, objective, simple plan and to think about the benefits for patients.Knowledge translation is seen by the students as a difficult process that they had not been aware of until the internship. Their involvement in the project increased their recognition of the value of scientific evidence, and it is this recognition that makes knowledge translation add value to health care.Science communication implies knowledge of research methods and techniques, the ability to methodologically evaluate studies and synthesize the results. It requires scientific communication skills, written and oral, and the ability to adapt the language to the target audience, which in the EBP is, most of the time, the clients of health care.Regarding the category of communicating science, the students said:In my opinion, based not only on my work, but that of my classmates, creating the posters was a way of synthesizing information, but it was also challenging because there was a lot of information and we had to be able to summarize it in the most pertinent way in order to put it on a poster.It was a very important time, because it forced me, not only to learn how to use scientific language, but also data presentation strategies, and we prepared ourselves ahead of time to answer hypothetical questions that could arise, because often we have data analyses with their conditioning factors and we need to know how to answer questions that might be made not only in terms of data communication but also about the conditioning factors found and how we resolved them.The students reinforced the importance of their learning from the experience of creating posters, collaborating in drafting scientific articles, and discussing them with other people. Science communication is a bilateral process that involves communication skills, the sharing of ideas, the synthesis of information, and the use of scientific language.EBP implies the use of the best available evidence to improve health care, which implies to change the clinical practice, improve patient outcomes, improve health indicators, change health policies, and create an evidence ecosystem.The participants also spoke about the opportunities for improving care practices that arise when translating knowledge into clinical practice. Regarding this aspect of EBP, the students explained that:We did other things than care delivery, I thought it was very interesting to observe the nurses involved in projects, improving care, concerned with the outcomes of their interventions, and how to use evidence.I realized that theoretical work can be implemented in practice and it’s satisfying seeing that the results we obtained with the integrative review could actually be used and it wasn’t just an assignment and that’s it. In this sense it was very gratifying because we knew our research would produce results, would change things in clinical practice, and we had the possibility of participating in this change, because we had begun to implement the project into the service with what we had and began to see changes. That was very encouraging, because we also began to want to know whether the nurses were adhering to this change, what the results are, and what has to be reformulated.The applicability of the projects in the clinical setting fostered the improvement of the quality of care provided to patients, in the short or medium term. By going through this experience in a practical setting, the students increased their awareness of the benefits of EBP for users and services.Third generation soft skills or competencies are important for EBP, because they imply interpersonal relationship skills, leadership, teamwork, active listening, and time management, among others that allow the ability to adapt and change that are necessary to work in evidence ecosystem.Finally, the participants demonstrated that they recognized the importance of developing cross-sectional skills relative to professional autonomy, time and conflict management, and leadership, expressed as follows:I felt I was the leader in some respects, I had to plan meetings, prepare content, negotiate with staff nurses what would be addressed in these meetings. It also meant additional research, exploring what was happening in other institutions, I felt competent in so many activities, that I was working side-by-side with professionals. I realized above all that there is work beyond what we usually do with patients in internships, it was very gratifying!It allowed for good time management, which was related to everything because there are so many of us, sometimes it’s hard to organize everybody’s schedule, and I felt that if there is time for us to truly focus on what this is and take advantage of opportunities, this will produce more learning outcomes.Cross-sectional skills develop in parallel when students can carry out the activities included in the projects, increasing the possibilities for students’ active participation in the projects and in clinical decision-making.The results of the present study reinforced the results of other research that has found that the implementation of successful EBP education is necessary for students, not only to understand the importance of EBP, but also to be competent in its use, basing their decisions on research results. In essence, the students’ experience contributed to developing professionals who value EBP and have the knowledge and skills to implement this practice, with the ultimate goal of enhancing the delivery of health care for improved patient outcomes .Creating an effective learning experience enables the understanding of evidence, scientific communication, evidence-based practice, and the development of skills. These findings corroborate the notion that active learning experiences that are well structured and that work closely with clinical contexts help construct nursing knowledge ,26, incrIn view of the above, some experts emphasize that joint and active work between academic and clinical educators across healthcare professions is necessary to foster a “real world” pragmatic approach to the integration of EBP education .A systematic literature review identified two key methods for EBP education among nursing undergraduate students: participation in research courses and workshops, and their collaboration with clinical practice, suggesting the incorporation of the five steps of the Sicily statement in these activities . DespiteGiven the above, organizations and nursing leaders can benefit from the development of a comprehensive strategy to promote the involvement of nursing staff in the EBP process by providing continuous education and mentoring programs . FurtherThe content analysis of the discourse of the participants in the two FGs showed that a close working relationship between the educational institution and the clinical settings, the possibility of ‘hands-on’ participation in the projects, and the knowledge translation that emerged in these contexts added value to their research, readings, evidence synthesis, and transfer of knowledge. It also showed the impacts that EBP can have on enhancing care, which tends to confirm that there are important skills and competencies to be learned for EBP, such as evidence-based decision-making, knowing how to ask questions, knowing how to translate knowledge into clinical practice, evaluating research, interpreting results, and communicating science, as has been observed in other studies ,11,26.It is important that students recognize the applicability of the activities they are involved in and that they teach evidence-based decision-making and knowledge translation into clinical practice. Clearly, to achieve significant results, evidence that stems from research (effective innovation) must be accompanied by effective implementation and an enabling context . Future It is worth noting that, in the evaluation of research initiation programs developed by Slattery et al.  and CardWe agree that EBP teaching should be a priority in nursing programs and should be translated into academic and clinical curricula ,11.This study has limitations associated with the nature of the study and the method and data collection technique. The intentional choice of participants and the concrete experience of having participated in the SF project limits the results to the context. The interaction between participants of the FG may have influenced the response to what is socially accepted.Despite the aforementioned limitations, it is reinforced that the qualitative nature of the study allowed us to understand the students’ perspective on the potential of the SF project for the development of skills necessary for EBP. The use of the qualitative analysis software of the findings allowed the organization of the findings and contributes to increase the rigor in the process of analysis, coding, and selection of illustrative excerpts of emerging categories.The two focus groups allowed us to analyze the contributions of the nursing students’ participation in EBP learning through knowledge translation projects in clinical practice. The discourse analysis of the fifteen participants allowed the definition of four categories: learning evidence (n = 94); communicating science (N = 22); evidence-based practice (n = 55); and developing skills (n = 21).The results of this study contribute to the public debate on the importance of EBP in nursing curricula and the need to coordinate the actions of academia and clinical contexts in order to promote the learning and development of skills that increase the scientific literacy of students and contribute to the development of an EBP culture in healthcare institutions.We corroborate the need to introduce content related to EBP in the curricula, using active methodologies that enable the development of skills for the research, synthesis, use, and implementation of evidence in clinical contexts of high complexity.


Drowning is the third cause of worldwide unintentional death in public health. This study aimed to extract the main components from epidemiological studies  for further development of prevention research.The scoping review was based on the Arksey and O’Malley framework. First, the research question was specified. Second, relevant literature was identified, and relevant studies were selected. Then, the data were mapped out. The results were summarized, synthesized, and reported. Finally, expert consultation was conducted. The articles published from the beginning to 2022 which were indexed in PubMed and Web of Science were retrieved using keywords referring to “drowning”. Besides, VOSviewer software was used to explore more data. Subsequently, 64 documents were screened.Death due to drowning is a common event in the world. It occurs firstly due to incautiousness and also due to various conditions like suicide, alcohol consumption, accident, and murder. Low- and middle-income countries, residents of rural areas, people with lower literacy levels, children and teenagers with mothers unfamiliar with swimming skills, and people with poor swimming skills are the most damaged.Teaching drowning prevention is recommended which results in disaster health literacy, a higher understanding of risk, social preventive measures, and community-based participation in all dimensions of the disaster management cycle . The courses can be included in the educational system and other general education programs. Since children are among the groups at risk, it is recommended that health policymakers make the necessary arrangements for tele-education, especially for mothers, to ensure the effectiveness and level of this type of literacy. Moreover, it is suggested to establish an early warning system (EWS) and improve health literacy for increasing awareness and integrating it into this system.Drowning, Epidemiology, Education, Literacy, Disasters