The work of developing clinical practice guidelines began just a little more than ten years ago in China. Up to now, there have been few studies about them.To review and analyze the status of Chinese clinical practice guidelines in 1997–2007.All Chinese guidelines from 1997–2007 were collected, and made a regression analysis, and a citation analysis for evaluating the impact of guidelines. To analyze the developing quality, the most influential guidelines were evaluated with AGREE instrument, and each guideline was evaluated to check for any updating. In order to analyze the objective and target population, all guidelines were classified and counted separately according to disease/symptom center, and whether towards specialists or general practitioners.143 guidelines were collected. An exponential function equation was established for the trend in the number of guidelines. The immediacy index in every year was very low while the average citation rate was not. Both the percentages of highly cited and never cited were high. For the evaluation with AGREE, only the average score of clarity and presentation was high (89.9%); the remaining were much lower. Editorial independence scored 0. Only 27 (18.9%) of 143 guidelines, were found to be evidence-based. Only a few had ever been updated, with an average updating interval of 5.2 years. Only 2.1% were symptom-centered, and only 4.2% were aimed at general practitioners.Much progress has been obtained for Chinese guidelines development. However, there were still defects, and greater efforts should be made in the future. Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances . A large (1) Only those guidelines that were developed by authoritative academic organizations were included. Those by individual suggestions of some specialists were excluded. (2) Guidelines that were translated from foreign ones were excluded for they were not developed in China. (3) Guidelines aimed how to use some medical equipment or how to handle some laboratory test were excluded. (4) The time scope of the search was from 1997 to 2007.Google Scholar, China National Knowledge Infrastructure (CNKI), Wanfang, Vip and the website of Ministry of Health were searched for all the clinical practice guidelines in China (1997–2007). The key words for the searches included Chinese words for terms such as ‘guidelines’, ‘clinical’, ‘clinical practice’, ‘prevention’, ‘diagnosis’ ‘treatment’, and ‘management’. Chinese Medical Citation Index (CMCI) was searched to compile the citation analysis (1997–2007).All the guidelines were recorded on an EXCEL form and were classified by the year when they were developed. A function equation of the number of guidelines according to time was established using SPSS software. According to the equation, the numbers of guidelines in 2008, 2009, and 2010 can be forecasted.CMCI, from 1997 to 2007, was searched to make the citation analysis. But not all the guidelines were collected in it. And the search was done in 2008. Guidelines developed after 2007 have less time to be cited. So the number of the citation would be expected to be less. This is a limitation of the study.Some citing indices such as the immediacy index, the highly cited rate, never been cited rate, and the average citation rate were calculated separately. The formulae and explanations of them are listed in Table For the formula of the immediacy index, the numerator and denominator of the fraction are of the same period, in this study, the year in the formula is designated a calendar year. If the same guidelines were published in different journals, we regard them as one guideline. We only calculated the number of times cited in the year when the guidelines were published for the first time.Those guidelines which were cited more than 30 times were regarded as highly cited guidelines.The highest cited guidelines (having been cited more than 500) were further evaluated using the AGREE I instrument (version 2003)[Each of these guidelines was evaluated across six domains including: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application, and editorial independence. And the standardization of scores (percentage) of them were calculated. Lastly, the average standardization of scores for 7 guidelines for every domain was calculated.All the guidelines were appraised whether they met the criterion that it is mentioned in the document about rating the quality of evidence or grading recommendation strength or having referred to allied evidence-based guidelines abroad in the process of guideline’s development. The percentage of them was calculated.All the guidelines that had been updated were collected and their percentage was calculated. And the average updating interval was obtained through using the sum of all updated interval divided by the total number of all updated guidelines.All the guidelines were divided into disease guidelines (disease center) and symptom guidelines (symptom center), and percentages of them were calculated, and those special for general practitioners were calculated.The total number of documents which were related to guidelines was more than 400. 143 guidelines were selected according to the selection criteria.Some statistics for the number of Chinese guidelines in 1997–2007 were calculated, that are listed in Table 2 (Coefficient of determination) =0.845, Adjusted R2 = 0.827, indicating a good fitting equation.‘F(t)’ represents the number of guidelines; ‘t’ is the number of year ; ‘e’ is the base number of natural logarithm. F value of the function equation is 48.919 (P = 0.000). RAll the actual numbers of guidelines are within the confidence interval as shown in Table From the function equation, the forecasted number of guidelines in 2008, 2009, and 2010 would be 47, 63, and 84 respectively.The Figure A total of 108 guidelines were collected for the citation analysis. The results are listed as below. (1) Immediacy index in every year is listed in Table  (2) The number of highly cited guidelines was 33 (30.6%). Among them respiratory and cardiology medicine had the most guideline with 12 (11.1%) and 6 (5.6%), respectively.The three most cited guidelines were the Guidelines for Prevention and Treatment of Bronchial Asthma (produced in 1997), the Gui (3) 20 guidelines were never cited (18.5%). (4) The average citation rate was 94.3. Different disciplines had different citation rates. The highest were respiratory medicine (429.9) and cardiology medicine (246.1). The average citation rates of most disciplines were between 2.5 and 86. The rates of some disciplines were very low, even 0 or 1.The standardization of scores (percentage) of six domains are listed in Table For all the domains of the seven guidelines being appraised, only clarity and presentation scored highly (89.9%). The remaining scored much lower including scope and purpose (41.3%), stakeholder involvement (10.1%), rigor of development (19.4%), application (23.0%), and editorial independence (0.0%).Editorial independence scored 0 because none of the guidelines provided any information about this criterion, as well as not for stakeholder involvement and applicability in most guidelines. For the domain of stakeholder involvement, only one guideline (i.e. Guidelines for Prevention and Treatment of Hypertension in China) scored 54.2% while two others scored 12.5% and 4.2%, the rest all 0. The average score of scope and purpose was better than other domains (except for clarity and presentation). Of this domain, the item of considering benefits, side effects and risks scored well in most guidelines. However, there was not any information provided in any guidelines for the items of external review and updating. The average score of rigor of development was not satisfactory either (<30%). For the criterion of selecting the evidence only one guideline scored 4, while all the others scored 1. Developers of most guidelines had not rigorously evaluated evidence by themselves.Only 27 (18.9%) of 143 guidelines, were found to be evidence-based. Some of them referred only to the evidenced-based ones from abroad. The developers had not rigorously assessed the evidence by themselves. And there were many guidelines in which the recommendations were not derived from formal consensus methods such as Delphi or Nominal Group Technique.Only 11 guidelines had been updated. For those the updating interval was between 2 and 10 years, with average interval of 5.2 years.Of all 143 guidelines, 140 (97.9%) were aimed at diseases, while only three (2.1%) aimed at symptoms, and only six (4.2%) special for general practitioners. There were not any guidelines aimed at referral between general practitioners and specialists.The study began 4 years ago, so the search for guidelines is just from 1997 to 2007. After that, much time has been used to write and edit this article. And the data has not been updated, which can not reflect the status of guidelines in China of the last 4 years. This is a limitation of the study.There has been an exponential increase in the number of Chinese guidelines during the last decade. Much progress had been made. Because the Chinese Society of Rheumatic Disease developed many guidelines for rheumatic disease in 2003 (t = 7), and the Chinese Society of Osteoporosis, Bone and Mineral Disease also developed many in 2006 (t = 10), a large increase in the number of guidelines was obtained in those two years.The Average Citation Rate is the number of times that all the guidelines having been cited divided by the number of all guidelines. This can reflect a journal’s influence. It is generally said that a journal has high academic impact when the average citation rate is high. The Immediacy Index is the number of times that all the guidelines were cited divided by the total number of guidelines published in the year when the guidelines were published for the first time. The index introduced by Garfield is used to measure the adoption speed. Good journals and good papers will be read and adopted quickly by many persons. These tThe results showed that the average citation rate of Chinese clinical guidelines was rather high (>30). That means the guidelines impact was acceptable. But the Immediacy Index of every year was low what indicated their adoption speed was not rapid. More attention should therefore be given to the dissemination. We can also see the impact difference of the guidelines as well as their quality from the uneven of these cited numbers.It must be admitted that the citation indexes could not completely reflect the guidelines influence as being cited does not equal importance. And as most Chinese guidelines did not include references, the number of citations of other papers used for their development has not been calculated. These are all the limitations of this study.There are accepted guideline evaluation instruments developed by different countries. Examples include the IOM’s “Provisional Instrument for Assessing Clinical Practice Guidelines” (IOM instrument), the “Method for Evaluating Research and Guidelines Evidence” (MERGE instrument), Cluzeau et al’s “Appraisal Instrument for Clinical Guidelines” (Cluzeau instrument), and Shaneyfelt et al’s methodological appraisal instrument (Shaneyfelt instrument). Of all these instruments, a study showed that The Cluzeau instrument was the most well developed and had been tested and described as a reliable and valid method of guideline evaluation.Based on the Cluzeau instrument, AGREE instrument was developed. Up to nMany other studies using the AGREE instrument for guideline evaluation reported the lowest scores in the applicability domain, and the highest in the scope and purpose domain. ContrasEvidence-based guidelines apply the principles of evidence-based medicine to the process of guideline development. The first step is defining the clinical question. This is followed by defining the eligibility criteria for the studies. A systematic search of the literature is then conducted and the evidence is evaluated. In developing recommendations, the likely benefits, risks, inconvenience and costs associated with each treatment must be considered in addition to addressing patients’ underlying values and preferences. The quality of the data supporting the recommendations is evaluated and is reflected in a grading system that describes the strength of the recommendation and the quality of the supporting evidence. This process ultimately results in the systematic development of recommendations that incorporate evidence with patients’ preferences and values and indicates the quality of the evidence.However, in China, there have not been any criteria on how guidelines should be developed. The method of developing Chinese guidelines is less scientific and lags behind the international level. From the results it can be seen that most Chinese guidelines not with the evidence-based method. This makes it difficult to ensure quality. In addition, most Chinese ones have not listed references of important evidence. The user is not therefore able to examine the validity of the recommendations.A ‘valid guideline should be up-to-date. Possible consequences of using out-of-date guidelines include a clinician’s use of diagnostic studies or treatments that do not provide the best-known outcomes. So a goOf all Chinese guidelines developed between 1997–2007, only a few have been updated. And of them the average updating interval is more than three years, falling short of international standards. Because the search was done in 2008, some guidelines developed after 2004 have less time to be updated. So the number of updated guidelines would be expected to be less. This is also a limitation of the study.There is shortage of Chinese guidelines aimed at general practitioners and referral to specialist care. There is also a shortage of aiming at symptoms. This is behind international levels. For instance, in the case of ‘cough’, there is only one guidelines named “Guidelines for Cough Diagnosis and Treatment (Draft) in China”, while there are 24 in America. While general practice is developing in China, more and more general practitioners require guidelines for them, especially of referral and symptom center. Those guidelines should be assigned a priority.This study shows that from amount to quality, much progress has been made of guidelines in China. But it was uneven in different disciplines. There were some problems in the development process and dissemination which should be solved for better effect on practice. The guidelines involving various objectives and target population should be developed in the future to help clinical practice.The authors declare that they have no competing interests.Z-h Z have made substantial contributions to design, acquisition and analysis of data and writing the manuscript, S-q C have made substantial contributions to conception and design, X-q L have made the substantial contributions to design and modify the manuscript, DZ revised the manuscript, W-n L have participated in the drafting the manuscript, FH have contribution to analysis and interpretation of data, X-n C have contribution to acquisition of data, Y-l Z have participated in the design, X-x P have contribution to analysis and interpretation of data, K-q R have participated in the drafting the manuscript, J W have contribution to analysis and interpretation of data. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/218/prepub


Inflammation exists throughout the incidence and progression of Alzheimer's disease (AD). Traditional Chinese medicine (TCM) differentiates the pathogenesis of AD as kidney essence deficiency and qi and blood deficiency as well as blood stasis in syndromes, whose action mechanisms are all associated with the intervention in its inflammatory process. Our preliminary studies both in clinic and in vitro have demonstrated that the syndrome of spleen deficiency and fluid retention has also been an important pathogenesis for the incidence and development of AD. Hence, the paper aims to further illustrate the correlation between inflammatory process in AD and the syndrome of spleen deficiency and fluid retention, laying solid foundation for the application of invigorating the spleen and eliminating the dampness in clinic, and enriching the theoretical connotation for AD prevention and treatment in TCM. The pathogenesis of AD is intricate and remains in inconformity. In past ten years, inflammatory injury, a significant pathological process during AD development, has received considerable attention . Some evα, IL-1β, IL-6,TNF-α, and TGF-β in SP and NFT [β-amyloid peptide (Aβ) induced neurotoxicity in culture and in animal experiments [Since 1994, Mc Gear and Roger.  initiall and NFT ; (4) braeriments , 8; epideriments .β plaques and tangles stimulates an acute inflammatory reaction to clear this debris [β production. This circumstance also inhibited the formation of soluble APP fraction and its neuronal protective effect [β stimulated the expression of proinflammatory cytokines in neurogliocytes [The latest hypothesis sees AD as an inflammatory process in the CNS, during which the intractable nature of the As debris . These ps debris –15. Aggrs debris , 17. Chrs debris . Inflamme effect –24. On tliocytes , 26, theliocytes –29, and liocytes –32.TCM currently considers the pathogenesis of AD a result of kidney essence deficiency –35, qi aα, IL-1β, and IL-6 [β, IL-6, and TNF-α in hippocampus [κB) and C reactive protein (CRP) expression and cutting down the inflammatory reaction in the brain [β and IL-6 in the brain [Modified Sanjia Powder realized its therapeutic effects of AD through relieving the inflammatory factors including IL-1and IL-6 . Dangguipocampus . Modifiehe brain . Liuwei he brain .From the foregoing, TCM realized its therapeutic effects mainly via its effective intervention to the inflammatory process of AD. Accordingly, with reference to TCM clinical and experimental data at home and abroad and in light of the physiopathologic characteristics of the senile, it is proposed that the syndrome of the spleen deficiency and fluid retention also plays a significant role in the incidence and development of AD –46. Plain Questions (Suwen) states that when one reaches thirty-five, qi and blood in the stomach meridian of foot-yangming start to decline with face getting withered and hair beginning to lose, which indicates that the outward manifestation of the spleen and stomach function decline is a key indicator for the physical aging. The saying clearly illustrates the corresponding relation between aging and visceral function declining that heart qi declines in one's sixties⋯spleen qi decreases in his seventies⋯lung qi diminishes in his eighties⋯and kidney qi reduces in nineties⋯from Miraculous Pivot (Lingshu). Despite the fact that a man seldomly lives up to seventy years old before, our ancestors still adopted spleen qi decreasing as a major character for the visceral organ function declining at this age. Hence, in light of the new diagnostic criteria and guideline for AD [It is generally known that our body functions tend to decline as a result of the inevitable aging process.e for AD , 48, whie for AD , 50, spl Collecting Record of Differentiation of Symptoms and Signs (Bianzhenglu) that the incidence of dementia is most probably caused by liver qi stagnation at the very beginning [Meanwhile, modern life style and dietary pattern have also made great impact on the formation of spleen deficiency in the senile , 52. Sineginning , 54. In eginning . To sum The spleen and stomach are the source of qi and blood, origin of acquired constitution, and center for the ascending and descending of qi transportation. Normal function of the spleen and stomach in transportation guarantees the ascending lucidity and descending turbidity, namely, lucid Yang ascending to the upper orifices, turbid Yin being discharged from the lower orifices, lucid Yang spreading into the body surface, turbid Yin flowing to five Zang-organs, lucid Yang replenishing four extremities, and turbid Yin moving through six Fu-organs , 57. Complete Works of Zhang Jingyue (Jingyue Quanshu) state the generation of phlegm and fluid retention as follows: originated from food, it will transform into qi and blood with active spleen and stomach functions, the rest of which will be the phlegm and fluid retention. With phlegm clouding the upper orifices, one may demonstrate language breakdown, intellectual deterioration, mood swings and mumbling, or motionlessness and speechless all day. Having phlegm and fluid retention in the middle-Jiao, one may show poor appetite, shortness of breath and unwillingness to speak, involuntary drooling, distention and fullness, fatigue, and white tongue with greasy coating. As phlegm and fluid flow downward, one can have blockage in the meridians characterized by symptoms such as fatigue, heavy limbs, sluggishness, laziness, and sleepiness.The spleen transportation deficiency can on one hand give rise to source insufficiency for qi and blood generation and later shortness for essence and blood, thus leading to brain marrow emptiness, brain collateral malnutrition, and mental activity disorder, which are characterized by absent-mindedness, lightheadedness, short-term memory loss, and sluggishness in clinical manifestation. On the other hand, the malfunction of the spleen will also bring about the dysfunction of body fluid distribution, which can contribute to phlegm and fluid retention, marked by rapid change and constant movement along with the qi movements, till internal organs and meridians, and external bones and muscles. TheThese pathological changes and symptoms, as consequences of spleen deficiency and fluid retention, share many similarities with the clinical manifestations of AD in Western medicine, namely, loss of cognitive functions, primarily memory, judgment, and reasoning, disorders in movement coordination, pattern recognition and executive function, and even behavior or personality changes. Accordingly, in line with the pathophysiological changes of human organs over time, the author deems that the syndrome of spleen deficiency and fluid retention is a significant pathogenesis for AD. Miraculous Pivot (Lingshu), is closely associated with its immune function in Western medicine. The defensive qi, originating from the essence of water and grain after spleen transportation, is distributed at the fleshy exterior with the function of warming, regulating, and defensing. A famous saying, quoted from Master Zhang Zhongjing, that a healthy spleen can keep one from evils of the four seasons, explicitly points out the significance of spleen in human defensing function. Qi and blood transformation and production insufficiency due to the spleen deficiency could lead to malnourishment of the fleshy exterior and weakening of human defensing strength.Defensing, one major function of spleen as stated inOver the years, more and more scholars have established animal models for the spleen deficiency; therefore, the similarities between inflammation and spleen deficiency in morphology, nonspecific, and specific immunities have been gradually uncovered. The author summarized inflammatory mediators involved in the spleen deficiency animal models and found out that cytokines, oxygen radicals, neuropeptide, and nitric oxide were all closely related to the syndrome of spleen deficiency, which directly certified the tight connection between inflammation and spleen deficiency.Chen et al. noticed that the levels of serums TNF, IL-6, and IL-2 dropped obviously in the spleen deficiency model rats, compared with that in normal control group, indicating that the spleen deficiency destroyed cytokine network regulating system balance . Qian et Plain Questions (Suwen) addresses the metabolism of normal body fluid as follows: once food is taken into the stomach, it transforms into essential substances in solution, which are moved upward to the spleen; spleen qi transports the essence to the whole body, sending lucid essence to five Zang-organs and their relevant meridians and collaterals and sending turbid to the bladder so as to regulate body essence and fluid passage, which echoes the process of blood circulation all over the body and the metabolic waste elimination procedure via the kidney to maintain body fluid and electrolyte stability in Western medicine.Inflammation actually not only is closely related to the spleen deficiency but also has something to do with the phlegm and fluid retention in fundamentals of TCM. Early inOnce the body fluid distribution dysfunction occurs, it can directly bring about phlegm and fluid retention in the body. Meanwhile, the center link for inflammatory process in Western medicine is the big blood vessels, which belong to meridians and collaterals in TCM. In consequence, vascular inflammation is one pathological change taking place in meridians and collaterals; in short, vascular inflammation can result in phlegm and fluid retention . hundreds of diseases are generated from phlegm and fluid retention in clinic. As for the nature of phlegm and fluid retention, Teng believed that, in accordance with its descriptions in Compendium of Medicine (Yixue Gangmu), which includes making people feel dry and itching all over and scorching in skin, extending to other place after scratching, and resulting in colorful spots, it actually shares similarities with the symptoms of type I allergy and can be caused by body fluid permeating into tissue after histamine induced vasodilation [Phlegm and fluid retention, both pathological product and pathogenic factor in TCM, can bring about wide ranges of illness; thus, we have the famous saying thatdilation . Gu helddilation . For insBased on the correlation between inflammation and the syndrome of spleen deficiency and fluid retention, the approach of invigorating the spleen and eliminating the fluid retention has been widely applied in the treatment of inflammatory process in the relevant brain diseases, which in turn provided clinical evidences for constructing the network of inflammation-spleen deficiency and fluid retention.P < 0.05), which indicated that this approach was obviously effective in clinical treatment of AD. To sum up, the syndrome of the spleen deficiency and fluid retention is a prominent risk factor for brain relevant illness and the method of invigorating spleen and eliminating excess fluid has presented good clinical significance for these diseases.Sun and Liu prescribed Jianpi Yiqi Huatan Decoction to treat 76 cases of Meniere's syndrome from out-patient department and the overall effective rate was 94.74% . Wang et Treatise on Febrile and Miscellaneous Diseases (Shanghanlun), is a classical formula for the treatment of this syndrome. Thus, the author summarized and studied the anti-inflammatory function of LGZGD in clinic and experiments.So far, a close relationship between inflammatory injury during AD development and the syndrome of the spleen deficiency and fluid retention has been established. Ling Gui Zhu Gan Decoction (LGZGD), originating fromP < 0.05), suggesting that modified LGZGD can increase the cure rates for Meniere's disease and reduce its recurrence rate.Wang observed the clinical effects of modified LGZGD  in the treatment of 47 cases of Meniere's disease from out-patient and in-patient departments . The resLi reported the effects of modified LGZGD  in the treatment of vascular nerve headache . Ten dayBased on the previous clinical study, our research group conducted experiments concerning its anti-inflammatory and protective effects on neurocytes, which further verified the close relationship between inflammatory injury and the syndrome of the spleen deficiency and fluid retention in AD.β, IL-6, and TNF-α, Aβ1−42 induced BV-2 microglia cell line was cultivated by Xi et al. and then intervened with LGZGD at different concentrations  [β, IL-6, and TNF-α were detected with ELISA. The results demonstrated that, compared with model groups, the levels of IL-1β, IL-6, and TNF-α in LGZGD group decreased, with high concentration group  showing significant reduction (P < 0.01), which indicated that LGZGD could inhibit the levels of IL-1β, IL-6, and TNF-α produced by Aβ1−42 induced BV-2 microglia cell line, and its good anti-inflammatory effect could be an important mechanism.To study the inhibitive effects of LGZGD on the production and release of proinflammatory cytokines IL-1−6 g/mL) . Later tβ25−35 induced SH-SY5Y cells in vitro to establish AD cell model and evaluate the protective effects of LGZGD on neurocytes injuries [−3, 1 × 10−4, 1 × 10−5, and 1 × 10−6 g/mL) were significantly higher than those in model group (P < 0.05) and normal control group (P < 0.01) dose-dependently, which suggested that LGZGD did have protective effects on Aβ25−35 induced SH-SY5Y injury in positive correlation.Sang cultivated Ainjuries . The resIn this research work, we provide a detailed explanation regarding the development and significance of the syndrome of spleen deficiency and fluid retention in the senile and how it correlates with the neuroinflammation in AD with reference to basic scientific studies in vitro and in vivo and relevant case reports from in-patient and out-patient departments. So far, close relationships between AD inflammation and spleen deficiency, AD inflammation and phlegm retention, and between spleen deficiency and phlegm retention have been clarified. Thus, the network of AD Inflammation-the syndrome of spleen deficiency and phlegm retention has been successfully established, which not only broadens TCM's vision of understanding AD, but also illuminates the pathological nature of the syndrome of spleen deficiency and fluid retention. Treatise on Febrile and Miscellaneous Diseases (Shanghanlun), LGZGD, a carrier with double functions, invigorating spleen, and eliminating dampness in the light of TCM and anti-inflammatory effect in view of Western medicine, was then selected to verify the above network, which demonstrated a new approach for the treatment of AD in clinic from the perspective of integrated Chinese and Western medicine and is complementary to the shortcomings and limitations of kidney-oriented treatment already existing.Hence, in accordance with classic syndrome differentiation theory inβ-mediated toxicity and cytokine imbalance in cells from histocytological or even molecular level. One limitation of the current study is that neuroinflammation is an important and prevalent pathogenesis for the incidence and development of AD but surely not the only one. Accordingly, when establishing animal or cell models, we can only partially imitate the pathogenesis of AD happening in real human brains. However, with the multitargeted effects of TCM, we feel positive that more and more underlying signal paths and action mechanisms will be uncovered.As a future work, the researchers are encouraged to explore the underlying mechanism of LGZGD inhibiting A


FGFR1 and TIF1 genes.Chromosomal rearrangements in acute myeloid leukaemia (AML) frequently give rise to aberrant fusion proteins, responsible for the disease onset . Five per cent of such cases harbour rare rearrangements, mostly translocations, resulting either in new rare fusion products or in the deregulation/truncation of specific genes. In this specific case, a new rearrangement between chromosomes 7 and 8 gives rise to a new abnormal fusion product between the in situ hybridization (FISH) can be used to evidence the presence of such a rearrangement, by selecting genomic clones mapping in the chromosomal region that contains the breakpoint. The presence of the rearrangement can be detected in both interphase and metaphase nuclei. In the shown image, the clone 350N11, spanning the FGFR1 locus, has been labelled in red and used to hybridize interphase and metaphase nuclei  on bone marrow cells derived from the patient. The presence of three signals indicates the clone is recognizing the normal chromosome 8, as well as the two derivative chromosomes 7 and 8, proving the presence of the breakpoint within this gene.Fluorescence


Dirofilaria immitis and Dirofilaria repens are key examples of the success of VBH spreading into non-endemic areas, another example is represented by Thelazia callipaeda eyeworm, an emergent pathogen of dogs, cats and humans in several regions of Europe. The recent finding of Onchocerca lupi causing canine and human infestation in Europe and overseas renders the picture of VBH even more complicated. Similarly, tick-transmitted filarioids of the genus Cercopithifilaria infesting the skin of dogs were recently shown to be widespread in Europe. Although for most of the VBH above there is an increasing accumulation of research data on their distribution at national level, the overall impact of the diseases they cause in dogs and humans is not fully recognised in many aspects. This review investigates the reasons underlying the increasing trend in distribution of VBH in Europe and discusses the diagnostic and control strategies currently available. In addition, this article provides the authors’ opinion on some topics related to VBH that would deserve further scientific investigation.Presently, 45% of the total human population of Europe, as well as their domestic and companion animals, are exposed to the risk of vector-borne helminths (VBH) causing diseases. A plethora of intrinsic biological and extrinsic factors affect the relationship among helminths, vectors and animal hosts, in a constantly changing environment. Although canine dirofilarioses by  A large number of vector-borne helminths (VBH) are prevalent in Europe, and some of them are of growing importance due to the significant level of disease they cause in dogs and humans -3. PreseDirofilaria immitis and Dirofilaria repens  are probably the best known. Indeed, D. immitis has a severe impact on veterinary medicine, because of the heartworm disease threatening dogs and cats, whereas D. repens, causing subcutaneous infestation in dogs, is the main agent of human dirofilariosis. Although Dirofilaria spp. above represent key examples of the success of this group of parasites in spreading into non-endemic areas, over the last ten years other zoonotic helminths, such as Thelazia callipaeda eyeworm  have been accounted as emergent VBH of animals and humans in several Europe regions , Culex pipiens pipiens  or ticks  to dogs, A. reconditum completes its life cycle in and is vectored by fleas  or lice  with a rate of infestation in fleas of about 5%   . Indeed,aegypti] . Growingmosquito . Therefon season .St. albopicta   and Ochlerotatus caspius, Culex pipiens quinquefasciatus, An. maculipennis, Oc. caspius, Culiseta annulata, Ochlerotatus scapularis, Culex declarator and Cx. p. pipiens) than cats , which is a potential vector of D. immitis in Belgium [D. immitis infestation [Prevalence of microfilaraemic dogs and presence and abundance of competent vectors also affect the rate of infestation within a given mosquito population, which, in turn, is directly related to the risk for a native dog to be infested. In an endemic area of north-eastern Italy out of 40,000 culicids captured from May to October, and screened for and site . In the ectively . By combthe year . Stegomy. immitis,73 and oD. repens is activ Belgium  and nort Belgium . This spestation ,77. OtheD. immitis mainly in Italy, France and Portugal [Dirofilaria spp. On the contrary, red foxes (Vulpes vulpes) were found infected by D. immitis in Italy, Spain and Bulgaria [D. immitis, 0.7% of D. repens, 15% of A. reconditum and 2.3% of A. dracunculoides[D. immitis are wolves (Canis lupus), in Belarus, Italy and Spain [Canis aureus) in Bulgaria [Lutra lutra) in Portugal and Spain [D. immitis in ferrets (Mustela putorius putorius) has also been reported [In Europe, cats were found infected by Portugal . In ItalPortugal . HoweverPortugal . Due to Bulgaria , with prBulgaria . In Italnculoides. Other hnd Spain ,81, jackBulgaria  and ottend Spain . The firreported , with a T. callipaeda, the reasons underlying the steady spread of this nematode throughout many European countries are not clearly understood, but it seems that the same zoonotic strain of T. callipaeda circulates in the continent within different animal species and humans [T. callipaeda in foxes (49.3%) as well as in other wild carnivore species  in some areas of southern Italy where canine thelaziosis is highly prevalent  indicates the status of hyper-endemicity of eyeworm infestation in this area and the primary role foxes play as reservoirs of the infestation [P. variegata nicely overlaps the behaviour of those wild species hosts. The aforementioned ecological considerations are supported by molecular data on the occurrence of a single haplotype  of T. callipaeda among different host species in the study area [P. variegata indicate a high level of affinity of the nematode for its vector [T. callipaeda and indicate that the infestation is mainly maintained by a large number of wildlife species that, altogether, could play a role in spreading the disease in many previously non endemic areas of Europe [In the case of d humans . The occestation . The seaudy area . The samudy area . These ms vector ,19,85 anf Europe ,13-16,86D. immitis and D. repens probably represent the species more frequently reported in humans where they are detected predominantly in the subcutaneous tissues, pulmonary vessels, testicles and also in the central nervous system, causing a range of clinical manifestations from asymptomatic to, more rarely, fatal syndromes [Dirofilaria spp. often induce nodular lesions, which may be erroneously diagnosed as cancers, hence representing a further challenge to physicians [D. immitis is the main agent of human dirofilariosis in the Americas [D. repens has been accounted for a long time as the sole species that infest humans in Europe [D. immitis were reviewed and re-attributed to D. repens[D. immitis have been recently described in Italy, Greece and Spain [O. lupi, which has probably been misdiagnosed for a long time with other filarioids localizing in the eyes. Indeed, O. lupi has only been suspected to act as a causative agent of infestation in humans until recently [Among the zoonotic filarioids, yndromes ,2,66. InAmericas ,66, D. rn Europe ,88. For nd Spain -91 and tnd Spain ,7,48-52.recently , when threcently ,93. Humarecently . The firrecently  and Spairecently , where trecently ,14,16. TO. lupi) and the possibility of misidentifications, the impact of VHD on human populations in Europe, mainly in remote rural areas, is much likely underestimated at present.Considering the lack of awareness for physicians concerning such exotic parasites  has been debated for long time [D. immitis infestation in dogs promoted by the European Scientific Counsel on Companion Animal Parasites (ESCCAP) and by the American Heartworm Society (AHS) suggest extending treatment to 7–8 months or even the year round. The rationale for that relies on the occurrence of certain mosquito vectors, such as St. albopicta, which may survive in temperate areas as adults even during winter and, at least, for nine months per year [Ivermectin is licensed in the Europe to prevent infestations by stration ,96. The ong time -99. Currper year .D. immitis infestation showed a decrease in the prevalence of infestation of unprotected dogs living in the same area, through the reduction of reservoir host population. This is the case of some areas of northern Italy where D. immitis was regarded as hyper-endemic until 20 years ago, whereas its prevalence decreased over the last decades [A. reconditum, A. dracunculoides and Cercopithifilaria spp.) infesting dogs. Consequently, their prevention currently mostly relies on the vector control [T. callipaeda by the use of bed nets has been recommended for avoiding human infestation [P. variegata.In addition, the use of broad-spectrum drug formulations enhance owner compliance and assist continued control of other helminths  and of c decades . Based o decades . No data control . Preventestation . No infoD. immitis if administered monthly at the preventive dosage of 6–12 μg/kg for not less than 16–30 months [extra label use of macrocyclic lactones as primary adulticides albeit their partial efficacy against microfilariae [Wolbachia rickettsial endosymbionts. Treatment with tetracyclines has been reported to damage D. immitis, even causing death of adult worms [D. immitis[The arsenical melarsomine dihydrochloride is the adulticide compound used for the treatment of canine heartworm, associated to confinement of dogs in cages during and for about a month after the treatment period, in order to prevent potentially fatal pulmonary thromboembolism after the death of the heartworms. Melarsomine is usually injected intramuscularly at the dose of 2.5 mg/kg either in a two-step (first intramuscular injection followed by the second 24 hr later) or three-step (first injection followed by the two-dose protocol 4–6 weeks later) regimen. Even though the three-dose scheme is indicated for those animals with a relevant risk of pulmonary thromboembolism post-treatment, this protocol is recommend by the AHS guidelines for the therapy of all infected dogs . Ivermec0 months . Howeverfilariae . In factfilariae ,104. Thefilariae ,105. A nlt worms . Long-la. immitis,108.D. immitis, are considered less clinically relevant, microfilaricide treatment is required to control D. repens microfilaria-associated syndromes  and to decrease the risk of human and animal infestation in endemic areas. However, only little information is available for the treatment of subcutaneous filariosis by D. repens, such as a combination of injectable melarsomine and oral administration of macrocyclic lactones [D. repens is reputed effective [D. repens infection, including potential ability to kill adults, after a single administration [Although other filarioids of dogs, but not lactones . The useffective ,111. Thestration -114. Surstration .A. reconditum, A. dracunculoides and Cercopithifilaria spp.), are considered clinically irrelevant, microfilaricide treatment should be always advocated to limit the reservoir function of infected hosts. Though reports on microfilaricide treatment for minor species are scant, evidence suggests that macrocyclic lactones  are effective against patent infestation when administered at the same dosage recommended for D. immitis[Although minor species of filarioids infesting dogs, . Key diagnostic features are differences in morphology and size measurements of particular structures. Head of D. immitis is slightly tapered, while that of A. reconditum and D. repens is blunt. The use of fixation in 2% formalin in the Knott’s test can cause a distinctive artefact in the tail of A. reconditum and D. repens which become curved (“button-hook” or “umbrella” tail), while that of D. immitis remains straight [A. reconditum and D. repens larvae present a straight tail cannot be ruled out. Hence, the body length becomes discriminatory for the identification at the species level. Indeed, microfilariae of D. immitis are 260–340 mm in length and 5–7.5 mm in width, while those of D. repens are longer and slightly wider (325–380 × 5–8 mm) and those of A. reconditum are smaller and thinner (240–290 × 4.5–5.5 mm) [D. immitis[D. immitis infestation in dogs is the use of commercial kits for the detection of antigens released in the blood by adult females. However, some microfilaraemic animals may score negative at these tests for the low worm burden or for the persistence of microfilariae after the death of adult worms [Laboratory diagnosis of infestations caused by d method . Blood cstraight ,124. Giv–5.5 mm) ,124. How. immitis. An altelt worms ,112,113.lt worms .O. lupi and Cercopithifilaria spp. can be detected by skin biopsies. Interestingly, it has been demonstrated that microfilariae of the latter species are unevenly distributed on the body of an infected dog with, however, higher frequencies on the interscapular region and on the head, where the tick vectors usually attach [Cercopithifilaria spp., two still unidentified at the species level, may infest dogs. However, dermal microfilariae of these three species can be differentiated morphologically based on their length and presence/absence of lateral alae [Dermal microfilariae of y attach . It shoural alae .D. immitis, D. repens and A. reconditum may be amplified and analysed with a restriction fragment length polymorphism, specific PCR amplifications or with primers yielding species-specific amplicons [D. immitis and D. repens and their quantification in blood samples and mosquitoes [D. immitis, A. reconditum and D. repens and of Cercopithifilaria spp. has also been shown to be useful for their molecular detection and differentiation in blood and skin samples [Cercopithifilaria affecting dogs might be discriminated from each other by differences in mitochondrial cox1 and ribosomal 12S sequences [Recent molecular-based assays have been reported for the unequivocal identification of filarioids, irrespective of their life cycle stage. Ribosomal or mitochondrial DNA sequence fragments of mplicons ,127 and mplicons ,128,129.squitoes . A multi samples . Finallyequences .D. immitis and D. repens), most of them have only been recently known to science, thus they remain enigmatic in many ways. The increasing trend of VBH in Europe is most likely due to the spreading process of several arthropod vector species and highlights the need for actions focussing on control of the vectors in the environment and the protection of animals at individual and population levels. Indeed public health authorities should be concerned about the potential risk of introduction and establishment of new and exotic vectors, which may alter the VBH scenario in a manner that may not be easily foreseeable.Although great scientific achievements have been gained over the past decades on several aspects of the biology, epidemiology, control and treatment for many VBH  and ban the aerial use of insecticides  0010) within the European Union. Since the range of alternatives is limited, identifying novel control strategies is essential.The authors declare that there are no competing interests.DO conceived the review and wrote the first draft of the manuscript with GC, DP, FD-T, EB, CG, DT. All authors equally contributed with the revision of the manuscript. EB elaborated figures. All authors read and approved the final version of the manuscript.


Clinical practice guidelines (CPGs) have become increasingly popular, and the methodology to develop guidelines has evolved enormously. However, little attention has been given to the updating process, in contrast to the appraisal of the available literature. We conducted an international survey to identify current practices in CPG updating and explored the need to standardize and improve the methods.We developed a questionnaire (28 items) based on a review of the existing literature about guideline updating and expert comments. We carried out the survey between March and July 2009, and it was sent by email to 106 institutions: 69 members of the Guidelines International Network who declared that they developed CPGs; 30 institutions included in the U.S. National Guideline Clearinghouse database that published more than 20 CPGs; and 7 institutions selected by an expert committee.Forty-four institutions answered the questionnaire (42% response rate). In the final analysis, 39 completed questionnaires were included. Thirty-six institutions (92%) reported that they update their guidelines. Thirty-one institutions (86%) have a formal procedure for updating their guidelines, and 19 (53%) have a formal procedure for deciding when a guideline becomes out of date. Institutions describe the process as moderately rigorous (36%) or acknowledge that it could certainly be more rigorous (36%). Twenty-two institutions (61%) alert guideline users on their website when a guideline is older than three to five years or when there is a risk of being outdated. Twenty-five institutions (64%) support the concept of "living guidelines," which are continuously monitored and updated. Eighteen institutions (46%) have plans to design a protocol to improve their guideline-updating process, and 21 (54%) are willing to share resources with other organizations.Our study is the first to describe the process of updating CPGs among prominent guideline institutions across the world, providing a comprehensive picture of guideline updating. There is an urgent need to develop rigorous international standards for this process and to minimize duplication of effort internationally. Clinical practice guidelines (CPGs) have become increasingly popular over the last two decades. In parallel, the methodology to develop guidelines has evolved enormously ,2. MajorIn guideline programs, the updating of guidelines is often scheduled irregularly . Althoughttp://www.guiasalud.es, an organization created in 2002 to promote the development and use of evidence-based guidelines and other tools for improving quality of care in the Spanish Health System. Following these objectives, a common methodology for producing, implementing , and updating CPGs has been developed [A significant step forward is the synthesis of available research on updating of CPGs included in the handbook of the Programme of Clinical Practice Guidelines in the Spanish National Health System. This programme is coordinated by GuíaSalud eveloped -12. WithWe employed a cross-sectional design for this study.Our study population included key informants and experts affiliated with organizations dedicated to CPG development.http://www.g-i-n.net/ that declared that they developed CPGs, (b) institutions included in the U.S. National Guideline Clearinghouse http://www.guideline.gov/ that had published more than 20 CPGs, and (c) institutions additionally selected by an expert committee based on relevance. The expert committee was composed of 12 health professionals and methodologists with experience in the field of guideline methodology and information specialists. We sent an email to each institution through the address identified via the internet. If the person receiving this email was not the person responsible for this matter, we requested that it be forwarded to whoever they considered appropriate within that institution to answer the survey.We selected participant institutions in spring 2009 using the following criteria: (a) members of the Guidelines International Network We designed a self-administered survey , the second was dedicated to the process of guideline updating (16 items), the third was aimed at the way users are alerted about guideline updates (two items), and the last domain focused on the future perspective on guideline updating (five items). Nineteen items included a free text area in order to gather comments or additional information.http://www.surveymonkey.com. The survey was pilot tested among five institutions . Their feedback was used to refine the survey for optimal understanding. Between March and July 2009, we sent the survey via email to persons of selected institutions. We sent three reminders at intervals of four weeks to those institutions that had not responded. Questionnaires with no response on more than 20% of the items were returned with the request to complete the questionnaire.Specific software was used to design the survey and to collect the responses Descriptive statistics were used to analyze the data. We calculated absolute frequencies and proportions for all items. We evaluated nonresponding institutions and compared their contact source , country, and number of CPGs produced with responding institutions using Fisher's exact test or Mann-Whitney U test . We finally excluded from the analysis four items .One hundred and fourteen institutions met at least one of the inclusion criteria. We contacted 106 of these institutions by email. We received a reply from 44 institutions (42% response rate) after three reminders. In the final analysis, we included 39 questionnaires. Five questionnaires were excluded because more than 20% of the questions were not answered , country of origin (Fisher's exact test p = .283), and the number of guidelines produced (Mann-Whitney U test p = .07).Characteristics of the responding institutions are presented in Table Sixteen institutions (44%) reported that they check more than five guidelines for the need for annual updating, some institutions reported variable figures n = 10, 28%), and the remaining 10 (28%) reported that they check five or less per year  and a rigorous process for guideline updating (Fisher's exact test p = .039) than are institutions who have been developing guidelines for 10 or less years (Table Twenty-six institutions (72%) described the process as moderately rigorous or acknowledged that it could certainly be more rigorous. Institutions that have been developing guidelines for more than 10 years are more likely to have a formal updating procedure (Fisher's exact test Institutions tend to check and review different parts of the guideline when deciding about the need to update a guideline. Twenty-nine institutions (81%) said they check all recommendations and the full guideline text. Less frequently, key questions and recommendations, supplementary annexes, and patient information are checked. The institutions use several search strategies Table . Twenty Twenty-five institutions (64%) supported the concept of "living guidelines" Table , definedOur study is the first international survey about the process of updating CPGs among guideline institutions across the world. Although most institutions reported having a process for updating guidelines, the process is not standardized and could be more rigorous. Many guideline developers, including those with long-standing experience, reported that they have plans to improve this process. Others are waiting for more evidence before modifying their current system.Surprisingly, half of the organizations do not have a formal process for deciding when a guideline becomes outdated. Guideline developers need to recognize this limitation when promoting guidelines as support tools for the practice of evidence-based medicine. Similarly, guideline users should be cautious when relying on guidelines of a certain age. This lack of rigor in methodology in general was recently found in a systematic review about the quality of guidelines in the last two decades ,14. On tThe majority of institutions support the concept of living guidelines. However, this type of guideline development is regarded as very labour intensive and resources may be insufficient. This modality could make more sense in fast-changing fields such as AIDS, cardiovascular risk management, and breast cancer. Guidelines on other topics, such as venous ulcer or sinusitis, may need less frequent updating. Some responders emphasized that guideline updating should be tailored to the topic in order to optimize the efficient use of resources Figure .A noted limitation of frequent updating of guidelines is that notifications of each update could be burdensome for developers and users Figure . Users' de novo guidelines. Research in the field of guideline updating is scarce. There is an urgent need for valid tools to estimate the rate of new relevant findings related to the topic of the guideline and for efficient search strategies to track new research evidence. In addition, more knowledge is needed about the best method to reach end users when guidelines are out of date and when guidelines are updated.Sufficient funding is important for appropriate guideline updating. Guideline organizations that are structurally embedded within the countries' healthcare system and funded by the government, such as the National Institute for Health and Clinical Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN), have more rigorous updating procedures. In organizations with fewer resources, funding is only available for developing Our survey shows that institutions consider guideline updating to be time consuming and resource intensive. Despite the limitations described above, over half of the institutions surveyed are eager to share the burden and work with peer institutions. International collaboration could further help to avoid duplication of effort. Some institutions suggested that a forum to discuss and share updating experiences would be helpful Figure . The GuiWork is being duplicated around the world, with institutions failing to work jointly, consolidating networks around health topics or fields. Timidly but progressively, international collaboration on guideline development and updating for chronic obstructive pulmonary disease (COPD) has been initiated recently . In the This study has a few limitations. First, the response rate was rather low, despite sending three reminders. Nevertheless, our survey included the most prominent guideline organizations, like NICE, SIGN, the United States Preventive Services Task Force, and the New Zealand Guidelines Group .Click here for file


Consumer eHealth interventions are of a growing importance in the individual management of health and health behaviors. However, a range of access, resources, and skills barriers prevent health care consumers from fully engaging in and benefiting from the spectrum of eHealth interventions. Consumers may engage in a range of eHealth tasks, such as participating in health discussion forums and entering information into a personal health record. eHealth literacy names a set of skills and knowledge that are essential for productive interactions with technology-based health tools, such as proficiency in information retrieval strategies, and communicating health concepts effectively.We propose a theoretical and methodological framework for characterizing complexity of eHealth tasks, which can be used to diagnose and describe literacy barriers and inform the development of solution strategies.We adapted and integrated two existing theoretical models relevant to the analysis of eHealth literacy into a single framework to systematically categorize and describe task demands and user performance on tasks needed by health care consumers in the information age. The method derived from the framework is applied to (1) code task demands using a cognitive task analysis, and (2) code user performance on tasks. The framework and method are applied to the analysis of a Web-based consumer eHealth task with information-seeking and decision-making demands. We present the results from the in-depth analysis of the task performance of a single user as well as of 20 users on the same task to illustrate both the detailed analysis and the aggregate measures obtained and potential analyses that can be performed using this method.The analysis shows that the framework can be used to classify task demands as well as the barriers encountered in user performance of the tasks. Our approach can be used to (1) characterize the challenges confronted by participants in performing the tasks, (2) determine the extent to which application of the framework to the cognitive task analysis can predict and explain the problems encountered by participants, and (3) inform revisions to the framework to increase accuracy of predictions.The results of this illustrative application suggest that the framework is useful for characterizing task complexity and for diagnosing and explaining barriers encountered in task completion. The framework and analytic approach can be a potentially powerful generative research platform to inform development of rigorous eHealth examination and design instruments, such as to assess eHealth competence, to design and evaluate consumer eHealth tools, and to develop an eHealth curriculum. The objective of this study was to explore how eHealth literacy can be systematically analyzed, measured, and quantified. We proposed a methodological and theoretical framework that systematically maps skill sets to successful performance of eHealth tasks. We employed a microanalytic strategy in which complex competencies can be broken down into constituent skills or local task demands. In our view, systematic understanding of the necessary competencies can inform development of targeted solution strategies to overcome skill- and knowledge-related barriers.The term eHealth refers to “health services and information delivered or enhanced through the Internet and related technologies” . ConsumeMany different factors can inhibit consumers’ meaningful use of eHealth tools, including environmental barriers , physicaThere is a divide between what consumers can reasonably be expected to do and the demands and available resources of different tools. Various research efforts, in areas such as educational media, health literacy, and numeracy research, have tried to bridge this gulf by addressing user knowledge and competence, and improving resources. Addressing access and skills barriers has helped underserved and vulnerable populations to use technology in terms of managing their health concerns ,21. TherOur approach is an effort to make this a more tractable problem by identifying candidate explanatory constructs and employing cognitive task analysis (CTA) methods to new applications. To the best of our knowledge, this is a unique effort to introduce systematicity to this complex and ill-defined research space. In our view, the success of consumer health informatics initiatives is partially predicated on an understanding of eHealth literacy demands and competencies.In this research, we endeavored to develop a systematic approach to analyzing competencies across eHealth interventions. The objective of this research was to understand the core skills and knowledge needed to productively use eHealth tools and to develop a set of methods for analyzing eHealth literacy. Previously, we presented a preliminary sketch of our framework for characterizing eHealth literacy task demands . In thisThe approach draws on two established models: the eHealth literacy model and Bloom’s taxonomy of educational objectives. eHealth literacy is defined as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem” . The eHeIn our framework, we adapted the eHealth literacy model proposed by Norman and Skinner in 2006 as a point of departure. Their model describes six components of eHealth literacy :Computer literacy describes a wide range of skills from basic knowledge of using a computer, such as opening a browser window, to participating in social networking activities.                            Information literacy encompasses the skills to articulate information needs, to locate, evaluate, and use information, and to apply information to create and communicate knowledge [                            nowledge .Media literacy is the ability to select, interpret, evaluate, contextualize, and create meaning from resources presented in a variety of visual or audio forms [                            io forms .Traditional literacy and numeracy encompasses reading and understanding written passages, communicating and writing a language coherently, quantitative skills, and the ability to interpret information artifacts such as graphs, scales, and forms [                            nd forms ,30.Science literacy includes familiarity with basic biological concepts and the scientific method, as well as the ability to understand, evaluate, and interpret health research findings using appropriate scientific reasoning [                            easoning .Health literacy is the acquisition, evaluation, and appropriate application of relevant health information that allows consumers to communicate about health, make health decisions, and use health services [                            services ,32.Although this model of eHealth literacy is not inclusive of all factors that may influence the use of eHealth , it is our contention that these six literacy types constitute the set of core skills and knowledge domains.We selected a second model that explains variation in task performance along an increasing continuum of cognitive demands. Bloom’s taxonomy is a well-known taxonomy developed in 1956 and was revised and updated in 2002 . The taxRemembering is retrieving, recognizing, and recalling relevant knowledge from long-term memory.                            Understanding includes constructing meaning from oral, written, and graphic messages through interpreting, classifying, summarizing, inferring, comparing, and explaining.                            Applying involves using knowledge to execute a procedure.                            Analyzing comprises breaking material into constituent parts, and determining how the parts relate to one another and to an overall structure or purpose.                            Evaluating involves making judgments based on criteria and standards.                            Creating consists of putting elements together to form a coherent or functional whole in a new pattern or structure.                            An overlay of Bloom’s taxonomy across the six eHealth literacies provides a framework to characterize and describe the different levels of cognitive demands within each of the six facets of eHealth literacy. It provides a structure to the analysis of human performance on eHealth tasks, allowing a differentiation of cognitive processes as well as of level of knowledge and skill.The aim of this study was to characterize the constituent elements of eHealth literacy in performing tasks. The hypothesis was that this method can be used to elucidate the barriers to effective task performance.The framework can be expressed as a matrix with the six facets of eHealth literacy along one axis and the six levels of complexity along the other axis, resulting in 36 combined categories. In our framework, we further separated the category of traditional literacy and numeracy into reading, writing, and numeracy and analyzed each separately, as shown in reading literacy, and then determined that reading is required at the a                    pplying level of complexity to use the information in the passage appropriately. The step also required information literacy at the u                    nderstanding level of complexity to be able to meet the appropriate information need while reading the passage. Most steps require more than one type of literacy.To characterize eHealth literacy demands, we employed CTA, a cognitive engineering method that decomposes a task to uncover knowledge, goal structures, thought processes, and strategies underlying task completion ,36. ExpeIn prior work, we illustrated the application of the framework analysis with CTA of three information-seeking tasks . When apIn the second step of our method, we recruited 20 users to perform the same tasks and observed their performance. These individuals were active computer users but had no previous experience using the website employed in the study, the Consumer Reports Health website , a resource that helps consumers make evidence-based decisions related to health issues.Participants were asked to verbalize their thoughts  while completing the task and to explain their answers. The think-aloud protocol can reveal any hesitation, confusion, or misunderstanding while completing the task . It can A step-by-step analysis of the participants’ performance was done based on the audio recording, video capture, and notes taken during observation of the session. The measures employed were (1) accuracy of response to each question in the task, and (2) any barriers encountered at each step toward completing the task. Task responses were scored according to a scoring scheme comprising specific criteria defining scores of 0 (incorrect), 1 , or 2 (correct). In our analysis, barriers were defined as events where participants struggled and may have been unable to make progress in the task or may have required some problem-solving steps before moving forward in the task. Barriers may be indicated when participants required prompts, asked questions, or made errors. A prompt was noted if the researcher provided some verbal assistance to participants, such as directing them to appropriate information or reminding them about the next step of the task. Questions occurred when participants asked a question, expressed confusion, or requested guidance from the researcher. An error was documented if there was a misstep or misinterpretation of information or system response, such as misunderstanding search results. For each barrier event, the framework coding could be applied to categorize the nature of the participant’s problem in terms of a type of literacy. For example, difficulty with scrolling would be categorized as difficulty with a computer literacy skill, whereas struggling with text passages would be categorized as difficulty with reading skills. We also matched each event with the corresponding step in the task completion process in which it occurred.We applied these methods to the analysis of a particular task that required a series of information-seeking and decision-making steps. We selected the Consumer Reports Health website because, in our judgment, it is a high-quality and well-designed site that reflects a genuine understanding of consumers’ needs. The task question see  asked usIn the Doctors & Hospitals page, read the article “How-to guide to choosing a hospital” which can be found at the bottom of the page.all hospitals in the New York, NY region.Look up the hospital ratings for use the Compare feature to compare New York Presbyterian Hospital, Lenox Hill Hospital, and Bellevue Hospital Center.Next, on the ratings page, Identify the hospital that is least aggressive on the “Aggressive or Conservative” scale.What do these ratings of “Aggressive or Conservative” tell you about the hospital?Identify the hospital with the highest “Average Cost to Patient”.Of these 3 hospitals, select the hospital that you would want to go to for a surgical procedure, and discuss what criteria are most important in your decision.                    To illustrate the application of the framework and method, we present the results from the analysis of the task question asking about hospital ratings.Interrater reliability was calculated for coding of the CTA. Cohen's kappa for literacy was .91 and Spearman correlation coefficient for cognitive complexity was .92, suggesting high levels of agreement for both dimensions. Completing these series of steps required the participant to navigate to the table, locate the relevant information, and interpret the data in the table. The aggressive/conservative scale see  correspo                    The framework coding was then applied to the task performance. Interrater reliability was calculated for the coding of task performance. Spearman correlation coefficient for cognitive complexity was .88, suggesting high agreement. Cohen's kappa for literacy was .68, suggesting lower but sufficient agreement to meet the minimum standard. The results from a single user are displayed in apply the knowledge and analyze it in different representational formats. Then in step 16, the participant provided an incorrect answer. The participant was unable to read, interpret, and analyze the health text to extract an accurate description of the terms aggressive and conservative as used in this context; this barrier reflects a struggle with health literacy. The participant required several reminders or explanations of task questions, in steps 11, 13, and 15. These reminders and explanations indicated information literacy barriers, reflecting a lack of recognition and understanding of the nature of the information need.This participant scored low on this task, earning 2 out of a total of 6 possible points. The participant encountered 18 barriers while completing this task. In step 10, the participant was looking for a specific piece of information but was on the wrong page; this barrier can be attributed to problems or deficiencies associated with information and computer literacies. In step 14, the participant was confused by the scale and provided an incorrect answer due to misinterpretation of the information presented in the aggressive/conservative scale. This barrier reflects a struggle with numeracy because the participant demonstrated an understanding of numbers as evidenced by the ability to draw inferences about the scale, but was unable to A summary of 20 users’ task performance results are presented to illustrate the aggregate measures obtained and potential analyses that can be performed using our approach. The users were recruited from the Union Settlement Association and the Columbia Community Partnership for Health Center in New York, NY.Participants recruited were adults between 18 and 65 years of age; all had basic proficiency with computers and the Internet. A total 14 of 20 (70%) of participants were female, most reported annual incomes below US $30,000, and a majority of participants reported their race as African American or Hispanic. Participants had a range of education backgrounds, with 7 participants reporting high school education, 7 having a college degree, and 6 with a graduate degree.As                     We aggregated the types of barriers encountered by users in a manner similar to the analysis in Clark et al , which pOverall, within the hospital ratings task, users scored highest on question B and encountered the most barriers in question A. The barriers identified reflected that users struggled primarily with information literacy, computer literacy, and numeracy skills in answering the question and completing the tasks.In this research, we adapted and integrated two existing theoretical models relevant to the analysis of eHealth literacy into a single framework to systematically categorize and describe task demands and user performance on tasks needed by health care consumers in the information age. The method derived from the framework is applied to (1) code task demands using a CTA, and (2) code user performance on tasks. The analysis shows that the framework can be used to classify task demands as well as the barriers encountered in user performance of the tasks. Our approach can be used to (1) characterize the challenges confronted by participants in performing the tasks, (2) determine the extent to which application of the framework to the CTA can predict and explain the problems encountered by participants, and (3) inform revisions to the framework to increase accuracy of predictions. In this study, we used the methods to document a range of literacy-related barriers that affected performance on eHealth tasks.The study found that 20 participants experienced some difficulty completing most tasks on a website designed for consumers without some assistance. The most frequent barriers encountered by our sample were challenges with information literacy and computer literacy skills. Specific examples of frequent barriers encountered are struggling with the ability to understand and successfully act on information needs, to interpret a graphical representation of a severity scale, and to effectively use checkboxes to make selections. Conversely, some activities in which we had predicted barriers were discovered to be easier than anticipated. Evaluating health information to inform decisions can be complex and challenging, but users scored well on the question with a decision point.There is little existing research that systematically analyzes the combined set of eHealth skills needed to attain proficient performance. Other investigators have expanded the scope of health literacy to describe the combinations of skills needed to interact effectively with health information  but did We view the framework as provisional and subject to more comprehensive validation and elaboration. This will necessitate a larger-scale study with a greater sample size, a more diverse population, and a wider range of tasks. In addition, the participants in the study were not familiar with the Consumer Reports Health website and this may have influenced our findings. Familiarity with content, style, and affordances common to this site would have likely reduced some of the barriers that participants experienced. Further studies should include participants with varying degrees of experience with a particular website or technology.The analyses in this paper focused on user competencies and did not take into consideration a range of issues, such as usability, or affordances and resources available within specific technology tools. In addition, the methods employed did not take into account individual motivation or attitudes toward technology. Similarly, this cognitive rational framework does not capture emotional and social factors that also play a significant role in decision making. It is well known that health literacy is a major public health issue in the United States affecting a substantial segment of the population . In geneAs previously described in Further studies are needed to determine whether the types of literacy described in this paper sufficiently cover the range of knowledge types that characterize eHealth competency. In addition, although Bloom’s taxonomy has an established history of characterizing cognitive dimensions of tasks in educational contexts, we cannot presuppose that the gradations of complexity will seamlessly transfer to eHealth. The results of this analysis suggest that it can be used meaningfully to differentiate and categorize cognitive demands for different literacy skills and can be used to approximate complexity in a range of eHealth tasks.As discussed, the tasks used in the study did not delve deeply into media, science, and to some extent health literacy. As health consumers choose what resources to use, media literacy will loom large. We anticipate that our methods will be adequate to model the skills and knowledge needed to demonstrate media literacy competency. The problems associated with low health literacy are well documented . ScienceThe proposed framework provides a basis for the development of an eHealth competence model. Such a model would yield insight into the specific skills and knowledge needed to perform at a proficient or higher level on system-specific instances of eHealth tasks, such as seeking information about hypertensive therapies on the WebMD site. The current set of framework-based methodological tools lends greater utility to the consumer health research community than to communities of practitioners and designers. Applying this method is time intensive and requires moderate expertise in the areas of cognition and human–computer interaction. We anticipate that the framework would give rise to simpler, more specific instruments  that could measure eHealth demands for a particular task and population as realized in a particular system or device. An analogy would be Nielsen’s heuristic evaluation method , which hWith further investigation, we envision that the framework and analytic approach can be a potentially powerful generative research tool for development of design guidelines of computer-based tools, evaluation heuristics, task-based eHealth literacy assessment, and educational objectives to increase consumer eHealth skills. For example, the framework could form the basis for development of a matching algorithm to identify appropriate tools for users with different skill sets. In particular, this framework and analysis method can be used with health care consumers with low eHealth skills to better understand barriers and to develop educational media or other mediating tools to facilitate engagement with and benefit from eHealth. Barriers fall on a continuum ranging from routine abilities (recognizing how to use widgets) to complex conceptual challenges . The proposed framework systematically characterizes eHealth barriers, which in turn enables more precise definition within the solution space of methods to overcome those barriers.In our view, this framework provides a systematic and potentially rigorous approach for analyzing eHealth competencies, which is a challenge of considerable complexity and great significance. Advances in technologies, such as Web 2.0 and social networking functionalities, offer new and ever-changing modes for consumers to interact with and manage health information. In the current environment where eHealth interventions are being developed without a thorough understanding of the consumers, efforts, and resources can be better focused to improve adoption and use rates as well as benefit from use. Unfortunately, these barriers disproportionately affect those who are most vulnerable and may actually serve to exacerbate disparities rather than bridge them. There is no doubt that consumers will be expected to assume a greater role in their health management in coming years, and low eHealth literacy will continue to be a barrier to productive participation. Progress in eHealth research will be integral to the success of consumer health applications and for reducing barriers to the use of those applications.


Pachyseris foliosa was apparently less resistant to the storm than the shallower high diversity area of this reef. Contradictory to common perception, this research shows that large foliose corals at deeper depths are just as susceptible to typhoon damage as shallower branching corals. However, descriptive functional group analyses resulted in only minor changes after the disturbance, suggesting the high likelihood of recovery and the high resilience capacity of this mesophotic reef.Little is known about effects of large storm systems on mesophotic reefs. This study reports on how Typhoon 17 (Jelawat) affected Ryugu Reef on Okinawa-jima, Japan in September 2012. Benthic communities were surveyed before and after the typhoon using line intercept transect method. Comparison of the benthic assemblages showed highly significant differences in coral coverage at depths of 25–32 m before and after Typhoon 17. A large deep stand of  Acropora, Montastraea, Porites, Agaracia, Diploria, Millepora, Siderastrea, Pocillopora, Pachyseris, Montipora, and Merulina  near Kume-jima, Okinawa, Japan before and after a typhoon reported that newly broken n damage .However, comparatively little has been published on the effects of tropical cyclones on deeper reefs . In geneTyphoon 17 (Jelawat) struck the west coast of Okinawa-jima Island on 29 September 2012 , headingPachyseris foliosa  by the dissolution of plaster balls. Plaster balls (10.5 cm diameter) were made following Ten meter line transects were surveyed both before (17 April 2012 and 11–12 September 2012) and after (14 December 2012) Typhoon 17 at locations near Stations 2  and 3 . Based on the amount of data available, only Stations 2 and 3 were included in analyses. For each line transect, a 10 meter tape measure was laid out along a constant depth contour and overlapping photographs or video was taken along the line. Photographs or videos taken along the transects were used to report the total distance occupied by each operational taxonomic unit (OTU) identified. When feasible, OTUs were identified to species level following Community data were analyzed using PRIMER 6 statistical software in order to find differences in coral communities before and after the typhoon . All perTo assess potential changes in the functionality of the coral community after the typhoon coral taxa were classified into functional groups according to the shapes of the colonies following Temperature sensors showed that the temperature was typically 0.1–0.2 degrees lower at Station 5  than at any of the other stations, although the temperature appeared to fluctuate the most at this station. Temperature drops were observed at all stations during and directly after typhoons, with the largest decrease in temperature at Station 1 (20.9°C after Typhoon 17) . Based oR = 0.572, p = 0.001) and Station 3 . At Station 2, the change in the occurrence of coral rubble on the transects contributed the most to this difference , Pachyseris foliosa (11.6%), then Galaxea sp. 1 (11.2%). At Station 3, every OTU contributed to <10% of the difference observed. Change in the occurrence of coral rubble contributed to only 6% of this difference  when the effects of the dominant OTU were not reduced using square root transformation. Functionality of the coral communities  may be due to upwelling or thermal averaging due to wind driven vertical mixing with deeper cooler water that was enhanced by the onset of the typhoon, as seen during other large storms. Many studies have found that increasing sea surface temperatures and global climate change have and will continue to cause increases in typhoon frequency, power dissipation, and storm intensity . Tu, Cho10.7717/peerj.151/supp-1Table S1Coral species and functional groups  and 3 (<30 m). Functional groups: 1, massive; 2, encrusting; 3, foliose; 4, columnar; 5, plate-like; 6, bushy; 7, arborescent; 8, unattached.Click here for additional data file.


Apis mellifera) from apparently healthy colonies. Although infections, toxins, and other stressors have been associated with the onset of CCD, the pathogenesis of this disorder remains obscure. Recently, a proteomics study implicated a double-stranded DNA virus, invertebrate iridescent virus (Family Iridoviridae) along with a microsporidium (Nosema sp.) as the cause of CCD. We tested the validity of this relationship using two independent methods: (i) we surveyed healthy and CCD colonies from the United States and Israel for the presence of members of the Iridovirus genus and (ii) we reanalyzed metagenomics data previously generated from RNA pools of CCD colonies for the presence of Iridovirus-like sequences. Neither analysis revealed any evidence to suggest the presence of an Iridovirus in healthy or CCD colonies.Colony collapse disorder (CCD) is characterized by the unexplained losses of large numbers of adult worker bees ( Apis mellifera) in hives, while both resources and brood remain. Since the initial description of CCD in 2006, annual colony losses in the United States have exceeded 30%, a number significantly greater than previous average losses Honey bee decline has become an increasingly important problem worldwide, and has been attributed to multiple underlying causes Nosema ceranaePicornavirales such as Israeli acute paralysis virus Although CCD continues to be associated with an annual colony loss of approximately 10% in the United States Iridovirus genus (Family Iridoviridae) has been proposed to act synergistically with N. ceranae to cause the development of CCD A. cerana) A. mellifera protein sequences. To reconcile this discrepancy and test the intriguing hypothesis proposed by Bromenshenk et al., we surveyed CCD and healthy A. mellifera colonies from the United States and Israel for the presence of several invertebrate iridescent viruses, and re-analyzed previously generated metagenomic data from CCD colonies for Iridovirus sequences.Recently, a double-stranded DNA virus (dsDNA) belonging to the Iridovirus genus. These were collected in 2007–2009 from 35 colonies distributed across nine commercial apiaries, seven of which have been previously described One hundred and sixty-three bees were surveyed for the presence of members of the Iridovirus genus, a second nested assay was developed based on an alignment of IIV-6 and IIV-31 (GenBank accession number AJ279821), the only members of the Iridovirus genus with available DNA polymerase sequence data. Finally, an assay targeting the only sequence available for IIV-24 (GenBank accession number AF042340) was developed in a highly conserved region of the capsid. PCR assays were performed in 20 µl reactions containing 0.25 µM of each primer, 0.125 mM dNTPs, and 1 mM MgCl2. The primer annealing temperatures for each assay are given in Armadillidium vulgare) were used as positive controls. The IIV-24-specific assay was also able to detect the IIV-6 positive control. The sensitivity of each assay was evaluated by serial dilution of the IIV-6 plasmid standard. To verify the quality of our extracted nucleic acid, we also determined the copy number of the bee nuclear genome present using a β-actin quantitative assay Invertebrate iridescent viruses have been shown to replicate primarily in the gut walls, Malpighian tubules and fat-bodies of bees Iridovirus genus (GenBank Tax ID: 10487) and a homology search with blastx Following the report of an IIV-6-like virus present in samples from the same colonies surveyed by Cox-Foster et al. in 2007 Iridovirus in healthy and CCD colonies. All four assays were optimized to detect 1–10 DNA copies. We found no evidence of Iridovirus in any of the 163 bees, despite detecting an average of 105–106 DNA copies of β-actin per microliter in these samples. During the initial characterization of IIV-24 in diseased bees (A. cerana), it was estimated that each bee contained an average of 1010–1011 viral particles Iridovirus sequences publicly available and the absence of any nucleic acid or amino acid sequences linked to the Iridovirus identified by mass spectrometry Iridovirus previously associated with disease in bees PCR assays were used to test for the presence of members of Iridovirus in CCD bees. Using an e-value cut-off set at 0.0001, two of the four RNA pools (representing pools of CCD positive samples) did not reveal any sequences with homology to any Iridovirus. The third and fourth pools, comprised of samples from healthy colonies and royal jelly, contained seven reads with low similarity to IIV-6 . Blasting these individual reads against the entire non-redundant protein-coding database revealed a higher similarity to bacterial or bee genomic sequence in all cases . Although these results do not exclude the possibility that Iridovirus sequences may have been present at extremely low concentrations in the 2007 sample set, they do not lend support to a linkage between invertebrate iridescent viruses and CCD.The results of our reanalysis of the metagenomic data from earlier studies of CCD colonies N. ceranae is also required) would also be present at levels high enough for the detection of iridescence. However, during the examination of bee tissues from a large number of CCD colonies, no iridescent qualities were observed (data not shown).Typical signs of infection with invertebrate iridescent viruses include lethargy, early and rapid mortality and in bees, the loss of flight A. mellifera proteins when the host proteome is included in the analysis Admittedly, the possibility exists that the invertebrate iridescent virus detected by mass spectrometry is unrelated to those targeted here, although we consider this to be unlikely. Indeed, it has been suggested that the peptides identified as IIV-6-like by Bromenshenk et al.


Modified vaccinia virus Ankara (MVA) encoding antigens are considered as safe vaccine candidates for various infectious diseases in humans. Here, we investigated the immune modulating properties of MVA encoding ovalbumin (MVA-OVA) on the allergen-specific immune response.+ and OT-II CD4+T cells. BALB/c mice were vaccinated with wtMVA, MVA-OVA or PBS, sensitized to OVA/alum and challenged with a diet containing chicken egg white. OVA-specific IgE, IgG1, and IgG2a and cytokine secretion from mesenteric lymph node (MLN)-cells were analyzed. Body weight, body temperature, food uptake and health condition of mice were monitored.The immune modulating properties of MVA-OVA were investigated using GM-CSF-derived BMDCs from C57BL/6 mice. OVA expression upon MVA-OVA infection of BMDCs was monitored by immunoblotting and ELISA. Activation and maturation markers on viable MVA-OVA infected mDCs were analyzed by flow cytometry. INF-g, IL-2, and IL-10 secretion was determined in a co-culture of BMDCs infected with wtMVA or MVA-OVA and MACS-sorted OVA-specific OT-I CD8+T cells in comparison to OVA, wtMVA or OVA plus wtMVA. Prophylactic vaccination with MVA-OVA significantly repressed OVA-specific IgE, whereas OVA-specific IgG2a was induced. MVA-OVA vaccination suppressed TH2 cytokine production in MLN cells and prevented the onset of allergic symptoms in a mouse model of OVA-induced intestinal allergy.Infection with wtMVA and MVA-OVA induced comparable activation of mDCs. MVA-OVA infected BMDCs expressed OVA and induced enhanced IFN-g and IL-2 secretion from OVA-specific CD8H1-immune response, likely mediated by the induction of IFN-g and IgG2a. MVA-based vaccines might be suitable for the treatment of allergic diseases.MVA-OVA vaccination induces a strong OVA-specific TNone declared.