While several papers have highlighted a lack of evidence to scale social innovations in health, fewer have explored decision-maker understandings of the relative merit of different types of evidence, how such data are interpreted and applied, and what practical support is required to improve evidence generation. The objectives of this paper are to understand (1) beliefs and attitudes towards the value of and types of evidence in scaling social innovations for health, (2) approaches to evidence generation and evaluation used in systems and policy change, and (3) how better evidence-generation can be undertaken and supported within social innovation in health.Thirty-two one-on-one interviews were conducted between July and November 2015 with purposively selected practitioners, policymakers, and funders from low- and middle- income countries (LMICs). Data were analysed using a Framework Analysis Approach.While practitioners, funders, and policymakers said they held outcome evidence in high regard, their practices only bear out this assertion to varying degrees. Few have given systematic consideration to potential unintended consequences, in particular harm, of the programs they implement, fund, or adopt. Stakeholders suggest that better evidence-generation can be undertaken and supported within social innovation in health by supporting the research efforts of emerging community organizations; creating links between practitioners and academia; altering the funding landscape for evidence-generation; providing responsive technical education; and creating accountability for funders, practitioners, and policymakers.How better evidence-generation can be undertaken and supported within social innovation in health is a previously under-operationalised aspect of the policy-making process that remains essential in order to refrain from causing harm, enable the optimization of existing interventions, and ultimately, to scale and fund what works. In recent years, there has been a proliferation of projects, organizations, businesses, and research studies aimed at solving problems stemming from the inaccessibility or lack of health care facing millions of people around the world. These efforts have developed ‘social innovations,’ defined by the editors of the Stanford Social Innovation Review as “the process of inventing, securing support for, and implementing novel solutions to social needs and problems.” Most stutypes of data are most useful and persuasive to policymakers and funders nor how these data are interpreted and applied. Consequently, practitioners working in the field  are left with little guidance on how to rigorously and efficiently assess effectiveness and feasibility of their intervention  can be improved” . For example, one practitioner was able to use the variability between programme sites to refine operations in places that were underperforming:… sites cross-share data [enabling them] to both critique and ask questions as to why their retention numbers are so high or so low, what kinds of things are they doing that might be different… (P10)III. Research as a means of fulfilling expectations of funders and policy-makers.Another group cited external pressure as the primary reason to conduct outcome and operational research. While they saw research as a burden  or were passive decision-makers in conducting research , others viewed building a joint research agenda as a positive, synergistic process. This is especially true of those practitioners working closely with the Ministry of Health (MOH) in their respective countries. By aligning or jointly developing research questions with the MOH, practitioners were better placed to scale nationally (P11) and create the trust necessary for novel approaches:If we had gone into these areas with the Ministry and said: “Oh we actually want to do something that is completely different than your current national policy,” the Ministry would have blocked it…the research we did together…opened the door to…joint innovation. (P2)While practitioners are in favour of research, they are not convinced that funders and policy-makers use it to make decisions. One practitioner declared, “a huge amount of interventions that happen in the global health space…are scaled in an evidence free zone” (P2). Several practitioners believe funders have a groupthink dynamic and suggested personal relationships often trump evidence:We just got a call from [a funder] on Friday, potentially giving us a million dollars to launch this [program]… as soon as one drops, others will drop… (P4)As in Yamey , practitI mean we do report to donors…[but] that's much more… stories than it is an analysis. (P1)Because if someone said, “give us evidence” we bring out someone who can tell a powerful personal story…there's a donor base that responds to [anecdotes] and doesn’t respond to “… RCTs and … confidence intervals”. (P4)While some practitioners conceded that this trend was changing—“in the coming years organisations that are not [becoming] evidence-based, they [will] face challenges in raising resources to support their work” (P14)—most felt that funders in particular did not understand evaluations well enough to critically appraise study designs and evidence quality:Few people understand…the difference between the clustered-randomized trial and one that’s just randomized. (P6)While funders say they hold outcome evidence in high regard, this is often not translated into practice. Funders spoke of the importance of external evaluations (F4), strong data systems (F1) and ultimately “creating an impact” (F4). Yet for several of the funders, especially those from family and corporate foundations, identification of potential grantees is not systematic and often based on referrals through "networks" of trusted partners . While most stressed that referrals guarantee closer scrutiny and not funding; two admitted that “it’s a bit of an echo chamber” (F2) and that “the deck is [potentially] stacked against” organisations without connections (F10). Moreover when asked how they evaluate potential organisations, funders cited organisational health metrics (F2), “visionary” leadership (F11), or novelty, rather than outcome evaluations:Sometimes it’s just a gut feeling. It might be something very new. It might be untested, but you kind of have a sense that there’s real excitement. (F9)Even when funders cited clear outcome metrics  they admitted they did not critically engage with the underlying studies. Several had misunderstandings of technical details in evaluation research or admitted research expertise was lacking on their teams:Frankly, we don’t have program officers who are extensively trained in M&E. (F7)Others questioned whether, as funders, they could ever adequately assess a given programme:I think one of the things you have to accept when you’re funding projects…is that reporting on an application to its owner is an honour-based system. (F5)There was recognition that funders could be driving the “evidence-free zone”:Most organisations don’t effectively measure their own impact because the funders don’t ask them to and the funders don’t ask them to because they don’t really understand it well enough or it’s … not in their best interests to ask for it…this sector has simply been … “put hopeful money in and be unclear on what you get out”. (F1)That said, funders are not a homogenous group, and several echoed practitioners on the idea that times were changing and had clear ideas about the types of evaluations they would like to see:We feel like [strong M&E] is now required by the field to scale and it’s just healthy…to know what impact you’re having. (F11)We’d love to see more organisations pay attention to meaningful, concrete quantification of their work … (F3)While some funders were very understanding of the challenges faced by organisations to generate quality evidence—noting the difficulty of gathering real time data (F6) or the challenge of doing qualitative research without “sufficient money” (F9)—other funders expressed their own frustrations with NGO and health service practitioners:Many organisations either don’t think very systemically about what they should measure to either show an impact or…how to iterate…their approach. Often, [it’s] implementation of an idea without clear testing beforehand. (F3)We would like obviously the grantees to have a strong theory of change…for that to be laid out in terms of a results framework…I think that’s where a lot of the grants frankly are lacking. (F7)Policymakers also mostly held evidence in high regard—e.g. “We’ll never take things on that haven’t worked yet,” (M6)—but were much more likely to be explicit about the types of evidence they valued to identify interventions to scale. As one Director General of a MOH in West Africa explained:New interventions are basically selected based on… if an intervention is proven to be effective…especially in similar settings, and if there are very strong evidences. (M3)One policy-maker however, admitted to not rigorously reviewing the evidence for solutions implemented: “I think the [research] evidence of those things… I’m assuming that it’s already known… but honestly I didn’t read anything recently.” (M5)Consistent with earlier findings , 18, theThere are some interventions that you need to do a pilot … and if those interventions are proven to be effective after the pilot, then you go for them. (M3)Policy-makers also recognised the challenges of generating evidence and did not always demand that evidence for policy and program interventions be generated with the same level of rigor as that required in clinical trials for drugs and diagnostics:When we find out that the benefits outweigh the risks, we sometimes say to them, “Go” without necessarily having the highest of all evidence, [a randomised trial], and then we monitor and rule on that as we go. (M6)Though, in keeping with previous literature , 4, poliWhat you bring—the quality of product that you bring—is very important, the amount of evidence, and the evidence of the impact this intervention had in other countries is very important. So, it’s not only the question of who brings it, but what contribution could it make [based on] the evidence. (M2)Practitioners face several barriers in undertaking research. A central tension is striking the right balance between rigor and operational relevance. While practitioners conceded that exacting methods would make their results more convincing—“in an ideal world I would want to see … more academic rigor… to really figure out how … you prove this” (P3)—many expressed concerns that such “over the top” designs could “slow [them] down” .Compounding this issue is the difficulty of finding accessible technical expertise. Almost every practitioner had a technical query they could not answer see . PractitPerhaps as a result, most of the organisations interviewed, despite being sampled from a group recognised as high performing , have never conducted longitudinal research, used counterfactuals, or identified which parts of their program mediate its effectsMore troubling is the finding that practitioners, funders, and policymakers have given little systematic consideration to potential unintended consequences of the programmes they implement, fund, or adopt. While a small number were open about harms, the vast majority did not have rigorous systems to measure harm, and several denied that harm was possible.Two practitioners talked very explicitly about harm, one due to unintentional exposure to environmental risks for staff and the other as a result of aggressive implementation leading to burn out, reductions in quality of delivery and thus potentially endangering patients . Both noted the role of constant data collection in being able to identify these damaging patterns and stressed that recognising such pitfalls was “as important, if not more important” as measuring programme success (P2).Many more practitioners, however, were not able to articulate how their programmes measure potential harms:That’s just a fascinating question. We have not dug in there. (P13)There are no ‘checks and balances’ that we put in place other than following the already predefined country rules and regulations. (P14)A small number were vigorously defensive about their organisations, dismissing the possibility of any ill effects or their severity—even after repeated probing:I’m a little stuck to answer that. I think there’s times when we don’t always do our work as well as we’d like but I think in the world of health, what we’re doing is…I’d hate to sound self-righteous, but it’s fairly noble. (P9)Funders fell into a similar taxonomy, with some denying it  and most having failed to consider it systematically (F7):Well, within the health space, we are really focused on the distribution of health services and goods so in terms of the harm aspect we haven’t spent a lot of time thinking about that. (F11)One difference is that, among those who had considered it, funders felt less likely to hear of harm or empowered to stop harm than practitioners:We also fund only people with really good monitoring systems in place so that untoward consequences, unintended consequences, should be picked up fairly early… I don’t know anybody who has a fool proof way of avoiding unintended consequence. (F1)My parents have asked me, “Well, what does the foundation do in situations [where harm has been caused]?” …and I don’t know. (F7)While most enquiries into scale and evidence generation have only spoken to one set of stakeholders and have thus collected a series of claims by one group about the failings of the other , 19, by Research is often side-lined during the early stages of organisational development, despite its importance. Practitioners cited the importance of establishing data collection mechanisms in the early stage of a new organisation as it is “costly” to compensate for poor or non-existent data down the line . Yet, as one practitioner points out, young organisations face a catch-22 when attempting to grow their programs and data systems:It's rough out there…community service organisations …don’t get funded because they don’t have evidence, and they don’t have evidence because they don’t have the money or the smarts. (P4)There is also the tension between exacting evidence standards without ‴extinguishing’ innovation and small community generated projects” (P4). Practitioners suggested prioritising identification of promising early-stage health organisations and supporting them to create "meaningful evidence…[when they] don't have the human resources and the financial resource" (P4). This includes “building the capacity of human resources” from LMICs, including local researchers and practitioners, as a central part of measurement and implementation (P9).Practitioners and funders noted that “academic research isn’t set up to match the most qualified investigators with implementing organisations that are trying to take on [big] problems” (P2). While, for example, the Economic and Social Research Council (UK) and other programs attempt this, all parties suggested an additional formal mechanism for partnerships be created and supported.Though organisations acknowledge that there are challenges in finding the right academic fit—“culture shock” (P6), “misaligned priorities” (P2)—many touted the benefits that academic expertise could bring: “[the academic team] made a control group…added measurements…[assessed] the long-term impact…we use [those] results to do advocacy”(P5). While others noted that an academic affiliation is typically required to receive ethics approval (P4).Echoing the findings of Yamey , respond… one of the things they’re working on at Harvard [and Johns Hopkins] is…recognising good, operational research as part of someone’s academic portfolio so that that gets rewarded in the tenure system. (P9)Even so, it was acknowledged that despite a few appointments based on these new criteria, there was a long way to go to change the perception that success only comes via “hardcore first and last author papers” (F8). A potential stopgap measure while this larger structural change takes place would be for funding agencies to provide small stipends for academics to be “fellows” (e.g. similar to IDEO) at global health NGOs (P6).While universities are partially responsible for structuring what type of research gets undertaken, the research grant-making process, especially in the United States, is another driving force:There are constraints on trying to get implementation science funded right now in the U.S. … there’s no National Institute of Implementation Science. So, implementation science or operations research is actually quite difficult …because it’s not obviously [funded] in one place or another. (F8)Some practitioners have found ways to "game the system" by finding academics who are willing to give a portion of their time  However, because they are "not on traditional NIH [National Institutes of Health] pathway" doing research requires mobilising large amounts of unrestricted funding that can be hard to come by:All your donors and your partners, all want lot of reporting and a lot of M&E stuff, but nobody really wants to pay for it. (P1)Often the last year of the program, people are scrambling so much for new money…I’m being paid to analyse data…but [right now] I’m writing [funding] proposals. (P12)One funder identified a funding gap as organisations grow:I’d like to see kind of a funder continuum…it’s a valley of death once you get to be like a 5 or 8 million dollar a year organisation…everyone wants to give $100,000 or $250,000 but no one wants to write a seven-figure check. (F10)The lack of unrestricted funding for research makes it harder to train local staff (P9), attract and retain qualified researchers (P14), build robust M&E platforms (P14), clean existing data , and conduct rigorous trials and in-depth qualitative work (P6):The ideal scenario is…if you look at any major tech company; they have an internal R&D department. Justifying funding for that is not complicated because they make a lot of money. Figuring out how to justify internal R&D departments at global health NGOs is super important. (P6)Unrestricted or research-oriented funding must be made available to encourage robust research.While several practitioners and funders accused researchers of “misplaced precision” (F8) they also valued “rigorous” research. Practitioners identified the need for “approaches to evaluation…readily off the shelf [that organisations could] use as tools to actually implement evaluation” (P10), smaller, “real-time” studies that enable organisations to “course-correct” as they go , and cheaper evaluation methods (P4).When people talk about evidence-based decision making… A lot of the programme teams don’t have that kind of analytic training. (P12)Such components could form part of a toolkit that would enable practitioners to easily perform unobtrusive, light touch—“lean”—research in everyday practice. Though others cautioned against re-inventing the wheel, noting that “a lot [of material] is already out there” (F2), suggests that an essential complement to any toolkit must be education regarding how to search for and understand existing strategies.A more profound and less easily operationalized suggestion was given voice by one practitioner:[We often say] we are doing things to “prove a model” etc. That presupposes that what we're doing already works and that we figured everything out and sometimes precludes opportunities to really take measurement as our opportunity for learning and for accountability, because a lot of global health interventions fail and a lot of great ideas don't end up working out. (P2)One funder noted, “organisations are not as…eager and willing to do a good job of implementing a high-impact model that they did not themselves develop” (F1). Rather than believe that individual organisations will solve any given problem, funders suggested that “most” practitioners “don’t have all of the pieces” and so should think of themselves as part of a larger team that should work together to solve a project (F6). While one practitioner mentioned her organization actively encouraged the adoption of any program with similar goals and outcomes (P13), the vast majority were focused on scaling their particular model. The ways in which this individualistic, competitive climate is encouraged by the celebration of social entrepreneurs and the conceptualization of social innovation in health as “a business” must be considered.Several policymakers were adamant that practitioners also needed to be held accountable for making early and transparent contact with the MOH in their respective countries. As one MOH representative from East Africa explained:NGOs [should] come direct into the Ministry…presenting what they have and how this could be integrated with what the government is doing… Continuously engaging with the Ministry…is very important. Sometimes, [practitioners] go somewhere without informing the Ministry and [do] something which is contrary to the … position of the Ministry…which is a disaster…because that resource is simply spent in vain in something that the Ministry doesn’t appreciate. (M2)Ministries of Health must likewise be held accountable for creating an environment that allows social innovation to flourish in their countries. This means proactively developing relationships with NGOs working in their countries to ensure alignment and create opportunities for collaboration and piloting new ideas. Moreover, as one funder asserts, “once something’s been proven with world-class research to work, the governments [should] free up resources to actually implement [it]” (F10).Funders recognize, however, that they too need to improve:I think there’s a lot of bad behaviour on the funders’ side: when they do single year and when they do restricted, when they take a lot of people’s time and make them jump through all kinds of hoops and then don’t use the information at all for anything. (F10)As one funder put it, “I don’t know if you can think of any foundation head who’s ever been fired for lack of impact, so why would you even measure it if it isn’t really that important?” (F1). One way of creating accountability for funders may be through the use of a priori evidence standards. The Social Research Unit at Dartington (UK) offers a framework for evidence standards based on questions around practicality, rigour, outcomes, side-effects and replicability . Their aThirty-two one-on-one interviews were conducted with purposively selected practitioners, policymakers, and funders from LMICs to explore (a) beliefs and attitudes towards the value of and types of evidence in scaling social innovations for health, (b) approaches to evidence generation and evaluation used in systems and policy change, and (c) how better evidence-generation can be undertaken and supported within social innovation in health.While practitioners are largely convinced of the merits of rigorous research, they face several barriers in undertaking it. A central tension is striking the right balance between rigor and operational relevance; an issue compounded by the difficulty of finding accessible technical expertise. Practitioners assert that funders and policymakers are more moved by stories or personal connections than rigorous counterfactuals, but these assumptions were not necessarily borne out in decision-maker narratives. Though funders didn’t typically question or critically appraise the evidence of effect with which they were presented, policymakers tended to be very explicit about the types of evidence they valued when considering interventions as candidates for scale. In several areas, funders and policy-makers align with practitioners.One area where practitioners, funders, and policymakers converge is that few have given systematic consideration to potential unintended consequences of the programmes they implement, fund, or adopt. While a small number were open about harms, the vast majority do not have rigorous systems in place to track harm, and a number are in denial that causing harm is even possible.By speaking with all groups concurrently we were able to convene a constructive discussion and guide the identification of areas in which actionable strategies for improvement could be generated. Those that emerged were: supporting the research efforts of emerging organisations; creating links between practitioners and academia; altering the funding landscape for evidence-generation; providing responsive technical education; and creating accountability for funders, practitioners, and policymakers.Only by fostering a conversation across the entire ecosystem of actors required to scale programs can entrenched issues be confronted in creative, mutually agreeable ways. This is the first qualitative study to simultaneously explore practitioner, funder, and policymaker views on evidence generation and scale. Three limitations of the study were (i) policymakers proved more difficult to secure for interviews than expected and so theoretical saturation was not reached for this group, (ii) researchers were not sampled as a separate group, despite emerging as a major actor in the discussion, and (iii) the relatively short interviews time (~35 min average), while enabling a large and relatively diverse sample, meant less depth was achieved with each participant. The credibility of this study was nonetheless enhanced by the use of multiple analysts to independently code data and review interpretations.The findings of this study highlight issues that are relevant to enabling better evidence generation and use in health by practitioners, funders and policymakers alike. Because this inquiry pushed participants for specific, actionable suggestions, the “doing better” proposals provide deep insights into evidence generation, understanding ‘pain points,’ and ideas for potential solutions.Better evidence is not a panacea—taking interventions to scale is a complex process that requires the recognition of the importance of evidence in decision-making, understanding between practitioners, funders and policy-makers and the use of a variety of evidence typologies. Nonetheless, how better evidence-generation can be undertaken and supported within social innovation in health is a previously under-operationalised aspect of this process that remains essential in order to refrain from causing harm, enables us to optimise existing interventions, and ultimately, to scale and fund only what works.S1 Appendix(DOCX)Click here for additional data file.S1 Dataset(ZIP)Click here for additional data file.


Dear Editor,It was with great interest that we reviewed the article by Rho et al. “Deconstructing Chronic Low Back pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part VIII: Lateral Hip and Thigh Pain” . We applIt is therefore puzzling that the treatment provided in the clinical case presented in this review was an “ultrasound-guided greater trochanteric bursa corticosteroid injection.” In fact, in this case  the patient unfortunately underwent two ultrasound-guided corticosteroid injections! This treatment would not only appear to be not indicated based upon the current literature cited in the review by Rho et al., but also potentially harmful in this 90-year-old patient with a history of several compression fractures. In addition, the known lack of efficacy of these injections results in not only a poor outcome but also increased cost. The review failed to include other types of injection treatments for this treatment, including simple needle of the tendon, that is, needle tenotomy, ultrasound-guided dextrose injection, or platelet-rich plasma injection (PRP). In a multicenter case series, Mautner et al. noted a significant benefit using PRP on a variety of tendons, including the hip abductor tendons, namely the gluteus minimus and medius tendons, which commonly demonstrated tendinopathic changes in these patients. Although the current scientific evidence for efficacy of PRP injection is limited, it is superior to the level of evidence for many current treatments for GTPS and certainly superior to corticosteroid injections . In our The practice of medicine requires us to provide the most effective evidence-based treatments to patients with the first caveat of “First DO No Harm.” We would argue that injection of corticosteroids for GTPS would not be supported by evidence-based medicine both in terms of effective treatment and avoiding the potential harmful effects.


Abha Mehndiratta and colleagues, as they describe a pragmatic approach to develop standard treatment guidelines for IndiaAdapting international guidelines to suit local context can drive evidence based practice in low and middle income countries, say  In the past decade, India has witnessed an increase in access to healthcare as it strives for universal health coverage. There has been a rise in publicly financed health insurance initiatives,Clinical guidelines are increasingly used around the world to help change practice and improve patient outcomes by promoting beneficial interventions while discouraging those that are ineffective or possibly dangerous. They assist practitioners in the uptake of credible research into practiceDeveloping guidelines is complex and resource intensive requiring technical skills and financial support, which are often scarce in low and middle income countries (LMICs). In the absence of evidence based “home grown” clinical guidelines, clinicians resort to recommendations from international guidelines. However, these are not always relevant to their practice because of variations in health systems, resource constraints, and different cultural and social context of patients that drive preferences.Adapting trustworthy guidelines offers a possible way forward for these countries. Guideline adaptation has been defined as a systematic approach to modify and contextualise evidence based guidelines to suit implementation in the local healthcare system.Methods and principles for developing high quality guidelines are now well established,21  In 2014, the Ministry of Health and Family Welfare (MoHFW), convened a guideline task force to develop a road map for standardising the clinical management of diseases in India.In India, clinical guidelines, also called standard treatment guidelines (STGs), are developed at the national and state levels and by a wide range of agencies.A sample of Indian guidelines reviewed by the task force showed that most guidelines had been adapted from international recommendations but contained little information on the adaptation process, making it difficult to assess their quality. Given time and resource constraints, the task force discounted developing new guidelines and opted to develop, with technical support from its secretariat at the National Health Systems Resource Center, a pragmatic method by which evidence based guidelines could be adapted to suit the Indian context.In the absence of an internationally accepted adaptation approach, the task force relied on a pilot adaptation framework prepared by the UK National Institute for Health and Care Excellence (NICE) through literature review and expert consensus. A simplified draft guideline development/adaptation handbook was prepared based on the US Institute of Medicine’s principles and standards for a trustworthy guideline.The adaptation framework used a 10 step approach . The GDG then drafted a scope for the guideline with details of the patient population covered, key clinical issues, relevant healthcare settings, and the main outcomes of interest. The group searched for existing guidelines on the specified topic using the National Guidelines Clearinghouse (NGC), which hosts guidelines that have had a quality check and have been developed, reviewed, or revised within the past five years.The GDG identified relevant recommendations from these guidelines and decided whether to adopt the recommendation or adapt it for the local context. The reasons for adaptation or for exclusion were documented. These recommendations were compiled to formulate a new comprehensive guideline with clear documentation of the sources for each recommendation. The process took around 8-15 months. A few members of the STG task force and the secretariat plus independent subject experts reviewed the draft guideline, after which it was sent for external peer review, as well as posted in the public domain on the MoHFW website for wider public consultation. Members of the GDG reviewed the feedback and incorporated changes as appropriate. The GDGs were required to provide the task force secretariat with a written explanation of how these comments were dealt with.The complete guideline, called the “full document” includes detailed methods along with implementation tools such as the quick reference guide for practitioners, a patient information document, and quality standards for measuring compliance to the guideline. The guidelines do not currently include a cost effectiveness analysis.Several lessons emerged from the adaptation process. Although it provided a uniform framework for GDGs, adherence to the steps varied. Documentation of the process of selecting each GDG, the deliberations, and how consensus was reached will help evaluate and refine the methods. Patient involvement was sought and the guidelines were open for public review. However, more robust engagement with patients across different social and cultural groups is required to ensure their concerns and expectations are adequately considered.Initially, topics such as “approach to acute abdomen” and “joint pains in adults” were selected for guideline development based on the high prevalence and variations in treatment seen in India. However, these were replaced with other topics because it was not possible to find a reliable source guideline on such a broad topic.The selection of source guidelines was challenging. An internal online survey conducted by the NHSRC among GDG members (28 respondents) showed that 93% of the respondents found some issues relevant to India missing in the source guidelines. However, none of the GDGs conducted a systematic review of evidence on areas where recommendations are lacking because of limited time and expertise.For some topics, such as snakebite and dry eye, the clearing house did not have all relevant guidelines. For these topics, GDG members identified guidelines through an independent search and assessed the technical quality and the development process using the AGREE II  instrument.The GDG judged how far to adapt a recommendation based on members’ expertise, and considering the diverse clinical practice settings in India, resource availability, and affordability. Adaptation ranged from minor edits such as more precise wording to major changes in a clinical recommendation. For example, the GDG on diabetic foot decided that recommending therapeutic footwear proved to relieve plantar pressure during walking was not appropriate because such footwear is not widely available in India. Instead, the GDG made a consensus recommendation on broad footwear features based on members’ collective experience.In selecting recommendations from multiple guidelines, GDGs found that guideline developers had used different systems for grading the quality of evidence. For example, the same evidence could be graded as II-2, B; C+, 1; or “strong evidence.” This made it difficult to confirm and communicate the strength of a recommendation. To make the recommendations easy to understand and use for providers across the country, the GDGs decided to use words such as “should,” “must,” “do it,” “avoid,” and “don't do it.”Few GDG members were familiar with evidence based methods, data interpretation, systematic reviews, and synthesis of evidence. This posed problems in determining how far recommendations could be altered without compromising the evidence. To mitigate this risk and enhance transparency, the GDGs were encouraged to document the rationale for adapting recommendations. However, the risk of bias is not completely avoided in the process.The pragmatic framework for adapting guidelines marks a step forward in India’s journey towards standardised clinical care and provides a feasible alternative to de novo guideline development for India and possibly other low and middle income countries.Since the work on STGs in India began, other frameworks for adapting guidelines have been published in the peer reviewed literature, showing the growing interest in this area. One such framework, GRADE-ADOLOPMENT, is an eight step process based on the GRADE working group’s evidence to decision frameworks.The MoFHW has published 12 STGs so far.Investment is urgently needed in developing clinical guidelines to ensure delivery of quality and ethical healthcare to the Indian populationAs part of a national framework a pragmatic approach was developed to adapt relevant evidence based guidelines to the Indian context commensurate with local resources12 standard treatment guidelines have been published using this method, with explicit documentation of the adoption and adaptation processThe adaptation framework contributes to wider global efforts to develop a validated approach to producing guidelines relevant to low and middle income countries


In Australia, approval by the Medical Services Advisory Committee (MSAC) is an important step in the implementation of new health technologies. The MSAC considers health technology assessments (HTA) when submitting a recommendation to the Minister of Health on a new technology’s suitability for public funding. Despite being such a critical tool in formulating policy, there has been little scrutiny on the impact of limited evidence on the performance of a national HTA agency’s mandate. We aim to determine the proportion of HTAs of orthopaedic technologies prepared for the MSAC that were supported by higher levels of evidence for effectiveness, and whether this affected the MSAC’s ability to conclude on efficacy. We also investigated whether the availability of higher level evidence affected the performance of cost-effectiveness analyses.We performed a cohort study of all HTAs prepared for the MSAC from 1998 to 2017 with regards to new technologies in orthopaedic surgery.P = 0.5). The proportion of HTAs where a cost-effectiveness analysis was performed was significantly higher (P < 0.05) when higher levels of evidence were available for the assessment of effectiveness.We identified seven HTAs encompassing nine orthopaedic technologies for inclusion. Higher levels of evidence were available for assessing the technology’s effectiveness in six out of the nine technologies. The results did not show a statistically significant relationship between the availability of higher level evidence and MSAC’s ability to make a clear conclusion on the assessment of effectiveness (The results indicate that there is a paucity of high quality evidence in the formulation of health policy with regards to the implementation of new orthopaedic technologies in the public healthcare system. This represents an opportunity for strong leadership from surgeons to help develop the tools needed for effective clinical decision-making. It is incumbent upon policy-makers to use evidence-based medicine to guide decisions with regards to which medical services and procedures should be allocated government funds. This is essential to ensure that finite resources are allocated wisely to those services that are proven to offer the greatest benefit in improving healthcare. This paper intends to identify the degree to which evidence-based medicine influences this decision-making process with respect to orthopaedic techniques and procedures in Australia.Randomised controlled trials (RCTs), when performed well, provide the gold standard in evidence for analysing efficacy of a medical intervention. Historically, difficulties have been cited in the performance of RCTs in the context of surgical interventions, including barriers to randomisation, difficulty in blinding, inherent variabilities of surgeon competency and technique, surgical learning curves, and patient’s equipoise . These ffund three medical breakthroughs to help people with severe disabilities walk again and support thousands of Australians facing crippling back pain” [The Australian Institute of Health and Welfare recognises arthritis and musculoskeletal diseases as one of nine national health priority areas, accounting for a substantial amount of disease burden in Australia . Orthopack pain” . This isoptimum value for money in the Government’s subsidisation of medical services, as well as prioritising the uptake of effective new technologies and procedures” [Key to the integration and delivery of a newly developed health technology are health technology assessments (HTA), which represent a multidisciplinary field of policy analysis that studies medical, social, ethical and economic implications of a new technology . In Austcedures” . Specificedures” .the strength of evidence in relation to the comparative safety, effectiveness, cost-effectiveness, and total cost of the medical service” under assessment [In advising the Minister for Health, the MSAC Terms of Reference require it to consider “sessment . The HTAsessment . Cost efsessment . This paOur aims were thus to (1) determine the proportion of the total HTAs performed by the MSAC, in relation to orthopaedic technologies, that were supported by higher levels of evidence , (2) determine whether the availability of higher level evidence affected MSAC’s conclusion of effectiveness, and (3) investigate whether the availability of higher level evidence limited the performance of cost-effectiveness analyses by MSAC.We performed a cohort study of HTAs prepared for the MSAC from 1998 to 2017 with regards to new technologies in orthopaedic surgery. We defined ‘orthopaedic surgery’ as the application of a manual or instrumented surgical technique by a surgeon in the diagnosis or treatment of injury, disease or deformity to the body’s musculoskeletal system. HTAs are usually publicly listed and available on the MSAC website. We reviewed each HTA of orthopaedic technologies that were completed and for which information was available on the MSAC website. We excluded applications that were withdrawn and any assessments for which information was unavailable on the MSAC website.We extracted data on the general characteristics of each included HTA report, including the name of the orthopaedic technology or procedure and year of the HTA. As part of its evaluation process, the MSAC makes an assessment of the evidence presented to them in the HTA report. This is usually made against a comparator procedure, which is considered the current gold standard at the time for the same disease entity. To evaluate the quality of evidence used in the decision-making process, the authors used the National Health & Medical Research Council Guidelines 2000 . Each ofP < 0.05. A Fischer exact test was also used to analyse the relationship between the availability of higher levels of evidence for the assessment of effectiveness, and any subsequent performance of a formal cost-effectiveness analysis in a 2 × 2 table. The level of significance was set at P < 0.05.A Fischer exact test was used to analyse the relationship between the availability of higher level evidence and the MSAC’s ability to make a clear (favourable or unfavourable) or equivocal conclusion on the assessment of effectiveness. A 2 × 2 table was used and the level of significance was set at The MSAC received 323 applications for the performance of HTAs during the assessment period, of which 14 were identified as possibly relating to orthopaedic technologies. Of these, seven HTAs were excluded (Table P = 0.5).In six out of the nine technologies assessed (66.6%), higher levels of evidence were available to the MSAC when assessing the technology’s effectiveness. The assessment of effectiveness for three out of the nine technologies showed clearly favourable or unfavourable evidence Fig.  and highP = 0.048) when higher levels of evidence were available for the assessment of effectiveness.In five of the six assessments where higher levels of evidence for the assessment of effectiveness were available, a formal cost-effective analysis was subsequently performed. In the remaining assessment , a cost-minimisation analysis was performed . No costThe MSAC made a recommendation to support MBS funding for two (25%) of the technologies assessed Fig. . Higher The Federal Government recognises that HTAs performed for the MSAC play a key role in allocating scarce healthcare resources . It is wthe trial enrolled few participants, did not report full data, had short-term follow-up (24 months), and participants, investigators and outcome assessors were not blinded to treatment” [lacked transparency, and was subject to a high risk of bias” [unclear whether the significant improvements in radiological outcomes translate to measurable clinical benefits for the patient, such as a reduction in revision rates” [Nevertheless, the findings regarding orthopaedic procedures presented herein should be viewed in the following context. Each of the three orthopaedic technologies for which MSAC found clearly favourable or unfavourable evidence for effectiveness were supported by level II or higher evidence. Conversely, for the three technologies for which higher levels of evidence for effectiveness were not available, each was found to have equivocal evidence for effectiveness. These points would, prima facie, suggest that the MSAC requires higher level evidence to effectively exercise evidence-based judgments for orthopaedic technologies. However, the results were affected by the inclusion of three HTAs ’, ‘Minimally invasive lumbar decompression and dynamic stabilisation using interlaminar device’, and ‘Computer-navigated total knee arthroplasty’ , 19), foeatment” . With reof bias” . For theBrauer et al.  previousWe have limited the current analysis to orthopaedic surgery given the historic limitations cited in the gathering of higher evidence in surgery and specifically the documented impact of these limitations on clinical decision-making in Australia. Given the findings, it is recommended that a future analysis consider this issue across all surgical subspecialties. Furthermore, in this instance, we did not consider the impact of RCTs on the assessment of safety. This is because the Therapeutic Goods Administration generally assesses the safety of new medical technologies as a precursor to the MSAC’s HTA process .A potential selection bias exists whereby, since 2010, companies applying for MSAC approval for a new technology may elect to have a submission-based assessment and not permit the full reports to be publicly published. Hence, while the outcome of the MSAC’s determination is evident, the quality of the evidence used to draw that conclusion is not always so. It should also be recognised that the sample size for the study was small, totalling nine HTAs. This is most likely due to the relatively low number of non-prosthetic-related orthopaedic surgical procedures being produced. This relatively low number may mean that the addition of a few more HTAs, either as they are submitted to the MASC over time, or through the application of different search criteria may change the results of the study.patient- and society-oriented and risk-adjusted outcomes, including cost-effectiveness, quality of life, and functional outcomes” [Finally, a decade ago, Rogers issued a ‘call to arms’ for surgeons to move towards research on “utcomes” . Howeverutcomes”  recentlyThe study results did not show a statistically significant relationship between the availability of higher level evidence and the ability of policy-makers to make a clear or equivocal conclusion on the assessment of effectiveness of new technologies in Australia. The realities of modern healthcare are such that policy-makers may, at times from necessity, drive a cost-effectiveness agenda at a trade off against patient choices and patient care. As society has become accustomed to having access to any new intervention, this may perpetuate a real or perceived conflict amongst surgeons, patients and policy-makers. As such, clinicians and policy-makers must remain mindful of the importance of including high quality, scientific evidence in funding decisions and maintain an interest in developing the tools needed for effective clinical decision-making at both micro and macro levels.


Linking persons with hepatitis B (HBV) and hepatitis C (HCV) infection with appropriate prevention and treatment requires that they first be diagnosed. The World Health Organization (WHO) has developed its first guidelines on testing for chronic HBV and HCV infection, using a framework based on methods from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group for the formulation of recommendations, including determining the strength of recommendations and quality of evidence. Recommendations were formulated based on the overall quality of the evidence, in addition to other considerations, including the balance between benefits and harms, values and preferences, feasibility and resource implications. This article summarizes methodological challenges and additional considerations encountered in applying these procedures to diagnostic testing for viral hepatitis, and strategies to address these. Direct evidence on the effects of tests and test strategies on clinical outcomes was not available. Given the availability of effective treatments for HBV and HCV that are generally acceptable to patients, the Guidelines Development Group (GDG) considered diagnostic accuracy a reasonable surrogate for clinical outcomes. In order to increase the number of patients identified with chronic HBV and HCV infection who could benefit from treatments, the GDG determined that tests and testing strategies associated with slightly lower diagnostic accuracy could be recommended when associated with lower costs; increased testing access, uptake, and linkage to care; greater feasibility; or if preferred by patients. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are major worldwide causes of chronic liver disease and associated morbidity and mortality , 2. Effewho to test  as well as how to test  recently developed its first guidelines on testing for HBV and HCV infection to inform national and regional scale up of testing. In the guidelines, the WHO addresses both s to use  and tests to use , 5. The The guidelines were developed in accordance with the procedures developed by the WHO Guidelines Review Committee (GRC) . The WHOHandbook for Guideline Development, 2012 . Re. Re45]. A challenge in developing the viral hepatitis testing guidelines was the lack of high quality evidence to support any recommendation. In general, GRADE suggests that strong recommendations should be avoided when the quality of evidence of low. However, for diagnostic tests, following such an approach would in the vast majority of cases lead to conditional recommendations, given that low quality (indirect) evidence is the norm. Although conditional recommendations for diagnostic testing are often appropriate, they also may be more difficult to implement, increase uncertainty, and may not accurately reflect judgments about likely benefits relative to harms. In the WHO viral hepatitis testing guidelines, nine recommendations were rated strong and 12 were rated conditional. As described above, some factors that informed strong recommendation ratings were high acceptability and feasibility, acceptable costs, supportive findings from predictive modeling studies, and whether the recommended test was the de facto gold standard.Given the availability of effective treatments for HBV and HCV infection, the GDG considered increased rates of testing and receipt of test results as a marker of additional patient health benefits because people who were aware of their infection would be more likely to receive treatment. In several cases, the GDG judged that the use of slightly less accurate diagnostic tests could be justified because the lower accuracy would be offset by increased uptake of testing and linkage to care. These recommendations were graded conditional because they involved trade-offs between lower diagnostic accuracy and increased access and linkage to care.Studies are needed to understand the effects of WHO testing recommendations on rates of testing, identification of persons with infection, linkage to care, and ultimately, clinical outcomes, in settings with different epidemiological patterns of viral hepatitis. In particular, research is needed to understand whether lower diagnostic accuracy for some conditionally recommended tests (e.g., RDTs , oral flThe GDG encourages efforts to further develop and standardize methods for developing recommendations on diagnostic testing and address methodological challenges such as how to determine when diagnostic accuracy is a suitable proxy for clinical outcomes, measure inconsistency across diagnostic accuracy studies, evaluate tests considered the de facto standard, incorporate modeling studies into recommendation decision frameworks, incorporate and weigh patient preferences and values in testing decisions, standardize methods for determining clinically important differences in diagnostic accuracy, and weigh potential trade-offs between diagnostic accuracy and improved access to testing and linkage to care.Identification of persons with chronic HBV and HCV infection is the critical first step for linking such persons to effective treatments and preventive strategies. To inform national programme managers and policy makers in LMICs who are responsible for the development of national hepatitis testing and treatment policy, WHO developed its first guidelines on HBV and HCV testing using the WHO GRC process based on methods developed by the GRADE Working Group. The GDG formulated its recommendations based on the overall quality of the evidence, the balance between benefits and harms, values and preferences, feasibility and resource implications. Modeling studies and surveys were used to supplement systematic reviews of diagnostic accuracy. Challenges in developing recommendations include the lack of direct evidence on effects of diagnostic tests and testing strategies on clinical outcomes, limitations in the evidence, and trade-offs between diagnostic accuracy and factors such as costs, increased testing access, and feasibility Table . Given t


We found that these two plasmids are essentially identical (99.99% nucleotide sequence identity), which proved the possibility of interspecies transmission. Comparative analysis of the plasmids revealed that the backbone of pEMA120 is 99% similar to a conjugative fosB-negative E. faecium plasmid, pZB18. There is a traE disrupted in the transfer region of pEMA120, in comparison to pZB18 with an intact traE. The difference of their transfer frequencies between pEMA120 and pZB18 suggests this interruption of traE might affect conjugative transfer. Two copies of the fosB gene linked to a tnpA gene, forming an ISL3-like transposon, were found at separate locations within pEMA120, which had not been reported previously. These two fosB-carrying transposons were confirmed to form circular intermediates by inverse PCR. The hybridization of plasmid DNA digested by BsaI, having restriction site within the fosB sequence, demonstrated that the presence of multiple copies of fosB per plasmid is common. The total copy number of the fosB gene as revealed by qRT-PCR did not correlate with fosfomycin MICs or growth rates at sub-MICs of fosfomycin in different transconjugants. From susceptibility tests, the fosB gene, regardless of the copy number, conferred high fosfomycin MICs that ranged from 16384 to 65536 μg/ml. This first complete nucleotide sequence of a plasmid carrying two copies of fosB in VRE suggests that the fosB gene can transfer to multiple loci of plasmids by the ISL3 family transposase TnpA, possibly in the form of circular intermediates, leading to the dissemination of high fosfomycin resistance in VRE.To further characterize the  L-cysteine, or bacillithiol, to the epoxide ring of fosfomycin  (Bacillus subtilis (63% nucleotide similarity)  is a global public health concern due to the increasing dissemination of these bacteria and limited clinical treatment options . Fosfomysfomycin , was thecus spp. . The fosrmediate . Additioilarity)  and in tilarity) . In our ilarity) . The plaEnterococcus faecium A120 and 17 additional fosB-carrying, vancomycin resistant E. faecium isolates were characterized in our previous paper  2015 guidelines  every 5 min for 16 h.Single colonies were grown at 37°C with shaking at 200 r.p.m. in 2 ml of brain heart infusion (BHI) broth. Independent overnight cultures were diluted (1:1000) and 200 μl was transferred to a 96-well plate that was incubated at 37°C. The turbidity was measured at ODA preliminary experiment using isolate A120 was carried out using a fosfomycin concentration gradient from 1/128 the MIC to the MIC. The growth of the 19 transconjugants that were exposed to 1/4 the MIC of fosfomycin was measured and compared with an antibiotic-free control. Each sample was performed in triplicate.Plasmids were isolated from the 19 transconjugants using a QIAGEN Plasmid Midi Kit . The manufacturer’s instructions were followed with the inclusion of the lysozyme treatment  prior to the lysis step with buffer P2 .BsaI , for which a target site is present within the fosB gene, was used to digest plasmid DNA. The hybridization probe was designed to bind within the latter half of the fosB gene after BsaI digestion  and fosB-latter-R (5′-TGA GGT TTA GCC TCT TTA TAA TAA CTC-3′).The restriction enzyme BsaI at 37°C in a water bath overnight. After the digested DNA was agarose gel electrophoresed for 2 h, the DNA fragments were transferred to a positively charged nylon membrane , hybridized with a DIG-labeled fosB-latter specific probe, and then was detected with a NBT/BCIP color detection kit .Plasmid DNA was first digested by fosB was measured via quantitative real-time PCR (qRT-PCR). The chromosomal housekeeping gene purK was chosen as an internal control. The sequences of the fosB and purK primers used are as follows:The copy number of fosB-F (5′-CTCAATCTATCTTCTAAACTTCCTG-3′),Q-fosB-R (5′-CGATTTTGAAGATTGGTATAACTGG-3′),Q-purK-F (5′-GATATCCAAGATGCGATTGAC-3′), andQ-purK-R (5′-CTTCTAAAACACAGGTTCCTTCTC-3′).Q-® Premix Ex TaqTM PCR kit , 2 ng of genomic DNA as template, and 2 pmol of each primer. The Ct values of each sample was measured under appropriate PCR conditions  on an Applied Biosystems ViiATM 7 Dx instrument . Data were calculated based on the 2t-ΔΔC method.Quantitative PCR reactions were carried out in a 10 μl reaction that contained 5 μl SYBRE. faecium pEMA120 and E. avium pEA19081 plasmids. The plasmid sequences were validated by PCR, annotated using the RAST server  was carried out to complete the whole genome sequencing of T server  and wereT server . A compafosB gene) and fosBiR    with genfosB-carrying plasmids, the plasmids from two VRE isolates (E. faecium A120 and E. avium 19081) were completely sequenced. Plasmid pEMA120 is 79,797 bp in size with an average G + C content of 33.8%. It contains 87 open reading frames (ORFs), 47 of which encode proteins with homology to proteins with known functions, which can be classified into several functional modules: antibiotic resistance, mobile elements, plasmid stability, replication recombination and repair, and conjugal transfer .To further characterize the previously identified fosB mediating fosfomycin resistance and vanA-type transposon causing vancomycin resistance. Two copies of fosB gene along with tnpA insert into different position of pEMA120 leading to diverse direct repeats . One fosB gene along with tnpA gene reversely inserts into the vanA-type Tn1546-like transposon between the vanRS and vanHAX intergenic region. Another fosB gene accompanied with tnpA gene is flanked by genes encoding a DNA topoisomerase and a RNA-directed DNA polymerase, which are required for replication, recombination and repair. No same structure was found in existing database, indicating that this is a novel insertion position of the fosB gene.In the antibiotic resistance region, there are two types of resistance determinants: fosB on pEMA120 was compared with fosB in other species  Plasmid-borne fosB in Staphylococcus haemolyticus and Staphylococcus aureus share 99.8 and 99.5% nucleotide identity with fosB in the plasmid of E. faecium, respectively. As to surrounding environment, there is a rep gene downstream fosB on Staphylococcus spp. plasmid instead of a tnpA gene adjacent to fosB on E. faecium plasmids.The surrounding environment of traB and traA of the conjugative plasmid pMG1 (traI gene (ORF38) shows 71% identity at the amino acid level with ORF34 of pHTβ encoding the putative DNA relaxase/nickase, which is needed for the initiation of DNA transfer in conjugative plasmids  to mid pMG1 . There imid pMG1 . The traplasmids .E. faecium and showed less than 80% identity, at both nucleotide and amino acid level, with any plasmid replicon type according to the classification system of enterococci . Plasmid pMG1 (GenBank accession no. AB183714) is a gentamicin and kanamycin resistance plasmid capable of highly efficient transfer among enterococci and originally isolated from a clinical strain of E. faecium in Japan, 1998  . In addition, this fosB-transposon circular intermediate could also be acquired by inverse PCR in the other 18 VRE isolates. However, the circular intermediates could not be detected by southern hybridization (using the fosB-latter specific probe) after gel electrophoresis using the uncut or S1 nuclease digested pEMA120 plasmid (data not shown).To determine whether  primers . As expe primers . Thus, TfosB-carrying plasmid by performing S1 nuclease-pulsed-field gel electrophoresis (PFGE)  . The thiFigure 5A shown, the DNA band pattern generated by BsaI digestion showed diverse restriction patterns in the plasmids from the transconjugants of 19 VRE isolates. The hybridization bands of isolate A120 in Figure 5B were well in accordance with the simulating graph of pEMA120 in Supplementary Figure BsaI-digestion method to explore the fosB copy number in a plasmid. The isolates IB3, A165, IA110, 19081, A166, 1001, A96, A155, A158, and IA28, which were analyzed but were not shown here, generated very similar two-band signals (16 and 9.5 kb) with isolate A120. This finding suggests that these isolates bear two fosB copies per plasmid. These results were verified by PCR amplification using primers (“between vanSH” and “fosB-2th”) designed to amplify an approximately 3-kb fragment surrounding each fosB ] reported in Table 1 range from 17.17 to 55.68 in the isolates with two-copies of fosB per plasmid . In the A3, A13, A9, A92, B42, IA14, A67, and A157 transconjugants, their total fosB copy number was less than 10, except isolate A9 (188.45).The total Table 1. From the susceptibility tests, the MICs of fosfomycin for these isolates and their transconjugants were extremely high, ranging from 16384 to 131,072 μg/ml (Table 1). The MICs of the transconjugants was discussed due to their purer genetic background. As shown in Supplementary Figure fosB . For example, although the fosB copy number of isolate A67 and B42 were low, their MICs of fosfomycin were higher than most of the other isolates.The detailed fosfomycin MICs (without an upper limitation) of 19 VRE isolates and their transconjugants is shown in fosB and growth rate, maximum optical density (OD600) or lag time . The growth of the 19 transconjugants following exposure to 1/4 MICs of fosfomycin was measured  and pHTβ  reflecting a stepwise evolutionary process through several recombination events.Recently, a series of complete genome sequences of quencing . Howeverus study , was verE. faecium A120 to the recipient strain E. faecium BM4105RF, using filter mating at a rate of 3.4 × 10-4 /donor CFU. The tra region of plasmid pEMA120, of highly homology with that of pZB18, has traB, traA, traC, traI, traG/D, traE and other transfer related genes. It is noteworthy that the gene encoding TraE of plasmid pEMA120 was disrupted, compared with that of plasmid pZB18. The plasmid transfer rate of pZB18 with an intact traE was 7.0 × 10-1 (filter mating) as provided by traE might affect conjugative transfer and would limit the dissemination of this fosB- and vanA-carrying plasmid to some extent compared to plasmid pZB18. However, it cannot be ignored that the transfer rate of 3.4 × 10-4 of pEMA120 still confer high capability of fosB- and vanA co-transmission.Conjugative transfer is an important means of horizontal spread of antibiotic resistance and an important driver in evolution . The plafosB gene in the E. faecium plasmid has a close phylogenetic relationship with that of Staphylococcus, with more than a 99% shared sequence identity. However, the sequence surrounding the fosB gene is diverse among different genera. Instead of the rep genes that are adjacent to fosB in staphylococcal plasmids (tnpA gene (an ISL3-like transposase-encoding gene) downstream of fosB that forms an ISL3-like transposon in enterococcus plasmids, as previously reported , which generates two AT-rich 8-bp target duplications upon insertion. ISL3-family elements have been reported to be involved in gene inactivation or transcriptional activation of silent genes in Pseudomonas strains . But this method used in our study had a limitation — if the digested fragments of different fosB copies were in similar sizes, it would be difficult to separate them clearly by agarose gel electrophoresis and distinguish them by Southern blotting. Therefore we also performed quantitative PCR to determine the total copy number of fosB in an isolate. It revealed that the total copy number of fosB in isolates carrying two copies of fosB per plasmid was more than double that of isolates carrying a single copy of fosB per plasmid, possibly due to the higher frequency of fosB-carrying circle formation in the former, as was reported previously , far exceeding the normal clinical theoretical dose as well as the maximum serum drug concentration (Cmax) used for intravenous fosfomycin (606 mg/l)  . In thisfosB gene in VRE was first reported in this study. The transfer region and comparative analysis of closely related plasmids suggested that pEMA120 is a pZB18-like conjugative plasmid that has undergone a series of evolutionary changes. The identification of a similar plasmid in E. avium proved the possibility of inter-species dissemination of the fosfomycin resistance. The multiple copies of the fosB gene in plasmids is common in our VRE isolates. However, plasmid-borne fosB, whether single- or multi-copy, can confer a high level fosfomycin resistance. Nevertheless, the fosB ISL3-like transposon, which can translocate to multiple loci in the plasmid, possibly in the form of circular intermediates, may accelerate the dissemination of fosfomycin resistance in VRE.A novel plasmid with two copies of the Conceived and designed the experiments: YY, YC, TQ, and LS; Performed the experiments: LS, PZ, and KS; Analyzed the data: XH and LS; Wrote the manuscript: YY, LS, TQ, YC, and PZ; All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The Trip database began more than twenty years ago in an effort to simplify searching for clinically relevant, high-quality, evidence-based information. Originally an acronym for Turning Research Into Practice, Trip is a meta-search tool and a convenient first stop for busy clinicians, librarians, and students who are seeking evidence for practice or learning. It is an excellent tool for librarians when they are developing search vocabulary during the early stages of a systematic review. Searching Trip can yield additional studies for systematic reviews because of its unique approach to retrieval.A comparison chart clearly outlines the free versus fee features . Trip PrUsers of all types of accounts are encouraged to register. Accounts allow users to change their passwords or associated email addresses; select a clinical interest, profession, and affiliated institution to access full-text collections; set up customized search strategies or specialty alerts; mark articles as favorites; return to prior searches via a history list; and receive updates and alerts from Trip.Trip’s motto is “Find Evidence Fast.” Multiple search types and functions are available, including Boolean operators, asterisk truncation, phrase searching, proximity searching, and date and title limit searching. Trip Pro users can use basic or advanced search or combine search statements using the “Recent” search feature. A patient/problem, intervention, comparison, outcome (PICO) search form is available to assist with retrieving evidence. Search term suggestions, based on searches by other users, appear when a topic is typed into the search box. Spelling and typing errors are corrected by a polite, “search for…instead?” prompt. Another helpful crowdsourced prompt, “Trip users also search for,” aids users in finding associated search topics. For those searching multiple topics or trying multiple iterations of a single topic, a clear query box function would be helpful in the basic search.The focus of Trip’s content is high-quality, evidence-based resources such as systematic reviews, clinical guidelines, and evidence-based synopses. These include a broad range of grey literature including regulatory advice, clinical trials, critically appraised topics (CATs), and patient decision aids. Trip users can access ten monographs per month from EBSCO DynaMed. Appropriate evidence-based resources are added at the suggestion of users or advisory group members, with a list of included publications provided , 4. TripAn algorithm scores the search results to determine their order and then sorts results based on quality of evidence. Users will find systematic reviews, primary research, evidence-based synopses, and clinical trials at the top of the results. A text score uses search term position and frequency; the publication score assigns a rank based on general quality of evidence for a publication; and the date score moves recent documents higher in the results. Filter options appear to the right of the results. Filters include evidence/publication types, search hedges for overdiagnosis and world development, limits for years, and links to previously viewed or starred favorites. A clinical filter allows users to limit results to a practice specialty. After selecting a result, a SmartSearch prompt appears offering closely related titles and other titles based on clickstream data .naloxone includes recent hot topics such as guidelines addressing use of the drug in recovery rooms, end-of-life care, substance abuse, and patient-controlled analgesia. Crowdsourced data are also used in the “Latest & Greatest” feature, which provides a list of the most frequently visited results for a topic searched in the past twelve months [Default display is by quality. Users can also display results by date, relevance, and popularity based on user views. For example, the popularity display for e months . As TripThe results display includes a color bar that links a result to publication type filters . Other dPubMed Central (PMC) and other Trip partner sites provide full-text, open access content through title links in the results list. Trip also offers OpenURL linking to hundreds of institutional full-text collections. Registered users select an institution (or multiple institutions if they are affiliated with more than one) in their user profiles. Institutional full-text links appear below results and may require institutional authentication for access. Librarians can send OpenURL linking information to Trip to be added as a full-text provider.Trip Pro allows users to email results or export them in comma-separated values (CSV) and Research Information Systems (RIS) formats. Test files imported smoothly into Endnote Web, but users will need to supplement data in some references. Some non-journal resources have incomplete metadata, which results in incomplete citation data in RIS files.Users can set up search topic alerts by performing a search, then clicking the Alerts link. Email alerts arrive monthly and include updates about Trip. Searchers may find the alert function a bit basic and may prefer to use other tools for more sophisticated alerting needs.naloxone, Trip provides a prompt at the top of the results: “Trip has 9 answers for related questions.” Clicking the Show link provides a list of common topics; then another click takes the user to content on any of the following topics: naloxone and opioid-induced constipation, clinical pharmacology, indication and usage, contraindications, warnings, precautions, adverse reactions, overdosage, and dosage and administration. Answers are culled from reliable sources, such as the National Library of Medicine’s DailyMed.Trip mines content to provide links to answers that are a click or two away from the results screen . For exaTrip has several other methods for helping users find answers more quickly. The results of a search on “influenza vaccine pregnancy” include a box labeled, “Trip’s best suggested answer.” This box contains a short summary on the topic of vaccination benefits to the fetus and infant, followed by a link to a Canadian Pediatric Society statement. Users can also use the Clinical Q&A publication filter to identify synopses of their search topics. Synopses dates can vary widely from topic to topic, so some topics may not present results that are recent enough for clinical users.Search results can be limited to images and videos. Those results can be limited further to “Only show images that are free to modify, share and use,” making Trip a useful resource for presentations or training.Trip Database has announced that an automated review system will be available to Trip Pro users in January 2018 . This toTrip is a web-based resource that is compatible with major browsers. A mobile version for all tablets and phone browsers works well for quick clinical searches . The mobThe cost for Trip is modest compared to many point-of-care tools that are used in medical libraries. The search functions offer flexibility for naïve and sophisticated searchers. Trip’s search functions are less robust than most vendor implementations of MEDLINE but more robust than those found in most point-of-care resources. The unique capabilities of Trip’s results sorting are not found in other products. Specialized filters focus results and are valuable to those who are interested in evidence-based information for clinical decision-making. Trip also includes grey literature that is not available in many other tools.Trip and Trip Pro offer many features of interest to clinicians and librarians by using ideas from linguistic analysis, answer summarization, crowdsourcing, and automation to provide quality information with fewer clicks. Trip combines results from many evidence-based sources, displaying them in an order that makes sense for evidence-based practice. Filters are designed with evidence-based clinical decision-making in mind. Increasing open access content and OpenURL linking to institutional journal collections puts full-text a click or two away from results. Output in RIS format allows users to import results into bibliographic citation databases. Alerts provide updates on Trip’s development along with links to new results on user topics.


Motor training induces plastic changes in the primary motor cortex (M1). However, it is unclear whether and how the latency of motor-evoked potentials (MEP) and MEP amplitude are affected by implicit and/or explicit motor learning. Here, we investigated the changes in M1 excitability and MEP latency induced by implicit and explicit motor learning. The subjects performed a serial reaction time task (SRTT) with their five fingers. In this task, visual cues were lit up sequentially along with a predetermined order. Through training, the subjects learned the order of sequence implicitly and explicitly. Before and after the SRTT, we recorded MEP at 25 stimulation points around the hot spot for the flexor pollicis brevis (FPB) muscle. Although no changes in MEP amplitude were observed in either session, we found increases in MEP latency and changes in histogram of MEP latency after implicit learning. Our results suggest that reorganization across the motor cortices occurs during the acquisition of implicit knowledge. In contrast, acquisition of explicit knowledge does not appear to induce the reorganization based on the measures we recorded. The fact that the above mentioned increases in MEP latency occurred without any alterations in MEP amplitude suggests that learning has different effects on different physiological signals. In conclusion, our results propose that analyzing a combination of some indices of M1 excitability, such as MEP amplitude and MEP latency, is encouraged in order to understand plasticity across motor cortices. We acquire many motor skills in everyday life. It is well known that there are two types of learning process  by measuring the amplitude and latency of the MEP with a mapping procedure.Twenty one healthy right-handed subjects with no experience of specific musical instrument training participated in this study after giving their written informed consent . Seventeen participants  joined in a first experiment, and eight participants  joined in an additional experiment . In the first experiment, we designed the experiment as a cross-over study involving two sessions. Each session was separated by at least 1 week. All experimental procedures were carried out in accordance with the Declaration of Helsinki and were approved by the ethics committee of Hiroshima University, Japan. Vulnerable populations were not involved in this study.Based on the methods of previous studies . In the explicit session, we told the subjects that the LED would light up sequentially (2-5-1-3-4-2-1-5-4-2-3-5-4-3-1) after the color of the LED changed from red to blue. The subjects were only told about the existence of the sequence, not its length or order. Nine subjects initially participated in the implicit session, whereas the other eight were subjected to the explicit session first.The protocol and the number of trials were identical to those used in previous studies . The mean RT during the random trials was calculated using the last 50 trials within each block. For the explicit learning measure, we asked the subjects to recall items of the sequence that subjects memorized during the SRTT after the retention test. We counted the number of items of the sequence that the subjects correctly recalled. We excluded the subjects who noticed the existence of a sequence during the implicit training period and were able to recall more than four items of the 15-item sequence at the end of the experiment. Five subjects were excluded from the subsequent analysis .Surface electromyogram (EMG) recordings were obtained from the right-flexor pollicis brevis (FPB) muscle using Ag/AgCl surface electrodes. The EMG signals were amplified, filtered (5–3 kHz), and sampled at 10 kHz. A figure-of-8 coil with a diameter of 70 mm connected to a MagStim200 stimulator  was used to evoke MEP in the FPB. We marked 25 stimulation sites around the optimal position (the hot spot) for evoking MEP on a cap worn by the subjects Figure . The hotMEP latency was automatically calculated using a custom-made program written in Matlab . MEP onset was defined as a deviation from the mean plus 2*standard deviation (SD) value for the rectified EMG activity recorded before the TMS trigger. We removed the data for signals involving MEP amplitudes of <0.25 mV to ensure that MEP onset was detected in a stable manner. One subject (who participated in the implicit session first) was excluded because we could not calculate MEP latency due to a large TMS artifact on their EMG recordings. We compared the relative frequency of MEP latency, which consists of MEP obtained from all 25 sites, between the pre-training and post-training periods. We normalized MEP latency using a shortest MEP latency recorded during the pre-training period to examine the changes in MEP latency across subjects because mean MEP latency differed across subjects. First, we defined a shortest MEP latency as a bin which the relative frequency of MEP latency in the pre-training period was firstly above 1%. Then, other MEP latencies were subtracted with the shortest MEP latency. This procedure allowed us to calculate the mean MEP histogram across subjects. We showed the range of the normalized MEP latency from 0 ms to 4 ms because there were few MEP that exhibited normalized MEP latency of >4 ms.To examine the effects of different trial number of SRTT between the implicit and explicit session on the results of first experiment, we performed an additional experiment. In this experiment, subjects performed the SRTT with explicit manner. The training block included 25 repetitions of the sequence, and the test block consisted of 15 repetitions of the sequence. Before and after the training, we recorded MEP from FPB muscle evoked by TMS on the 25 stimulating points as with the first experiment. post hoc test was used to further the analysis. Mauchly’s test examined sphericity in the repeated measures ANOVA models. Mauchly’s test of sphericity was not significant in all repeated measures ANOVA’s test. We calculated point-biserial correlation coefficient (r) and partial η2 as an effect size for the post hoc test and for the ANOVA, respectively. In all analyses, the level of statistical significance was set at p < 0.05. All data are shown as the mean ± SE values.Three-way repeated measures analysis of variance (ANOVA) was used to test the differences in the MEP amplitude in each site , and the differences in histogram of the MEP latency , and the differences in the histogram of the MEP amplitude . Two-way repeated measures ANOVA was also used to test the differences in amount of skill improvement between the implicit and explicit session , and the mean MEP latency . Bonferroni’st-test revealed a significant differences in skill between the pre- and post-test , and between the pre- and retention-test , but not between the post- and retention-test . To examine whether amount of skill improvement differed between the two sessions, we subtracted the post- and retention skill with pre-skill . Two-way repeated measures ANOVA yielded no significant main effect of session  = 3.67, p = 0.08, partial η2 = 0.27), time  = 1.44, p = 0.26, partial η2 = 0.13), and their interaction  = 1.39, p = 0.27, partial η2 = 0.12) on the amount of skill improvement. This indicates that the amount of skill improvement did not differ between the two sessions.We calculated the difference in mean RTs between the random and sequence trials as a skill to analyze sequence specific improvement of RTs through the training. In both the sessions, Bonferroni’s For the explicit measure, we asked the subjects to recall the sequence at the end of the experiment and recorded the number of correctly recalled items. The subjects were able to recall 0.27 ± 0.27 items of the sequence in the implicit session. This indicates that the subjects learned the sequence implicitly through the implicit session. By contrast, the subjects were able to recall 8.82 ± 1.74 items of the sequence in the explicit session. Therefore, subjects learned the sequence explicitly through the explicit session.F = 10.17, p < 0.05, partial η2 = 0.50) on MEP amplitude obtained from the 25 sites, but there were no significant main effect of session  = 0.54, p = 0.46, partial η2 = 0.05) and time  = 3.13, p = 0.08, partial η2 = 0.24), and no significant first and second interaction between these factors . As for the factors affecting the mean MEP latency, two-way repeated measures ANOVA detected no significant main effect of time  = 4.50, p = 0.06, partial η2 = 0.31) and session  = 1.46, p = 0.26, partial η2 = 0.13), but the interaction between these parameters was significant  = 5.10, p < 0.05, partial η2 = 0.34). Bonferroni’s post hoc test detected a significant increase in MEP latency in the implicit session , but not the explicit session . To reveal the details of the changes in MEP latency, we compared the relative frequency of MEP latency between the pre-training and post-training periods. To calculate the mean histogram of MEP latency across subjects, we normalized MEP latency using a shortest MEP latency, which the relative frequency of MEP latency in pre-training period was firstly above 1%. We subtracted other MEP latency with the shortest MEP latency. Figure F = 1.67, p = 0.04, partial η2 = 0.14). Hence, we analyzed the data separately. In the implicit session, two-way repeated measures ANOVA detected a significant main effect of latency  = 15.62, p < 0.01, partial η2 = 0.61), but not a main effect of time  = 4.34, p = 0.06, partial η2 = 0.30), and the interaction between these parameters was also significant  = 2.50, p < 0.01, partial η2 = 0.20). In short-latency MEPs, significant reductions in the relative frequency were observed. In contrast, the relative frequency in long-latency MEPs was significantly increased. However, no such differences were seen in the explicit session, except for the main effect of latency  = 19.51, p < 0.01, partial η2 = 0.66, time: F = 2.63, p = 0.14, partial η2 = 0.21, interaction: F = 0.39, p = 0.99, partial η2 = 0.04). Figure Figure Through the first experiment, we found the increases in MEP latency without any changes in MEP amplitude after implicit, but not explicit session. In the first experiment, the number of repetition of sequence trials differed between the two session. There remains a possibility that the different number of trials during training between the two sessions would affect the different changes in MEP measure. Therefore, we performed an additional experiment. Table The novelty of this study is the increases in MEP latency without the alteration of the orientation of the coil, the background EMG level, and the MEP amplitude through the implicit, but not the explicit session. Our findings suggest that the acquisition of implicit knowledge involves the reorganization of the corticomotor pathway. In contrast, acquiring explicit knowledge does not appear to induce the reorganization based on the measures we recorded.The memory systems associated with implicit and explicit knowledge are considered to be different (Pascual-Leone et al., In the present study, we found the increases in MEP latency through implicit, but not explicit learning. Although it is impossible to know the detailed mechanisms of present results through our experiment, we describe some possibilities to explain the results.In the implicit session, the significant bins of relative frequency of MEP latency were ~1.2–1.4 ms intervals. TMS induces I-waves that the intervals between the I-waves are about 1–1.5 ms-long (Day et al., In this study, we used higher stimulus intensity to evoke MEP than those previous studies. Furthermore, we did not examine the learning-induced plasticity using recruitment curve of MEP amplitude. This may cause no changes in MEP amplitude through the implicit session because of two reasons. One is that high intensity stimulation would stimulate other areas adjacent to the M1. The other is a ceiling effect. However, the results of previous studies (Rosenkranz et al., In addition, there remains a possibility that our results were task-specific. Previous study has demonstrated the task-specific effects of direct current stimulation over the M1 on learning and memory formation (Saucedo Marquez et al., The findings of this study suggest that the acquisition of implicit knowledge involves M1 reorganization. The changes in MEP latency with no alteration of MEP amplitude suggest balanced plastic changes at different neural substrates. Therefore, analyzing a combination of some indices of cortical excitability, such as MEP amplitude or latency, with mapping procedure is encouraged to fully understand plasticity across the motor cortices.MH designed the study and analyzed data. All authors conducted the experiment and participated in the interpretation of the data. MH drafted the manuscript. SK and KF helped with the writing of the manuscript. All authors approved the final version of the manuscript submitted for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.