Objective: Animal bites represent a significant global health issue. The evidence in the literature regarding their management in many areas is conflicting and unclear. This project attempts to identify current evidence in the literature on the management of animal bites and assess if current practice in the United Kingdom is evidence based. Materials and methods: A literature review on the management of animal bites was performed, and a national UK survey was contacted using a questionnaire based on the available evidence in the literature. Results: The results from this survey show that 98% of plastic surgery units routinely use prophylactic antibiotics in all animal bite wounds; 58% close low-risk injuries primarily after initial washout, and there are conflicting opinions regarding the management of associated fractures and soft tissue injuries. The available data in the literature suggest that appropriate wound management is the most important factor for prevention of infection in animal bites. Antibiotic prophylaxis should only be given in high-risk wounds and primary closure should be performed in low-risk wounds. Conclusions: The management protocols of many plastic surgery units often diverge from the available evidence within the literature. On the basis of a thorough literature review, a guideline for the management of animal bites is presented. Future studies should investigate the management of associated fractures and soft tissue injuries. There is a lack of published epidemiological studies from the United Kingdom, and most of the microbiological and epidemiological data in the literature come from the United States. They represent 1% to 2% of new accident and emergency (A&E) attendances in the United Kingdom,2A MEDLINE and Cochrane literature review was conducted to identify the available evidence on the management of animal bites using the search strategies shown in A structured questionnaire was developed on the basis of the literature review, concentrating on identified controversial issues. A telephone survey, of all plastic surgery departments in the United Kingdom that provide emergency services, was conducted using the structured questionnaire. Forty-five plastic surgery units were identified in the United Kingdom and contacted by telephone. The questionnaire was completed by either the on-call plastic surgery Senior Registrar or the on-call plastic surgery Senior House Officer.Level Ia evidence: 1 systematic reviewLevel Ib evidence: 9 randomized controlled studiesLevel IV evidence: 7 observational studiesLevel IV evidence: 10 retrospective case seriesIncluded in the study were publications written in the English language and relevant to the management of animal bites. Narrative review papers and single case reports were excluded from the study. The literature review resulted in the following:All 45 units that were contacted completed the phone survey. Sixteen plastic surgery units (36%) had a written protocol for the management of animal bites. In 25 hospitals (57%), A&E dealt with the initial management and patients were referred to plastic surgery units after the initial washout. The survey results regarding antibiotic prophylaxis, wound cultures, wound closure, and use of local anesthetics are shown in ,7,3,5,9,6,10,3,8,6,9,6,10,13,8,9,9,15In the United States, where most epidemiological data are available, dogs are associated with 80% to 90% of domestic animal bites, after cats.6,19-6The primary morbidity from animal bites is infection.4-16,18The significant amount of devitalized tissue in severe injuries, such as full-thickness wounds and extensive crush injuries, predisposes to bacterial colonization and growth, leading to infection; therefore, such wounds are recommended to be washed and debrided as soon as possible.3,Animal bites to the hand have a higher risk for development of infection than facial wounds because of the multiple small compartments and joints in the hand and a better blood supply to the face.5,17,20,13,14,18,20,23,14,17,The most important factor to prevent infection in animal bites is adequate wound cleaning as shown by many studies.4Recommendation: Animal bites should be washed using high-pressure irrigation with 20-mL syringe and 19-gauze needle and debrided as soon as possible, in the A&E or operating theater depending on the severity of the injury (level of evidence Ib).Local anesthesia is required to achieve adequate wound washout and debridement during the initial wound management. When a local anesthetic is used, it is suggested that it should be injected through uninvolved skin.Recommendation: Local anesthesia should be used to achieve adequate initial washout and debridement of animal bites in the A&E (level of evidence IV).,14,Pasteurella multocida, which is part of the natural oral flora of domestic cats. The most frequent microorganism in dog bites is Staphylococcus aureus after P. multocida.12,Staphylococcus and Streptococcus, anaerobes such as Fusobacterium and Bacteroides and Capnocytophaga canimorsus, which, although rare, can cause a serious and potentially fatal infection.10,Pasteurella multocida is a small, nonmotile, facultative anaerobic, Gram-negative, pleomorphic coccobacillus. Pasteurella wound infection is characterized by an early onset of local intense cellulitis, purulent discharge, and lymphangitis, usually within the first 12 to 24 hours after the injury. Culture and sensitivities are usually available after 48 hours of incubation and if not treated it can lead to sepsis and multiple organ failure. The early onset helps to differentiate it from staphylococcal or streptococcal causes, which usually develop after 24 hours.7,10,25The majority of infections are polymicrobial and involve aerobes and anaerobes from the skin flora of the victim and the mouth of the animal.10,23,In a prospective multicenter microbiological study by Talan et al,19Recommendation: Co-amoxiclav should be the antibiotic of choice for the empirical management of infected animal bites (level of evidence Ib).,11,17,20,23,20,8,11,7,7,20,23,There is a big controversy regarding the use of prophylactic antibiotics in noninfected animal bites. Although they are classified as contaminated wounds, a fact that for many justifies the use of prophylactic antibiotics, most studies show that there is no statistically significant difference in the incidence of infection between patients who receive antibiotic prophylaxis and those who do not.8Recommendations:Prophylactic antibiotics are not necessary in low-risk animal bites (level of evidence Ia).Prophylactic antibiotics should be considered in high-risk injuries (level of evidence Ib).Culture and sensitivities should be sent only in infected cases to guide antibiotic therapy (level of evidence IV).The objective of surgical management in animal bites is to avoid immediate mortality in severe life-threatening injuries, followed by wound washout and debridement of devitalized tissues to prevent infection. In addition to wound closure, repair of damaged structures and reconstruction are required to achieve the best cosmetic and functional outcome. In children and adults with severe injuries, repair is usually performed in the operating theater.Recommendations:Minor animal bites in adults should be repaired in the A&E (level of evidence IV).In children and adults with severe injuries, the repair should usually be performed in the operating theater (level of evidence IV).,14,17,2,3,7,13,18,20,3,13,22,11,13,20,3,18,Surgical debridement is suggested for the wound edges and nonviable tissue, using sharp debridement.5Recommendation: Animal bites can be closed primarily after adequate surgical treatment, but special care should be given in high-risk wounds .Head and neck injuries, which as previously mentioned are more common in children, are often the most serious. Neck exploration may be required to exclude damage to the great vessels of the neck and aerodigestive tract. Damage to the larynx and trachea is considered the most serious traumatic injuries from dog bites. Extensive scalp lacerations present a challenge for plastic and reconstructive surgery because of the difficulty to restore hair-baring skin across the scalp, thereby affecting the cosmetic appearance of the patient. Severe injuries to the head and neck may require multistage procedures, for example for extensive hair-bearing skin loss, pinna lacerations or damage to the facial nerve, and may require a prolonged hospital stay.15Because of many conflicting opinions and approaches to the management of animal bites in the United Kingdom, we reviewed all evidence in the literature to find an evidence-based approach to their management and summarized our recommendations in a simple proforma .This study has shown that there is a great variety in the way these injuries are managed in plastic surgery units across the United Kingdom, and we think that this step-by-step guideline can ensure that animal bites are treated in an evidence-based fashion.We recommend further research into the risk factors for the development of infection and the ideal time to repair associated fractures and soft tissue structures but believe that our work can help maintain a consistent, evidence-based approach, ensuring that patients are treated appropriately and to a high standard.


To summarize recommendations of existing guidelines on the treatment of upper respiratory tract infections (URTIs) in children, and to assess the methodological quality of these guidelines.We searched seven databases and web sites of relevant academic agencies. Evidence-based guidelines on pediatric URTIs were included. AGREE II was used to assess the quality of these guidelines. Two researchers selected guidelines independently and extracted information on publication years, institutions, target populations, recommendations, quality of evidence, and strength of recommendations. We compared the similarities and differences of recommendations and their strength. We also analyzed the reasons for variation.Thirteen guidelines meeting our inclusion criteria were included. Huge differences existed among these 13 guidelines concerning the categorization of evidence and recommendations. Nearly all of these guidelines lacked the sufficient involvement of stake holders. Further, the applicability of these guidelines still needs to be improved. In terms of recommendations, penicillin and amoxicillin were suggested for group A streptococcal pharyngitis. Amoxicillin and amoxicillin-clavulanate were recommended for acute bacterial rhinosinusitis (ABRS). An observation of 2–3 days prior to antibiotic therapy initiation for mild acute otitis media (AOM) was recommended with amoxicillin as the suggested first choice agent. Direct evidence to support strong recommendations on the therapy for influenza is still lacking. In addition, the antimicrobial durations for pharyngitis and ABRS were still controversial. No consensus was reached for the onset of antibiotics for ABRS in children.Future guidelines should use a consistent grading system for the quality of evidence and strength of recommendations. More effort needs to be paid to seek the preference of stake holders and to improve the applicability of guidelines. Further, there are still areas in pediatric URTIs that need more research. Acute respiratory infections (ARIs) are classified as upper respiratory tract infections (URTIs) or lower respiratory tract infections (LRTIs) A proliferation of clinical guidelines published in peer-reviewed journals has been seen due to the high morbidity of URTIs. It is important that these guidelines provide appropriate guidance for the treatment of URTIs. Nevertheless, the growing number of guidelines has been accompanied with a growing concern about variance and conflicts among guideline recommendations and the quality of guidelines The aim of this study is to assess the quality of evidence-based guidelines for drug therapy of URTIs in children and to compare the recommendations of the existing evidence-based guidelines. Special attention was devoted to areas of disagreement and discussion with an ultimate aim to improve the clinical practice in treatment of URTIs for children. Such an assessment is important as it may explain some of the variability in guideline recommendations and may assist health care providers in choosing among available guidelines.We searched Pubmed, Guidelines International Network (GIN), U.S. National Guideline Clearinghouse (NGC) and four Chinese databases: Chinese Biomedical Literature Database (CBM), China Knowledge Resource Integrated Database (CNKI), VIP Database and Wanfang Database for evidence-based guidelines (until March 2013) using the following items: respiratory tract infections, common cold, laryngitis, pharyngitis, tonsillitis, rhinitis, rhinosinusitis, otitis media, middle ear inflammation, influenza, grippe as Medical Subject Headings (MeSH) or keywords. The searches were limited to guidelines published in English or Chinese. We also searched guidelines at web sites of academic agencies, such as American Academy of Pediatrics (AAP) and Infectious Diseases Society of America (IDSA). Retrieved references were considered if they met our inclusion criteria.Types: evidence-based guideline with systematic literature review and grading system for quality of evidence and/or strength of recommendation Diseases: URTIs including rhinosinusitis, pharyngitis, laryngitis, rhinitis, otitis media, tonsillitis, common cold and influenza.Patients: children ages 0–18 years oldInterventions: drug therapyTypes: guideline of hospital level; old version of guidelineDiseases: non-infectious upper respiratory diseasesInterventions: vaccinesQuality of evidence-based guidelines was assessed by using AGREE II from the following domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, editorial independence and overall guideline assessment. Each of the AGREE II items and the two global rating items were rated on a 7-point scale (1-strongly disagree to 7-strongly agree). A score was assigned depending on the completeness and quality of reporting. Domain scores were calculated by summing up all the scores of the individual items in a domain and by scaling the total as a percentage of the maximum possible score for that domain. The scaled domain score was calculated as: (obtained score-minimum possible score)/(maximum possible score-minimum possible score) We used the intraclass correlation coefficient (ICC) as a measure of agreement between reviewers. The ICC was applied to each guideline. Calculations were carried out by using SPSS 13.0.Two researchers selected guidelines independently and extracted the following information: publication years, institutions, target populations, recommendations, quality of evidence, and strength of recommendations. We compared the similarities and differences of recommendations and their strength and analyzed the reasons for variation.A total of 1,785 citations and abstracts were identified in the initial searches. Finally, 13 guidelines meeting our inclusion criteria were included, covering a period from 2005 to 2013 . These 1Half of the 13 guidelines are from America developed by the American Academy of Pediatrics (AAP) and the Infectious Diseases Society of America (IDSA). Five guidelines are developed specially for children, while the rest are for both adults and children. All guidelines, except one, announced the conflict of interests and none were founded by industrial partners. All guidelines stated the formulation of recommendations was based on evidence. However, there is a huge variation in the grading systems of evidence quality and recommendation strength used .There were huge differences among 13 guidelines concerning the categorization of evidence and recommendations. Eight different grading systems were used, two of which failed to give strength of recommendations. Four guidelines used GRADE This domain evaluates the overall objectives, expected benefit or outcomes, and target population of guidelines. The medium score for this domain was 90.28% (76.39%–97.22%), indicating that most guidelines satisfied criteria of this domain.This domain evaluates the degree of relevant professional group involvement and whether the views and preferences of the target population have been considered and the definition of target users has been clearly presented. The overall score in this domain was low with a medium of 61.11% (33.33%–83.33%). Most of the guidelines involved relevant professionals in the development process and declared the target population. However, the guideline developers did not seek the preference of target populations sufficiently resulting in a decrease in score of this domain.This domain addresses the method of evidence search, grading, summarizing and the formulation of recommendations. The medium score for this domain was 76.04% (32.81%–91.15%), with 1 guideline scoring <50%. This guideline failed to demonstrate the link between evidence and recommendations. It was not reviewed externally before its publication either.This domain evaluates presentation and format of guidelines. The medium score was 95.83% (90.28%–98.61%), indicating that all guidelines satisfied criteria of this domain.This domain evaluates the consideration of facilitators or barriers to its implementation, as well as monitoring criteria. The medium score of this domain was 56.25% (10.42%–83.22%), the lowest of all domains. Four of 13 guidelines scored ≤50%. Most guidelines failed to consider the applicability sufficiently in guideline development.This domain addresses founding issues and competing interests of guideline development members. The medium score was 81.25% (8.33%–97.92%), with 3 guidelines scoring<50%.Recommendations on antibiotics from IDSA and ISCI are consensus. The first choice was penicillin or amoxicillin. For penicillin-allergic patients, cephalosporins, clindamycin, or macrolides were recommended. Only IDSA, however, gave a recommendation on the duration of antibiotics (10 days). In terms of adjunctive therapy, IDSA suggested nonsteroidal anti-inflammatory drugs (NSAIDs) as adjunct to an appropriate antibiotic for treatment of moderate to severe symptoms or control fever. Aspirin should be avoided in children due to the risk of Reye’s syndrome All of the 5 guidelines supported the use of antibiotics in pediatric ABRS. However, AAP emphasized the onset of antibiotics should be in cases of severe onset or worsening course, while the other four recommended antibiotics for all clinical diagnosed ABRS. Guidelines from FSP and SIP recommended amoxicillin as first-line choice due to the low risk of treatment failure H1N1: Both IDSA and WHO recommended antivirals for confirmed or highly suspected H1N1 infection. However, IDSA recommended zanamivir rather than oseltamivir, while WHO recommended oseltamivir for children (>1 year) who have severe or progressive clinical illness.H3N2: Only IDSA released a guideline on the treatment of H3N2 and recommended oseltamivir or zanamivir for laboratory-confirmed or highly suspectedH3N2. IDSA also warned that adamantanes should not be used.H5N1: The recommendations on use of antiviral drugs for H5N1 were based predominantly on studies of infection with human influenza rather than clinical trials on treatment of H5N1 patients. Both WHO and IDSA placed a high value on the prevention of death and relatively low values on adverse reactions, development of resistance, and costs of treatment. Oseltamivir and zanamivir were recommended as first-line therapy and amantadine was recommended when neuraminidase inhibitors were not available.Influenza-like syndrome: The SNLG did not recommend the routine use of amantadine, rimantadine, oseltamivir or zanamivir for influenza-like syndrome because of their side effects, the emerging resistance phenomena, and the irrelevance of the outcomes considered in the selected studies. Instead, SNLG recommended the use of oseltamivir in the post-exposure prophylaxis in non-vaccinated institutionalized patients.SIGN, JOS and AAP all recommended an observation of 2–3 days before antibiotic therapy for mild AOM. AAP recommended amoxicillin as the first choice and an antibiotic with additional β-lactamase for children with risk factors. SIGN and JOS recommend amoxicillin, amoxicillin-clavulanic, cephalosporins and macrolides with a statement that cephalosporins and macrolides can be used but less safe than amoxicillin CTFPHE was first published in 1979 by Canadian Ministry of Health. The quality of evidence is based on the study design and the strength of recommendation depends on sufficiency of evidence. CTFPHE was the first grading system developed and is the foundation of many other grading systems. However, the CTFPHE still has some drawbacks The potential benefits of guidelines are only as good as the quality of the guidelines themselves. Appropriate methodologies and rigorous strategies in the guideline development process are important for the successful implementation of the resulting recommendations Although an important level of consensus appears throughout the various guidelines, there are still some conflicts in recommendations for drug choice and durations of therapy. There are three main reasons contributing to the variances. First, the geographic difference leads to the variance of pathogens and its drug resistance. Second, the recommendations of guidelines were based on different evidence. Recent studies may overturn the results of previous studies. Thus, the timely updated guidelines are more reliable. Third, the expectation and preference of guideline developers and patients may influence the final recommendation. Therefore, a local guideline is more useful for health professionals if there is a conflict among guidelines.The durations of antimicrobial therapy for rhinosinustis and acute otitis media are still controversial. More studies are needed to compare the different durations of antibiotics in children. In addition, the antivirials for influenza also lack direct evidence. Many recommendations are based on indirect evidence. Thus, more clinical trials or prospective observational studies are needed.Future guidelines should use a consistent grading system for quality of evidence and strength of recommendations and seek the preference of stake holders to improve the applicability of guidelines. Further, there are still some areas in pediatric URTI that need more research.Checklist S1(DOC)Click here for additional data file.


Clinical practice guidelines have been defined as systematically developed statements to assist practitioner and patient decision-making about appropriate health care for specific clinical circumstances. They play an important role in guiding evidence based clinical practice. The Australian National Health and Medical Research Council has developed and pilot-tested a new framework for guideline development, the FORM approach, the role of which has yet to be further defined.We critically review the elements of the FORM approach and compare it to other, more established methods for rating the quality of evidence and strength of recommendations.FORM recognizes five factors that impact the strength of a recommendation which are the evidence base, consistency, clinical impact, generalizability and applicability. Consideration of these elements leads to a four-tiered rating system represented by the letters A ("body of evidence can be trusted to guide practice") to D ("body of evidence is weak and recommendation must be applied with caution"). It builds on other existing guideline methodologies such as those developed by the Scottish Intercollegiate Guidelines Network (SIGN), the Strength of Recommendation Taxonomy (SORT) and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) groups. FORM distinguishes itself from other systems by its strong emphasis on applicability, which is separated out as its own category and relates the relevance of the body of evidence to the Australian healthcare system.The FORM approach offers a methodologically rigorous alternative approach to guideline development that places particular emphasis on aspects of applicability. This feature is unique and may prompt future adoption by other guidelines systems Clinical practice guidelines have been defined as systematically developed statements to assist practitioner and patient decision-making about appropriate health care for specific clinical circumstances. AlongsiSince their humble beginnings in the early nineties, the defining characteristics of clinical practice guidelines that can rightfully consider themselves "evidence-based" have increasingly been developed. These iThe FORM framework represents a new arrival of an evidence-based methodology to develop clinical practice guidelines. It cleaAlthough this system is novel, it should be recognized that it differs little from the existing guidelines systems. For example, when comparing FORM with GRADE, which is used by more than 55 organizations in 23 countries, "clinical impact" refers to the likely benefit that application of the guideline can realize while also taking into account the relevance of the effect to patients , precision and effect size. GRADE cIn an ideal world, guidelines developers would employ a unified system to rate the quality of evidence and strengths of recommendations. Doing s5 = 1024 combinations. These must be considered in conjunction with recommendations that are made using a four-tiered scale for or against an intervention (42 = 16 combinations). This results in a mind-boggling 16,384 (1024 × 16) ways in which a body of evidence can theoretically be categorized to support clinical recommendations. It is, however, highly likely that some combinations are more prevalent than others making development of the guidelines system more feasible than these theoretical calculations appear to indicate. Nevertheless, it is also likely that this complexity, hitherto only implicitly acknowledged by the people in the field, drives the efforts to develop new systems for guidelines development. It is also clear that as we strive to develop a unified guidelines system, we must find a way to rate a body of evidence and strength of recommendations in a reproducible and reliable manner. We believe that the most important next step in the EBM field relates to the need to perform empirical methodological research to evaluate which of the existing guidelines systems is most reproducible and performs best in the hands of the individuals they are meant to serve. Without undertaking this research, the entire evidence-based medicine edifice may lose its solid ground, built so carefully over the last 20 years.How should we arrive at the "best" system? To do so, one would ultimately like to show that a) the system results in making recommendations that will lead to better outcomes than recommendations by other systems and b) the system is more reproducible than others. The first point will be difficult to prove empirically and may therefore remain forever unresolved. The second point relates to the issue of whether a system such as FORM can be operationalized in terms of practical, reproducible policy and procedures. To illustrate the challenge, consider the number of combinations that can arise from the FORM system that (as shown in table 1 in the manuscript) distinguishes between five factors that can be rated in four different ways thereby resulting in 4The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2288/11/17/prepub


In 2011, the Scottish Government asked Health Protection Scotland (HPS) to deliver evidence based recommendations within 1 year to update national infection control (IC) care bundles. Aimed to support frontline staff to reduce healthcare associated infection (HAI) these featured bundles to prevent bloodstream infections associated with surgery and intravascular devices. NHSScotland has used national evidence based bundles since 2008. The results of the recent National HAI Prevalence Study[- To prepare a model for rapidly delivering evidence reviews.- To issue literature reviews on key infection control interventions.- To issue key recommendations from the reviews to inform the update of existing care bundles.An algorithm of a proposed, chronological rapid evidence review model was developed including 1) a high level review to identify relevant mandatory, national/international evidence based guidance, then assessed using the AGREE instrument 2) to address lack of evidence/conflicting recommendations, targeted full database searches; Medline, CINAHL, EMBASE with resulting papers appraised using SIGN checklists and graded using HICPAC method 3) a decision making framework used to formulate final key recommendations for practice.During July to Nov 2012, using the rapid review model identified a number of existing bundle criteria which required a targeted evidence review and resulted in changes to recommendations consistent with the evidence. In total, 13 recommendations were made for preventing surgical site infection, 12 for peripheral vascular catheters and 13 for central vascular catheters.To meet the demands of those aiming to deliver safe care in NHSScotland, we issued evidence based recommendations within a tight timescale, which could be adopted into care bundles addressing pre, peri and post surgery care and peripheral, central vascular catheter insertion, maintenance and removal. The impact of these recommendations is reviewed through national programmes of HAI reduction work.None declared.


Ultrasonographic studies have demonstrated transient reduction in spleen volume in relation to apnea diving. We measured spleen volume under various respiratory conditions by MR imaging to accurately determine the influence of ordinary breath holding on spleen volumetry.Twelve healthy adult volunteers were examined. Contiguous MR images of the spleen were acquired during free breathing and during respiratory manipulations, including breath holding at the end of normal expiration, breath holding at deep inspiration, and the valsalva maneuver, and spleen volume was measured from each image set based on the sum-of-areas method. Acquisition during free breathing was performed with respiratory triggering. The duration of each respiratory manipulation was 30 s, and five sets of MR images were acquired serially during each manipulation.Baseline spleen volume before respiratory manipulation was 173.0 ± 79.7 mL, and the coefficient of variance for two baseline measures was 1.4% ± 1.6%, suggesting excellent repeatability. Spleen volume decreased significantly just after the commencement of respiratory manipulation, remained constant during the manipulation, and returned to the control value 2 min after the cessation of the manipulation, irrespective of manipulation type. The percentages of volume reduction were 10.2% ± 2.9%, 10.2% ± 3.5%, and 13.3% ± 5.7% during expiration breath holding, deep-inspiration breath holding, and the valsalva maneuver, respectively, and these values did not differ significantly.Spleen volume is reduced during short breath-hold apnea in healthy adults. Physiological responses of the spleen to respiratory manipulations should be considered in the measurement and interpretation of spleen volume. Splenomegaly occurs in various disorders, such as hematological diseases, malignant neoplasms, liver diseases, infection, and autoimmune disorders. The quantitative measurement of spleen size using an imaging method plays an important role in detection, severity assessment, and monitoring of splenomegaly. Spleen size can be evaluated by ultrasonography –4, compu The spleen serves as a reservoir of blood cells and releases them into the central circulation in response to physiological stresses such as exercise and apnea , resulti Previous studies –22 have  The study subjects were 12 healthy adult volunteers (6 men and 6 women), aged 31.0 ± 5.1 (mean ± SD) years. They had no history of chronic diseases or smoking and no contraindications to MR imaging. No experienced diver was included. Before participation, the ability of 30-s breath holding at expiration was confirmed. The study protocol was approved by the institutional review board of Kitasato University School of Medicine and Hospital , and written informed consent was obtained from all subjects before participation.MR images of the spleen were acquired during free breathing, breath holding at the end of normal expiration, breath holding at deep inspiration, and the Valsalva maneuver, and spleen volume was measured from each image set. A 1.5-T clinical scanner  and a 12-channel phased-array coil were used. Thirteen contiguous slices of 8-mm thickness were obtained in the sagittal or coronal plane to cover the entire spleen using a two-dimensional fast imaging employing steady-state acquisition (FIESTA) sequence with fat saturation. Although the axial images are the most popular in abdominal MR imaging, the superior-inferior dimension of the spleen is relatively long. We used sagittal or coronal images to reduce the number of slices and slice thickness. Scan parameters were as follows: repetition time, 3.0 ms; echo time, 1.2 ms; flip angle, 45°; number of excitations, 1; bandwidth, ±125 kHz; field-of-view (FOV), 400 mm; acquisition matrix, 200 × 200; phase FOV, 0.9; and reconstruction matrix, 512 × 512. A parallel imaging technique, the array spatial sensitivity encoding technique (ASSET), was used with a reduction factor of 2. Acquisition during free breathing was performed with respiratory triggering, and one slice was acquired for a 266-ms data acquisition window at the end of expiration in one respiratory cycle. Without respiratory triggering, acquisition time for the entire image set comprising 13 slices was 6 s. On the day before MR imaging, the subjects practiced respiratory manipulations after detailed explanation. MR imaging was performed in the evening after a 4-h or longer fast. A bellows was placed around the abdomen to monitor respiratory motion, and a pulse oximeter  was attached to the fingertip to monitor peripheral oxygen saturation and pulse rate. First, the spleen was imaged in the sagittal and coronal planes during free breathing. The better plane for demarcation of the spleen was selected visually from the sagittal and coronal planes, and subsequent acquisitions were performed in that plane.Spleen volume was measured from each image set. An operator demarcated the spleen using the volume utility on a workstation . For demarcation, a thresholding method combined with manual processing was used  mL. The coefficient of variance for the two baseline volumes was 1.4% ± 1.6%. The two baseline volumes were closely correlated with a correlation coefficient of 0.999, and the difference between them was limited with a bias of 1.5 mL and a 95% confidence interval of -4.5 mL to 7.6 mL, suggesting excellent repeatability ( Reduction in spleen volume was observed during the respiratory manipulation, and the degree and time course of the volume change were similar irrespective of manipulation type ( The normalized pulse rate increased slightly during all types of respiratory manipulation, and returned to the control value 2 min after cessation of the manipulation (via sympathetic activation [Ultrasonographic studies have demonstrated reductions in spleen volume in relation to breath-hold apnea –22. The tivation ,22–24, ativation ,21, althtivation  or withotivation  face immtivation –21, suggtivation  and did tivation . Palada tivation . The restivation  would betivation –21. HoweIn the present study, we repeatedly measured spleen volume in non-divers using MR imaging and demonstrated approximately 10% volume reduction during short breath holding, indicating a small but substantial influence of respiratory conditions on the estimated spleen volume. Spleen volumes measured during free breathing and breath holding are not exchangeable, and estimates should be presented with specification of the respiratory condition. In previous studies, the percentage of reduction ranged from 14% to 25% when reduction was observed –22. The Volume reduction was observed immediately after the start of respiratory manipulation and remained constant throughout the 30-s manipulation. This rapid response was consistent with the results of Palada et al. , who exa In clinical settings, spleen volume may be measured from images obtained under various respiratory conditions. CT is commonly performed during deep-inspiration breath holding, and MR imaging is performed during expiration breath holding, deep-inspiration breath holding, or free breathing. Some patients may elevate intrathoracic pressure during deep-inspiration breath holding, similar to the Valsalva maneuver. The Valsalva maneuver increases intrathoracic and intra-abdominal pressure, reduces venous return, and stimulates sympathetic activity . An 18% We allowed a 2-min interval between the end of respiratory manipulation and the first assessment of recovery to ensure regular respiration cycles during data acquisition, and revealed the resolution of volume reduction in the first assessment, in agreement with the findings of Palada et al.  after shin vivo physiology as well as for clinical diagnosis. MR imaging enables to measure spleen volume during free breathing with the aid of respiratory triggering and fast imaging techniques, and appears to be suitable for the assessment of spleen response to physiological stress. One slice was acquired for 266 ms at the end of expiration in one respiratory cycle in the present study, and the effect of movement during acquisition should be negligible. Stress-induced reduction in spleen volume has been speculated to be mediated by sympathetic stimulation [ MR imaging provides morphological and functional measures with high accuracy and reproducibility under various conditions. Lack of radiation exposure facilitates repeated measurement and measurement in normal volunteers. MR imaging is a powerful tool for the investigation of mulation ,22–24 an The present MR study demonstrated that spleen volume is reduced during short breath-hold apnea. The presence or absence of breath holding is a major determinant of spleen volume, and the influences of the type of breath holding are limited. The response to breath holding is a rapid process. Spleen volume decreases just after the start of breath holding, and recovers soon after the end of breath holding. Physiological responses of the spleen to respiratory manipulations should be considered in the measurement and interpretation of spleen volume.


Health practitioners play a pivotal role in providing patients with up-to-date evidence and health information. Evidence-based practice and patient-centred care are transforming the delivery of healthcare in the UK. Health practitioners are increasingly balancing the need to provide evidence-based information against that of facilitating patient choice, which may not always concur with the evidence base. There is limited research exploring how health practitioners working in the UK, and particularly those more autonomous practitioners such as health visitors and practice nurses working in community practice settings, negotiate this challenge. This research provides a descriptive account of how health visitors and practice nurses negotiate the challenges of communicating health information and research evidence in practice.A total of eighteen in-depth telephone interviews were conducted in the UK between September 2008 and May 2009. The participants comprised nine health visitors and nine practice nurses, recruited via adverts on a nursing website, posters at a practitioner conference and through recommendation. Thematic analysis, with a focus on constant comparative method, was used to analyse the data.The data were grouped into three main themes: communicating evidence to the critically-minded patient; confidence in communicating evidence; and maintaining the integrity of the patient-practitioner relationship. These findings highlight some of the daily challenges that health visitors and practice nurses face with regard to the complex and dynamic nature of evidence and the changing attitudes and expectations of patients. The findings also highlight the tensions that exist between differing philosophies of evidence-based practice and patient-centred care, which can make communicating about evidence a daunting task.If health practitioners are to be effective at communicating research evidence, we suggest that more research and resources need to be focused on contextual factors, such as how research evidence is negotiated, appraised and communicated within the dynamic patient-practitioner relationship. Evidence-based practice and patient-centred care are two important aspects of UK Government policy reforms to improve the delivery of healthcare -4. HowevIn the past, the production of evidence and its implementation into practice has been viewed as a positivistic and linear process . More reAlthough there is a body of research addressing communication within healthcare ,24-27, lOur present study follows on from this work  and formhttp://www.nhscareers.nhs.uk/explore-by-career).Eighteen in-depth telephone interviews were conducted with health visitors (n = 9) and practice nurses (n = 9) between September 2008 and May 2009. Participants for this study were recruited across the UK via adverts on the Royal College of Nursing website (n = 6), posters advertising the study at the 2007 Community Practitioners and Health Visitors Annual Conference (n = 8), and through recommendation (n = 4). Convenience sampling was used to obtain a diverse range of practitioners in terms of: age; length of experience in the health service; type of caseload; and geographical location within the UK . Across the interviews, participants spoke of a wider cultural change in their relationship with patients, which involved patients becoming more proactive in assessing evidence themselves and less accepting of ‘blanket’ (HV 05), ‘one size fits all’ (PN02) health advice. For instance, as one practice nurse suggested: “There is a kind of new era where, you know, our parents’ generation wouldn’t have questioned us as health professionals, but now more and more people are becoming questioning, because people go to university and feel more confident in themselves, confident in their own work lives and they’re professional” (PN09). Similarly, another practice nurse spoke about practitioners generally having less influence, stating: “…even doctors aren’t just, aren’t just like you know, accepted what they say as gospel anymore, people are encouraged to find things out for themselves really now” (PN04).Some participants drew on the MMR vaccine controversy to illustrate the communication challenges they experienced when patients questioned and disputed evidence. The participants often discussed how the most dissent about the vaccine was voiced by more affluent parents. Although this new wave of patients were viewed as being well informed and savvy, participants spoke of the troubles they experienced trying to communicate evidence-based information to parents who were basing their beliefs on personal and social influences as opposed to the existing body of research evidence. As one health visitor explained: “During the MMR controversy the evidence was unclear and parents often based their judgements on the views of friends and family, and that kind of evidence can be very persuasive” (HV06). Other participants also spoke about the role of anecdotal or experiential evidence. It was mentioned that when people base their decisions on experiences rather than on research evidence it raises difficulties for participants who champion evidence-based practices. As one health visitor stated: “How do you say that’s not fact, it’s one person’s experience”’ (HV02). Similarly, a practice nurse suggested that people rely on different forms of evidence, stating: “…it can be quite different to different people” (PN07). It was common for participants to describe patients becoming more assertive about their healthcare decisions. The exception to this, mentioned by some participants, was that patients from deprived communities were: “…less educated and less likely to question the care or information they were given, they tend to just say ‘yes, it’s good for the child’ and they’ll do whatever you suggest” (HV01)., “silly” (PN01), and “a complete idiot… a twit” (PN04) to describe how they felt about their level of skill in assessing evidence. Participants spoke of how dealing with knowledgeable patients could impact negatively on their own self-esteem. As one health visitor explained: “It actually makes you feel quite de-skilled, because you end up thinking […] they’re much better than me, and I can’t add anything to this conversation” (HV07).Another strong finding that emerged from the data was the impact that more critical and questioning patients were having on the participants’ confidence to communicate best evidence. Participants illustrated this by references to feeling ‘inadequate’ when talking to ‘more educated parents’ about research evidence, and to difficulties that arose when parents and patients have read extensively around specific topic areas . Some participants described feelings of embarrassment and they used words such as “stupid” Another issue that emerged was that participants often felt patients have unrealistic expectations about the depth and breadth of health visitors’ and practice nurses’ knowledge. For example, one practice nurse said: “There are so many areas that we cover, patients sort of challenge you. They expect you to know everything” (PN04). It was common for participants to feel that they did not have a good understanding of the strengths and limitations of different types of evidence. They talked about feeling pressured by patients to know more, as this quote illustrates:I have had some parents, sometimes, questioning me about evidence to the extent to where I say, “I don’t know, for God’s sake, don’t ask me things like that.” They’re asking me about, you know, the constitution and the make up of vaccines, and I think, you know, I know a reasonable amount and I could find out for them, but sometimes you just think – I’m not a bloody scientist. What do you expect me to know? […] You know you feel almost like you are under attack (PN09).There was a sense from all the interviewees that the more confident the participant is about understanding the strengths and limitations of evidence, the more likely they feel they are to have a positive impact on patients’ understandings.Managing and maintaining long-term positive relationships with patients, often referred to in literature as a therapeutic relationship, also emerged as a key theme. Many participants felt that managing their relationships with patients carefully was crucial to facilitating effective communication of research evidence. Throughout the interviews, participants often stressed the importance of building trust with patients. As one health visitor commented:There is a fine balance between advocating something that you have strong views about but also recognising their view. That’s the beauty of health visiting because that’s the whole way you work, getting a relationship going with the client and you might be trying to say something which they don’t want to hear but it’s only through time and trust, building a relationship, then they might not necessarily change what they do but they will hopefully hear what you’re saying […] we’re gonna be saying some things which people don’t want to hear but […] and you’ve got to have a relationship with your clients that you can still get into the house again (HV07).Participants commonly spoke of how building a trusting relationship with patients was the foundation to effectively communicating about evidence. A couple of participants recalled specific examples to highlight this point. One health visitor spoke of a successful relationship that she had nurtured over several years:She was a single mother and trusted me. I think that’s really important. I worked with her to get the information across, so you know, we work together because otherwise people get disengaged and then there’s nobody left there to work with them (HV08).). When probed about what kinds of things they do to strengthen their relationship with patients, it became evident that developing a long-term relationship tended to be achieved by taking a non-directive approach when speaking about evidence. From many of the participants’ accounts provided, persuading patients to accept evidence-based practices was secondary to maintaining the integrity of the patient-practitioner relationship. Being non-directive was associated with “being careful about what you say” (PN08), “not doing anything to harm the relationship” (HV05), and “knowing when to back off” (HV07). For example, one health visitor explained the use of a less directive approach as a means to avoid alienation when giving advice:Not having the necessary information at hand to be able to answer patients’ queries was thought, by some participants, to undermine patients’ trust in them. For instance, one practice nurse stated: “If they think that you don’t know what you’re talking about, then they’ll have no trust in you…” .Only one participant, who had over 20 years of practice experience and worked in a deprived community setting, discussed using a more directive, paternalistic approach when talking with patients to ensure research evidence was clearly communicated and adhered to. She made no mention of this approach being detrimental to her relationship with patients (HV01).Our findings complement previous work that has explored health practitioners’ experiences of communicating evidence ,28. The Wider socio-cultural conditions, often discussed in terms of late-modernity and the rise of consumerism, are proposed to underpin the changing nature of patients and their increasing knowledge and expectations about healthcare -39. AccoCommunicating with critically-minded patients about evidence-based practice proved a greater challenge for practitioners when evidence was contested within the public domain. Although public access to health information is expanding, this poses challenges in knowing who to believe and trust. Health practitioners in this study were unsure of the level of weight to give second-hand or third-hand accounts of evidence, such as media reports or re-told stories from friends or family that are often readily available. Tools to assist health practitioners to discuss the merits and pitfalls of such sources of evidence may be a useful resource.The findings also highlight the lack of clarity, on the health practitioners’ part, about how to contextualise patients’ personal and social influences and experiences with existing evidence-based guidelines. This echoes the ongoing debates within the literature about what types of knowledge constitute evidence and how to integrate these different types of knowledge into guidelines and practice . It has Patients’ growing confidence in their own knowledge to make decisions about health information, and in turn their increasing expectations of healthcare, appeared to have a detrimental effect on some health practitioners’ confidence to communicate evidence. On examination, our participants, many of whom had more than ten years of professional experience, attributed their own confidence issues to a lack of knowledge about appraising evidence, which could leave them feeling deflated and embarrassed when challenged by seemingly knowledgeable patients. Wilson et al.  similarlThe therapeutic relationship is often said to be at the heart of effective nursing practice and involves using a patient-centred approach to build respect and trust between the patient and the practitioner ,50-52. CA potential limitation of this research is that the health visitors and practice nurses who took part in this study were self-selected and may represent a highly engaged sub-section of their professions. One obvious drawback to using telephone interviews is the absence of non-verbal cues, which can make this method more difficult. However, the researcher carrying out the interviews was experienced in this technique. There are also some contextual differences between the roles and settings in which health visitors and practice nurses work (aforementioned in the methods section) that could have affected the relationships that these two groups of health professionals have with their patients, although this was not evident in the data. It is also important to recognise that small-scale qualitative studies, such as this one, provide contextually bound in-depth accounts and as such are not necessarily generalisable to other contexts or groups. As previously mentioned, our data was collected in 2008/2009 and UK healthcare policy and training has undergone substantial changes in recent years. For example, undergraduate and postgraduate university education increasingly form a core aspect of nursing and midwifery training, and new policies have led to changes in the roles, responsibility, expertise and professional boundaries of multidisciplinary healthcare teams ,53. HoweThis research highlights some of the emerging challenges that health practitioners face around communicating evidence in practice. Although the overall responsibility of evidence implementation is shared across teams, organisations and wider policy initiatives, frontline practitioners need to have the skills, knowledge and confidence to ensure they can effectively communicate about evidence with their patients. Our findings suggest that increasing public access to complex, and sometimes contradictory, health information alongside higher patient expectations may result in growing demands and challenges being placed upon busy health practitioners. How health practitioners deal with and respond to these challenges may reflect how confident they feel in their own abilities to assess and communicate about research evidence and the type of relationship they build with their patients. In the UK, healthcare reforms in nursing and midwifery aspire to increase educational training and there are a greater number of opportunities for continued professional development for practitioners to learn about appraising and communicating evidence. Reforms have also led to greater interdisciplinary team working, which may improve access to expertise and support.Health practitioners in this study often found it challenging to know how to contextualise best evidence with conflicting information, patients’ preferences and wider social and political influences that shape patients’ attitudes and beliefs. As a result, in some instances where patients were entrenched in their views, practitioners would ‘weigh up’ these various factors and decide not to advise patients about the evidence in fear of jeopardising their valued longer-term relationships. Community-based health practitioners should seek to combine their relationship-building skills and information giving skills to enter into more meaningful and engaged conversations with patients about evidence and how specific treatments and care would fit in with their patients’ values and preferences.One of the big challenges that healthcare continues to face is how to operationalise evidence-based practice. If health practitioners are to be effective at communicating research evidence in the current healthcare system, we suggest that more research and resources need to be focused on contextual factors such as understanding how research evidence is negotiated, appraised and communicated within the dynamic patient-practitioner relationship.The authors declare that they have no competing interests.JvB participated in the analysis and drafting of the manuscript. SH participated in the design, data collection, analysis, and in drafting the manuscript. Both authors approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6955/12/17/prepub


Although hemodialysis is the main modaility of treatment of end-stage renal disease, no practice guidelines are available in Egypt. Applying international guidelines for hemodialysis would not be suitable or feasible, because of different health system and lack of resources. The aim of this project was the development of evidence- and consensus-based clinical practice guidelines for hemodialysis in Egypt. The Egyptian guidelines were adopted from the standards developed by The College of Physicians and Surgeons of Alberta (Canada), The National Kidney Foundation (USA), The Clinical Standards Board for Scotland (Scotland), and The College of Physicians and Surgeons of Ontario (Canada). In addition, the guidelines published in Oxford Handbook of Dialysis were reviewed. Thereafter, a panel of Egyptian experts in the field of nephrology and hemodialysis was selected and invited to participate in this project. The Delphi technique was applied to build up the consensus among the experts on the formulated guidelines. The final version of the Egyptian Hemodialysis Practice Guidelines included five main sections; personnel, patient care practices, infection prevention and control, facility, and documentation/records. A consensus on practice guidelines for hemodialysis has been successfully produced and is supported by levels of evidence. The 12 Egyptian experts who participated in the Delphi technique and the reviewers assured the completeness and acceptability of the developed practice guidelines. Also, including experts from the university hospitals together with the Directorates of Cairo and Giza Health Affairs of the Egyptian Ministry of Health (MOH) avoided conflicts between clinical recommendations and feasible application in the MOH hemodialysis facilities. End-stage renal disease (ESRD) is one of the main health problems in Egypt. Currently, hemodialysis represents the main mode for treatment of chronic kidney disease stage 5 (CKD5), previously called ESRD or chronic renal failure.In Egypt, the estimated annual incidence of ESRD is around 74 per million and the total prevalence of patients on dialysis is 264 per million. The hemoThere is sufficient evidence that implementation of quality management in the health sector will reduce the cost and provide higher quality. It is imperative to be understood that quality assessment and improvement is the way of the future in the healthcare industry.5 QualityIn the United States, the National Kidney Foundation Dialysis Outcome Quality Initiative (NKF-DOQI) selected some aspects of the management of ESRD and developed, to date, 13 practice guidelines including vascular access for hemodialysis patients; treatment of anemia for patients with chronic renal failure; adequacy of hemodialysis; and adequacy of peritoneal dialysis. Other orThe National Program of Accreditation in Egypt has established some standards for certain clinical areas in hospital services including surgery, anesthesia but has not yet established standards for hemodialysis.The objective of the study was to develop practice guidelines for hemodialysis in Egypt and developing countries.The development of the Egyptian Haemodialysis Practice Guidelines entailed the participation of experts in Nephrology and Healthcare Quality Management from Cairo, Giza, and Minia governorates.The duration of the study was 12 months, from April 16, 2005 to April 15, 2006.This study is considered one of the health system researches. The study was carried out in two phases :In this phase, preliminary quality standards were formulated through:a) Review of literature to collect the quality standards that have already been implemented in different countries including NKF-DOQI, The ClinKt/V. Other guidelines are opinion based such as examination of the site of the fistula for signs of infection. The level of evidence was examined through systemic reviewing of related articles keeping the consensus opinion for practices having limited researches.The above-mentioned sets of standards combine both evidence-based standards and other opinion-based standards. Example of evidence-based guideline is the regular measurement of the delivered dose of hemodialysis and the method of its measurement using b) A preliminary version of the Egyptian practice guidelines for hemodialysis was formulated with the contribution of an expert of nephrology.The Delphi technique was applied to build up a consensus among the experts on the preliminary version of the formulated practice guidelines. This conThe technique was applied to 12 experts from different public universities, MOH, and other health care facilities, including private sector.The selection of the experts was done after a meeting attended by the Project Team, Professor of Nephrology and representative of the Department of Nephrology in Giza Governorate (MOH). The selection of the experts was based on experience, high educational background, and to cover diverse geographical areas. The objective of this meeting was to ensure the selection and participation of nephrologists from different health sectors in Egypt.The first version of the formulated practice guidelines was delivered to the Egyptian experts after explaining the aim and methodology of the study (first round). After 2–3 weeks, the responses were collected and analysed. Thereafter, the areas of disagreement were identified and highlighted. The second version of the guidelines was delivered to the same experts of the first round after clearing up the areas of disagreement and considering the different recommendations of the panel experts regarding them (second round). After 2–3 weeks, the responses were collected and analysed to formulate the third version of the practice guidelines. Thereafter, a meeting was organized and four experts were invited to review the third version in order to reach a final format for the practice guidelines. The four experts included two who previously participated in the first and the second rounds of the Delphi technique and two new experts; the director of the hemodialysis center in a university hospital and the supervisor on hemodialysis centers in Cairo. After the meeting, the final version of the Egyptian Hemodialysis Practice Guidelines was formulated. The final version was reviewed by a Professor of Nephrology in Ain Shams University. Thereafter, the reviewed version was delivered to Professor of Nephrology in Cairo University and Chair of the Clinical Practice Guidelines Committee—The International Society of Nephrology for final revision and approval.The final version of the Egyptian Hemodialysis Practice Guidelines included five main sections; (1) personnel, (2) patient care practices, (3) infection prevention and control, (4) facility, and (5) documentation/records .These formulated guidelines are prepared in nine pages. The personnel section included the staffing pattern and their qualifications. Patient care practices included the writing order for hemodialysis, pre-dialysis preparation, dialysis process, and care between dialysis sessions. Infection prevention and control section covered the different preventive measures for the patients, medical staff, reprocessing, sterilization, and disinfection for equipments and surfaces as well the housekeeping and waste management measures. The facility guidelines included the physical standards as well the administrative standards. The last section of the guidelines consisted of the documentation and records maintaining.Healthcare facilities are seeking nowadays to develop practice guidelines for the sake of improving healthcare services. In the healthcare sector in Egypt, trials for establishing guidelines have been lead by the MOH.Although hemodialysis is often used for treatment of ESRD, no practice guidelines are available in Egypt. Worldwide, international organizations set some guidelines like the National Kidney Foundation, which published guidelines concerning the adequacy of hemodialysis, adequacy of peritoneal dialysis, treatment of anemia in chronic renal failure patients, and vascular access. Other inApplying international guidelines for hemodialysis in Egypt would not be suitable or feasible, because of different health system and lack of resources. The main aim of this project was the development of evidence- and consensus-based clinical practice guidelines for hemodialysis in Egypt.Clinical practice guidelines often grade the “strength” of their recommendations according to the robustness of the supporting research evidence.Accordingly, we reviewed five practice guidelines from four developed countries to formulate the first set of the Egyptian hemodialysis practice guidelines. Thus, the first version of the Egyptian guidelines was not identical to any of the reviewed practice guidelines, and rather included all controversial issues.Using the Delphi technique, an exercise was undertaken to ascertain whether a consensus on general protocol for hemodialysis practice could be reached among Egyptian experts. The main problem at this stage was the selection of the Egyptian experts. Currently, Egypt has 17 medical schools together with specialized medical institutes. Selection of the Egyptian experts was a tiresome job. We decided to include consultants from all health sectors in Egypt rather than including only university professors or specialized institutes consultants. Healthcare in Egypt is offered through different sectors , thus it was recommendable to include at least an expert from every sector. We also included an expert from the Directorate of Giza Health Affairs, to be sure that the practice guidelines will be acceptable and recommendable by stakeholders in the Egyptian MOH.In general, a panel of 12 experts to build a consensus on national practice guidelines is more or less enough. Previously, the Surviving Sepsis Campaign included critical care and infectious disease experts representing 11 international organizations to develop management guidelines for severe sepsis and septic shock.One round was not enough to develop the Egyptian hemodialysis guidelines, but a second round was conducted on conflicting issues and detailed explanation was given regarding these issues to all experts, including the different American and European recommendations.The developed practice guidelines after the two rounds were reviewed in a meeting, which included two university professors and two experts from the Directorates of Cairo and Giza Health Affairs. This meeting aimed to ensure the completeness of and acceptability to the practice guidelines, especially that two of the four participants were not included in the Delphi technique. These two new participants were the director of the hemodialysis unit in a university hospital and the supervisor on hemodialysis centers in Cairo governorate, to avoid conflicts between clinical recommendations and feasible application in the MOH hemodialysis facilities.Kt/V. Although all international guidelines recommended its measurement every month, our guidelines recommended its measurement, after the meeting, every 3 months, because of its high cost. We referred in this case to the practice guidelines published in Oxford Handbook of Dialysis (2004).[An example of a conflicting issue was the frequency of measuring s (2004).The President of the National Kidney Foundation, a branch of the Egyptian Society of Nephrology, reviewed the final developed practice guidelines. Previously, the Egyptian Society of Nephrology and Transplantation developed management guidelines for hemodialysis, especially concerning the personnel item.The revised guidelines were reviewed again by the Chair of the Clinical Practice Guidelines Committee , who is also the Past-President of the Egyptian Society of Nephrology and Professor of Nephrology at Cairo University, to ensure compliance with the international guidelines and appropriateness for application in Egypt.According to basic concept of evidence based-medicine, half of all we are taught will in 10 years show to be wrong. Thus, the developed Egyptian Hemodialysis Practice Guidelines should be reviewed and updated regularly by the MOH and the Egyptian Society of Nephrology and Transplantation.The process of reviewing the published guidelines and quality standards in hemodialysis units tried to include multiple sources to avoid monopoly as well to broaden the options. However, one aspect that has been curiously looked for is the nonclinical administrative and facility quality standards applicable in the hemodialysis centers. This aspect is often unclear or improper in the common organizations delivering hemodialysis in Egypt. Although few published guidelines were used as a basis for this work, yet most of the published guidelines in this field agree with their recommendations and those used in this research are not by any means superior but more or less covering some missing aspects in the Egyptian practice such as the administrative and facility organization.The present study is an initial step in preparing a set of Guidelines for Hemodialysis that are applicable for the Egyptian practice to cover most of the areas in any hemodialysis center including the personnel and practice. A complementary part for this study is to validate the selected standards by checking the baseline compliance of these guidelines in some hemodialysis centers and hence gives an idea on the gaps and the difference in practices which will evidently determine the further integration of these standards in the regular practice. It will highlight the necessary training areas as well the baseline data after which monitoring will be carried out.These formulated guidelines were communicated to the quality directorate in the MOH in Egypt. However, the implementation of such guidelines is, till the date of submitting this manuscript, in its first evolutionary steps and depending mainly on individual efforts. Accordingly, the following is recommended to ensure wide application of such standards:The formulated practice guidelines for hemodialysis should be distributed to all hemodialysis facilities in Egypt. It will be advisable to print the Egyptian hemodialysis guidelines as a small handbook, which could be delivered to all healthcare workers working in hemodialysis facilities.Organize 1-day workshops for hemodialysis consultants and directors of hemodialysis facilities to orient them with all items of the developed practice guidelines. Attendants should be from both public and private sectors.The developed practice guidelines should be reviewed and updated, if needed, yearly. The Egyptian Society of Nephrology and Transplantation could take care of this scientific task.


We argue that the current status of fMRI studies on lie detection meets neither basic legal nor scientific standards. We identify four general classes of hurdles  and provide an overview on the stages and operations involved in fMRI studies, as well as the difficulties of translating these laboratory protocols into a practical criminal justice environment. It is our overall conclusion that fMRI is unlikely to constitute a viable lie detector for criminal courts.Following the demise of the polygraph, supporters of assisted scientific lie detection tools have enthusiastically appropriated neuroimaging technologies “ Gerard, : 5. Thes Recent empirical findings with neuroimaging techniques challenge the central idea of free will around which much of the criminal law has been shaped  del 18 settembre 2009; Tribunale di Como (n.536/2011) del 20 maggio 2011] and it seems that not before long functional Magnetic Resonance Imaging (fMRI) scans will be routinely requested by the defense when searching for either mitigating factors, such as anatomo-functional abnormalities, and/or the presence of any crucial memories when self-reports can be doubted  should be challenged, and if necessary modified, to make them more http://noliemri.com/ and CEPHOS—http://www.cephoscorp.com/), one that has not (yet) been subjected to the same regulation as the polygraph and thus is not considered an illegal means of assessment in pre-employment settings. As “trust” is increasingly prioritized in certain business sectors, top-tier corporations may be tempted to assess the trustworthiness of their key current and future employees by requesting they undergo a lie detection test via fMRI. However, in the more conservative criminal justice sector, several hurdles confront any use of fMRI as a viable lie detector. We will attempt herein to provide a realistic and accessible evaluation of such hurdles by discussing those questions raised by fMRI use for lie-detection purposes in criminal courts.Despite all these concerns fMRI is already being advertised as a scientifically proven lie detector by private companies having strong links with academia , in a quest for converging evidence about mental processes and brain substrates.fMRI is one of the most popular measurement techniques in cognitive neuroscience. It has been in use for about 20 years and is qualified as pulse sequencebrain structural information , and functionalAs implied by its name, fMRI makes use of strong magnetic fields to create images of biological tissue. Depending on the blood oxygenation level-dependent (BOLD) signallying and not-lying conditionsnot-lying and lying conditions are matched, the more precise the conclusions that can be drawn about the neural correlates uniquely associated with lying. While this type of analysis is not the only possible or optimal way to draw informative inferences from fMRI data .The outcome of data analysis is a function of a series of consensus-based decisions, including options and parameters chosen for realignment, normalization, and smoothing, statistical models for analyses, and the associated correction criteria that can be more or less conservative. Finally, strategic decisions may guide choice of the evidence that will find its way in the final report on a peer-reviewed journal. Although raw data may be requested by anyone for further analyses, most readers will exclusively rely on the information provided in a polished report. Furthermore, in very competitive scientific environments there is no incentive for investigators to try and replicate their own findings as journals typically promote the publication of novel designs rather than replications . Notably, this same level of (in)accuracy holds true even for professional categories such as lawyers, policemen, magistrates, and psychiatrists . Lying is fundamental to healthy behavior, as shown by the disastrous social interactions of patients with orbito-frontal lesions. Indeed some of these patients become notoriously tactless—which in a final analysis can be achieved by always being completely frank and honest. The literature on orbito-frontal patients suggests in turn that the ability to lie depends on the integrity of localized neural circuits . Finally, a great part of research on the neural correlates of deception has been focused on group-level results , whereas any real-world application would require a differential approach .Recent attempts have been made with fMRI to specify the neural correlates of lying or deception . fMRI is thus useful inasmuch as it hands over to techniques with complementary inferential power a map for (1) identifying cortical networks that play a necessary role in deception, and (2) testing their role by directly manipulating an individual's ability to deceive. This information could then feed back into fMRI maps and enable the identification of the most relevant correlates of lying for applicative purposes. The ability to establish causal links between brain substrates and behavior resides in the fact that the functionality of the brain tissue underlying stimulators can be temporarily modulated  or non-intentional  factors may lead to inconclusive results. In this respect, a recent study by Ganis et al.  has eloqLegal systems are not new to influences from the cognitive neurosciences. For example, admissible MRI evidence showing the absence of frontal lobe maturation in the brains of teenagers contributed to the elimination of the death penalty for minors in some US states . Attempts are being made to admit fMRI evidence in criminal courts; for example at the end of 2009 tests performed by No Lie fMRI were presented as evidence by the defense in a child protection hearing to prove innocence claims of a parent accused of committing sexual abuse. Had they been admitted that would have been the first time fMRI was used in an American court  or the succeeding requirements under Daubert v Merrell Dow Pharmaceuticals Inc.  as applied in Kumho Tire Co. v Carmichael , the presence of statutory requirements, international conventions, Federal Rules of Evidence, or any permutation of these. Drawing from these various requirements there are general principles that scientific evidence must be both relevant and thereby possessing probative value, as well as being reliable. It is primarily this second concept of reliability that is our focus here.Legally, for scientific evidence to be admissible in criminal trials it must meet the legal standards as set down in the relevant jurisdiction, be these common law requirements such as either the test under believe is being measured is actually being measured; the processes being measured are both understood by scientists and are agreed upon by scientists working in the field or who choose to examine the processes; and the scientific processes being relied upon apply equally to all individuals regardless of any internal or external traits or influences, or if there is variation this has been addressed in relation to the individual at hand. While these requirements may appear somewhat ill-defined to the objective scientist, they reflect the style of judge-made legalistic tests whereby relatively broad requirements may be set down. Within the field of law this flexibility is not seen as a vice as it both allows a future court to judge a case on its merits and does not undermine the role of the jury as the final arbiter of truth.Within the specific constraints of the criminal law we can comprehend scientific evidence as being reliable if, amongst other things: the methods and results are both consistent and consistently applied; the accuracy of results meets an acceptably high standard while both false positives and false negatives are minimized; what practitioners reliability threshold. Issues which require addressing by cognitive neuroscientists are set out below:Assumptions and inferences underlying fMRI processes and technologies need to be confirmed (or dispelled) so as to give credence to the scientific claims being made. Cognitive neuroscience, for example, assumes that complex thoughts have a physical counterpart that is both accessible and interpretable with technologies such as fMRI :Looking across various common law legal systems, a number of constitutional principles, and human rights conventionssearch of the subject, and when such a search will be considered lawful or unlawful. Discussions in this area tend to center on the US Constitutional Fourth Amendment protecting against unreasonable or unlawful searches  the European Court of Human Rights (ECtHR) was explicit that the right not to self-incriminate is an implicit component of one's Right to a fair trial under Article 6 ECHR  drew a distinction between material which respects the will of the suspect to remain silent and materials which exists independent of the suspect's will such as DNA, blood, urine, and breath. Unfortunately what they left for a future court to decide is whether or not an individual's brain activity exists independent of their will to remain silent?Another set of issues is whether fMRI questioning undermines the right to silence and the right not to self-incriminate. Neuroimaging technology has the potential to undermine these rights if it can operate without the individual needing to speak. Within the United States, the Supreme Court has previously speculated that “the involuntary transmission of incriminating lie-detection evidence would violate a suspect's right to silence” Simpson, : 767. UnJackson,  though iJackson, . The ECtIt must also be asked whether questioning in fMRI without consent engages Article 8 Right to respect for private and family life and Article 9 Freedom of thought, conscience and religion of the ECHR. Article 8(1) has been broadly interpreted in the past, and it is readily conceivable that processes which seek to determine the veracity of our statements by measuring neural activity will engage this right. The question will turn on whether or not police will be able to conduct questioning in fMRI under the Article 8(2) qualifications of national security, public safety, and crime prevention, and what protections will needed to ensure proportionality. The answer to this might well be tied with Article 9, for to allow the state to access thoughts without consent and knowledge may have a chilling effect on both individuals and society as they seek to exercise their freedom of thought. Courts may well-seek to impose stringent safeguards on neuroimaging technology to prevent both the overuse and misuse of them if they feel these rights are threatened.Human dignity states that human dignity is inviolable and must be respected and protected. It is possible to argue that fMRI questioning without consent undermines an individual's dignity. Article 3 Right to the integrity of the person potentially poses the greatest challenge; especially Article 3(1) that everyone has the right to respect for their physical and mental integrity. This right may also be engaged by enforced or non-consensual fMRI questioning, especially given the express recognition of both physical and mental components. It is worth noting here that within France, Art.45 of LOI n°2011-814 of 7 July 2011  which created Art.16-14 of the French Civil Codemust be obtained in writing prior to any imaging, and that this consent is revocable at any time. Given how few national legislators have specifically acknowledged the use of neuroimaging in judicial proceedings, let alone the issue of consent, this early approach by the French government takes on considerable significance.Additionally a number of rights within the Charter of Fundamental Rights of the European Union (CFREU) may also prove challenging for fMRI use in court proceedings. Article 1 Protection of personal data poses a number of interesting questions. Firstly would fMRI data constitute personal data and thus fall under the protection of this article? Given the uniquely nature of such imaging in relation to an individual this must surely be the case. Assuming this is correct, under Article 8(2) everyone has the right to access their personal data and to have it rectified. As a result given the current fallibility of fMRI evidence, one could always argue that an interpretation of such data is incorrect and must be rectified. It would be interesting to see the effects on the admissibility of fMRI evidence in courts where one party seeks to challenge the ostensibly incorrect interpretation of their fMRI results by the other.Finally Article 8 CFREU Compelled questioning and covert surveillance:fishing trips whereby police would question an individual to determine whether they have committed criminal acts in the past without any pre-existing evidence or reasonable suspicion. For police to search before they suspect is to undermine the presumption of innocence upon which our common law legal systems are built. Though as Pardo (The issues of compelled questioning and (as the technology develops) covert neuroimaging surveillance are ones which courts will be forced to face given the potentially profound impact covert surveillance of this nature will have on society as a whole. One of the concerns raised is the potential for authorities to use these technologies for as Pardo  notes, iProbative value, unfair prejudice, and undermining the Province of the Jury:relevant, thus possessing probative value. The probative value of evidence can be defined as “the extent to which [this evidence] increases or decreases the probability of a fact in issue”  to be admissible in criminal courts it must be  Dennis, , p.108. degree of relevance evidence possesses, which is the extent to which evidence influences the probability of a fact in issue in the mind of a rational juror. Within England and Wales if the judge considers the probative value of evidence will have a prejudicial effect on this juror “disproportionate to the rational strength of the evidence as a means of proof, [then] the exclusionary discretion is available [to the judge] to prevent an accused suffering prejudice”  it risks unfairly prejudicing the accused? Fears have been raised that: the graphic nature of fMRI evidence will result in unfair prejudice; that scientific lie detection evidence will unduly influence and taint jury deliberations; that jurors will not use their intuition and independent reasoning to critically challenge neuroimaging evidence; and that through function-creep such evidence will trespass into the Province of the Jury by effectively usurping their role as arbiter of fact Supporters of neuroscience technologies consider concerns over the undermining of judges and juries as unfounded; rather neuroimaging evidence will simply make the predictions of veracity by jurors and judges more reliable Pardo, . Pardo mlie detection and statement veracity will not be clearly explained at the start of a case and/or not maintained and reinforced as the case progresses, leading juries to overestimate the capabilities of this technology. This is highlighted by the remainder of the above quote where the neuroimaging test results are already being presented by the author as the de facto position of truth, one which can only by overridden should other evidence regarding credibility override the test results; i.e., the tests shall be the truth unless you can prove otherwise. This statement, while seeking to defend neuroimaging technologies, actually serves to highlight the potential disproportional probative effect of neuroscience lie detectors. Cognitive neuroscientists must be careful not to overplay what these technologies can offer criminal courts nor their vision of the potential future role of neuroscience within criminal courts, lest they overplay themselves out of the courtroom altogether.While this statement seeks to defend and support fMRI in criminal courts, it unwittingly demonstrates the danger that this technology will import unfair prejudice into criminal trials. To explain; by rightly accepting that even a highly reliable neuroimaging test does not directly establish knowledge or lies one must ask “what is the point of introducing evidence to a jury from a technology that cannot provide direct evidence as to the veracity of statements made but is still marketed and promoted as a scientifically accurate lie detectorRight to a fair trial:all parties to the trial are subjected to pre-trial questioning in fMRI. Presenting fMRI evidence from only one party to the case may result in an artificial disparity of evidence; i.e., the neuroimaging evidence plus testimony vs. testimony without neuroimaging evidence. Justice may now depend on whether or not a jury will question a technology promoted as a highly accurate lie detector, so to ensure parity of arms and a fair trial all parties should be subjected to pre-trial questioning in fMRI if they are ever introduced. Of course such a scenario depends on all the parties being capable of undergoing fMRI testing which is not the case when the victim is dead or comatose. In these circumstances fMRI evidence may need to be prohibited.Depending on how questioning in fMRI is conducted for criminal trials it can be argued that the fairness of trials will be placed at risk unless but only by the defense represents an arguably unacceptable asymmetry of measures; one which potentially undermines the overall fairness of the trial  and the rights of victims.Nevertheless, it is conceivable that fMRI evidence may become admissible solely as a defense instrument given that structural brain scans have already found acceptance and are widely admissible as mitigating evidence during sentencing proceedings. Indeed such use may help ensure a trial is ultimately fair. However, any attempt to extrapolate from this niche application such that fMRI evidence can be used throughout the entirety of the trial vice versa. However, following our assessments of the science underpinning fMRI as a lie detector and how this relates to the law, we must conclude that the current state of this technology, and potentially the technology per se, fails to meet either acceptable scientific or legal standards.Our discussion throughout has focused on the scientific, legal, and ethical hurdles facing those seeking to introduce fMRI evidence into trials as a means of assisting judges and juries in determining the veracity of statements made. Schauer  suggestsThe evaluation of fMRI accuracy in lie detection—in some cases claimed to be as high as 0.90—is indeed based on laboratory experiments conducted with compliant participants, which is unlikely to be true of most legal settings where non-compliance and the use of countermeasures would make its accuracy figure drop dramatically (e.g., Ganis et al., carte blanche acceptance.Neuroimaging in courts also raises the specter of potential constitutional and human rights violations. Questions arise as to whether or not such testing constitutes an illegal search as well as how it respects rights to privacy, silence, thought, and a fair trial are all engaged by this technology yet left unanswered. Unless the admissibility decision is taken out of the hands of the judiciary by politicians, which is itself a likely scenario, ultimately it will be for the courts to decide the fate of fMRI evidence in criminal trials. Given the range and depth of the legal and ethical issues identified in the earlier sections, the likely outcome will probably fall on a spectrum somewhere between outright rejection through to some form of restricted and regulated usage, as opposed to the highly unlikely scenario of operational and social barriers to the widespread use of fMRI testing in criminal trials. These barriers are potentially just as daunting as their scientific and legal counterparts.What we have not discussed within this paper are both the practical operational perspective, issues which require future examination include; the cost of purchasing, staffing, and maintaining sufficient fMRI machines to cater for a national justice system; the additional time and monetary costs fMRI testing will add to criminal cases; how fMRI testing can be made to work within adversarial systems of questioning and cross-examination based on earlier responses; and the lack of a courtroom-friendly portable fMRI system. Additionally there are questions specific to the assessment algorithms used when interpreting fMRI response data: will only a single universal official algorithm be allowed?; will commercial patented algorithms be admissible if they are not completely open for inspection and independent verification?; and finally what happens when new algorithms and new fMRI scanners are inevitably developed as the science is continually refined which prove to be more reliable and sensitive than previous algorithms/machines? It is conceivable that those who maintain their innocence and are appealing their conviction under the previous technology will seek to be re-tested with the new machines and the new algorithm in an effort to prove their innocence placing a further burden on the criminal justice system. All of these points possess the potential to impact upon the fairness of future trials.From the societal acceptability, without which technologies such as neuroimaging techniques for determining the veracity of statements within criminal trials will lack both public confidence and legitimacy. Future research needs to gauge the levels of public support for such technologies, for even if neuroimaging proves superior to humans as arbiters of statement veracity in criminal courts, this fact in of itself may not be enough for the public to accept their introduction if they are apprehensive or hostile to what such technologies represent for their future. We cannot escape from asking the question, will people accept mind reading machines? This is obviously not what the current generation of neuroimaging technologies is, but they are a small step down this long path.A final hurdle to the widespread introduction of fMRI testing is Our societies have developed to both accept and respect an individual's right to keep secrets, and in so doing they do not seek to override human beings' evolved capacity to keep secrets, for a society where individuals are denied secrets is not a human society as we know it. The developers and proponents of fMRI testing must respect this fact and engage society in their research as it progresses. Otherwise they may find they successfully negotiate the frying-pan of scientific and technical challenges in perfecting fMRI testing only to be consumed by a fire of legal, ethical, social, and political opposition.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.