Tcf1 is known to function as a transcriptional activator of Wnt-induced proliferation during T cell development in the thymus. Evidence for an additional contrasting role for Tcf1 as a T-cell specific tumor suppressor gene is now presented. −/− mice have previously been characterized and show developmental blocks at the CD4−CD8− double negative (DN) to CD4+CD8+ double positive transition. Due to the blocks in T-cell development, Tcf1−/− mice normally have a very small thymus. Unexpectedly, a large proportion of Tcf1−/− mice spontaneously develop thymic lymphomas with 50% of mice developing a thymic lymphoma/leukemia at the age of 16 wk. These lymphomas are clonal, highly metastatic, and paradoxically show high Wnt signaling when crossed with Wnt reporter mice and have high expression of Wnt target genes Lef1 and Axin2. In wild-type thymocytes, Tcf1 is higher expressed than Lef1, with a predominance of Wnt inhibitory isoforms. Loss of Tcf1 as repressor of Lef1 leads to high Wnt activity and is the initiating event in lymphoma development, which is exacerbated by activating Notch1 mutations. Thus, Notch1 and loss of Tcf1 functionally act as collaborating oncogenic events. Tcf1 deficiency predisposes to the development of thymic lymphomas by ectopic up-regulation of Lef1 due to lack of Tcf1 repressive isoforms and frequently by cooperating activating mutations in Notch1. Tcf1 therefore functions as a T-cell–specific tumor suppressor gene, besides its established role as a Wnt responsive transcription factor. Thus, Tcf1 acts as a molecular switch between proliferative and repressive signals during T-lymphocyte development in the thymus.The HMG-box factor Tcf1 is required during T-cell development in the thymus and mediates the nuclear response to Wnt signals. Tcf1 −/− mice spontaneously develop thymic lymphomas. Thorough investigation of these thymic-derived tumors revealed that the mechanism underlying these lymphomas is, paradoxically, increased levels of Wnt-signaling. We propose that Wnt-signaling in these tumors is mediated by up-regulated expression of the Tcf1-homologue, Lef1, and specifically its long isoform. Furthermore, we have evidence to propose that in a normal thymus, short isoforms of Tcf1 that cannot respond to Wnt signals act as repressors of Lef1-mediated Wnt-signaling. Thus, we propose that Tcf1 has a dual function developing T cells in mice: it functions as a T-cell–specific tumor suppressor gene in addition to its established role as a transcriptional activator of Wnt-induced proliferation. Whether loss of function of Tcf-1 as a tumor suppressor gene actually occurs in human T-cell lymphoblastic leukemias is currently under investigation.Cancers often develop as a consequence of deregulated expression of key factors that operate during normal development. T-cell factor 1 (Tcf1) has an established role in the nuclear response to Wnt signaling during normal T-cell development in the thymus. Here we show in mice that the absence of Tcf1 can trigger tumorigenesis. As expected from previous work, lack of Tcf1 results in a small thymus with several partial blocks in T-cell development in the thymus. Surprisingly, we observe that a large proportion of Tcf1 Cancers often develop as consequence of deregulated expression of key factors that operate during normal development. Deregulation of the Wnt signaling pathway has been implicated in many types of malignancies, especially in solid tumors (reviewed in −/− thymi showing severely reduced numbers of DP and a block of the preceding CD8+ Immature Single Positive (ISP) stage −/− mice.A large body of evidence has shown that canonical Wnt signaling is essential for thymocyte proliferation and normal T-cell development −/− mutant mice have a severe reduction of thymic cellularity and a partial block in thymocyte differentiation at the transition from the CD8+ ISP stage to the CD4+CD8+ double positive (DP) stage −/− mice do not proliferate as strong as their wild-type counterparts −/− mice have normal T-cell development, mice deficient in both Lef1 and Tcf1 have a complete block in T-cell differentiation at the ISP stage, which indicates redundancy between these two factors Studies on mice deficient for the Wnt-responsive nuclear proteins reveal crucial roles for Tcf1 in T-cell development and Lef1 in B-cell development −/− mice have thymi characterized by low cellularity . The thymocytes overpopulating the thymus were present in other hematopoietic organs such as spleen, bone marrow, and lymph nodes  and a heterogeneous mix of bands characteristic of a polyclonal cell population  were present in peripheral blood in 50% of the recipient mice . Analysis of components of the Wnt pathway confirmed that Tcf1 (Tcf7) expression was absent (as expected) in the Tcf1−/− thymocytes (with and without a tumor), whilst in all but one Tcf1−/− tumor sample, the expression level of the transcription factor Lef1 was up-regulated compared to control (Tcf1+/−) thymocytes . The Tcf1−/− tumor samples were clearly distinguished by factors involved in the Wnt-signaling pathway, Axin2, Lef1, and Tnfrsf19, or in the Notch signaling pathway, Deltex1 and Hes1 . These data show ectopic up-regulation of Wnt signaling as demonstrated by high expression of Lef1, CyclinD1, and c-Myc as well as Notch target genes Hes1 and Deltex1  of lymphomas in combination with the universally up-regulated Lef1 expression indicates a marked increase in Wnt signaling in these lymphomas. Further analysis of this panel of lymphomas showed that the expression levels of Hes1 and Deltex1, two target genes of Notch1 signaling, were enhanced in all tumor samples compared to the control samples , Tcf1−/− thymocytes (thin line), and tumor Tcf1−/− thymocytes (thick line). The thymocyte subsets of a Tcf1−/− control mouse without a tumor show severely reduced Wnt-activity in ISP and DN3 thymocyte subsets compared to the Tcf1+/− control mouse , indicating a strongly diminished nuclear response to Wnt signals due to the Tcf1 deficiency. Interestingly, residual Wnt-activity can be measured in Tcf1−/− thymocytes, which suggests that Lef1 is mediating low levels of Wnt-activity in Tcf1−/− mice as a likely compensatory mechanism . The thymi of the Tcf1+/− control mouse and the two Tcf1−/− tumor mice displaying high Wnt activity were further examined for the RNA expression levels of Lef1 and Hes1. The expression level of Lef1 was increased in both Tcf1−/− induced lymphomas, indicating that these high levels of Lef1 underlie the highly active Wnt signals in these tumors (6 cells) were high levels of the Notch target gene Hes1 observed, indicating that Notch signaling accelerates or maintains tumor development once it is initiated by deregulated Wnt-signaling. Indeed, when we compared the thymus size to the expression level of Hes1, we found that only in large Tcf1−/− tumors (>25×106 cells) is the expression level of Hes1 increased (−/− thymi (without tumor) and Tcf1+/− samples, no mutations were found in the three exons . Analysis of the panel of 40 Tcf1−/− thymic lymphomas demonstrated mutations in exon 34 in all but one thymic lymphoma sample (unpublished data), which is known to promote Notch1 signaling by increasing the half-life of intracellular Notch, hence promoting tumor survival and growth. Together, these results suggest that Tcf1 deficiency leads to a pre-leukemic stage that favors additional mutations, most notably in Notch1.To confirm the paradoxical finding that mice lacking Tcf1 suffer from thymic lymphomas due to deregulated high Wnt signaling rather than low, we crossed Tcf1e tumors . Interesncreased . These d−/− tumor samples (RNA and protein) revealed that the normal ratio of long over short isoforms for Lef1 was altered in favor of the long isoform of Lef1, which mediates transcription of Wnt-β-catenin target genes , whilst the non-Wnt-dependent Jurkat cell line was minimally affected  was found. This up-regulation of Lef1 likely acts as a compensatory mechanism for the lack of Tcf1 and is probably caused by lack of repression by Tcf1. We show much higher Tcf1 than Lef1 expression in the normal thymus, including the naturally occurring dominant negative isoforms of Tcf1. This suggests a direct repressor function of Tcf1 for Lef1 expression given the normally much higher Tcf1 than Lef1 expression in thymus. Especially since Lef1 has more long-beta catenin responsive isoforms (except in the SP stage), while Tcf1 has slightly more expression of the short form. Hence in the complete absence of Tcf1, Lef1 will take over as a Wnt-responsive transcription factor in the thymus. Thus, the lymphoma development is initiated by developmental arrest due to lack of Tcf1; thereby, the suppression of Lef1 expression by short Tcf1 isoforms is lifted. This leads to higher Lef1 expression and a propensity to higher Wnt responsiveness, restoring proliferation and increasing Wnt target gene expression and concomitantly to the possibility of induction of somatic mutations, such as those found in Notch1. Lef1 expression can be further enhanced by Notch, as shown in lymphomas that lack the E2A transcription factor Lmo2 and Mef2C in the Tcf1−/− thymocytes may also contribute to the preleukemic nature of these cells. Importantly, the in vivo evidence for this model was provided by crossing Tcf mice with Axin2-LacZ-reporter mice. Tcf1−/− mice without tumors have a reduced level of Wnt-activity in all thymocyte subsets compared to Tcf1+/− mice, whilst Tcf1−/− thymic lymphoma cells show a very high level of Wnt-activity in blocked thymocytes.During normal hematopoiesis, Tcf1 is required to induce and maintain proliferation of developing T cells in the thymus rvations . First o−/− lymphomas with two other murine lymphoma models, namely those induced by activated β-catenin and by lack of E2A. The development of Tcf1−/− lymphomas contrasts with thymic lymphomas induced by overexpression of β-catenin in that the latter show no Notch1 mutations −/− thymic lymphomas easily gain additional mutations in the Notch1 gene (in contrast to the β-catenin-dependent lymphomas), which leads to further development of these lymphomas. Once Notch1 expression is established, it may serve as an accelerator of the Lef1-mediated deregulated Wnt signaling, ensuring increased survival and expansion of the lymphoma cells It is of interest to compare the Tcf1In the human equivalent of these T-cell lymphomas, T-cell acute lymphoblastic leukemias (T-ALL), several genetic abnormalities have been described including Notch1 mutations in a large proportion of all human T-ALL Two recent studies from the Bhandoola and Gounari laboratories, respectively, have conclusively demonstrated a key role for Tcf1 in establishing T-cell commitment Mx-Cre-mediated deletion of β-catenin Deletion of β-catenin in the thymus has been reported both to affect T-cell development (using Lck-CRE) or to have no effect at all, when uisng In summary, we here report that Tcf1 has a dual function during T-cell development: first, it is needed as a transcriptional activator of Wnt-induced proliferation, but unexpectedly it also acts as a transcriptional repressor and tumor suppressor gene to prevent the development of thymic lymphomas and it may also function in a Wnt-independent way in these early stages of T-cell development, as suggested by recent work −/−ΔVII/ΔVII were originally described by Verbeek −/− mice were obtained from the Jackson Laboratory, and Conductin(Axin2)-LacZ mice were kindly provided by B. Jerchow and W. Birchmeier  C57Bl/6 Tcf1−/− mice were stained with H&E or with antibody against CD3  and biotinylated goat anti-rabbit IgG  as the secondary antibody. Visualization was enforced with ABC staining kit  with 3,3′-diaminobenzidine tetrahydrochloride  as substrate. Mayer's hematoxilin was utilized as nuclear counterstaining.Paraffin sections of organs of Tcf1The following antibodies were obtained from BD Biosciences : anti-CD3-APC (145-2C11), anti-CD4-PeCy7 (RM4-5), anti-CD8-PerCP(53-6.7), anti-CD25-PE (PC61), anti-CD44-PE (IM7), anti-CD24-FITC (M1/69), anti-cKit-PeCy7 (2B8). Lineage markers Mac1 (M1/70), Gr1 ((RB6-8C5), B220 (Ra3-6B2), and Ter119 and Nk1.1 (PK136) were all biotinylated and streptavidin APC-Cy7. Cells were stained in Fluorescence-activated cell sorter (FACS) buffer  for 30 min at 4°C. Intracellular β-galactosidase activity was measured by staining cells with 2 mM fluorescein di-β-D-galactopyranoside (FDG) substrate (Molecular Probes). FDG was loaded into the cells by hypotonic shock at 37°C for 1 min, prior to cell surface antibody staining. The β-galactosidase reaction was stopped with 1 mM phenylethyl β-D-thiogalactopyranoside . Cells were washed and immediately analyzed on a Canto I (BD Biosciences). Data were analyzed using FlowJo software .5) were injected in the tail vein of sublethally irradiated (4 Gy) Rag1−/− mice. The mice were bled every 4 wk until the end of the experiment. The presence of lymphoma cells was investigated by flow cytometry.Lymphoma or thymocyte suspensions of previously characterized mice were prepared aseptically. Cells . Southern blots were probed with a 32P-labeled 1.2 kb EcoRI-ClaI genomic fragment recognizing the Jβ2 region of the TCRβ gene.DNA (10 µg) was digested with Total protein lysates and nuclear extracts were generated from total thymocytes and sorted populations . Total protein lysates were generated by immediately lysing the cells in boiling sample buffer . Nuclear extracts were generated by resuspending cells in buffer A  for 15 min on ice. Subsequently NP40  was added, thoroughly mixed, and the cytoplasmic extract was removed by centrifugation. Remaining nuclei were lysed by incubating with buffer C  for 30 min at 4°C. Nuclear extracts were ready after centrifugation. Protein concentration was measured using BCA Protein Assay kit . Lysates containing 1 µg of protein were separated by electrophoresis on a 10% SDS-polyacrylamide gel and transferred onto PVDF membranes. Nonspecific binding was blocked by incubation in blocking buffer (2.5% BSA in TBS-Tween) followed by incubation with the primary antibodies and the appropriate secondary antibodies conjugated to horseradish peroxidase. All isoforms of Tcf1 were detected by anti-Tcf1 antibody , and all Lef1 isoforms were detected by anti-Lef1 antibody . Equal loading was confirmed by reprobing the blots with an anti-actin antibody.http://cran.r-project.org/) and Bioconductor 2.9 software (http://www.bioconductor.org/) using the bpca +/−, Tcf1−/−, and Tcf−/− tumor samples, using selection of Wnt and Notch response genes . The first three principal components are displayed.Thymocytes were homogenized for RNA isolation using Qiagen RNeasy minicolumns. The quantity and quality of total RNA was determined using spectrophotometry (Nanodrop) and an Agilent Bioanalyzer. One µg of RNA was used to generate cRNA using Affymetrix One cycle cDNA synthesis kit , after which the samples were biotinylated using an Affymetrix IVT labeling kit (Affymetrix). The samples were hybridized overnight at 42°C to GeneChip mouse genome 430 2.0 Arrays (Affymetrix). Washing and staining steps were performed on a Fluidics station 450, and the Genechips were scanned using a GeneChip scanner 3000 (Affymetrix) at the Department of Immunology, Erasmus Medical Center. Raw data were normalized and summarized using Robust Multichip Average (RMA) method 5′-GAAGAACTTGAATGGCACTGG-3′; reverse primer: 5′-GTTTGGGTGCTCGTGTCAG-3′; Lef1 short forward primer: 5′-GCGACACTTCCATGTCCAG-3′; reverse primer: 5′-TCCTGTTTGACCTGAGGTGTTA-3′; Lef1 long forward primer: 5′-TGGTTAACGAGTCCGAAATCA-3′; reverser primer: 5′-AGAGGACGGGGCTTGTCT-3′; Axin2 forward primer: 5′-GCAGGAGCCTCACCCTTC-3′; reverse primer: 5′-TGCCAGTTTCTTTGGCTCTT-3′; Hes1 forward primer: 5′-AAACACTGATTTTGGAGCACT-3′; and reverse primer: 5′-TGCTTCACAGTCATTTCCAGA-3′. RQ-PCR results were normalized to Abl expression in the same sample: forward primer: 5′-TGGAGATAACACTCTAAGCATAACTAAAGGT-3′; reverse primer: 5′-GATGTAGTTGCTTGGGACCCA-3′; and probe: 5′-FAM-CCATTTTTGGTTTGGGCTTCACACCATT-TAMRA-3′.Total RNA was extracted using Qiagen RNeasy minicolumns. One µg of total RNA was used as a template for cDNA synthesis, using Superscript II reverse transcriptase , Oligo dT, and random hexamer primers. The RQ-PCR reaction was performed using TaqMan Universal mastermix  and was run on a PRISM 7700 sequence detection system containing a 96-well thermal cycler (Applied Biosystems). The following primers were used in combination with FAM-labeled probes from the universal probe library (Roche): Deltex1 forward primer: cDNA of total thymus was used for the amplification of exons encoding the Notch1 heterodimerization and PEST domains. Primers used for the identification of activating Notch1 mutations are described elsewhere −/− cell lines were established from Tcf1−/− thymic lymphomas, and all cell lines show Notch1 mutations and a high ratio of Lef1 long over short isoform. Transfection experiments were performed by transfecting the cell line with eGFP together with either a control construct (pcDNA3) or a dominant negative Lef1/Tcf1 construct  using AMAXA electroporation technology. Transfected cells were identified based on GFP positivity and phenotype, and cell viability was determined 6 h after transfection. Discrimination between viable and dead cells was performed by staining the cells with AnnexinV and 7AAD (BD Bioscience). Tcf1−/− cell line cultures were performed in the presence and absence of the γ-secretase inhibitor DAPT  or Quercetin (50 µM). At the indicated time points, cell cycle analysis was performed using propidium iodide, live cells were determined by 7AAD/AnnexinV stain, and RNA was isolated for gene expression levels.Several Tcf1293 T cells were cultured in Iscove's Modified Dulbecco's Medium supplemented with 10% fetal bovine serum, L-glutamin, and penicillin/streptomycin and transfected using the Fugene method according to the manufacturer's procedures (Roche). The cultures were transfected with 1.5 µg LEF-1 4000 luciferase reporter plasmid (containing four Tcf/Lef-responsive elements) or 1.5 µg of the LEF-1 600 luciferase reporter plasmid  .


Knowledge translation strategies are an approach to increase the use of evidence within policy and practice decision-making contexts. In clinical and health service contexts, knowledge translation strategies have focused on individual behavior change, however the multi-system context of public health requires a multi-level, multi-strategy approach. This paper describes the design of and implementation plan for a knowledge translation intervention for public health decision making in local government.Four preliminary research studies contributed findings to the design of the intervention: a systematic review of knowledge translation intervention effectiveness research, a scoping study of knowledge translation perspectives and relevant theory literature, a survey of the local government public health workforce, and a study of the use of evidence-informed decision-making for public health in local government. A logic model was then developed to represent the putative pathways between intervention inputs, processes, and outcomes operating between individual-, organizational-, and system-level strategies. This formed the basis of the intervention plan.The systematic and scoping reviews identified that effective and promising strategies to increase access to research evidence require an integrated intervention of skill development, access to a knowledge broker, resources and tools for evidence-informed decision making, and networking for information sharing. Interviews and survey analysis suggested that the intervention needs to operate at individual and organizational levels, comprising workforce development, access to evidence, and regular contact with a knowledge broker to increase access to intervention evidence; develop skills in appraisal and integration of evidence; strengthen networks; and explore organizational factors to build organizational cultures receptive to embedding evidence in practice. The logic model incorporated these inputs and strategies with a set of outcomes to measure the intervention’s effectiveness based on the theoretical frameworks, evaluation studies, and decision-maker experiences.Documenting the design of and implementation plan for this knowledge translation intervention provides a transparent, theoretical, and practical approach to a complex intervention. It provides significant insights into how practitioners might engage with evidence in public health decision making. While this intervention model was designed for the local government context, it is likely to be applicable and generalizable across sectors and settings.ACTRN12609000953235.Australia New Zealand Clinical Trials Register  The beesources , minimizesources -9, and besources -12.However, in order for EIDM to operate efficiently and effectively, a series of mechanisms are required: research evidence needs to be conceptualized, conducted, and communicated in a way that is meaningful to decision makers ,14; reseTo address these barriers, a range of strategies, often conceptualized as knowledge translation (KT), have been developed, described, and in some instances, implemented, particularly in clinical and health services contexts. KT is informed by and builds upon conceptual understandings of the translation of research into practice, for which key theories include diffusion, dissemination, and implementation. Diffusion efforts are generally passive while dissemination is a more active strategy to promote the spread of particular ideas . Implemee.g., improving access to research to ensure decision makers know where and how to access it) [Despite the interest and advocacy for KT activities, there has been limited evaluation of their impact on research use in practice and policy and ultimately, EIDM in public health. The implementation of KT strategies to date has tended to focus on individual behavior change of decision makers (cess it) . Howevercess it) , where tcess it) , for exaGiven the distinct need for further intervention research examining the effectiveness of KT strategies for public health decision-making, we explored the interest of the LG sector. There was strong support for participating in an intervention to explore the effectiveness of KT strategies. The KT intervention, named Knowledge Translation for Local Government or ‘KT4LG,’ was developed with the 79 LG locations and implemented within the research context of an exploratory cluster randomized controlled trial. The evaluation of this intervention represents a KT implementation study and was registered with the international clinical trials portal . The study protocol for the design and methods for the mixed method evaluation was published prior to commencement [The KT4LG intervention aimed to increase the use of research evidence to support EIDM for public health in LGs. The purpose of this paper is to describe the design of, and implementation plan for, the intervention. We conducted four preliminary studies to produce findings to contribute into the development of the logic model. The studies aimed to explore:1. What KT strategies are described in the literature in public health and more broadly and what do we know about their effectiveness?2. What types of evidence are used by Victorian LGs, and how is it used within the context of decision making?3. What KT strategies are most applicable to Victorian LGs to support EIDM?A program logic was developed from findings of these studies to articulate and describe the intervention components, intended outcomes of the intervention, and possible evolutions at organizational- and system-levels .e.g., [http://www.healthyactive.gov.au/internet/healthyactive/publishing.nsf/Content/healthy-communities). In this context, the KT intervention was designed to address known barriers to research evidence uptake and to identify strategies that are effective in improving the degree to which research evidence is accessed, assessed, adapted and applied by decision makers.In Australia, LGs represent the third tier of government and are responsible for community-level issues, controlled by Acts of state or territory parliaments. Broadly, their responsibilities include: planning and building; roads and parking; health services ; people services ; waste management; animal management; recreation and culture; and local laws . The pole.g., ,33) MoreThe purpose of this paper is to describe the design of and implementation plan process for a KT intervention for public health decision making in LGs (the KT4LG study). Documenting the design and implementation of KT interventions is particularly important given that there is limited research but increasing interest in the application of KT to public health.This section describes the methods and provides a broad overview of results of the studies that informed intervention design and the implementation plan. This differs from a traditional methods section, but we feel it is important to document these studies to demonstrate their impact on intervention design and implementation. These preliminary studies included a review of theoretical and narrative literature, a systematic review of the effects of KT strategies ; a surveTo understand potential barriers and facilitators, types of KT strategies and theoretical perspectives described and applied in contexts relevant to public health decision-making, we conducted a scoping review of the literature, including peer reviewed and grey literature. The search comprised a range of electronic databases and online sources . Search terms included derivatives of translation, exchange, transfer, utilization, mobilization, evidence-based, evidence informed, public health, diffusion of innovations, knowledge management, decision making, policy. This provided insight into how EIDM might occur in public health decision-making contexts, and revealed gaps in the literature particularly in relation to theoretical models to guide KT intervention design.Barriers to EIDM have been well documented, however the literature is primarily relevant to clinical and health service decision-makers. Of relevance to public health, the available literature suggests that issues include an unsupportive culture, lack of experience in assessing evidence, staff turnover, information overload, and lack of actionable messages . Facilite.g., systematic reviews, clearinghouses), strategies that aim to encourage decision makers to seek out evidence  and strategies that aim to encourage the interaction between researchers and decision makers . Studies with a focus on KT conducted in clinical medicine and allied health have traditionally focused on behavior change outcomes [The literature identified the broad range of interventions characterized as supporting EIDM, albeit largely applied in clinical and health service settings, including strategies that aim to push evidence towards decision makers , in an organization that was supportive of evidence use, led to positive outcomes. The KB did not appear to be effective, but it was noted to be potentially useful where the culture for evidence use was low. This may suggest a need for externally-driven capacity building for individuals , where the organizational culture is not supportive of evidence use. In sum, the systematic review of international published and unpublished literature found only one study, and thus limited evidence to explain what interventions facilitate evidence use in decision-making processes; no published information from a LG context; and no literature from the Australian context.Systematic reviews are important syntheses of the current state of best available evidence. They are also valuable in terms of identifying research gaps . A systeGiven the lack of literature describing public health engagement with evidence and a lack of intervention design to support EIDM within this context, the EviDenT (Evidence-informed Decision-making Tool) was developed to survey LGs across the state of Victoria. Informed by previous tools ,49, the e.g., health promotion, environmental health, planning) and position titles . The interviews were based on three core questions on defining evidence, practising EIPH, and processes for EIPH: how do you define evidence? Is this different from how evidence is perceived in your organization? What are typical example/s of decisions and attempt to track evidence-informed process?; What strategies would support EIDM in your council? This final question encouraged LGs to help to create the design of the intervention, and as such the intervention was viewed very much as one designed in partnership. Key themes emerged related to defining evidence, how evidence was being used generally, and contextual influences upon evidence use. Thematic analysis identified potential strategies that would be most useful to facilitate EIDM in the contexts of participants interviewed. These are described below.Although EviDenT provided an understanding of the degree of access, confidence, skills, and the influence and use of evidence across a sample of LGs in Victoria, it did not address the individual experiences and contextual barriers of evidence use and general decision-making processes. A qualitative study using in-depth interviews was conducted to explore the processes associated with EIDM in LGs. All EviDenT participants were invited to participate in interviews, 98 volunteered, 19 participants were selected, and 13 interviews were conducted. Interviewees were sampled according to a matrix to ensure a mix of professional backgrounds . Frequency and duration of training was discussed, as turnover in LG staff would prevent one-off workforce development sessions from impacting on EIDM. Search skills for accessing evidence were called for given the variability in familiarity with Internet repositories between individuals.Tools to support EIDM were proposed, reflecting a need to support understanding in assessing trustworthiness of evidence, and applying evidence to decision making; as was guidance on where evidence could be used in the stages of decision-making processes, how different sources of evidence can be combined, and access to tailored resources, such as evidence summaries.e.g., other government agencies, academics) were considered to be more useful in promoting evidence sharing. The seniority of individuals attending networking opportunities also appeared to be a consideration if networking was to be a KT strategy. Support from senior management was recognized as important to ensure networking opportunities drive action. Participants acknowledged the importance of relationships with researchers, although the relevance of research and understanding of LGs purpose and context for evidence use needed to be understood. Access to external support was perceived to be potentially useful (including assisting with access and making sense of research evidence). This may also facilitate skill development.A range of networks already existed that supported LG staff, however networks with external input  were also used to inform the intervention design. In particular, the framework developed by Bowen and Zwi describes the importance of policy processes, such as the policies influencing current planning within LGs, and the ways in which evidence can be sourced, used, and applied . Given tWe integrated the findings from the preliminary research studies Figure  to inforThe overall aims of the intervention were:1. To increase access to research evidence through provision of evidence summaries and additional individualized support, such as tailored messages.2. To develop skills in accessing research, assessing trustworthiness, and applying research evidence to local context.3. To develop and implement strategies that assist in the development of an organizational culture that supports EIDM within LGs.Figure The components of the intervention were integrated and delivered continuously across two years, based on reflections from previous research for a longer implementation period .The intervention was designed to be implemented by a Program Coordinator (RCl and then subsequently TP), who would also provide a point-of-contact and act as a KB. The term ‘program’ was used as it was deemed more appropriate for use with the target population. While the overall priority content area was obesity prevention, the intervention and skills required of the Program Coordinator needed to be wider in order to meet the demands of public health practitioners in the LG sector. Given the variation in LG size, the numbers of invited participants from each council would vary but were limited to four.Monthly one-on-one contact with staff in councils would occur via telephone, initiated by the Program Coordinator. This could be more or less frequent depending on participant needs. Phone calls will focus on public health related projects, ideally with a focus on obesity prevention. The Program Coordinator planned to identify how evidence could be further incorporated at various stages of the program planning, implementation, and evaluation cycle. Barriers and facilitators to EIDM will be discussed in order to provide the Program Coordinator with information to tailor support. Assessment of need for tailored support would be conducted at the initial and mid-intervention visits.The preliminary studies and review of theoretical perspectives recommended the inclusion of site visits, highlighting the potential usefulness of enhanced interaction between researchers/knowledge brokers and the individuals/agencies. A mid-term site visit was therefore proposed for each LG. The objectives of the visits would be agreed mutually by the LG and Program Coordinator, and could include activities such as group training, working meetings, or presentations. Site visits may also be used to discuss individual and organizational culture for use of research evidence among the public health team, guided by self-assessment tools developed and evaluated by the Canadian Health Services Research Foundation ,65. StraGroup training would be held biannually in a central location. A modular approach was planned to cover core principles of evidence-informed public health asking answerable questions, searching, trustworthiness, assessing applicability and transferability, and evaluation; with a range of activities designed to encourage networking between councils. It was anticipated that participants would contribute to the focus of these sessions. Shared development of the logic model identified the need for networking sessions, which would be incorporated into the group training sessions rather than run separately as it was felt that LG staff may already be participants in formal networks and additional networks may prove too time consuming.Mid-intervention council visits would be used to examine the fidelity of the intervention, and to assess the context of EIDM within each council. Council-based training would be offered once, at the mid-point of the intervention, as a mechanism to engage a wider audience (increase within-council reach) and to meet the needs of the council, particularly if geographic distance is a barrier to regular attendance at central training sessions.Evidence summaries, outlining possible obesity prevention intervention options, were to be developed in partnership with participants and other LG contacts across Australia. Legislative requirements of councils would be explored and considered, and relevance to the role of councils in service delivery and program implementation incorporated. The Program Coordinator would work in partnership with councils to develop these documents prior to distribution to ensure appropriateness and relevance of content. Evidence summaries would be available to all LGs. These summaries would be used to promote evidence-informed options within intervention LGs. In addition, the Program Coordinator would send intervention LGs targeted communication that may include newly published studies or reviews, and upcoming conferences and training opportunities.As the logic model proposes, a range of outcomes would be possible at the individual-, organizational-, and system-levels. The KT4LG intervention study  sought tThe design of the intervention is limited primarily to the implementation of KT interventions targeted at individuals. The logic model demonstrates how individual interventions may be linked to organizational- and system-level interventions. Given the paucity of literature on interventions directed at these levels with the intent of increasing organizational culture we will explore potential strategies during the implementation of KT4LG.The size and scope of LG was identified as an issue for the implementation of KT4LG in the preliminary studies—particularly the qualitative study. It was anticipated that participating in this intervention might be more challenging for LGs with smaller staffing levels, smaller budgets, and/or limited research capacity.The design of KT4LG revealed the challenges in measuring outcomes at both individual-, organizational-, and system-levels. Based on the results of the preliminary studies the research team chose to focus on three core domains: access, confidence, and organizational culture. There was limited evidence on which to base this decision. The implementation and evaluation of KT4LG will reveal more about the usefulness of these domains.KT4LG aims to respond to the lack of rigorous evidence to guide KT in public health decision-making contexts. Preliminary research informing the intervention included a review of theoretical and narrative literature, a systematic review of the effects of KT strategies, a survey of LGs in Victoria, and a qualitative study exploring decision-making processes in this setting. The KT4LG intervention was designed using a partnership approach and involved an international research team interested in the development and mixed method evaluation of innovative and evidence-based complex interventions and practitioners in LG public health. As such, KT4LG aimed to co-generate new, practical evidence on what works to support EIDM in the LG context. The intervention design was informed by diffusion of innovations theory, research utilization theory, and KT frameworks. The intervention outlined in the logic model was designed to address contemporary demands including: imposed policy expectations for the use of evidence in policy and planning; organizational demands for best available evidence; identification of factors for system-wide solutions; opportunities to embed KT competencies into planning and employment; the need for increased access to relevant research; skills to interpret and use research; and network building. Guided by the overarching logic model, intervention components included selection of participants involved in key public health decision-making contexts, group training and networking sessions, monthly contact with a Program Coordinator, and relevant evidence summaries.The interest in ‘what works for whom and why’ about public health issues such as obesity prevention while addressing trustworthiness and relevance of research evidence, is compelling and a great drawcard for a new, realistic approach to public health research and evidence-informed public health in particular. Answering questions of relevance and priority can help bridge the evidence-practice gap. KT4LG is an example of a facilitated KT intervention that presents an approach designed to increase the use of research evidence in policy and practice.APAIS: Australian public affairs information service; CINAHL: Cumulative index to nursing and allied health literature; EIDM: Evidence-informed decision-making; KB: Knowledge broker; KT: Knowledge translation; KT4LG: Knowledge translation for local government; LG: Local government.The authors declare that they have no competing interests.All authors were actively involved in the development and design of the intervention and study. RA drafted the initial manuscript. EW is the principal Chief Investigator and led the study, RA was the project manager, RCl and TP coordinated intervention activities and in this capacity RCl contributed to the logic model development. All authors contributed to the draft of this paper and signed off on the final version.


Policies targeting obesogenic environments and behaviours are critical to counter rising obesity rates and lifestyle-related non-communicable diseases (NCDs). Policies are likely to be most effective and enduring when they are based on the best available evidence. Evidence-informed policy making is especially challenging in countries with limited resources. The Pacific TROPIC  project aims to implement and evaluate a tailored knowledge-brokering approach to evidence-informed policy making to address obesity in Fiji, a Pacific nation challenged by increasingly high rates of obesity and concomitant NCDs.The TROPIC project draws on the concept of ‘knowledge exchange’ between policy developers  and researchers to deliver a knowledge broking programme that maps policy environments, conducts workshops on evidence-informed policy making, supports the development of evidence-informed policy briefs, and embeds evidence-informed policy making into organisational culture. Recruitment of government and nongovernment organisational representatives will be based on potential to: develop policies relevant to obesity, reach broad audiences, and commit to resourcing staff and building a culture that supports evidence-informed policy development. Workshops will increase awareness of both obesity and policy cycles, as well as develop participants’ skills in accessing, assessing and applying relevant evidence to policy briefs. The knowledge-broking team will then support participants to: 1) develop evidence-informed policy briefs that are both commensurate with national and organisational plans and also informed by evidence from the Pacific Obesity Prevention in Communities project and elsewhere; and 2) collaborate with participating organisations to embed evidence-informed policy making structures and processes. This knowledge broking initiative will be evaluated via data from semi-structured interviews, a validated self-assessment tool, process diaries and outputs.Public health interventions have rarely targeted evidence-informed policy making structures and processes to reduce obesity and NCDs. This study will empirically advance understanding of knowledge broking processes to extend evidence-informed policy making skills and develop a suite of national obesity-related policies that can potentially improve population health outcomes. Policies targeting obesogenic environments and behaviours are critical to counter rising obesity rates and lifestyle-related non-communicable diseases (NCDs). Integrating evidence into appropriate and effective public policy is challenging, given that researchers, policy developers and decision makers (politicians) operate in different cultures -4, with In the case of obesity-prevention, evidence-informed policies require access to evidence on the causes of obesity, as well as the implications of failing to address the immense social, health and economic costs of obesity and concomitant NCDs. However, the onus is on researchers to produce timely and relevant evidence that is readily accessible to policy developers. Policy makers need to communicate their priorities, evidence needs and timelines to evidence producers.While some targeted obesity-prevention initiatives have reduced obesity, at least in the short term, multi-faceted efforts are needed at a population level. Evidence from rigorous intervention studies can inform policies and practices. For example, the Pacific Obesity Prevention in Communities (OPIC) project comprised community-based interventions and analytical studies  to prevent adolescent obesity in four countries  . HoweverThere appears to be a policy window in the Pacific Republic of Fiji, which is governed by a military regime that has streamlined policy-making processes and is committed to improving the health of all Fiji citizens . Policy The current TROPIC  project draws on evidence from the Pacific OPIC study, and elsewhere, to heighten awareness of the high prevalence of obesity in Fiji and, importantly, inform policies that can contribute to obesity reduction, either directly or indirectly.” refers to academic evidence , “grey literature” , and “tacit knowledge”  [“Evidence-informed decision making” refers to the use of evidence to inform decisions ,13, whilowledge) . The besowledge) . The proowledge) .exchange highlights the building of collaborations between evidence producers and evidence users from the outset [The process of translating research knowledge to policy and practice has been variously framed as knowledge transfer ,18, knowe outset , an impoe outset ,21,23. TKnowledge exchange also requires evidence-users (policy-developers and decision-makers) to have the commitment and skills to effectively access and critically analyse the best available evidence, and apply it to policy documents and decisions . This reKnowledge brokers have been employed to bridge the gap between evidence producers and evidence users ,28, assuThe purpose of this paper is to describe and rationalise the research design and methods used in the TROPIC project, which draws on the concept of knowledge exchange to answer the research question: “Can a ‘knowledge broker’ influence the translation of obesity prevention research findings into practice and policy?”. The specific objectives of the TROPIC project are to:· Extend evidence-informed decision making skills in selected partner organisations· Use a knowledge-broking approach to increase the uptake of evidence from the OPIC project and other relevant sources in the development of policy and advocacy documents· Expand an organisational culture that supports evidence-informed policy makingThe project comprises seven phases: 1) recruitment of participating organisations; 2) advocacy for more policies to address obesity; 3) analysis of evidence-informed policy making capacity and support at baseline; 4) development and delivery of tailored workshops on evidence-informed policy making; 5) support for individual participants to develop evidence-informed policy documents (policy briefs or advocacy documents) relating to obesity; 6) conduct activities to embed evidence-informed policy making into organisational culture; and 7) evaluation  will be recruited on the basis of recent work with participating organisations, and their experience and expertise in policy making processes and/or governmental organisations, and/or evidence-based policy. These local advisors will advise the knowledge broking team on the organisational structure and culture of each participating organisation, especially in terms of policy making processes and the use of evidence, and suggest initiatives to sustain organisational interest in and commitment to the evidence-informed policy making process and strategies to embed evidence-informed policy making within organisations. Advice will also be provided by the TROPIC investigators as required.While all participating organisations will engage in a similar programme of evidence-informed policy making, the knowledge broking team will tailor the evidence-informed policy making activities to the needs of each governmental and nongovernmental organisation. Tailored programmes are desirable, given that evidence-informed policy making is context-specific  and thatThe Pacific Republic of Fiji is a lower-middle-income country that facThe Pacific OPIC project yielded multiple data sets relating to adolescent obesity in Fiji, including data on the prevalence of obesity , obesogeSampling will be purposive. Organisations from a range of policy sectors  will be recruited because many obesity-related policies are developed outside the public health domain . Further· Potential to make or influence policies that improve food and/or physical activity environments· Wide demographic  representation to ensure a broad reach , thereby maximising the potential impact of policies· Capacity to release and support staff to participate in KE-TROPIC activities· Potential to share evidence-informed policy making knowledge and skills, both within and between organisations· Previous relationships with the OPIC team, as strong relationships predict successful knowledge brokering/evidence-informed policy making ,46.Each participating organisation will be asked to nominate a senior staff member as a focal/contact person. For each organisation, between five and 12 staff members (TROPIC participants) who are engaged in policy development will participate in the study, as a critical mass of individuals within an organisation predicts the use of evidence-informed decision making .The knowledge brokering team will advocate for the development of policies that have the potential to impact on obesity at a population level, especially in non-health sectors where there is likely to be limited awareness of either interrelationships between environments, obesity and health ,48, or oAn audit of each organisation’s goals, structures and primary activities will be conducted in order to tailor the TROPIC programme to the specific needs of each organisation, thus increasing the potential for the programme to be effective . NationaIn addition, semi-structured interviews (participant interviews) will be conducted with the TROPIC participants in order to determine participants’ knowledge about and experience with generating and/or using evidence, research, policy development and evidence-informed decision-making, as well as participants’ perceptions of enablers and barriers to evidence-informed policy making. A second set of semi-structured interviews (expert interviews) will be conducted with participants who have an in- depth knowledge of and recent experience with one or more of the participating organisations. The aim of these expert interviews is to determine interviewees’ perceptions of organisational culture, resources and support for evidence-informed policy making, thus providing a local ‘outsider’s’ perspective. Questions will probe: current internal and external facilitators and barriers to evidence use ; organisIs Research Working for You? A Self-Assessment Tool and Discussion Guide for Health Services Management and Policy Organisations” (Is Research working for you? survey)[The 2009 survey tool “? survey) will be ? survey). The sur? survey).A series of workshops will be provided for each organisation. It is anticipated that the workshops will address: policy and policy cycles, the Fiji policy making environment; relationships between policy and obesity; definitions of evidence; evidence sources; skills in accessing, analyzing, synthesising and adopting evidence for policy documents; policy/advocacy topic areas that could potentially impact on obesity and are commensurate with national/organisational goals  reinforce skills gained during workshops, and 2) ensure that there is relevant evidence available to inform the brief. As with the workshops, the nature and the level of the support will be informed by the preliminary analyses of individual and organisational strengths and requirements. Support may also include the production of written guidelines on evidence-informed policy making processes and summaries of relevant evidence.Embedding activities will include the: 1) strengthening of relationships between evidence-producers and evidence-users, 2) building of a critical mass of people within and between organisations who have the skills to acquire, assess and adapt evidence to inform policy, 3) advocacy for clear structures and processes to support evidence-informed decision making, as well as formal recognition and rewards for evidence-informed policy making, and 4) facilitation of networks of evidence-informed policymakers within and between organisations.The effectiveness of a knowledge broker in increasing the use of evidence in the development of policy documents to reduce obesity will be identified through examination of several data sets  prior to and following the completion of the TROPIC programme. This will facilitate assessment of the changes in the valuing and utilisation of evidence-informed decision-making.Participants will complete the survey tool “Individual and organisational perceptions of the effectiveness of the TROPIC programme will be elicited by interviews that will complement the survey data by examining the impact of TROPIC on individuals and organisations. Interviews will be conducted with all participants in the TROPIC programme, and a high-level officer (non-participant) from each participating organisation .The knowledge brokering team will keep a diary of all evidence-informed decision making activities initiated either by the TROPIC team, or the participants and/or their organisations. Based on Dobbins et al. (2009), the diary will detail all TROPIC activities within and across organisations, including details about who initiates and responds to an activity, the nature of the request, type of response and resources involved in this engagement . The team will also maintain a diary of the outputs arising from TROPIC, specifically the completion and progression of policy briefs and advocacy documents, as well as actions related to embedding of evidence-informed decision-making practice .The various data sets  will be analysed in order to examine the effect of the TROPIC knowledge-broking approach on the evidence-informed policy making of individual participants, as well as participating organisations. Participant interviews will be transcribed, checked and uploaded onto NV8 , software for the analysis of qualitative data. Data will be coded using a combination of pre-determined codes relating to the research questions, as well as codes that arise from the transcripts. Data will then analysed at several levels: descriptive categories; underlying themes; and constant comparative analysis in order to compare results from different sub-groups (e.g. the level of engagement during TROPIC). Analyses of interviews will be collaborative, with the first and second authors conducting independent analyses and then comparing and reconciling any differences. Collaborative analysis is critical when undertaking exploratory studies, and particularly in the case of TROPIC data where analyses require careful contextual interpretation. Survey data will be entered into SPSS (V19). Descriptive statistics will be used to summarise scores on the various dimensions of the evaluation tool. Changes in pre- and post-TROPIC scores across the different organisational and individual dimensions will be assessed using repeated measures ANOVAs. Process data will be analysed descriptively to determine relationships between resource-use and level of engagement in TROPIC activities (e.g. workshop completion), and outputs .The TROPIC project will contribute significantly to knowledge about the effectiveness of a knowledge brokering approach to increase the utilisation of obesity-related evidence in policy and advocacy documents by employing a mixed-methods approach to analysis and evaluation. The combination of qualitative and quantitative data sets is important, given the exploratory nature of the project and the need to describe and explain cultural and behavioural factors influencing evidence-informed decision making. The mixed-method analyses  will enable in-depth examination of relationships between evidence-informed policy making activities and outputs in relation to the level of engagement with TROPIC activities, as well as how these might be moderated by intrapersonal variables (e.g. education background). Further, the use of a repeated measures design will enable important information about more subtle changes in evidence-informed decision making to be discerned.The emphasis on process evaluation is based on the concept that knowledge translation is a process rather than a single event ,52. The While the duration of the TROPIC initiatives is relatively short, positive changes in evidence-informed policy making are predicted, given that the project will: 1) reflect national and organisational goals of participating organisations, 2) provide intensive support for participants to develop policy documents, and 3) build on strong researcher-end-user relationships established in the five-year OPIC study. The use of a knowledge brokering team rather than an individual knowledge broker is advantageous, given the complexity of integrating evidence-informed policy making into any policy environment .Public health interventions have rarely targeted evidence-informed policy making structures and processes synergistically to reduce obesity and NCDs. This study will advance our understanding of knowledge-broker approaches to extend evidence-informed policy making skills in relation to obesity- prevention policies. However, the evidence-informed policy making skills gained during TROPIC are generic and can be transferred to any policy area; the transferability of skills is especially important in a LMIC with limited policy making resources.processes in the TROPIC project design are especially important in countries like Fiji, given the additional challenges for evidence-informed policy development in LMICs. Specifically, LMICs often have fewer resources and less capacity to either access or adapt evidence for policy documents [Evaluation of the knowledge brokering ocuments , or fostocuments . Ironicaocuments . The TROThe authors declare that they have no competing interests.HM reviewed the literature, led the design process and drafted the manuscript. GW contributed to the study design, in particular providing advice on the applicability of the study to the local setting. MM contributed to the study design and critically reviewed the manuscript. PK contributed to the study design and critically reviewed the manuscript. MMcC contributed to the study design and critically reviewed the manuscript. WS critically reviewed the manuscript. BS contributed to the study design and critically reviewed the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/552/prepub


Wandering spleen is a rare condition characterized by the absence or underdevelopment of one or all of the ligaments that hold the spleen in its normal position in the left upper quadrant of the abdomen. It is an uncommon clinical entity that mainly affects children. Among adults it most frequently affects women of reproductive age, in whom acquired laxity of the splenic ligaments is usually the cause. Patients with a wandering spleen may be asymptomatic, present with a movable mass in the abdomen, or have chronic or intermittent abdominal pain because of partial torsion and spontaneous detorsion of the spleen. A 26-year-old woman was admitted to our hospital with vomiting and abdominal pain. Abdominal examination revealed a large ovoid hypogastric mass. A CT scan showed a wandering spleen in the hypogastric region. Exploratory laparotomy revealed an ischemic spleen. A total splenectomy was performed. A wandering spleen, defined as a spleen without peritoneal attachments, is a rare entity characterized by splenic hypermobility due to laxity or maldevelopment of the supporting splenic ligaments. Patients with a wandering spleen may be asymptomatic, or may present with a palpable mass in the abdomen, or with acute, chronic, or intermittent symptoms due to torsion of the wandering spleen. The non-specific signs and symptoms together with the rarity of this condition hamper the clinical diagnosis in which imaging modalities play an important role. Treatment should be planned according to the vitality of the spleen.A 26-year-old woman presented to the emergency department after three days of abdominal pain, vomiting and constipation. On admission she had normal vital signs and a temperature of 38.5°C. Abdominal examination revealed marked diffuse abdominal tenderness and guarding. A large ovoid hypogastric mass was palpable. Laboratory tests revealed increased white blood cells (WBC) of 24000 µ/L. The platelets count and haemoglobin rate were normal.A CT scan showed absence of the spleen in the left upper quadrant  as well The patient underwent exploratory laparotomy through a midline incision. This revealed the absence of all splenic ligamentous attachments and short gastric vessels with a consequent dislocation of a bigger and congested spleen in the pelvis. This organ, wrapped in the omentum, was in serious ischemic suffering due to a 240°: clock torsion around its exceptionally long pedicle (≈ 25 cm). A total splenectomy was performed. The patient′s post-operative course was uneventful. The patient was discharged with appropriate postsplenectomy treatment.Wandering spleen is defined as a mobile spleen that is attached only by an elongated vascular pedicle, allowing it to migrate to any part of the abdomen or pelvis. It is a result of congenital anomalies in the development of the dorsal mesogastrium and the absence or malformation of normal splenic suspensory ligaments ,2. HowevThe clinical presentation of a wandering spleen is variable. Affected patients may be asymptomatic and this condition may be incidentally discovered on physical examination, or on imaging studies performed for other unrelated reasons, as an abdominal or pelvic mass that may not be accompanied by gastrointestinal or urinary symptoms . The majSonography showed the characteristic comma-shaped spleen in an ectopic position and the lack of splenic tissue in the left upper quadrant. Computed tomography is the preferred study for diagnosing a wandering spleen when torsion is suspected clinically or on other imaging studies.The CT manifestations included: (1) absence of the spleen anterior to the left kidney and posterior to the stomach, (2) a lower abdominal or pelvic mass with homogenous or heterogenous splenic parenchyma and an attenuation value less than that of normal splenic tissue. Multislice spiral CT is helpful in the diagnosis at an earlier stage before the spleen progresses to infarction .Detorsion and splenopexy is a reasonable surgical option, even in patients presenting with an acute abdomen, when there is no evidence of infarction, thrombosis, or hypersplenism. Splenic preservation is highly recommended in very young patients, those under 1 year of age up to those in the third decade of life, who are at particular risk for overwhelming post-splenectomy sepsis . Open meRecently, laparoscopic procedures have been introduced for splenic surgery, and it has been shown to offer the benefits of minimally invasive surgery ,9. LaparThe diagnosis of wandering spleen is extremely difficult to establish because it is such a rare condition and is clinically nonspecific. An early diagnosis and surgical care are the best guarantee for preserving the spleen. Additional imaging examinations, especially abdominal sonogram as the imaging examination of choice, can help establish a diagnosis when faced with an abnormal location of the spleen. When wondering spleen is diagnosed, the treatment of choice is splenopexy in asymptomatic or even symptomatic patients without the presence of splenic necrosis. If splenic necrosis is present, a splenectomy usually is required.


Clinical practice guidelines have the potential to facilitate the implementation of evidence into practice, support clinical decision making, specify beneficial therapeutic approaches, and influence public policy. However, these potential benefits have not been consistently achieved. The limited impact of guidelines can be attributed to organisational constraints, the complexity of the guidelines, and the lack of usability testing or end-user involvement in their development. Implementability has been referred to as the perceived characteristics of guidelines that predict the relative ease of their implementation at the clinical level, but this concept is as yet poorly defined. The objective of our study is to identify guideline attributes that affect uptake in practice by considering evidence from four disciplines  to determine the relationship between the perceived characteristics of recommendations and their uptake and to develop a framework of implementability.e.g., its text and content) and how changing these elements might impact clinical practice and clinical decision making. It also allows for the exploration of 'what works for whom, in what circumstances, and in what respects'. The realist review will be structured according to Pawson's five practical steps in realist reviews: (1) clarifying the scope of the review, (2) determining the search strategy, (3) ensuring proper article selection and study quality assessment, (4) extracting and organising data, and (5) synthesising the evidence and drawing conclusions. Data will be synthesised according to a two-stage analysis: (1) we will extract and define all relevant guideline attributes from the different disciplines, then create a shortlist of unique attributes and investigate their relationships with uptake, and (2) we will compare and contrast the attributes and guideline uptake within each and between the four disciplines to create a robust framework of implementability.A realist-review approach to knowledge synthesis will be used to understand attributes of guidelines (Creating guidelines that are designed to maximise uptake may be a potentially effective and inexpensive way of increasing their impact. However, this is best achieved by a comprehensive framework to inform the design of guidelines drawing on a range of disciplines that study behaviour change. This study will use a customised realist-review approach to synthesising the literature to better understand and operationalise a complex and under-theorised concept. A comprehensive review found that overall improvement in quality of care using extrinsic strategies was generally modest  and descriptive norms [people's perception of what is commonly done in specific situations]), and (3) perceived behavioural control [i.e., the strength of their intention or motivation). The second predictor is normative beliefs , which refers to the perceived social pressure to use or not use guidelines. The third predictor is the degree of perceived behavioural control, which can be conceptualised as the perceived ease or difficulty of performing guideline use or uptake. This may reflect past experiences as well as anticipated impediments and obstacles of the behaviour. Together, these three predictor factors can lead to the formation of behavioural intention. In general, we can predict that the more favourable the attitude and subjective norm with respect to using guidelines, and the greater the perceived control, the stronger the individual's intention to adhere to them. Intention is thus an immediate antecedent of guideline use, but the degree of success will also depend on other nonmotivational factors, such as availability of requisite opportunities and resources  [Well-studied theories related to changing behaviour include the Social Cognitive Theory , the The control . In the llpower) . Based oOur preliminary list of candidate theories are as follows:i.e., attributes of implementability). For example, guidelines and their recommendations are too complex, lengthy, and time consuming to use and are difficult to follow 1. Clinical practice guidelines are not used by physicians in part because of specific perceived guideline characteristics (2. There are 'trade-offs' between various guideline attributes that hinder or facilitate uptake (the examination of the trade-offs between the various dimensions will help clarify our understanding of how and why this theory makes sense).e.g., duplicate reviewing from a large search retrieval with a low potential for identifying relevant articles). This finding is consistent with Greenhalgh et al.'s review of complex evidence  [i.e., electronic database and hand searching), whereas snowball sampling  yielded the majority of relevant articles (51%) [There are two key differences in searching between realist reviews and traditional systematic reviews. In realist reviews, there is no finite set of relevant articles that can be defined and then found. In contrast, traditional systematic reviews often take a linear, time-restricted approach to searching the literature, striving for completeness by attempting to identify every single paper on a given topic or intervention ,35. The sations) , which fes (51%) . In factes (51%) ,38. We wi.e., manually searching for references of references or the process of identifying cases from people who know people who have relevant information), or opportunistic sampling for information-rich cases, with the goal of retrieving materials to answer specific questions or to test particular theories. This process requires taking a more flexible and iterative approach to the literature to capitalise on unanticipated findings. We will also consider a model of searching called 'berrypicking', which asserts that typical search queries are not static but evolve, gather information in 'bits and pieces rather than in one grand best retrieved set', and use a wide variety of search techniques and sources beyond common bibliographic databases such as MEDLINE [We will use the multiple-search strategy approach of realist reviews, which seeks to explore and contextualise the intervention in multiple settings. This will thus be an iterative, interactive, and purposive sampling strategy with no predefined sampling frame ,35. Sear MEDLINE . Our stri.e., going through existing materials of the research team). We then conducted a scoping review in MEDLINE and EMBASE using the following initial list of search terms, which were compiled from the collective knowledge of our research team consisting of clinician scientists and knowledge-translation researchers: 'implementability/implementation', 'clinical practice guidelines', 'knowledge translation'.The purpose of the background search is to 'get a feel for the literature' to determine what and how much information exists, in what form, and where it is. We gathered a preliminary core set of articles using a 'desk drawer' search strategy , as we believe this will provide a broader insight into the concept of implementability. Snowball sampling will be used to identify experts in the four discipline areas, who will then be consulted to direct us where to look for and identify potentially relevant literature and concepts. This may also involve purposively searching discipline-specific databases for articles suggested by key experts in the four discipline areas.To gather the comprehensive evidence needed, our strategy will involve searching the literature across four different disciplines relevant to the topic . This strategy was selected because previous work to identify optimal approaches to updating systematic reviews  or to vei.e., scanning the reference lists of relevant articles) from stage 1 (core articles) and stage 2 (expert directed) searching.We will look for other potentially relevant articles using snowball sampling , and (b) approaching each discipline expert to identify unpublished documents .We will look for other potentially relevant articles by purposively scanning the literature of key authors and the articles discovered through snowball and opportunistic searching and serendipitous discovery. This stage will also include searching for grey literature: (a) websites, such as those for the Agency for Healthcare Research and Quality, Institute of Medicine, and various foundations  or to answer the research questions [a priori or to determine the number of studies at which theoretical saturation will occur. However, the reporting of this process will be transparent, and each step will be carefully documented.Setting a threshold for stopping the search is an important consideration for conducting systematic reviews. In realist reviews, searching continues in a cyclical and iterative process that is not designed to be exhaustive. However, it remains important to not only create parameters to decide which studies are 'fit' for identifying, testing, or refining the theories but also to decide when a sufficient amount of evidence has been assembled to satisfy the theoretical need  and rigour  [i.e., to correctly interpret the inclusion/exclusion criteria because we anticipate a steep learning curve). We also anticipate that the duplicate review process will serve as a great platform for reflexive discussion that will enable informed decisions among reviewers for identifying relevant data [e.g., physician providers) about intrinsic factors that influence intentions to use guidelines. We will define guidelines in other disciplines as any recommendations or guidance for behaviours that are consistent with those of clinical practice guidelines in medicine (and implementability will be defined as the uptake of recommendations). For example, guidelines might include instructions for mortgages or financial statements (management) and technical manuals for products (human-factors engineering). Exclusion criteria are opinion-driven studies , non-English language articles, articles that focus on how guidelines were developed or do not discuss the reasons for why guidelines are not implemented, and articles that discuss guideline implementation strategies that are extrinsic.Although realist reviews acknowledge the principle that a quality filter should be applied at some point during the evidence synthesis, Pawson rejects the 'hierarchy of evidence' approach to study quality assessment . He argurom it?) . Two revant data . If there.g., for studies that have the same concepts but with differing methodological rigour or to adjudicate between studies that have similar methodologies but conflicting results). We will apply judgment to resolve conflicts amongst reviewers by considering whether the results can be applied to the context of healthcare providers using clinical practice guidelines. We want to be careful not to exclude articles based on methodological rigour alone, as the primary studies contribute different elements to the rich picture that constitutes the overall synthesis of evidence. In realist reviews, the study itself is rarely ever used as the unit of analysis; instead, realist reviews may consider small sections of the primary study  to test a very specific hypothesis about the relationships between context, mechanism, and outcomes [The process for determining 'rigour' is described by Pawson in terms of 'whether a particular inference drawn by the authors has sufficient weight to make a methodologically credible contribution to the test of a theory' and to apply 'judgment' to supplement formal critical appraisal checklists (if they are used) . Applyinoutcomes . We willoutcomes ,35.e.g., stage 2 expert-identified searching), discipline , study design, relevance, and the name and author's definition and operationalisation of the guideline attribute that was discussed in the article , for whom, in what circumstances, in what respects, and why'. We will then borrow synthesis methods from meta-ethnography to identify and interrogate specific guideline attributes and their potential trade-offs as well as their relationship with uptake by physicians [We will synthesise data using several analytic approaches. First, we will use the realist-review approach to interrogate our final theory, which will be to determine 'what is it about practice guidelines that works  of guideline implementation by family physicians. The logic behind this approach is that interventions are only as strong as their weakest link. We will then look for rival theories of implementability (if they exist) to refine the understanding of how practice guidelines work by using evidence to 'adjudicate' between these rival theories of implementability. Next, we will consider the same theory in different settings. This approach assumes that particular intervention theories may work in some settings but not in others. We will attempt to make sense of the patterns of data that relate to the facilitator and barrier circumstances in which guidelines are successfully implemented or not. Finally, we will attempt to synthesise the data by comparing official expectations with actual practice . This approach is particularly useful for comparing the 'official' theory  and what actually happens in practice.We will first explore what have been the typical weak points and major stumbling blocks  and then LOA analysis will be used to come up with second- or third-order interpretations. For example, themes can be compared across studies and matched from one study to another (using RTA), ensuring that a key theme captures similar themes from different studies. We will begin this process by creating a list of themes or metaphors related to guideline attributes and determining how they are related . This integrative approach allows these terminologies to be combined so that the differences between attribute terms can be negotiated to decide which might be the most relevant in the context of medicine. The RTA can then proceed to higher-order interpretations using the LOA synthesis method. According to Schutz's notions of 'orders' of constructs [i.e., third-order interpretation) [i.e., how the study author understands the concept). It is possible to then build on and extend these interpretations to reveal third-order constructs, which represent a new model, theory, or understanding. For example, the way in which guideline implementability is understood in the four disciplines (second-order interpretation) may be distilled further to reveal their relevance in the context of medicine (third-order interpretation). The output from these analyses is called the 'synthesizing argument', which represents the integration of evidence across studies into a coherent theoretical framework  [RTA and refutational methods will first be used to translate definitions of guideline attributes from different disciplines into one another  . For exaesearch) . RTA andImplementation research is complex, given the interplay of patient-, provider-, organisation-, and system-level factors. This is likely why the impact of implementation strategies has been modest, and general conclusions about which strategy should be applied in what context have been so limited . Our worOur work also represents a novel approach to knowledge synthesis. We will test how the use of a customised approach to synthesising the literature can answer research questions around a complex and under-theorised concept such as guideline implementability. Although we initially considered conducting a systematic review, there is increasing evidence that this may not be the most appropriate method for investigating complex and multidisciplinary topics . AnalysiThe authors declare that they have no competing interests.All authors participated in the design of the study. MK drafted the manuscript, and all authors reviewed and approved the final manuscript.Inclusion/exclusion criteria.Click here for fileExample of the data extraction form.Click here for file


Dirofilaria immitis and Angiostrongylus vasorum are both important potentially fatal canine nematodes with overlapping endemic areas, especially in Europe. The preadult and adult stages of both species are living in the Arteria pulmonalis and the right heart, and diagnostically detectable circulating parasite antigens have been demonstrated for both species. For the detection of D. immitis infections, a variety of commercial tests have been developed, however, they have not been evaluated for cross-reactions against circulating antigens of A. vasorum.A. vasorum and which had circulating antigens as confirmed by a species-specific ELISA, were evaluated for the detection of A. vasorum antigen in six commercially available D. immitis test kits.In this study, potential cross-reactions of sera from 16 dogs, which were experimentally infected with A. vasorum-infected dog (6.2%) tested positive.In three fast tests , all sera were negative. One fast membrane ELISA (SNAP® HTWM RT Test) was positive with four sera (25%), and one serum delivered a non-valid result twice. In the PetChek® HTWM PF Test, depending on the interpretation protocol, 5 or 8 dogs (31.2 – 50%) were positive. With the DiroCHEK®-ELISA, a single A. vasorum in commercially available test kits for the detection of D. immitis antigen, the simultaneous use of highly specific diagnostic methods for the differentiation of these two canine heart worms is recommended.Due to potential cross-reactions with  Dirofilaria immitis, a filarial nematode, and Angiostrongylus vasorum, a metastrongylid nematode, are both localized in the Arteria pulmonalis and the right heart of their definitive hosts. Dogs, foxes and some other carnivores are the definitive hosts of both parasites, while Culicidae and Gastropoda are the intermediate hosts of D. immitis and A. vasorum, respectively.The adult stages of D. immitis is present in coastal Mediterranean areas with expansion northwards, while in North America the parasite has expanded from the south-eastern coastal areas northwards and westwards [A. vasorum was diagnosed for the first time in France in 1913 [A. vasorum in North America, with a potential for expansion to further regions [A. vasorum and D. immitis have therefore to be accounted for. Furthermore, in non-endemic areas of D. immitis, this agent has to be considered based on anamnestic information (travelling with pet dogs or imports) and differentiated from A. vasorum infections.In Europe, stwards  up to Castwards . A. vasoin 1913 ,5. Its pin 1913 ). Reportin 1913 -10 or biin 1913 ,12 may hregions ,13,14. OD. immitis infection are usually prevented by the monthly use of macrocyclic lactones in known endemic areas [Wolbachia with doxycycline supported by administration of macrocyclic lactones [A. vasorum, instead, are treated using macrocyclic lactones such as moxidectin [Fatal clinical consequences of c areas -17, and c areas  and/or, actones . Dogs inidectin  or milbeidectin , or applidectin . Prophylidectin .D. immitis is based on the detection of microfilariae or circulating antigens released by mature adult female worms into the blood circulation, both being detectable starting from 6 months after infection [Dipetalonema reconditum[Dirofilaria repens, indicating that modern test kits may overcome cross-reactions detected in previously developed test kits for these parasites [Ancylostoma caninum and Trichuris spp. [A. vasorum infections in dogs is the isolation of first stage larvae (L1) from faecal samples, which are produced by the parasites approximately 6–7 weeks after infection. Larval migration techniques such as the Baermann-Wetzel method [A. vasorum have been described [A. vasorum have been developed. These latter ones have been evaluated for cross-reactions against Crenosoma vulpis[Toxocara canis, Ancylostoma caninum) and, importantly, against D. immitis[The currently used diagnostic laboratory methods for the detection of these parasites are divergent. The diagnosis of fection . A variefection -24. Testfection , while tfection ,26,29,30econditum,31 or Dirasites ,33, and,is spp. ,34. The  method  are commma vulpis,10 and a. immitis, showingA. vasorum and D. immitis may share epitopes responsible for potential cross-reactions in antigen detection tests. This hypothesis has been confirmed during the development of the ELISA for the detection of circulating antigen for A. vasorum[Due to their common localization within the definitive hosts, their considerable size and particularly the well documented production of circulating antigens ,36, it w. vasorum.A. vasorum in six different commercially available tests for the detection of D. immitis antigen.The aim of the study was to evaluate potential cross-reactions of sera from dogs experimentally infected with A. vasorum were obtained during previously performed studies [A. vasorum antigen [Dirofilaria immitis infection was excluded based on the fact that the dogs were living in a non-endemic area under controlled experimental conditions, and at necropsy.A total of 16 sera from dogs experimentally inoculated with 200 third stage larvae (L3) of studies . Infectistudies , by the antigen  and by tAll tests were performed blinded with an identity code from 1 to 16, by veterinarians (fast tests) or by experienced laboratory technicians from the IPZ (ELISAs).All sera were non-haemolytic, stored at −20°C and tested within 11–40 months after collection. The following test kits were used, adopting the manufacturer’s instruction and within the indicated expiry dates:1) Witness® Dirofilaria, lateral flow 2) SensPERT® Canine Heartworm, lateral flow 3) SNAP® HTWM RT, membrane ELISA 4) SNAP® 4Dx® Plus, membrane ELISA 5) Petchek® HTWM PF Antigen Test , ELISA 6) DiroCHEK®, ELISA Single test results are shown in Table A. vasorum antigen was highly positive for all experimentally infected dogs, with absorbance values  varying between 0.263 and 2.007 , with aA. vasorum infected dogs were positive for D. immitis antigen, and one serum delivered a non-valid result twice. In the PetChek®-ELISA two methods for interpretation were adopted: following the instruction for veterinary practitioners based on eye detection, 5 dogs resulted positive for D. immitis infection, while following the instructions under laboratory conditions with OD measurements, a total of 8 dogs were seropositive. With the DiroCHEK®-ELISA, a single A. vasorum infected dog was D. immitis seropositive. With one exception (76 dpi), all cross-reactions were observed in dogs infected with A. vasorum for more than 90 days, with worm burdens varying from 10–170.In three fast tests  all sera resulted negative, while in one fast membrane ELISA (SNAP® HTWM RT) four D. immitis antigen detection kits with sera of dogs infected with A. vasorum. The two ELISAs for D. immitis detection (PetChek® and DiroCHEK®) and the membrane ELISA SNAP® HTWM RT showed single cross-reactions against A. vasorum, which had not been considered so far. In contrast, the adopted ELISA for the detection of circulating A. vasorum antigen has been developed evaluating different monoclonal antibodies, which had been selectively chosen based on their absence of cross-reactivity against D. immitis circulating antigens, resulting in an overall high specificity [This study provides evidence of false positive reactions in ificity .D. immitis antigen tests are considered to be more sensitive than microfilariae concentration methods or other procedures [D. immitis – positive dogs have been discussed in previously performed studies evaluating different D. immitis test kits. Low worm burden and low number of female worms have been shown to reduce sensitivity of the tests [A. vasorum. An unknown number of dogs with travel anamnesis and testing positive for circulating heartworm antigen may have falsely been diagnosed positive due to A. vasorum cross-reactions, and erroneously treated with melarsomine and/or macrocyclic lactones. Therefore, serological results for D. immitis should be confirmed or excluded by additional diagnostic tests  or diagnostic imaging frequently delivering pathognomonic findings for heart dirofilariosis [Generally, cedures . In partcedures  for the e tests ,26,39. Hariosis ,41 or anariosis ,43.A. vasorum cross-react in commercially available test kits for the detection of circulating D. immitis antigen. The simultaneous use of highly specific diagnostic tools is recommended for epidemiological studies where both heart worm species occur or for individual dogs with a suspected heart worm infection.In this study we confirmed that sera of dogs infected with The authors declare that they have no competing interests.MS participated in the design of the study, collected the samples, carried out the diagnostic assays and drafted the manuscript. PD conceived the study and implemented the draft of the manuscript. Both authors have read and approved the final manuscript.


An accessory spleen is defined as ectopic splenic tissue that develops due to failure of fusion of cells during embryonic development as they migrate from the midline to the left upper quadrant. While benign, complications may arise which include trauma, torsion, or infarction of the ectopic tissue. Additionally, patients who have had a splenectomy secondary to treatment for previous pathology such as a haematological malignancy or idiopathic thrombocytopenia purpura may experience persistent symptoms due to the accessory splenic tissue. The presence of an accessory spleen is therefore of significant diagnostic and therapeutic importance. To the best of the authors' knowledge, this case is the second and largest reported case of a giant right suprarenal accessory spleen and highlights the difficulty in differentiation of these masses from malignant adrenal tumours. The spleen is an organ found in the left hypochondrial region of the abdomen, between the gastric fundus and left hemidiaphragm. It plays an important role in the haematological and immune systems and acts as a reservoir for approximately 10–20% of blood volume [Congenital abnormalities of the spleen are rare, but include splenic agenesis, polysplenia, and the presence of accessory spleens or splenunculi . AccessoThis case is the second and largest reported case of a giant right suprarenal accessory spleen and highlights the difficulty in differentiation of these masses from malignant adrenal tumours.A 24-year old male thalassaemic patient presented electively with a history of a right-sided abdominal mass on self-examination, with no other complaints. A magnetic resonance image of the abdomen was requested, which revealed a 20 cm mass arising in the right suprarenal region, which was suspected to be a malignant adrenal tumour. Investigations revealed no evidence of adrenal dysfunction. The Patient was optimized for surgery in keeping with haematological recommendations and prepared and consented for removal of the right suprarenal mass.A Chevron incision was made to provide adequate access. At surgery, a giant highly vascularized tumour was excised from the right suprarenal region. There was an easily dissectible plane around the mass and its blood supply originated from a short pedicle from the aorta and inferior vena cava. There was no evidence of invasion into the surrounding structures. The patients' primary spleen and other intra-abdominal organs were otherwise normal in anatomy and size.Histological examination revealed this mass to be normal splenic tissue with a small central area of infarction and no evidence of malignancy noted Figures , and 4.An accessory spleen may develop during embryological development due to failure of lobulation of splenic tissue to fuse as the spleen migrates from the midline to its position in the left upper quadrant. They may occur anywhere along this path in the abdomen including the hilum of the spleen, the tail of the pancreas, the gastrosplenic and splenorenal ligaments, the walls of the stomach or intestines, the greater omentum, the mesentery, the adrenals, and the gonads in the case of splenogonadal fusion and do not usually exceed 2-3 cm in size .Satellite splenic tissue can also occur in splenosis, which is a condition whereby fragments of splenic tissue are implanted at well-vascularized areas of the abdominal cavity following splenectomy or rupture of the spleen .Enlargement of the spleen can result due to a number of conditions such as B-lymphoproliferative disorders, haematological disorders, and hyperreactive malarial splenomegaly  as well There have been previous cases that describe an accessory spleen mimicking a left-sided adrenal tumour , 8–10; hThe diagnosis of an accessory spleen should be considered as a differential for retroperitoneal and intraabdominal masses despite position. This case, to the best of the authors' knowledge, is the largest right suprarenal accessory spleen reported, measuring approximately 20 cm in size, and should be considered as a differential in planning an approach to surgery especially in patients with underlying haematological or lymphoproliferative pathology.


First spike latency is the long-lasting period preceding the first spike of a neuron submitted to a super-threshold stimulus. It has been suggested that this latency could code for stimulus recognition in several sensory systems ,2.+-current of type A [To encode information reliably, first spike latency should be sensitive to sensory inputs but robust to external perturbations. This paper studies the robustness of the first spike latency in spiking neuron models. These models are nonlinear and possibly high-dimensional. Understanding which parameters govern the first spike latency sensitivity in these systems generally requires extensive numerical simulations. We show that a local sensitivity analysis of the system is a good predictor of the global robustness of the latency code. This analysis, motivated by previous work on delayed decision-making in bistable models , relies f type A , a curreOur results show that first spike latency coding is particularly robust for a new type of excitability called regenerative excitability .