Until now, the use of technology in health care was driven mostly by the assumptions about the benefits of electronic health  rather than its evidence. It is noticeable that the magnitude of evidence of effectiveness and efficiency of eHealth is not proportionate to the number of interventions that are regularly conducted. Reliable evidence generated through comprehensive evaluation of eHealth interventions may accelerate the growth of eHealth for long-term successful implementation and help to experience eHealth benefits in an enhanced way.This study aimed to understand how the evidence of effectiveness and efficiency of eHealth can be generated through evaluation. Hence, we aim to discern (1) how evaluation is conducted in distinct eHealth intervention phases, (2) the aspects of effectiveness and efficiency that are typically evaluated during eHealth interventions, and (3) how eHealth interventions are evaluated in practice.A systematic literature review was conducted to explore the evaluation methods for eHealth interventions. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. We searched Google Scholar and Scopus for the published papers that addressed the evaluation of eHealth or described an eHealth intervention study. A qualitative analysis of the selected papers was conducted in several steps.We intended to see how the process of evaluation unfolds in distinct phases of an eHealth intervention. We revealed that in practice and in several conceptual papers, evaluation is performed at the end of the intervention. There are some studies that discuss the importance of conducting evaluation throughout the intervention; however, in practice, we found no case study that followed this. For our second research question, we discovered aspects of efficiency and effectiveness that are proposed to be assessed during interventions. The aspects that were recurrent in the conceptual papers include clinical, human and social, organizational, technological, cost, ethical and legal, and transferability. However, the case studies reviewed only evaluate the clinical and human and social aspects. At the end of the paper, we discussed a novel approach to look into the evaluation. Our intention was to stir up a discussion around this approach with the hope that it might be able to gather evidence in a comprehensive and credible way.The importance of evidence in eHealth has not been discussed as rigorously as have the diverse evaluation approaches and evaluation frameworks. Further research directed toward evidence-based evaluation can not only improve the quality of intervention studies but also facilitate successful long-term implementation of eHealth in general. We conclude that the development of more robust and comprehensive evaluation of eHealth studies or an improved validation of evaluation methods could ease the transferability of results among similar studies. Thus, the resources can be used for supplementary research in eHealth. The use of electronic health  is still driven by assumptions about the benefits of eHealth rather than its evidence . With tieHealth was introduced in the 1990s [The term he 1990s ; howeverhe 1990s . Accordihe 1990s :e-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies.Eysenbach believes eHealth stands for more than internet and medicine . In our Systematic evaluation can capture the evidence and criteria that evaluative judgment is based on and curtail the sources of biases . The quaIt is relevant to understand evidence-based medicine (EBM) while discussing the importance of evidence in eHealth interventions. A common query is how EBM can help generate evidence for eHealth interventions :Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research.evidence in EBM is conspicuously related to the clinical aspect. Although it is argued whether EBM is only about randomized controlled trials [As per this definition, d trials  or not [d trials , it is qd trials ,11,17. HOur objective was to elucidate how the evidence of effectiveness and efficiency of eHealth can be generated through evaluation. Consequently, a literature review was conducted to understand the evaluation process regarding both theories of eHealth and the practices in case studies of eHealth interventions. We decided to employ a broader perspective at the beginning of the review process to achieve our research objective. As the literature review progressed, our research objective narrowed, and the research questions were redefined several times. However, the objective was always to understand the evaluation of eHealth from a comprehensive perspective. It was pertinent to recognize the phases of eHealth interventions where evaluation occurs and the aspects of effectiveness and efficiency that are evaluated during such interventions. Our 3 research questions were as follows:How is evaluation conducted in distinct eHealth intervention phases?What aspects of effectiveness and efficiency are typically evaluated during eHealth interventions?How have eHealth intervention case studies been evaluated?Finally, we presented an approach to evaluate eHealth interventions by developing a model—Evidence in eHealth Evaluation. To our knowledge, this model is a novel way of looking into evaluation of eHealth interventions for comprehensive evidence. This conceptual model was based on the findings of the literature review.A systematic search of relevant literature was conducted following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines . Google The screening of the papers was conducted in 3 steps. For the first 2 steps, the screening was based on the title of the manuscripts using a predefined set of exclusion and inclusion criteria. Only scientific papers were used, whereas books and patents were excluded during the search. To avoid overanalysis and repetition of the papers, the exclusion criteria for the first step were citations, literature reviews, and meta-analyses. In addition, studies addressing specific health issues designed to answer clinical research questions were excluded . The number of records was reduced to 813 after the first elimination. At this point, all the records were listed together, and duplicate records were removed. During the second step, title screening was conducted. For papers whose titles did not explicitly mention the intervention target group, the abstracts were read to decide. When in doubt, the papers were included for further scrutiny in the next step. Consequently, only those records that included either a conceptual discussion about eHealth interventions or discussion about eHealth interventions that focused on adult patients and caregivers were selected. The third step of the screening process started with 279 records; this time, all the abstracts and the methodology of the papers were read by 2 of the authors individually. Previously, we devised the inclusion parameters for this stage; specifically, the selected papers ought to (1) be aligned to the study objective, (2) have the potential to provide insight for 1 or more research question, and (3) comply with the inclusion and exclusion criteria described above. At the end of step 3, the authors discussed their observations, and 81 papers were selected for thorough reading and analysis. Besides the papers selected through systematic search, 10 records were added for further analysis. These records were found from the citation of the papers selected using the systematic literature search. All 10 papers were included in this study because of their relevance to our objective.Planning the topic and scope of a review in the Cochrane review [learning point was included by us. This section of Cochrane review was adapted to identify the potentials of the selected papers in fulfilling the research objectives. On the other hand, it seemed advantageous to record novelties of the studies concerning learning points for our own development. During these phases, the papers (N=91) were read meticulously, which led to the final screening. As a result, 46 papers were selected for the qualitative analysis that categorically focused on evaluation in terms of phases and aspects. The flow diagram of the papers selection process is presented in To extract and record useful information from the papers and to gain a general overview of evaluation in eHealth interventions, a Microsoft Excel spreadsheet was created with the criteria shown in e review , criteriOn the basis of the summary of studies mentioned in the previous section, the papers (N=46) were classified into 2 categories: (1) conceptual exploration of eHealth interventions (n=21) and (2) case studies of eHealth interventions (n=25). Using the summary table , the papFor the papers in group A, thematic scrutiny was applied by mapping out the content of the papers and grouping the phases of intervention with similar objectives, activities, or results. The objective of the analysis was to understand whether the researchers emphasize some phases over others during evaluation and, if so, what phases are most frequently evaluated during an intervention.The studies in group B elaborated on the aspects evaluated to gather evidence of the efficiency and effectiveness of eHealth evaluations. These aspects and their key area of measurements were extracted from the papers to understand the parameters of efficiency and effectiveness that are emphasized by eHealth literature.The studies categorized as case studies of eHealth interventions were analyzed based on several characteristics . The purpose of the analysis was to conduct a descriptive comparison of the characteristics of evaluation performed in case studies with that of the conceptual papers.design, pretesting, pilot study, pragmatic trial, evaluation, and postintervention. This subsection concentrates on how evaluation is conducted in distinct phases of an eHealth intervention. From the selected studies in group A, a spectrum of phases of an eHealth intervention was identified including It can be ascertained from organizational aspect, technological aspect, human and social aspect, clinical aspect, cost and economic aspect, ethical and legal aspect, and transferability aspect. We determined the aspects that researchers evaluated to gather the evidence of efficiency and effectiveness of an eHealth intervention. To understand the aspects of efficiency and effectiveness, we compiled the dimensions of eHealth interventions that are proposed to be measured by the studies categorized in group B (n=11). While excerpting the dimensions during the qualitative analysis, we found that they can be classified into 7 aspects: The papers categorized as case studies of eHealth intervention show substantial variation in the approaches taken to evaluate the interventions. The use of standardized frameworks and theories for evaluating the interventions was hardly noticed in these studies. To summarize From the papers reviewed in this study, it has been revealed that numerous approaches to conceptualize and conduct eHealth intervention coexist. Several attributes of evaluation of eHealth intervention have become known through this review. There are vivid differences between how evaluation is conducted in practice (case studies) and how it is discussed in the conceptual papers. Moreover, a wide range of variety prevails within each group. Evaluation has been depicted as both static action performed at the end of the intervention ,24,26-28Although analyzing standardization of eHealth evaluation was not an objective of this review, the variability found in the studies compelled us to think whether it hinders the sharing of evidence among eHealth interventions. Scarcity of evidence, in turn, could delay the growth of eHealth. It is noticeable that the need for evidence is not clearly stated in any of the papers. The evaluation of the empirical studies typically focused on the success or failure of the technology  in that intervention. It seems that the numerous efforts taken in eHealth research are still quite disconnected, and they are thus unable to create a synergic effect on the growth of eHealth.It was noticeable from the review that although some studies elaborate on the aspects of evaluation for eHealth intervention (studies from group B) and some organize the evaluation of intervention into certain phases (studies from group A), no visible interaction has been made so far between these 2 groups of works . There is a gap where a connection can be made between the distinct phases of intervention and aspects of evaluation. This led us to develop the Evidence in eHealth Evaluation model , which edesign, pretesting, pilot study, pragmatic trial, evaluation, and postintervention) was conceived as a comprehensive intervention. We propose that the generation of robust evidence of effectiveness and efficiency would be plausible when the evaluation is conducted through all intervention phases. Moreover, the aspects of evaluation  would vary in each phase depending on activities of the phases. For example, when an eHealth intervention initiates with the design phase, the decisions are made based on the evaluation of the technological aspect and cost of technology development. The formal evaluation of the intervention begins in succeeding phases. The evaluation of technological, human and social, and cost aspects occurs in the pretesting phase. During the pilot study phase, the focus of evaluation shifts primarily to clinical aspect followed by human and social, technological, and ethical and legal. Depending on the evidence garnered in the pilot study, the intervention may proceed to the next phase or go back to the design phase. As the intervention is scaled up in the pragmatic trial, the evaluation is conducted to identify whether the technology-enabled care can be executed within the realistic layout of an organization. Hence, the key areas of evaluation in this phase are organizational and cost aspects along with other aspects such as clinical, human and social, technological, and ethical and legal. The last phase of gathering evidence is summative evaluation, where all the aspects are assessed including transferability. This comprehensive evaluation process gradually accumulates the evidence that reaches its peak in the summative evaluation phase and is used in the postintervention phase to make future decisions. The model also exhibits how the involvement of patients increases continuously from the design phase to the pragmatic trial, escalating the complexity of the evaluation process.In this study, an eHealth intervention comprising all 6 phases  allows creating reusable knowledge to facilitate the transfer of results to other settings  and to oWe acknowledge the fact that an eHealth intervention including all the phases presented in the model will become cumbersome because of high resource consumption. This conceptual model is not a prescription but just a way to show the progression of evidence in eHealth intervention in a reliable manner.To date, the importance of evidence has not been discussed as rigorously as the diverse research approaches and evaluation frameworks have been discussed. In this study, the Evidence in eHealth Evaluation model was developed to exhibit how evidence can be generated by evaluating certain aspects in each intervention phase. Assessing distinct aspects during distinct phases is a novel concept discussed in this study and requires further analysis. Moreover, this study implies an inconsistency between the literary concepts and practices of eHealth intervention, which has not been noted until now.As health interventions are context-specific, the transferability of results from eHealth studies may be difficult. Moreover, neither the conceptual nor the case studies suggested the long-term implementation of specific technology into the health care settings where it has been tested. We believe that this might be caused by a lack of or insufficiency of preliminary evidence of the effectiveness and efficiency after conducting the micro-trials or short-term tests on the effects of the technology. Consequently, it appears that lack of evidence hinders the growth of eHealth. Further research directed toward evidence-based evaluation can not only improve the quality of that intervention study but also facilitate long-term implementation of eHealth in general. We conclude that the development of more robust and comprehensive evaluation of eHealth studies or an improved validation of evaluation methods could ease the transferability of results among similar studies. Thus, the resources can be used for supplementary research in eHealth.This study is not devoid of limitations. We tried to include and analyze as many papers as possible; however, unknowingly and unintentionally, some papers may have been omitted. Furthermore, regarding the model, its development is in the preliminary stages; therefore, it cannot be compared with other validated frameworks.


Dirofilaria immitis is transmitted by bloodsucking mosquitoes and causes heartworm disease in dogs and wild canines. In the last decade, D. immitis has spread in southern Europe including Italy. Few autochthonous foci of infection have been reported in previously non-endemic areas of southern Italy based only on the identification of microfilariae, antigen and serological tests, and polymerase chain reaction assay from both the blood of dogs and mosquito vectors with no description of cases of heartworm disease in both domestic and wild canines. Here, we report first on two cases of heartworm disease found at post-mortem examination in two roaming dogs from the urban area of Castel Volturno in Campania region of southern Italy. Immunological analyses of 11 roaming dogs from the same pack of those two submitted for necropsy and available necropsy data from the dogs recovered from the Campania region along the past 10 years were both negative for D. immitis infection. Although rare in southern Italy, these two cases are noteworthy because D. immitis may cause serious human infection. We highlight the need to identify the mosquito vectors of heartworm disease in this area using sensitive molecular assay for D. immitis DNA for predicting and controlling the spread of infection. We strongly recommend the control and systematic treatment of the domestic and roaming dogs that could constitute the most important infection reservoir.The zoonotic filarioid nematode  Dirofilaria immitis (Nematoda: Filariidae) causes heartworm disease, which is widespread throughout tropical and temperate regions of the world including Europe. The disease is transmitted by bloodsucking mosquitoes of the family Culicidae mainly to dogs and wild canines  with good nutritional status, found on March 5, 2019, in the urban area of Castel Volturno in the Caserta municipality of the Campania region, were submitted to the IZSM  for post-mortem workup. At routinely parasitological investigation, several large nematodes were observed in the right heart and pulmonary artery of both dogs . HelmintD. immitis antigen according to the manufacturer's instructions. The PetChek Canine Heartworm Antigen Test shows a sensitivity of 98% [95% CL (confidence limit) 91.1–100%] and a specificity of 100% (95% CL 99.5–100%).After the post-mortem examination of the two roaming dogs, in March 2019, blood samples of 11 live roaming adult dogs  from the same pack and neighborhood of those two submitted for necropsy were collected for immunological analysis. Immunological analyses were performed using an enzyme immunoassay test  for the detection of In addition, retrospective analysis of available necropsy data of dogs recovered from the Campania region (from January 2010 to February 2019) and submitted to the IZSM in Portici were obtained from the database of the IZSM and reviewed to estimate occurrence and prevalence of dirofilariosis during the last decade. Unfortunately, data on the chemoprophylactic treatments used by the dog owners were unavailable.The IZSM is accredited by the Italian Ministry of Health to perform systematic surveys on infectious diseases of animals. Procedures for this study were performed in accordance with the guide for the care and use of animals by the Italian Ministry of Health.D. immitis mature specimens including 11 from the male and 20 from the female  from the municipalities of Mt. Vesuvius area in Campania region; however, the two D. immitis positive dogs were not native of southern regions but had come from the endemic area of northern Italy. Otranto and Dantas-Torres  and may be influenced by human behavior regarding application of chemoprophylaxis and any trips to or from regions of endemicity ; both dogs born and always lived in the neighborhood where they were found dead with no history of travel outside the municipality or history of chemoprophylactic treatments. The site of Castel Volturno is located on the Tyrrhenian coast, and it has a typical Mediterranean climate with long hot summer and mild winters. It has many rural and marshy areas hosting dense populations of susceptible canine reservoirs including feral, roaming, and pet dogs and red fox Vulpes vulpes that live in close proximity in the area studied. The area also hosts a large amount of competent mosquito vectors including the most important species  involved in the transmission of D. immitis infection in Italy, which, in this temperate area, are feeding at least for 8 months per year (D. immitis in Naples (about 50 km from Castel Volturno) to be May 11 and October 31, respectively. This large period of transmission is of particular concern in urban areas with a dense canine population that, if the canine reservoirs are infected and not subjected to specific treatment, may provide microfilariae to mosquitos that in turn may infect other canines and humans. No presence of heartworm disease noticed at post-mortem examination by retrospective analyses of those 1,560 dogs from the Campania region confirm that D. immitis infection in southern Italy is rare in occurrence. However, it does not confirm that those dogs were negative for larvae and pre-adults of D. immitis in their bloodstream since the first preadult worms arrive in the pulmonary artery and right ventricle of canine hearts at between 70 and 85 days post-infection (Here, we reported on two cases in which adult specimens of per year , 6, 12. per year  estimateD. immitis-positive. Potential explanations for failing to detect antigen in dogs with D. immitis infection may include the following: low worm numbers, male-only infection, presence of immature worms, inappropriate handling or use of an assay, and/or presence of immune complexes (D. immitis.Concerning the immunological negative results of 11 roaming dogs from the same pack of those two submitted for necropsy, Little et al.  reportedomplexes , 14. Moromplexes , 14, 15.D. immitis may cause serious human infection. Based on data presented, studies to identify mosquito vectors using sensitive molecular assay for D. immitis DNA (D. immitis, its presence should not be disregarded in humans who come into contact with mosquitoes, which have fed on infected dogs.In conclusion, we report the first autochthonous foci of the infection in the urban area of Castel Volturno. Although rare in southern Italy, these two cases are noteworthy because itis DNA  in this itis DNA . We stroAll datasets generated for this study are included in the manuscript/supplementary files.Experimental conception and design were done by MS and GF. Collection of samples was done by GM, LV, and SR. Immunological analyses was done by LS. Analysis, interpretation, and paper writing were done by MS. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Robopets are small animal‐like robots which have the appearance and behavioural characteristics of pets.To bring together the evidence of the experiences of staff, residents and family members of interacting with robopets and the effects of robopets on the health and well‐being of older people living in care homes.Systematic review of qualitative and quantitative research.We searched 13 electronic databases from inception to July 2018 and undertook forward and backward citation chasing.Eligible studies reported the views and experiences of robopets from residents, family members and staff  and the effects of robopets on the health and well‐being of care home residents . Study selection was undertaken independently by two reviewers. We used the Wallace criteria and the Cochrane Risk of Bias tool to assess the quality of the evidence. We developed a logic model with stakeholders and used this as a framework to guide data extraction and synthesis. Where appropriate, we used meta‐analysis to combine effect estimates from quantitative studies.p = 0.03]). Not everyone had a positive experience of robopets.Nineteen studies  met the inclusion criteria. Interactions with robopets were described as having a positive impact on aspects of well‐being including loneliness, depression and quality of life by residents and staff, although there was no corresponding statistically significant evidence from meta‐analysis for these outcomes. Meta‐analysis showed evidence of a reduction in agitation with the robopet “Paro” compared to control (−0.32 [95% CI −0.61 to −0.04, Engagement with robopets appears to have beneficial effects on the health and well‐being of older adults living in care homes, but not all chose to engage. Whether the benefits can be sustained are yet to be investigated.Robopets have the potential to benefit people living in care homes, through increasing engagement and interaction. With the robopet acting as a catalyst, this engagement and interaction may afford comfort and help reduce agitation and loneliness. This is the first systematic review to synthesise research that has focussed on the experiences and effects of pet‐ or animal‐like robots (robopets) in older adult residential care settings.For those that choose to engage with them, robopets have the potential to reduce loneliness and agitation, increase social interactions and provide comfort and pleasure.Not everyone engages with robopets, and some older adults, families and nursing staff might actively dislike them.Training in how to best use and introduce robopets may help improve resident engagement and staff confidence in using them.Resident‐robopet interactions are highly varied and influenced by personal histories and the type and characteristics of the robopet.Whilst robopets should not be considered a replacement for human interaction, there appears to be scope for using them as therapy for agitated or isolated residentsResearchers can build on the gaps  and use more appropriate outcome measures in future trials of robopets that assess staff, family and carer perspectives such as comfort, pleasure, appreciation and communication.There is a still a paucity of evidence on the long‐term sustainability of robopets: Does the novelty wear off or do interactions deepen?Until recently, robopets have been prohibitively expensive. A new wave of cheaper robopets may facilitate more robust research in this area.1In recent years, there has been increasing interest in the use of pet or animal‐assisted therapy in care and nursing homes as a type of non‐pharmacological therapy that can provide sensory enhancement and facilitate social contact  What are the experiences, views and perceptions of residents, families/carers and care home staff of interacting with robopets in the older adult residential care setting?, and (b) what are the measured effects of robopets on the health and well‐being of older people living in residential care and of the staff that care for them?2Our review used best practice methods of evidence synthesis  in consultation with experts and used a combination of relevant controlled vocabulary terms  and free text terms. The MEDLINE search strategy is shown in Figure 2.2Eligible articles reported either (a) the views, experiences and perceptions of interacting with robopets of older people resident in care homes, their families and carers and care home staff, or (b) the effects of robopets on health and well‐being , social interaction, engagement, physical function, behavioural symptoms, medication use and adverse events. Robopets were defined as small animal‐like robots which have the appearance and behavioural characteristics of a companion animal or pet.Qualitative studies using recognised methods of qualitative data collection  and of analysis  were considered eligible for inclusion, as were randomised controlled trials, randomised crossover trials and cluster randomised trials. Eligibility criteria were applied to all unique titles and abstracts by two researchers  independently. The full texts of articles initially considered as meeting the inclusion criteria were retrieved and the eligibility criteria applied in the same way. Discrepancies at both stages were discussed and resolved with another reviewer (JTC) where necessary.2.3We used the Wallace criteria  and fully checked by another (JTC). Data were extracted on the study design, sample characteristics, format and duration of intervention, type of robopet, setting, outcome measures and results. We also collected data on the source of study funding and any conflicts of interest declared by the study authors. Where data were missing, we contacted study authors for further details. Four out of six authors contacted responded to this request.2.62.6.1Two authors who had each read and re‐read the papers discussed whether all components of the model were observed in the data, and whether any new components or underlying themes were evident in the data that were not part of the initial model. The same two authors refined the logic model and a second iteration of the model, which included both modified and new elements that had not been anticipated in the first iteration, was produced and shared with the wider team and EAG for discussion.2.6.2Random effect meta‐analyses were performed where we had sufficient data from RCTs assessing the same outcome  met the inclusion criteria Other woman:leash!S5:…I will take a leash and I will put it around your neck (Paro moves its head) no?  Look at him he understand [sic] everything!”.3.7.1Staff and family believed that holding, touching and talking with the robopet reduced the loneliness experienced by some residents , see Figure Three studies, all involving residents with dementia, assessed the effects of robopets on agitation. Two of the studies , see Figure Five studies, all investigating Paro, reported on the effects on depression: three studies in residents with dementia and two in mixed care home populations , see Figure The effect of PARO on quality of life was assessed in three studies with residents with dementia , eye contact (p < 0.001) and verbal communication (p < 0.05) when compared to a usual care control  and pain (p = 0.005) medications in the Paro group at post‐intervention compared to control group, but no effect on the dosage of sleep medication (p = 0.955) or depression medication (p = 0.083).Three studies, all involving Paro, investigated the impact of robopets on medication usage. Pooling of the data was not possible. Two studies .The effect of Paro on apathy was investigated by two studies in residents with dementia  and the consequent impact on medication . However, this is only one component of the model. Impact on staff and relatives, explored in the qualitative research, was not measured in the quantitative research but are important considerations for implementation in care homes. Whilst quantitative studies did explore aspects of engagement, the qualitative evidence synthesis expands this to provide rich detail about how people interact with the robopet and others in the care home (including other residents and care staff). This function of the robopet as a catalyst for communication, connectivity and interaction comes through strongly in the qualitative evidence synthesis, which also shows how contact with the robopet stimulated this through, for example, reminiscence. There were also some negative responses seen in the qualitative evidence, such as the robopets (particularly CuDDler) being perceived by some as potentially infantilising. Conversely, some residents were reported as caring too much for the robopet, potentially increasing anxiety, including around not wanting to share with others.Alleviating loneliness, identified as important in the qualitative evidence synthesis, was not statistically significant in the pooled analysis in the quantitative review, despite both studies reporting beneficial changes in loneliness. This may be a result of the use of the University of California, Los Angeles (UCLA) loneliness scale. The utility of this scale has been questioned due to its weak theoretical foundation that conceptualises loneliness as a uni‐dimensional concept and the continuous nature of the scale which determines a point that distinguishes lonely from non‐lonely Victor, . It is aThere was no statistically significant evidence from meta‐analysis on the effects of robopets on other aspects of physical and mental well‐being including depression or quality of life. The qualitative evidence synthesis shows, however, that there is a wide range of responses to robopets, with some residents very keen and others not at all interested. In measuring average impacts, particularly where there are small sample sizes, quantitative research may mask these extremes of response. Impact on sleep was measured in the quantitative review but not reported as an issue in the qualitative evidence synthesis.4This is the first systematic review to bring together qualitative and quantitative evidence of the experiences and effects of robopets for older adults in residential care. Whilst there have been reviews of socially assistive robots or companion robots in older adult care (Bemelmans et al., Variation in the nature of robopet “interventions” is important to note and makes unequivocal conclusions on the benefit, or otherwise, difficult to reach with the current state of evidence. There were also a wide range of comparator groups in the studies. Prior research has highlighted how different individual and contextual factors may influence how people respond and interact with robots, in particular that one‐to‐one interaction may be more beneficial than group interactions (Liang et al., Some of the robopets were very expensive, and this may be prohibitive for some care homes, although as the technology becomes more common, prices may be reduced. The qualitative evidence synthesis also suggests that robopets may not be for everyone, and could annoy or bore some residents, or even cause some to become over‐attached—effects that were not captured in the quantitative evidence, but which have been highlighted by other researchers (Bemelmans et al., Differences between the findings from the qualitative and quantitative evidence may be due to sample sizes in the quantitative research being too small to detect true differences or because the outcomes most important to care home residents were not assessed. Most of the outcomes measured in the quantitative studies were related to symptoms of BPSD, which comprised only a small segment of the overall logic model. It may also be possible that there is an “amalgamation of marginal gains” effect—whilst impact on any single outcome may be small, the overall impact is experienced as beneficial (Richards, A strength of this review is that it followed best practice guidelines for both quantitative and qualitative syntheses and was informed by stakeholders. We searched widely for relevant literature and did not limit by date or language, and authors were contacted to provide additional data where necessary. The qualitative and quantitative evidence was brought together through the use of a logic model which developed as the review progressed. We used the logic model as a dynamic tool to refine and actively synthesise the results and bring together findings from both bodies of literature, incorporating stakeholder views in this process. This approach to synthesis was both structured and flexible, allowing for deductive and inductive identification of themes. The review is, however, limited by the quality of the included studies—many of the quantitative studies were small, of short duration and with no follow‐up measurements. In addition, the blinding of participants was often not possible as studies’ aims were commonly disclosed to participants in order to inform consent. Another limitation of the research is the appropriateness of outcome measures. Qualitative research included in the review was generally of higher quality, although few studies were explicitly aligned to a theoretical perspective for their work.4.1There are some promising findings in this review suggesting that, through increased engagement with the robopet and collective interactions with the robopet, other residents and staff, there may be benefits for people living in care homes. Using the robopet as a catalyst, these interactions may reduce agitation and loneliness. However, it is clear that not all people are likely to respond positively, so consulting with family members about preferences and history with pets is likely to be important. Staff may also need training to ensure that the robopet is used appropriately, including when to use as part of a group activity and when as a one‐to‐one.No clear picture emerged about whether one type of robopet is better than another—most research has so far been done on one product. It is also not known if there are long‐term impacts of robopets, or whether novelty confers some of the possible benefit. It is possible that the nature of interactions may change from those initially stimulated through curiosity, but whether these reduce impact or simply change it needs to be investigated. In addition, innovations in methods used in quantitative research to capture the nature of engagement and interaction impacts, as well as how comfort, affection and pleasure may be facilitated, would be useful. The qualitative research also identified some potential harms which could also be incorporated in to future quantitative assessments.5This systematic review integrates the evidence from rich qualitative studies with effectiveness evidence from RCTs on the impact and interactions of robopets for older adults in residential care. Together the findings indicate that robopets, for those that engage and interact with them, appear to have the potential to impact favourably on outcomes such as loneliness and agitation. The evidence to date, however, comes from studies of low to moderate quality and is both diverse and complex. Understanding more about their long‐term impact and the implications for implementation is required before robopets could be considered for routine use with older adults in residential care.For those that choose to engage with them, robopets have the potential to reduce loneliness and agitation, increase social interactions, as well as provide comfort and pleasure. Interactions are highly varied and influenced by personal histories and the type and characteristics of the robopet.Not everyone engages with robopets, and some older adults, families and nursing staff might actively dislike them. Training in how to best use and introduce robopets may help improve resident engagement and staff confidence in using them.Whilst robopets should not be considered a replacement for human interaction, there appears to be scope for using them as therapy for agitated or isolated residents.The authors declare no conflict of interest.RA, JTC and RG conceived the concept of the study and all authors contributed to the design of the study. AB designed the searches. RA, NO, PM, BW and AB screened and data extracted the literature. RA and NO carried out the data syntheses. RA and NO drafted the manuscript, and all authors commented on subsequent drafts and contributed to the discussion and implications. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file.


A wandering spleen is a mobile spleen as a result of deficient splenic peritoneal ligaments and elongation of its vascular pedicle. It is a rare entity affecting mainly young adults commonly females and children, presenting as an asymptomatic abdominal mass or abdominal discomfort due to torsion and de-torsion of the pedicle.We report a 35-year-old female presented with intermittent colicky abdominal pain that worsened in severity over three weeks. Diagnostic laparoscopy showed torsion of spleen without infarction. Detorsion and Splenopexy in an extra-peritoneal pouch was performed. Post operatively, the patient recovered well and was healthy at two months follow up.A wandering spleen is either congenital or acquired. The condition results in a long vascular pedicle, which predispose to the torsion resulting in a partial or complete infarct of the spleen. Laparoscopic approach is the preferred technique and de-torsion of the splenic pedicle and splenopexy is a reasonable surgical option, when there is no evidence of infarction of the spleen.The diagnosis of wandering spleen is very rare and extremely difficult to establish and is clinically nonspecific. An early diagnosis and surgical care are required for preserving the spleen. Additional imaging examinations can help establish a diagnosis. As a re2A 35-year-old lady, presented thrice to the emergency department within a week with the complaints of severe intermittent colicky abdominal pain, increasing in intensity upon admission. No associated symptoms such as vomiting, fever and constipation. She complained of similar episodes of intermittent mild pain since three years. She had a past history of ovarian cystectomy and LSCS twice. She smokes 40 cigarettes per day, does not consume alcohol. She has contrast allergy.On general examination, the patient was afebrile (37 °C), pulse rate of 90 bpm, and blood pressure of 120/70 mmHg. No pallor, jaundice, finger clubbing or lymphadenopathy noticed. Systemic examination was unremarkable. An abdominal examination revealed mild tenderness and no guarding in the left hypochondrium.Laboratory parameters showed Hemoglobin 12.3 gm/dl (11.5–15.5), white blood cells 7.0 K/μL (4.011.0) and the platelet count was 200.0 K/μL (150.0–450.0); CRP 5 mg/L (0.0–5.0), ESR 18 mm/h (0–32), serum amylase 58 IU/L (25–125), lipase 30 U/L (8–78). LFTs, urea and electrolytes were normal.A computed tomography (CT) scan of the abdomen with oral and IV contrast was performed. As shown in The patient was scheduled for a diagnostic laparoscopy under general anesthesia. The operative findings showed that showed an enlarged and congested spleen overlying the bowels , Fig. 4 nd postoperative day and the patient consumed a normal diet on the post-operative day. Thereafter, she was discharged on oral analgesia. She was followed up for two months post operatively without any sinister complaints.23A wandering spleen is either congenital or acquired ,7. The cSonography may show characteristic comma-shaped spleen in an ectopic position and the lack of splenic tissue in the left upper quadrant. Multi slice spiral CT scan is the investigation of choice to demonstrate the position and the viability of spleen ,10. PresThe various techniques of splenopexy have been described in the literature such as splenopexy in an extra peritoneal pouch  or creat4The diagnosis of wandering spleen is very rare and extremely difficult to establish and is clinically nonspecific. An early diagnosis and surgical care are required for preserving the spleen. Additional imaging examinations can help establish a diagnosis. Laparoscopy usually confirms the diagnosis. When wandering spleen is diagnosed, splenopexy is the treatment of choice, irrespective of the presence or absence of symptoms, even without the presence of splenic infarction and necrosis. Splenopexy is feasible, less invasive, and does not affect the splenic function. If splenic necrosis is present, splenectomy usually is required.No funding.Ethical approval taken from the Mediclinic Research & Ethic Committee.The head of our medical team/hospital or legal team have taken responsibility that exhaustive attempts have been made to contact the family and that the paper has been sufficiently anonymised not to cause harm to the patient or their family. A signed document to this effect can be provided on request.Dr. Mariyem Awan – Original Draft writing, editing and literature review.Dr. Jose Luis Gallego – Laparoscopic Surgeon who performed Splenopexy.Dr. Annett Al Hamadi – Reviewing the draft.Dr. Vijay Chander Vinod – Emergency Physician who 1st saw the patient and performed the CT to establish initial diagnosis. Draft writing and editing.Not applicable.Dr Mariyem Awan.Dr Vijay Vinod.Not commissioned, externally peer-reviewed.No conflicts of interest.


Mediterranean fever (MEFV) gene mutations are associated with familial Mediterranean fever (FMF). Recent studies have suggested that MEFV gene mutations may act as disease modifiers in neuro‐Behçet's (NBD) disease and neuro‐Sweet disease (NSD). We investigated MEFV genes and clinical features in 17 patients with NBD or NSD. MEFV gene mutations were frequently observed (70.6%). Headaches and exertional leg pain were associated with MEFV gene mutations (P < 0.05). Moreover, higher frequency of white matter lesions without sites predilection (P < 0.05) and non‐parenchymal lesions (P < 0.05) were also observed. MEFV gene mutations may be associated with particular findings and lesion sites. Neuro‐Behçet's disease (NBD) and neuro‐Sweet disease (NSD) are neurological manifestations of Behçet's disease (BD) and Sweet disease, respectively, with occasional serious sequelae.MEFV) gene, which is associated with familial Mediterranean fever (FMF),MEFV gene in NBD and NSD is important for elucidating the mechanism of central nervous system (CNS) inflammation and developing treatments.Genetically, class I human leukocyte antigen (HLA) serotypes have been associated with BD MEFV gene mutations might serve as susceptibility, or disease‐modifying factors in patients with CNS inflammation, resulting from NND. Furthermore, we hypothesized that specific clinical manifestations related to FMFMEFV gene mutations in patients with NBD or NSD.We hypothesized that HLA class I subtypes and MEFV gene mutations in patients with NBD or NSD.Herein, we investigated FMF‐related symptoms and their associations with HLA class I alleles and This retrospective study included 17 patients who visited Mie University Hospital between April 2014 and December 2018 and received confirmed NBD or NSD diagnosis. The International Consensus Recommendation criteria were used for NBD diagnosis,MEFV gene analysis was conducted in all patients. Mutations in the five hotspot regions  were assessed through polymerase chain reaction A In addition to neurological syndromes , symptoms indicative of FMF Brain magnetic resonance imaging (MRI) was performed with a 3T MR scanner . All patients underwent 3D fluid‐attenuated inversion recovery (FLAIR), 3D T1‐weighted imaging (T1WI), T2‐weighted imaging, T2 star‐weighted imaging or susceptibility‐weighted imaging, diffusion‐weighted imaging, and MR angiography diagnostic imaging. Post‐gadolinium (Gd) FLAIR (FLAIR‐Gd) and Gd‐T1WI (T1WI‐Gd) were performed on 11 patients without renal failure. These patients provided written informed consent for the use of Gd. Regional brain lesion locations were categorized into brain stem  and negative group (MEFV−) and compared the frequency of HLA class I genotypes between the groups. Group‐wise differences in symptoms, laboratory data, and neuroimaging data were also assessed. All data analyses were performed using SPSS version 25 for Windows (IBM Corp.). To assess statistical differences between categorical variables, we used the chi‐square test. The significance level was set at 0.05 for all analyses.Patients were divided into a MEFV gene analysis, 12 (70.6%) displayed heterozygous or homozygous mutations. The frequencies of occurrence of HLA‐B51, HLA‐B54, and HLA‐Cw1 were 23.5%, 29.4%, and 52.9%, respectively. The most frequent symptoms were headache (76.5%) and oral mucosal lesions (76.5%), followed by incomplete joint disorders (64.7%). MRI revealed that the lesions in the brain stem (BS) (64.7%) were most common, followed by the white matter lesions, without predilection for a particular site (58.8%).The demographic, genetic, radiographic, and therapeutic data of patients are summarized in Table MEFV positive (+) and MEFV negative (−) groups is presented in Table MEFV+ and MEFV− groups. Although insignificant, MEFV+ patients had B54 alleles frequently  and A02 alleles less frequently . Common symptoms in the MEFV+ group included headaches  and exertional leg pain . MRI findings indicated that MEFV+ patients exhibited a higher frequency of white matter lesions without site predilection  and non‐parenchymal lesions . There were no significant differences in laboratory data including inflammatory markers in blood and cerebrospinal fluid of patients classified as MEFV+ and MEFV−. Responses to the treatment were not significant between MEFV+ and MEFV− patients.A comparison of the clinical symptoms of the MEFV gene mutations. Furthermore, patients with MEFV mutations commonly experienced headaches, exertional leg pain, and sustained white‐matter lesions without site predilection and non‐parenchymal lesions.Patients with CNS inflammation and symptoms related to NBD or NSD frequently exhibited MEFV gene are common and were found to occur in one‐quarter of patients diagnosed with FMF.MEFV gene mutations. This result supports the hypothesis that MEFV gene mutations may act as disease modifiers in NND. The most frequent mutations in Japanese patients with FMF included E148Q (40.2%), M694I (21.0%), L110P (18.8%), P369S (5.4%), and R408Q (5.4%).MEFV gene mutations were E148Q (52.9%), R202Q (11.8%), P369S (11.8%), R408Q (11.8%), E84K (5.9%), G304R (5.9%), and L110P (5.9%). Headaches and exertional leg pain are often observed in patients with FMF.Single heterozygous mutations in the ), P369S .4%, and MEFV gene mutations showed no significant associations, B54 showed relatively high enrichment among patients with MEFV gene mutations (P < 0.10). The HLA class I B54 allele and MEFV gene mutations may additively contribute to onset of CNS inflammation.Although serotypes of HLA class I and MEFV+ disproportionately occurred in the white matter without site predilection. The typical predilection sites of NBD are brainstem and basal ganglia.MEFV gene mutations.The MRI lesions of patients who were MEFV gene,MEFV gene mutations in NBD and NSD, MEFV gene mutations have also been reported in multiple sclerosis.MEFV gene may be involved in CNS‐inflammation in various neurological diseases.While HLA is mainly associated with adaptive immune responses, the inflammasome machinery is present in numerous cell types and contributes to innate immune activation in multiple organs and in the CNS.MEFV mutation was remarkably responsive to colchicine. Colchicine is a treatment for FMF caused by MEFV gene mutations. In patients with CNS inflammation with MEFV mutations, colchicine may be an effective treatment option. Large cohort studies including other diseases manifesting neurological inflammation are warranted to clarify the relationship between MEFV gene mutations and neurological inflammatory diseases.In our study, one patient diagnosed as probable NSD with MEFV gene analysis and edited the manuscript. AS and HT were involved in the design of the study and contributed to the interpretation of the findings and critical revision of the manuscript.HI contributed to the conception and design of the study, acquisition, and analysis of data; drafted the initial draft of the report and revised and edited the manuscript. YI was involved in the design of the study, contributed to the interpretation of the findings, and revised and edited the manuscript. AN, YN, KM, NK, AM, KT, YH, HM, AOI, and AT were involved in the design of the study, acquisition of the data, and revision and editing of the manuscript. DK was involved in The authors declare no conflicts of interest.


Osteopaths are an integral member of the health care team, playing a pivotal role in the provision of care for patients with musculoskeletal disorders. Osteopaths, like other health care providers, are under increasing pressure to deliver evidence-based health care and to improve patient outcomes. However, the extent to which osteopaths engage in evidence-based practice (EBP), particularly in Australia, is not well understood. This study therefore set out to investigate the attitudes, skills and use of EBP, and perceived barriers and enablers of EBP uptake, among osteopaths practicing in Australia.National cross-sectional survey of Australian registered osteopaths. Eligible participants were invited by email and other digital media recruitment strategies to complete the online Evidence-Based Practice Attitude and Utilisation Survey (EBASE).A total of 332 osteopaths completed the survey. The demographic characteristics of respondents were generally consistent with the characteristics of the Australian osteopathy workforce. The respondents were mostly favourable of EBP, with the majority agreeing or strongly agreeing that EBP assists in making decisions about patient care (86.7%) and improves the quality of patient care (75.6%). While most respondents (88.3%) had some training in EBP, most reported a moderate level of perceived skill in EBP. The majority of respondents engaged infrequently (0–5 times) in EBP activities within the last month, and most indicated that a very small or small proportion of their clinical practice was based on clinical research evidence. Leading barriers to the uptake of EBP were lack of time and lack of clinical evidence in osteopathy. Key enablers of EBP uptake were access to the internet and online databases at work, and access to full-text articles and EBP education materials.Osteopaths participating in the survey were largely supportive of evidence-based practice, yet engaged infrequently in EBP activities. An important next step in this research is to identify suitable strategies that effectively improve EBP uptake in osteopathy, and perchance, improve patient outcomes. Osteopathy has been described as a person-centred approach to manual therapy that focuses on the neurological, musculoskeletal and visceral structures of the body . OsteopaOsteopaths play an important role in the delivery of musculoskeletal healthcare. In fact, musculoskeletal back pain is the leading reason why patients consult an osteopath . As for Osteopathy has achieved some form of national statutory regulation in a number of countries across the world, including several European countries, the UK, New Zealand and Australia . The devOsteopathic physicians primarily work in the USA, and are licensed to practice the full scope of medicine, including surgery and the prescription of medications, but they rarely specialise in the use of manual therapy techniques in practice . By contThe role that research evidence plays in informing osteopathy practice and clinical decision-making is another area that has been keenly discussed across the globe –19. DeveRecent research has highlighted several challenges with embedding EBP into osteopathic practice and education. For example, in a survey of 370 UK osteopaths, Weber and Rajendran  found thOur previous research examined the barriers and facilitators of EBP uptake amongst UK osteopaths . The worNational, cross-sectional survey.To what extent do Australian osteopaths engage in evidence-based practice (EBP)?What level of importance do Australian osteopaths place on EBP?What factors enable Australian osteopaths to practice EBP?What barriers prevent Australian osteopaths from practicing EBP?What skills and level of training do Australian osteopaths possess in order to practice EBP?What types of interventions would facilitate Australian osteopath uptake of EBP?Is there an association between practitioner demographics, and EBP use, skill and attitude?The study was designed to answer the following research questions:All osteopaths registered with the Osteopathy Board of Australia (OBA), and practicing osteopathy in any state or territory in Australia, were eligible to participate in the study. Based on a target population of 2,277 practicing registered osteopaths (as at 31st March 2018) ) were posted an invitation by email, with a reminder email posted 2 weeks later. Links to the survey were also disseminated via posts on social media, including the research team’s Twitter, Instagram and LinkedIn accounts, as well as pertinent Facebook pages.www.surveymonkey.com]). Participants providing informed consent to participate , were able to commence the survey. All survey items were made compulsory in order to mitigate the risk of missing data. The estimated completion time of the survey was 10–15 min. Data collection was undertaken between March 2018 and May 2018.All recruitment materials provided a web-link to the subject information sheet and online survey, which was hosted by SurveyMonkey™  for coding and statistical analysis. Surveys identified as being partially-complete (i.e. more than 20% of items were unanswered due to respondents dropping out of the survey) were excluded from the analysis . Multipln = 2) and surveys with more than 20% unanswered items (n = 34), the adjusted sample size was 332. This exceeded the minimum sample size required for the study. As the number of osteopaths receiving an invitation to participate could not be determined, it was not possible to report an exact survey response rate.A total of 368 Australian osteopaths completed the survey. Excluding multiple responses from single respondents , aged between 30 and 49 years (54.5%)  working in clinics with other CAM providers Table . These pRespondents reported a median attitude subscore of 31 , suggesting attitudes toward EBP were generally positive . In particular, respondents largely agreed that professional literature and research findings are useful for practice (83.4%), and that EBP assists in clinical decision making (86.7%), is necessary in the practice of osteopathy (84.6%), improves the quality of patient care (75.6%), and is fundamental to the advancement of the profession (73.2%) (Table p = 0.012). A weak positive association between attitude subscore and hours per week participating in research  was also found. Associations between attitude subscore and other demographic characteristics were not shown to be statistically significant.A weak negative association was observed between attitude subscore (categorised by quartiles) and years since receiving highest qualification , signifying a mostly moderate level of perceived skill in EBP (with scores between 39.1 and 51.9 indicative of a predominantly moderate to somewhat high skill level). Relatively higher perceived skill levels were reported for items pertaining to the first stage of the EBP process . The lowest perceived skill levels were reported for items relating to advanced research activities, such as the conduct of systematic reviews and clinical research, with 72.9 and 83.7% of respondents, respectively, reporting low to low-moderate skill levels for these tasks (Table p = 0.002), highest qualification , hours per week teaching in the higher education sector  and hours per week participating in research . Associations between skill subscore and other demographic characteristics were not found to be statistically significant.Skill subscore (categorised by quartiles) was found to be weakly positively associated with age , representing a moderately-low level of engagement in EBP activities (with scores between 6.1 and 12.0 indicative of a moderately-low level of use). The majority (49.7–71.1%) of respondents participated in EBP activities (i.e. the first six items) no more than five times in the previous month. Most respondents also engaged infrequently (i.e. 0–5 times in the previous month) with the lay literature (80.7%) or with colleagues/industry experts (66%) (Table p = 0.022), hours per week teaching in the higher education sector  and hours per week participating in research . There was also a weak negative association between use subscore and years since receiving highest qualification . Associations between use subscore and other demographic characteristics were not shown to be statistically significant.A weak positive association was observed between use subscore (categorised by quartiles) and highest qualification  or small  proportion of their clinical practice was based on clinical research evidence. Those reporting a moderate (51–75% of practice) or large (76–99%) proportion of their practice as being based on clinical research evidence represented 25.9 and 7.8% of respondents, respectively. Few respondents indicated that none (1.8%) or all of their practice (0.9%) was informed by evidence from clinical trials. Traditional knowledge was the highest ranked information source  used by respondents to inform clinical decision making. This was followed by clinical practice guidelines  and consultation with fellow practitioners or experts  (Table The majority of respondents had undertaken some degree of training in evidence-based practice/osteopathy (88.3%), evidence application (78.9%), critical thinking/analysis (76.8%), and clinical research (61.8%), and to a lesser extent, the conduct of systematic reviews and meta-analyses (53.9%). In most cases, this training was completed as a minor (27.4–32.2%) or major (9.6–29.5%) component of a study program.Respondents reported few barriers to the uptake of EBP in osteopathy, with 11 of 13 listed factors  being perceived as either not a barrier, or only a minor barrier to EBP uptake. The only factors identified as ‘moderate’ or ‘major’ barriers to EBP uptake were lack of clinical evidence in osteopathy (59.9%), and lack of time (52.7%).Most respondents indicated that the 10 listed enabling factors facilitated the uptake of EBP in osteopathy, albeit with varying levels of perceived usefulness. Enablers considered to be ‘very useful’ by most participants were improving access to the internet in the workplace (69.6%), online EBP education materials (63.6%), free online databases (62.3%), databases requiring licence fees (57.2%) and critical reviews of research evidence relating to osteopathy (50.6%), as well as the ability to download full-text articles (63.0%). Among enablers perceived to be ‘moderately to very useful’ were access to critically appraised topics relating to osteopathy (69.9%), critical appraisal tools (60.5%) and research rating tools (58.7%), and online tools that facilitate practitioner appraisal of the evidence (51.5%).This study has revealed some important insights into Australian osteopaths’ attitudes, skills and utilisation of evidence-based practice, as well as the barriers and enablers of EBP uptake among this professional group. Australian osteopaths were generally supportive of EBP, but largely reported low levels of EBP uptake in clinical practice. Further, despite most respondents completing some form of EBP-related training, perceived EBP skill levels were generally modest. Understanding the implications of these and other identified barriers and enablers of evidence-based practice uptake is a logical next step of this research, and consequently, is the focus of this discussion.Encouragingly, respondents reported positive attitudes to the role of EBP in osteopathic practice. They also reported moderate-to-high levels of self-perceived skill in the identification of clinical questions and knowledge gaps in practice, as well as appraising and applying evidence from research to their clinical practice. These findings were similar to the perceived EBP skill level reported by UK osteopaths . InteresThe lowest perceived skill levels relating to EBP were reported for the conduct of clinical research and/or systematic reviews. Given that this survey was distributed to practicing osteopaths, most without academic or research affiliations, it should be expected that they use research findings rather than produce them. Again, our findings are similar to recent studies, where Malaysian physiotherapists , US chirDespite the favourable view of EBP and moderately-high level of perceived skills in EBP, the majority of respondents reported low levels of engagement in evidence-based practice activities (i.e. they participated in these activities no more than five times in the previous month). Surprisingly, over a quarter of respondents reported that they never used an online database to search for practice-related literature or used this literature to change clinical practice over the last month. Similarly, about 20% of respondents reported that they never read or reviewed clinical research findings related to practice in the previous month. Instead, only around 15 % of respondents regularly reviewed clinical research findings, searched online databases or used professional literature to assist in daily clinical decision-making. Adding to this, nearly 60% of respondents reported very small/small proportions of their clinical practice to be based on EBP.Most respondents relied upon traditional knowledge, clinical practice guidelines and fellow professionals to inform their clinical decision making. What is not clear is whether this dependency on traditional knowledge in Australian osteopathic practice is largely a ‘capacity’ issue , a more entrenched ‘cultural’ issue , or a product of both of these factors, or something entirely different . RegardlAlthough the findings of the current study, and those of our recent UK study  indicateA possible explanation for the relatively low frequency of EBP activity among Australian and UK osteopaths may relate to the presentation of patients with a consistent range of symptoms and disorders that do not require frequent searching of evidence. However, if that were the case, one might expect chiropractors, and possibly physical therapists, to see a similar patient population. Yet, both chiropractors , 32 and Given the positive attitude to evidence-based practice, but the low level of EBP utilisation among respondents, an examination of the barriers to EBP uptake should be revealing. However, participants perceived 11 of the 13 listed barriers to EBP as being only a minor barrier or not a barrier to EBP at all. The only factors identified as moderate or major barriers to EBP uptake were lack of clinical evidence in osteopathy and lack of time.It is true that there is a lack of osteopathy-specific clinical research for both common and uncommon conditions treated by osteopaths; and while clinical evidence for osteopathic manipulative therapy is now emerging, methodological rigour is often lacking . HoweverLack of time is not only a major barrier to EBP uptake reported by osteopaths , but alsAustralian osteopaths agreed that research findings are useful for practice, and that EBP assists in clinical decision making and is necessary in the practice of osteopathy. The majority of respondents also identified themselves as having a moderate or moderate-high level of EBP skills. Despite this, the reported frequency of EBP activity was low. In the absence of many identified barriers to EBP beyond relevant evidence and time constraints, the perceived enablers of EBP may provide useful insights on how to promote greater uptake of EBP in osteopathy.Two factors perceived by respondents as being particularly helpful in enabling EBP uptake in osteopathy practice were accessibility of evidence  and access to EBP training . These enabling strategies were consistent with those reported by UK osteopaths  and CanaWhile it is not possible to accurately determine the response rate to this survey due to the nature of sampling/recruitment, the survey appeared to be completed by approximately 14.6% 332/2277) of Australian osteopaths. This not only exceeded the minimum sample size required for this study, but also the response rates for other EBP surveys involving complementary medicine disciplines, including Canadian chiropractors (8%) , UK oste/2277 of The above limitations, as well as the understandings gained from this study, highlight the need for further research in this field. For instance, there is a need to investigate the skill/competency level of osteopaths with regards to applying EBP, and to better understand the skills that are required for the successful integration of EBP into osteopathic practice. A related area of research is the development, implementation and evaluation of appropriate interventions that facilitate the uptake of EBP by the osteopathy workforce. Such work could be facilitated through improved collaboration between professional, educational and academic research bodies, as has already been demonstrated through the recent Osteopathy Research and Innovation Network (ORION) project .This study has revealed important insights into Australian osteopath attitudes, skills and utilisation of EBP. Overall, respondents were generally positive toward EBP, and the majority agreed or strongly agreed that EBP assists in making clinical decisions, improves the quality of patient care, and is necessary in the practice of osteopathy. Despite the majority of respondents reporting a moderate or moderately-high level of EBP skills, the level of engagement in EBP activities over the preceding month was low. Principle barriers to EBP were identified as lack of time and a paucity of clinical evidence in osteopathy. The main enablers of EBP uptake related to improving access to evidence and training in EBP. The findings suggest that continuing professional education initiatives in EBP may be valuable in assisting osteopaths to more frequently engage in EBP activities in clinical practice.


Nutritional support continues to receive much attention as a possible intervention to prevent loss of lean tissue mass, promote recovery and re-establish proper immune function in critical care patients. Yet there remains much controversy regarding the clinical efficacy of such interventions. In addition to the direct effect of nutrition in terms of micro- and macronutrient content, nutritional formulations may exert an effect via the physiological response to feeding. Here, we highlight the key role of postprandial reabsorbed bile acids in attenuating both the inflammatory response and autophagy. These observations suggest that not all patients would benefit from aggressive nutritional support. Three observations strongly suggest that sickness-associated anorexia (SAA) serves an important function during an infection. First, the fact that inflammatory mediators such as interleukin-1 beta (IL-1β), IL-6 and tumour necrosis factor (TNF) induce SAA ). Also, Notwithstanding these considerations, nutritional support is administered in various contexts. The implementation of aggressive nutritional support is motivated by two considerations. First, it is often argued that a decrease in appetite removes the incentive for foraging behaviour, thereby conserving energy for other critical functions such as the mobilisation of the immune response. However, nutritional support can be administered to patients without the associated metabolic cost of gathering food. Second, activation of an inflammatory response is associated with a remarkable increase in metabolic rate, leading to a severe nitrogen deficit and the loss of lean tissue mass. In addition, critically ill patients are most often immobile which likely aggravates the catabolism of lean tissue. Since the loss of lean mass is associated with an increase in mortality and morbidity, nutritional support not only may halt the extensive catabolism in critically ill patients but also may avert malnutrition. These considerations then provide a rational justification for implementing nutritional support in critically ill patients.Despite these considerations, there is currently no single study providing “unequivocal evidence that feeding protocols targeting full-replacement nutrition early in the course of critical illness result in clinical benefits” . A numbeHere, we argue that a major mechanism by which nutritional support mediates its therapeutic effects relates to the hormonal effect of postprandial reabsorbed bile acids (BAs). In particular, BAs may attenuate the inflammatory response transcriptionally but also could compromise lipopolysaccharide (LPS) clearance by attenuating the expression of scavenger receptors as well as autophagy, a cell survival response. Emerging evidence has also implicated BAs as transcriptional inhibitors of autophagy. Furthermore, evidence has demonstrated that BAs alter the vascular system, suggesting that postprandial reabsorption of BAs may have an impact on the development of shock. Finally, we briefly point out that nutritional support may exert other clinically relevant effects such as altering the microbiome. Taken together, these observations strongly suggest that, during an infection, nutritional support may curtail immunological functions and compromise autophagy but conversely may also prove beneficial in averting an excessive inflammatory response to sterile injury.Following a meal, fatty acids in the lumen of the gut induce the release of cholecystokinin, which in turn causes the sphincter of Oddi to relax and bile to flow into the small intestine. Of note, the fatty acid chain length plays a vital role in regulating the release of cholecystokinin, and long-chain fatty acids provide a much more pronounced release of cholecystokinin , 7. MechAlthough BAs are typically associated with digestion, BAs have long been known to mediate an anti-inflammatory effect. As an example, BAs induced a 50% suppression of IL-6, IL-1 and TNF-α in monocytes at a concentration of between 60 and 80 μmol/L . SimilarMechanistically, it is now well established that the reabsorbed secondary BAs act as hormones targeting cell surface G protein–coupled BA receptors  and the nuclear receptor, farnesoid-X-receptor (FXR) , which aBAs may also indirectly alter the inflammatory response by compromising LPS clearance. The scavenger receptor class B type I (SR-BI) plays an important role in transporting cholesterol associated with high-density lipoprotein (HDL) into a range of cells, including macrophages and hepatocytes . LPS alsTaken together, these observations demonstrate that nutritional support may exert clinically relevant effects through the subsequent reabsorption of BAs. The effect of BAs may be particularly relevant in the context of bacterial infection: given the observation that hepatic clearance of LPS is important in preventing excessive inflammation , it is pet al. [Another important consequence of feeding is the suppression of autophagy. Here again, the postprandial reabsorption of BAs has been shown to attenuate autophagy transcriptionally via the activation of FXR. FXR activation suppresses the expression of various proteins involved in autophagy by antagonising the function of other transcription factors such as cAMP response element-binding protein (CREB) . Similaret al.  recentlyet al.  and posset al. .Indirect evidence also suggests that the inhibition of autophagic/lysosomal function may result in a compromised ability to clear LPS during an infection. Earlier studies have documented the localisation of LPS within lysosomal vesicles . In thisIt is thus evident that increased BA reabsorption as a result of nutritional support may alter the immune response and impact on the inflammatory status of a patient. However, BAs have also been implicated in a range of other clinically relevant contexts. As an nutritional support may also complicate haemodynamics, not only by directly increasing blood flow towards intestines but also indirectly through the effect of BAs on the liver. It has long been noted that BAs cause an increase in blood flow through the splanchnic circulation . In hepaThere is also a need to evaluate the role of BAs in other peripheral systems beyond the liver. BAs have been shown to alter haemodynamic parameters outside of the enterohepatic circulation, which collectively result in decreased blood pressure (reviewed in ). This iOther evidence suggests that BAs may have a protective role in liver regeneration. Cholic acid has been shown to promote liver regeneration in mice in an FXR-dependent manner . SimilarConversely, in both rats  and humaTaken together, these observations highlight a number of mechanisms by which BAs mediate clinically relevant physiological response Fig. . It is tFinally, although we have focused on postprandial BAs, it is also worth noting that other elements of nutrition may have adverse effects on critically ill patients. As an example, iron is the rate-limiting element in bacterial growth, and it is now well established that iron withdrawal plays an adaptive immunological function directed at starving bacteria of this critical element . Yet it It is thus clear that elevation of BAs resulting from nutritional support may alter autophagy and inflammation and possibly impact the development of shock. Collectively, these observations suggest that nutritional support may be more beneficial in patients where an immediate threat of infection is not present or where an anti-inflammatory effect is pursued. However, it is not clear how elevated BAs after a meal and the elevation of BAs in other disease states  are functionally related. There is also a need for more targeted studies aimed at elucidating the direct effect of BAs and the possible therapeutic application of BA supplementation in critically ill patients. Finally, the potential impact of postprandial reabsorbed BAs highlights an important consideration: nutritional support may exert effects that extend beyond the nutrient needs of the patient.


PEDro is searched millions of times each year by users worldwide. Societá Italiana de Fisioterapia  has entered into a collaboration with the developers of PEDro. In addition to describing the evidence available on PEDro and who uses it, this paper also summarises the features of PEDro that can facilitate evidence-based physiotherapy. This paper concludes by outlining the collaboration between SIF and PEDro.This paper provides an overview of a free resource that can be used by physiotherapists to assist their efforts to undertake evidence-based practice. The resource is the Physiotherapy Evidence Database (PEDro;  The approach to the clinical care of patients known as “evidence-based practice” is becoming more widely accepted within the physiotherapy profession. The approach was defined by its developers as the “integration of the best research evidence with clinical expertise and patient values” . ClinicaIt is difficult for physiotherapists to keep abreast of all the research that might be relevant to the types of patients they treat in clinical practice. One contributor to this difficulty is that, with ongoing publications, the number of trials of physiotherapy interventions is growing exponentially , 3. If wwww.pedro.org.au. This section of the paper will describe the content and features of PEDro, relating these to how they can assist physiotherapists who want to keep abreast of the growing body of evidence about physiotherapy interventions. This section will conclude with a review of how often and how widely PEDro is used.To address the situation described above, a group of physiotherapists established the Physiotherapy Evidence Database. More commonly referred to as ‘PEDro’, the database is freely available for anyone to use at randomised clinical trials of physiotherapy interventions (or interventions that could become part of physiotherapy care). Another type of document is systematic reviews that include at least one randomised trial of a physiotherapy intervention.clinical practice guidelines that are based on a systematic literature search and that contain at least one recommendation relevant to physiotherapy practice. Although there are other forms of evidence , the most unbiased evidence about the effects of interventions comes from the forms of evidence indexed on PEDro: randomised trials, systematic reviews and clinical practice guidelines.PEDro indexes the bibliographic details and abstracts of three types of documents. One type of document is musculoskeletal, cardiothoracics, neurology and gerontology contribute the greatest share of records to PEDro, although even the subdisciplines with the fewest records have substantial evidence for interested users.In February 2019, PEDro indexed over 33,000 trials, over 8000 systematic reviews, and over 650 clinical practice guidelines. The trials examine interventions from a wide range of subdisciplines, as shown in Fig. In 2010 and again in 2014, it was reported that the number of records indexed on PEDro was expanding exponentially . This paThe sustained exponential growth in research into the effects of physiotherapy interventions generates a wonderful body of evidence for the profession to draw upon. However, it also portrays the growing difficulty that a physiotherapist, whether working clinically or in academia, would have in keeping abreast of the evidence relevant to their areas of interest.Two studies have examined the completeness of coverage of randomised trials of physiotherapy interventions by PEDro and a range of other databases , 5. AlthAs discussed at the beginning of this paper, searching a general database for high-quality evidence about physiotherapy interventions is inefficient. Even if the desired study design  is successfully incorporated into the search terms, it is still likely that many trials or reviews related to surgery, medication or other non-physiotherapy interventions will be retrieved. Because PEDro only indexes randomised trials, systematic reviews and clinical practice guidelines related to physiotherapy interventions, it permits a more targeted and therefore more efficient search for physiotherapists who want to know about the effects of an intervention.In addition to targeting evidence about physiotherapy interventions, searches of PEDro are designed to be efficient in other ways. Searches can specify the type of therapy from a pull-down menu that includes 13 categories. These categories (in order of the amount of evidence available on PEDro) are: fitness training; strength training; education; stretching, mobilisation, manipulation or massage; skill training; behaviour modification; electrotherapy, heat or cold; acupuncture; respiratory therapy; orthoses, taping or splinting; health promotion; neurodevelopmental therapy or neurofacilitation; and hydrotherapy or balneotherapy. In addition, searches can specify the problem experienced by the patient from a pull-down menu that includes 12 categories. These categories (in order of the amount of evidence available on PEDro) are: pain; reduced exercise tolerance; muscle weakness; motor incoordination; impaired ventilation; muscle shortening or reduced joint compliance; frailty; incontinence; oedema; reduced work tolerance; difficulty with sputum retention; and skin lesion, wound or burn. The search can also be targeted to one of 11 body regions or one of the 10 subdisciplines shown in Fig. If a particular known paper is required, then PEDro can also be searched by entering whichever of the following citation details are known: journal, year of publication, author, and words in the title. In fact, any combination of the search fields that have been mentioned so far can be used in a search.https://www.pedro.org.au/italian/downloads/pedro-scale/).The study design of the desired evidence  is another field that can be specified from a pull-down menu. If none of these is selected, all types of evidence will be retrieved, with clinical practice guidelines (if any are available) listed first in the search results, because they are the most condensed form of evidence. Next will be listed any systematic reviews that are identified by the search, with Cochrane reviews listed first because on average they use more rigorous methods than non-Cochrane reviews . Last inThe order in which search results are listed on the site is associated with how often the indexed research papers are accessed by users of PEDro. Specifically, synthesis research  are more commonly accessed than trials; Cochrane reviews are more commonly accessed than other reviews; and trials with higher PEDro Scale summary scores are more commonly accessed than lower quality trials . It is uWhen users of PEDro run a search, the results are initially presented as a list of titles. If a user sees a paper listed in the search results that might be of interest, clicking on it will reveal further details, such as the abstract , the full details of which PEDro Scale items were achieved , and links to full-text sources of the paper. In a random sample of 100 papers indexed on PEDro, 100% had one or more links to a full-text version online and 46% had at least one link to a free full-text version of the paper. Users of PEDro also have the option to select records from the search results and to email themselves the list of selected records.https://www.pedro.org.au/italian/search-help/) to help users improve their search skills. These videos include how to: ask a clinical question in PICO format, perform a PEDro search, optimise searching, and access full-text copies of papers identified by the search. Most of these videos are available in 12 different languages, including Italian. In fact, the whole PEDro website is now available in Italian and 11 other languages.The developers of PEDro have studied how users search the database , which rEvidence in your inbox service . Each month, the details of any trials, reviews and guidelines that have just been added to the database can be emailed to you for free. Simply choose from 15 areas of practice  have beSince being launched in October 1999, PEDro has been used to answer 18,632,434 clinical questions . The usahttps://training.pedro.org.au/). This online course develops skills in appraising the methodological quality of randomised controlled trials.SIF and its members make important contributions to PEDro. Along with 46 other physiotherapy associations and societies from around the world and other industry partners, SIF provides PEDro with some financial support. Collectively, these donations make it possible for PEDro to be kept up-to-date and freely available for the global physiotherapy community. Through this partnership with PEDro, SIF encourages its members to enhance their skills in aspects of evidence-based practice and actively contribute to the indexing of evidence in PEDro. Approximately 40 SIF members have completed the PEDro Scale Training Program , SIF members also rate trials in their area of clinical interest that are written in English. Collectively, SIF members have rated over 400 of the trials indexed on PEDro.By supporting and collaborating with PEDro, SIF is doing a lot to encourage physiotherapists to undertake evidence-based practice. Italian physiotherapists should respond by taking the opportunity to use the Italian-language interface to access PEDro to improve their knowledge of available evidence about physiotherapy interventions. Italian physiotherapists can be proud of the work that SIF has done to facilitate evidence-based physiotherapy, because it provides a great example for other national physiotherapy associations globally. If physiotherapy associations and societies in all countries followed this lead, patient care would be enhanced through the shared use of the best evidence.