One RCT (n = 309) found that advice to consume cranberry juice had no statistically significant effect on UTI frequency symptoms (mean difference (MD) −0.01 (95% CI: −0.37 to 0.34), p = 0.94)), on UTI symptoms of feeling unwell (MD 0.02 (95% CI: −0.36 to 0.39), p = 0.93)) or on antibiotic use (odds ratio 1.27 (95% CI: 0.47 to 3.43), p = 0.64), when compared with promoting drinking water. One RCT (n = 319) found no symptomatic benefit from combining cranberry juice with immediate antibiotics for an acute UTI, compared with placebo juice combined with immediate antibiotics. In one RCT (n = 60), consumption of cranberry extract capsules was associated with a within-group improvement in urinary symptoms and Escherichia coli load at day 10 compared with baseline (p < 0.01), which was not found in untreated controls (p = 0.72). Two RCTs were under-powered to detect differences between groups for outcomes of interest. There were no serious adverse effects associated with cranberry consumption. Conclusion: The current evidence base for or against the use of cranberry extract in the management of acute, uncomplicated UTIs is inadequate; rigorous trials are needed.Background: Effective alternatives to antibiotics for alleviating symptoms of acute infections may be appealing to patients and enhance antimicrobial stewardship. Cranberry-based products are already in wide use for symptoms of acute urinary tract infection (UTI). The aim of this review was to identify and critically appraise the supporting evidence. Methods: The protocol was registered on PROSPERO. Searches were conducted of Medline, Embase, Amed, Cinahl, The Cochrane library, Clinicaltrials.gov and WHO International Clinical Trials Registry Platform. We included randomised clinical trials (RCTs) and non-randomised studies evaluating the effect of cranberry extract in the management of acute, uncomplicated UTI on symptoms, antibiotic use, microbiological assessment, biochemical assessment and adverse events. Study risk of bias assessments were made using Cochrane criteria. Results: We included three RCTs ( Women often experience symptoms attributed to urinary tract infection (UTI)  and a hiCranberry fruit (Vaccinium macrocarpon) grows on evergreen shrubs that are native to North America . CranberEscherichia coli (E. coli) from binding to the bladder uroepithelium [n = 4473) of men, women and children found that cranberry did not significantly reduce recurrent UTI compared with placebo, advice to increase water intake or no treatment. A subgroup analysis of women with recurrent UTI found that cranberry consumption resulted in a non-significant reduction in recurrent UTIs [Cranberry extract could be a potential alternative to antibiotics to treat acute uncomplicated UTIs. Proanthocyanidin (PAC) with A-type linkages, or their metabolites, are believed to be the active ingredient in cranberry, preventing ithelium  and therithelium ,14. A 20ent UTIs .Whilst many studies have evaluated the effectiveness of cranberry extract in reducing recurrent UTI, few have assessed effects on symptoms of acute UTIs . The aimhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=166785). The protocol was registered on the PROSPERO database on the 13th March 2020  and Google Scholar for relevant studies. Search terms included, but were not limited to, cranberry, vaccinium and urinary tract infection  comparing the effectiveness of cranberry extract with any other treatment for acute uncomplicated UTIs in patients aged 18 years and above. Non-randomised studies  assessing the use of cranberry in treating acute UTIs were also eligible. For inclusion, cranberry extract needed to be orally administered as juice, fruit or as capsules/tablets/pills. In studies in which a cranberry product was combined with another intervention/exposure, data allowing the effect of cranberry on the outcome(s) of interest to be isolated were required. Included studies needed to report at least one of our primary or secondary outcomes. Primary outcomes were assessment of participants’ symptoms/clinical status/wellbeing assessment , antibiotic use (immediate and/or delayed) and clinical cure. Secondary outcomes were microbiological cure/assessment; biochemical assessment; assessment of mechanisms of action; and assessment of harms/adverse events.We excluded studies of exclusively complicated UTI ; studies assessing recurrent UTI; animal studies; case reports; and systematic reviews. Systematic reviews were used as sources for references.We assessed the risk of bias of included studies using the Cochrane risk of bias tool . Two revWe extracted data from included studies on study setting, participants, study duration, the intervention and comparator and the results. We reported the risk of bias across the studies graphically using RevMan  and usedClinicalTrials.gov, Google Scholar and WHO ICTRP did not identify additional studies suitable for inclusion. After removal of duplicates, 1976 citations were screened at the title and abstract stage and 79 eligible articles were identified. Thirty seven studies were excluded because the study design did not fit our criteria [Electronic database searches identified 3337 results . Searchicriteria ,53,54,55criteria ,64,65,66criteria ,71,72,73criteria ,75,76,77criteria ,78 and acriteria . One anicriteria . Eight scriteria ,43,65,68criteria , the autcriteria , one wascriteria  and one criteria . Three scriteria ,86,87.All three RCTs were conducted in outpatient settings and included between 60  and 319 The included RCTs provided information on outcomes relevant to this review; however, the primary objective of the studies was not assessment of cranberry extract for acute UTI. Two studies focused on cranberry for preventing recurrent UTI ,87. BarbThe primary objective of the trial by Little et al. was to determine the effectiveness of five treatment strategies in the management of suspected acute, uncomplicated UTI, with participants randomly assigned to: (1) immediate antibiotics; (2) delayed antibiotics; (3) antibiotics dependent on the participant’s symptom score; (4) antibiotics offered if the dipstick was positive; and (5) antibiotics targeted to according to midstream urine results . Four foThe risk of bias of included studies was judged as moderate a,b, provAdditional biases included cranberry industry involvement  and insup = 0.94)) or the severity of unwell symptoms (MD 0.02 (95% CI: −0.36 to 0.39), p = 0.93)), compared with advice to drink water. Advice to drink cranberry juice compared with water did not affect the duration of symptoms rated moderately bad or worse—that is, rated three or more on a scale of zero to six (incident rate ratio (IRR) 1.18 (95% CI: 1.95 to 1.47), p = 0.13)).Little et al.  analysedSengupta and colleagues reported a significant within-group improvement in symptoms at 10 days compared with baseline in both the high- and low-dose cranberry intervention groups, but not in the untreated controls . No empiBarbosa-Cesnik et al.  reportedp = 0.64). Little et al.  found thE. coli load after 10 days of treatment with both low-dose cranberry (p < 0.01) and high-dose cranberry (p < 0.0001), but not in the untreated controls (p = 0.72). At baseline, 4/13 (30.8%) of the untreated controls were E. coli positive, whilst 14/21 (66.7%) of the low-dose cranberry group and 17/23 (73.9%) of the high-dose cranberry group were E. coli positive.Sengupta et al.  reportedp = 0.17)) in the RCT by Little and colleagues [There was no significant impact of cranberry juice consumption on time to re-consultation compared with advice to drink water (hazard ratio (HR) 0.74 (95% CI: 0.49 to 1.13), lleagues .There were no major adverse events  reported for any group in the trial by Little et al. . SenguptE. coli load and improve symptoms after 10 days of consumption compared with baseline. The studies did not report evidence of serious harm associated with cranberry consumption. These results must be interpreted with caution as they come from a limited number of studies with a moderate risk of bias for the outcomes of interest in this review, which were not the primary objectives of the trials. The current evidence base for or against the use of cranberry extract in the management of acute, uncomplicated UTIs is inadequate. The existing, limited RCT evidence identified suggests that advice to consume cranberry juice does not improve urinary frequency symptoms, feeling unwell or the duration of symptoms rated moderately bad or worse in women with acute UTIs, compared with encouraging the consumption of water. Advice to consume cranberry juice did not reduce the use of antibiotics compared with promoting the consumption of water or time to re-consultation. In women receiving immediate antibiotics and cranberry juice, urinary symptoms were not reduced compared with immediate antibiotics and placebo juice. Consuming encapsulated cranberry powder may reduce We identified two trial registrations pertinent to this review. One of these trials, an open-label RCT in Spain, aims to recruit 128 women from emergency departments and outpatient clinics with acute UTI to assess the non-inferiority of acute treatment with a Cysticlean cranberry capsule (containing 240 mg PAC) compared with a 3-gram stat dose of Fosfomycin . The priA Cochrane review assessing cranberry products for symptoms of acute UTIs, last updated in 2020, did not find any eligible studies, nor did it identify either of the trial registrations discussed above . This reE. coli anti-adhesion activity in urine. Urine samples were collected from study participants before and after consuming cranberry capsules containing varying amounts of PAC or placebo capsules. The anti-adhesion activity of the participants’ urine was tested ex vivo against a uropathogenic E. coli strain. There was a significant increase in the anti-adhesion activity of PAC compared with placebo (p < 0.001), and the effect increased in a dose-dependent fashion. They determined that the optimal amount of PAC to consume was 72 mg per day. In the study by Little et al., the amount of PAC consumed by participants in the cranberry juice arm was not specified, and in the trial by Sengupta et al., participants in the high-dose cranberry group received 15 mg of PAC daily. It is therefore possible that participants in the cranberry arms of these studies were consuming sub-therapeutic doses of what is believed to be the active ingredient in the intervention.Howell et al.  conducteSome studies have found that advice to take non-steroidal anti-inflammatories (NSAIDS) reduces the consumption of antibiotics for acute urinary tract infections, although they control UTI symptoms less effectively than antibiotics and patients had more cases of pyelonephritis ,4,6,89. We employed a broad search strategy to maximise the chance of capturing relevant studies, including grey literature. In addition to electronic database searches and trial registries, we contacted companies that sell cranberry products and experts in the field. When needed, we contacted authors of eligible studies to check whether they were suitable for inclusion. However, we recognise that there are limitations to this review. We identified few studies suitable for inclusion, with moderate risk of bias, and empirical data were not provided for all of the outcomes assessed in this review. This is probably in part because cranberry extract as an acute UTI treatment was not the primary focus of the included RCTs. It is possible that we may have missed some studies that were suitable for inclusion, particularly unpublished studies. There was heterogeneity in the outcomes reported by the studies, and in the amount of PAC in the interventions used, making it difficult to make direct comparisons between studies. Two of the studies were under-powered to determine the effects of cranberry on outcomes, which can lead to exaggerated effect sizes . One stuOne study reported within-group comparisons rather than between-group comparison; this can lead to high Type I error (rejection of a true null hypothesis) and misleading results . Whilst Few studies have assessed the utility of cranberry in treating symptoms of acute UTIs; further adequately powered, well-conducted randomised clinical trials are required. These studies should use standardised interventions with a specified amount of PAC and must also report potential harm associated with cranberry consumption. It would also be helpful if the outcomes reported were standardised, to allow direct comparisons to be made between studies and meaningful meta-analysis of multiple studies to be performed. Given that cranberry extract is commonly used by women for symptoms of acute UTI, disseminating the results of well-conducted studies evaluating cranberry extract as a treatment for acute UTI to both clinicians and the public will be important. There is a drive towards increasing the use of delayed antibiotic prescription for self-limiting bacterial infections in primary care . In primThere is a paucity of studies evaluating cranberry in the management of acute UTIs; none of the identified trials were primarily focused on cranberry as an acute UTI treatment. The existing studies are at moderate risk of bias. Evidence of the effectiveness and safety of cranberry extract as a treatment for symptoms of acute, uncomplicated UTI is inconclusive; rigorous trials addressing these outcomes are required.


Long-term literacy outcomes for children with hearing loss, particularly those with severe-to-profound deafness who are fitted with cochlear implants (CIs) lag behind those of children with normal hearing (NH). The causes for these long-term deficits are not fully clear, though differences in auditory access between children who use CIs and those with NH may be a partial cause. This paper briefly reviews the emergent literacy model as proposed by  Reading is a critical skill that is typically acquired in childhood. Reading skill, acquired knowledge, and academic success increase together . CultivaCochlear implants have provided access to sound to thousands of prelingually deafened children. Along with this access to sound, many of these children have experienced substantial gains in their spoken language skills . Despiteemergent literacy factors at kindergarten  have a direct impact on children’s gains on another factor  c.f., . We arguBecause we have hypothesized a causal chain of development any tests of our hypotheses must allow for inferences of causality. Many teams have recognized the usefulness of longitudinal data for tracking developmental progressions in children with hearing loss, including those who use CIs. Modeling longitudinal data using structural equation modeling would allow us to infer causal influences between emergent literacy constructs (for an example applying this approach to literacy data in children who use CIs see We have presented evidence demonstrating that children who use CIs show performance deficits on nearly every aspect of emergent literacy. Though this can be attributed in part to differences in children’s auditory experiences, the fact that many high schoolers who use CIs are not reading at grade level suggests that improving auditory skills alone will not be sufficient and interventions that specifically target literacy for children who use CIs are necessary. We argue that these interventions should emphasize emergent literacy in prereaders who use CIs, to reduce disparities in emergent literacy early, and give children who use CIs a foundation for literacy instruction. Here, we have laid out our framework to describe how the auditory access provided by the CI influences the co-development of emergent literacy factors. We have provided hypotheses on mechanism, as well as alternatives to several of those hypotheses. Within this framework, we have speculated on those interventions that may be most likely to produce emergent literacy gains if our hypotheses are supported. We recognize that many of these interventions remain to be explicitly tested and the long-term benefits of these interventions will need to be ascertained. Thus, though it is a cliché to wrap up this review with the statement, “More work is needed,” we look forward to empirical tests of our hypotheses and interventions, with the aim of improving literacy outcomes for children who use CIs.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Uncertain information exists in each procedure of an air combat situation assessment. To address this issue, this paper proposes an improved method to address the uncertain information fusion of air combat situation assessment in the Dempster–Shafer evidence theory (DST) framework. A better fusion result regarding the prediction of military intention can be helpful for decision-making in an air combat situation. To obtain a more accurate fusion result of situation assessment, an improved belief entropy (IBE) is applied to preprocess the uncertainty of situation assessment information. Data fusion of assessment information after preprocessing will be based on the classical Dempster’s rule of combination. The illustrative example result validates the rationality and the effectiveness of the proposed method. Artificial intelligence technology has brought new weapons to intelligent air combat, e.g., the ALPHA software system ,2,3. In The aforementioned methods can inherit the advantages of the corresponding intelligent algorithm. However, more attention should be addressed to the data fusion process of the heterogeneous information coming from multiple sources . Due to To address the uncertainty in air combat situation assessment, an improved belief entropy (IBE)-based situation assessment method in the evidence theory framework is proposed. Firstly, evidence modeling will be based on an understanding of air combat situations according to the knowledge in the military domain. Secondly, the uncertainty of each evidence is measured and applied to evidence modification. The uncertainty measure for evidence is based on the IBE , which iThis rest of this paper is organized as follows. The preliminaries are introduced in Some basic definitions in DST are presented as follows ,13.Definition 1.Ω is the frame of discernment (FOD). The power set of Ω consists of Assume that Definition 2.A mass function m is a mapping from the power set If Definition 3.In DST, two independent mass functions where k is a normalization factor defined as follows:A, and Belief entropy in the DST framework is still an open issue ,26,27. BA typical framework of situation assessment in air combat is presented in The framework of the IBE-based situation assessment method for air combat is proposed in Step 1: battlefield environment information modelingAll the information about the two sides in the battlefield, the weather, the terrain, the international political situation, and the military expert assessment information should be included in the model of the battlefield environment. Step 2: sensor information acquisitionBattlefield information acquisition will be based on many kinds of sensors, including satellites, air reconnaissance aircraft, ground-based radar, airborne radars, and intelligence agent. Step 3: sensor data fusionThe heterogeneous sensor information acquired from the previous step will be fused for air combat situation assessment. The sensor data fusion method needs to be chosen cautiously, which is another important issue.Step 4: air combat situation understanding and evidence modelingSensor data fusion results shall be modeled in the DST framework based on air combat situation understanding. The knowledge in the military domain includes clustering analysis of multi-enemy targets, behavior analysis of the enemy, etc. Step 5: IBE-based uncertainty measure and preprocessing of the evidence for situation assessmentith piece of evidence coming from air combat situation understanding and evidence modeling, and Before applying evidence fusion of the situation assessment information, the uncertainty of each evidence is measured and applied for evidence modification. If evidence has a high degree of uncertainty, which is represented by a high value of IBE, then the reliability of the evidence is low, which means the evidence makes a small contribution to the final decision. Based on this cautious rule, the preprocessing of the evidence based on the uncertainty measure results will be based on the following function:Equation .Step 6: information fusion of air combat situation assessment and the prediction of military intentionn.In this paper, Dempster’s rule of combination is chosen for information fusion after evidence modification. The prediction of military intention will be based on the fused situation assessment information. If the evidence modification is based on 1) n=1,2,… pieces Step 7: real-time decision-making of air combatReal-time decision-making in air combat situation assessment aided by the aforementioned intelligent information fusion method will be used to support the pilots and commanders.The seven steps in the IBE-based situation assessment method for air combat are described as follows.r and b, the distance is R, the azimuth angle is V represents the speed.In air combat, assume that there are two fighter planes in the battlefield environment, as shown in The military intention of the opposite fighter plane can be assessed and modeled in the DST framework.Assume that the threshold of the belief for the intelligence-aided decision support system in the air combat situation assessment is 90%. In other words, if the final decision of a pilot is based on an intelligent method provided by the decision support system, then the belief of the proposal for the intelligent decision-making should be no less than 90%. The high belief condition set for the intelligent decision support system is to ensure high reliability in possible practical engineering applications. This is reasonable because it is a matter of life and death. If the intelligent aided decision support system has not reached its threshold for intelligent decision-making, then the belief on each candidate should be presented to human beings for reference.Steps 1–3. Battlefield environment information modeling, sensor information acquisition in battlefields, and the corresponding sensor data fusion are key issues corresponding to environment sensing of situation assessments in air combat. Related work can be found in ,33,34. TAt time T0, the sensor reports event At time T1, the sensor reports event At time T2, the sensor reports event At time T3, the sensor reports event Step 4: air combat situation understanding and evidence modeling Assume that there are four types of battlefield situation: the attack situation, denoted as The mass functions of the aforementioned situation assessment information in air combat are shown in Step 5: IBE-based uncertainty measure and preprocessing of the evidence for situation assessment The uncertain degree of each piece of evidence is measured. With Equation , the uncIf evidence has a high degree of uncertainty, which is represented by a high value of IBE, then the reliability of the evidence is low, which means the evidence makes a small contribution to the final decision. Based on this cautious rule, the preprocessing of the evidence based on the uncertainty measure results will be based on the following function:mwSAj=∑i=n , and modeling and fusing conflict situation assessment information cautiously for reliable decision-making in air combat.


Exclusive enteral nutrition (EEN) is progressively being used as a therapeutic option for adults with Crohn's Disease (CD); however, there is no standardized approach to delivering this therapy. The aim of this study is to develop an optimal care pathway for using EEN in adults with CD. This will create a standard of care that can be used as a benchmark practice and will provide direction for future research.A working group of 12 multidisciplinary inflammatory bowel disease specialists across Australia and New Zealand was convened to develop a practical, clinically focused care pathway for using EEN in adults with active CD. Six key areas were identified as part of the care pathway: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. Current literature was identified via systematic review, and quality of evidence was graded. Consensus expert opinion was used where literature gaps were identified.An optimal care pathway for using EEN in adults with CD was developed with six key consensus statements on how to use EEN in adults with active CD. These key statements identify clinical indications for use, nutrition assessment, enteral prescription and duration of therapy, monitoring criteria, food reintroduction, and the role of partial EEN. An accompanying patient resource was also developed.EEN is recommended as a treatment option to induce remission in adults with active CD. The consensus statements developed are practical and are based on best available evidence and expert opinion to assist in developing a standardized approach to delivering EEN therapy. Exclusive enteral nutrition (EEN) is an alternative therapeutic option to corticosteroids for patients with Crohn's disease (CD). This study aimed to develop an optimal care pathway for using EEN in adults with active CD. Six key consensus statements regarding the practical application of EEN in adults with active CD were developed based on available evidence and expert opinion to assist clinicians in delivering this therapy. The role of exclusive enteral nutrition (EEN) in the management of adult patients with active Crohn's disease (CD) is evolving. The basic premise of efficacy is the same as pediatric patients, yet few studies have been conducted on the adult cohort. This difference has been attributed to the lack of access to a multidisciplinary team, perceived intolerance and noncompliance in adults, and a lack of experience amongst inflammatory bowel disease (IBD) physicians.Although high‐quality studies are limited, and existing study findings are heterogeneous, EEN may offer similar efficacy to corticosteroids for induction of remission in adults with CD.In pediatric IBD populations, the evidence base for EEN is stronger. EEN is globally considered a first‐line treatment for remission induction in children with CD 60–80%).0%.8, 9, In tertiary IBD centers in Australia and New Zealand, a standardized approach to delivering EEN therapy is lacking. International IBD standards of care guidelines provide little guidance.A working group of nine IBD‐specialist dietitians and three IBD‐specialist gastroenterologists from Australia and New Zealand was created through an expression of interest to the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) and Dietitians Crohn's and Colitis Australian Network members. Clinicians were defined as adult IBD experts if they were currently working in IBD services in Australia and New Zealand where EEN therapy is used.Six key areas for an optimal care pathway were identified by group consensus: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. The expert working group was then split into six groups. Each group conducted literature searches of Medline, Embase, and Cochrane Library databases between June and October 2018 using the following MeSH terms: inflammatory bowel diseases, Crohn's disease, enteral nutrition, nutrition therapy, nutritional support, diet therapy, diet, nutrition assessment, and malnutrition.Key summary statements were developed for each area of the care pathway by reviewing literature quality using National Health and Medical Research Council, Oxford Centre for Evidence‐based Medicine Levels of Evidence, and Melynyk and Fineout‐Overholt hierarchies of evidence.A patient resource detailing instructions for following an EEN protocol was developed and reviewed by the expert working group and a Victorian patient advisory group.http://www.auspen.org.au).The optimal care pathway Fig.  guides aEEN is likely to be as effective as corticosteroids for remission induction in adults with CD who are able to tolerate EEN therapy (level 3 evidence).EEN may be effective in managing complicated CD, including enterocutaneous fistulae and inflammatory strictures (level 4 evidence).EEN may downstage CD severity prior to surgery and improve surgical outcomes or obviate the need for surgery (level 3 evidence).Trials reporting on EEN for the induction of remission in adult patients with CD report variable results and are of low quality, with limitations discussed elsewhere.vs 30–100% in corticosteroid group).A narrative review of seven studies evaluating EEN compared to corticosteroids in adults with CD found that EEN is likely to be as effective as corticosteroids when tolerated . A significant decrease in CRP was also observed. There was a ninefold increase in the incidence of postoperative abscess and/or anastomotic leak  in the control group. This study also showed that EEN may facilitate avoidance of surgery all together. Of patients who received EEN, 25% successfully progressed to immunomodulator therapy without surgical intervention.There is emerging evidence for the role of preoperative EEN in improving surgical outcomes for patients with complicated CD. In a retrospective case‐controlled study, 51 adult patients with stricturing or penetrating CD received preoperative EENIn another retrospective study of 114 patients, an average of 3 weeks of presurgical EEN reduced anastomotic leakage and the need for a diverting stoma.n = 59), EEN administered for 12 weeks achieved radiological remission of stricturing disease in 54% and resolution of clinical symptoms in 65% of patients.Small studies have shown the efficacy of EEN for management of CD complications. In a group of adult patients with inflammatory stricturing CD .Patients commencing EEN should have a comprehensive nutritional assessment to inform nutrition prescription and monitoring (level 7 evidence).EEN should be available as a primary therapy for adults with CD.Malnutrition among IBD patients is well documented and linked to adverse outcomes.As part of establishing goals for EEN therapy, patients should be screened for malnutrition risk and should undergo a comprehensive nutritional assessment by a dietitian.A polymeric whole‐protein formula is recommended for EEN (level 2 evidence).EEN should be available to all IBD patients via health‐care subsidy programs or pharmacies (level 7 evidence).No other table food or fluids are recommended for consumption when following an EEN regimen except for water (level 4 evidence).The duration of EEN regimen should be determined by the preidentified clinical goals (level 7 evidence).EEN can be commenced at target volume on day 1 (level 7 evidence).EEN should be ceased if there is failure to respond within 2 weeks (level 7 evidence).EEN regimens may need individualization to promote adherence (level 7 evidence).Formula choice should be informed by established efficacy and tolerability Table . MultiplEEN should be encouraged orally, with the option of nasogastric administration if patients are unable to tolerate adequate oral volumes.EEN formulas are available through health‐care subsidy programs or privately (online retailer or pharmacy). Providing patients with formula options and samples can assist in promoting compliance. Out‐of‐pocket expenses are likely to vary between individual services depending on whether site‐specific supplement programs are available or health‐care subsidies exist.There is inconsistent practice in the consumption of other fluids and food items with EEN. Survey data suggest it is common practice to include other nonnutritive food and drink items, such as chewing gum, broth, tea, or coffee, with EEN.Variable timeframes of EEN therapy have been evaluated in clinical trials of adult patients with CD, ranging from 10 days to beyond 12 weeks. Accordingly, guidelines for the duration of EEN therapy for remission induction in adults are inconsistent.The optimal duration of EEN therapy therefore remains unclear. Current data suggest that duration should be tailored to clinical indication Table . The likEEN can be commenced at target volume on day 1 of administration if a polymeric formula is used. Gradual upgrade of formula over a 2–7‐day period may be required if an elemental formula is used as these are less palatable and can be poorly tolerated. Titration of therapy may also be required in those with problematic vomiting or diarrhea or are at risk of refeeding syndrome.All members of the IBD multidisciplinary team (MDT) should encourage and support adherence to EEN therapy (level 7 evidence).Regular monitoring of EEN should be undertaken by the IBD team (level 7 evidence).If EEN therapy does not induce clinical response within 2 weeks, an alternative treatment should be considered (level 7 evidence).Nonadherence to EEN is a well‐documented barrier to achieving remission induction with EEN in adults.Like any medical intervention, EEN therapy needs to be monitored and adjusted to ensure optimal efficacy Table . Given tIn the absence of adult data, pediatric consensus guidelines recommend that EEN therapy should be ceased if no clinical improvement is seen within 2 weeks.A normal diet can be reintroduced rapidly, one meal per day, following a prescribed course of EEN therapy (level 4 evidence).An unrestricted, nutritionally balanced diet, tailored to patient preference, is recommended (level 7 evidence).Reintroduction of EEN should be considered if there is a flare of disease during the food reintroduction phase (level 4 evidence).Formula can be reduced in volume and frequency, whilst food is reintroduced one meal at a time over a period of 5 days Fig. .43Food can be reintroduced at a rapid pace as tolerated by the individual without risk of reducing EEN efficacy Fig. .43 If thA normal, unrestricted diet in line with national healthy eating guidelines should be the final goal of therapy when food is reintroduced.Dietary intake after EEN should be personalized by the dietitian and gastroenterologist, with consideration of stricturing disease, patient preference, comorbidities, motivation, and quality of life. If functional gastrointestinal symptoms persist when CD is in remission, an experienced IBD dietitian can provide additional dietary guidance.Retrospective pediatric data suggest that reinitiation of EEN should be considered if IBD disease activity flares during food reintroduction (57–77% efficacy); however, subsequent courses of EEN have lower treatment adherence.Partial enteral nutrition (PEN) cannot currently be recommended for the induction or maintenance of remission in adults with CD (level 7 evidence)vs 64% relapse rate, respectively).Four published adult studies have used PEN to induce or maintain remission. The results are conflicting and limited by high dropout rates, different PEN regimens, and lack of control groups.The evidence for using EEN as a treatment option for inducing remission in adults with active CD is increasing and is supported by pediatric data. In adults who are adherent to EEN, there is no mechanistic reason, including disease duration or disease distribution, to conceive that efficacy would differ from pediatric cohorts.Corticosteroids and biologic therapies are currently more commonly used as first‐line therapy in adult populationsEEN prescriptions should be individualized based on clinical indication identified by a multidisciplinary IBD team and a comprehensive nutritional assessment by a specialist IBD dietitian. Food should be reintroduced liberally with the long‐term goal of an individualized, unrestricted diet. Future multisite randomized controlled studies are required to evaluate the efficacy of using EEN as a therapeutic option in adults with CD.


Taenia solium taeniasis in endemic populations. The advantage of systematic reviews over selective reporting of the research evidence is that they seek to minimize bias and use transparent methods to find all research that meets pre-defined inclusion criteria. Our systematic review used the highest quality systematic review methods [White et al. have raised a number of concerns about the findings of our systematic review . However methods  and the  methods . We beliIn relation to some of the specific points raised by White et al. we note that we have presented the meta-analysis results stratified by drug and dose to allow the reader to identify any important differences in effectiveness, which was the aim of the review. It was not possible to further stratify the results by the diagnostic test used due to the relatively small number of studies. However, more important than the diagnostic tests used is the fact that all studies had a high risk of bias due to issues such as lack of randomization, incomplete outcome data and lack of blinding of outcome assessors ; a fact T. solium scolex and egg shedding may still occur after treatment is raised by White et al. 2020, though not substantiated with research evidence. We were unable to find evidence to confirm this statement but note the findings of one study of mass drug administration (MDA) with ALB 400mg triple dose included in the systematic review that used both Copro-PCR and Co-Ag-ELISA [The possibility that albendazole (ALB) does not kill the In relation to the analysis of side-effects, White et al. 2020 quote two publications. One is a case report of neurological side-effects after MDA with 5mg/kg praziquantel  and neitWhite et al. also note that neurological side-effects would be anticipated to occur 3 to 5 days after treatment but, again, they did not cite any evidence to support this claim and we were unable to find any supporting evidence for their statement. In fact, those studies that do note the time of occurrence of side-effects generally report effects within the first 1–3 days , 10 follT. solium endemic countries need help to control the problem. To make decisions about possible solutions, they need an impartial summary of the best available evidence of effectiveness and safety, along with an assessment of other factors important for decision-making, including whether the problem is a priority, a rational assessment of the balance between desirable and undesirable effects, values and preferences, resource requirements, impact on equity, feasibility, and acceptability [We encourage constructive criticism of all research, including our own, but we suggest that this should be based on research evidence rather than reliance on perception and opinion. tability , 12.Some authors are staff members of the Pan American Health Organization. The authors alone are responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the Pan American Health Organization.


To report on the 2019 EuGMS Congress in Krakow.Evidence-based medicine in geriatrics is a previously neglected, now rapidly expanding field. Heterogeneity of our older population brings many questions and challenges for research.Personalized approaches based on evidence-based practices, standardisation of definitions and meaningful outcomes, in collaboration with older people themselves, and with other specialties, are the new frontiers and challenges for research. The 2019 EuGMS Congress “Evidence-Based Medicine in Geriatrics” was held in Krakow, Poland, and attended by over 1600 participants from 64 different countries. A summary and reflection on the congress was presented in the Closing Ceremony by European Academy for Medicine of Aging graduates, and summarised in this article. Keynote lectures, ‘state of the art’ sessions and symposia presented the evidence relating to different age-related conditions, their prevention, management and treatments. Hot topic areas included frailty and multimorbidity, and evidence-based attempts to address these conditions at different life stages. The field of geriatrics represents unique challenges for evidence-based medicine practice. There is much research going on. Clear leadership is needed to facilitate consensus agreements on standard definitions, methods and relevant outcomes, in collaboration with older people themselves, to maximise the opportunities and benefits of doing this research, and benefiting our patients and society at large. Evidence-based medicine (EBM) was first described by David L. Sackett as the “conscientious, explicit and judicious use of the best current clinical research evidence in making decisions about the care of patients”. This, hThe traditional pyramid of evidence-based medicine is evolving , Fig. 1.A resounding message from the congress was that exercise at every stage of life is vital and we should promote it much more. It should be viewed as a medicine—consider recommending a dose, a time and a frequency. Regular physical activity can reduce the risk of hip fracture by up to 68%, type 2 diabetes up to 40%, cardiovascular disease by up to 35%, dementia, depression, colon cancer and all-cause mortality each by up to 30% [A submitted symposium highlighted the increasing evidence of an interplay between gut microbiota and physical function , cognitiStefania Maggi told us in a Keynote session that vaccination annually saves > 2.5 million deaths related to communicable diseases. At the same time reduction in all cardiovascular events was associated with vaccination . This shThe results from the European MID-Frail study were presented, a 12-month multimodal intervention in older people with type 2 diabetes. This demonstrated improvements in frailty and quality of life, and in a cost-effective manner . This isManaging blood pressure in older people is still a challenge and with ongoing debate and current research looking at optimal target blood pressure measurements for our older and more frail population. Recalling the past can sometimes be illuminating, however: attendees were astonished at the high systolic blood pressures people lived with only a few decades ago .The updated European guidance for the Diagnosis and Management of Osteoporosis in Postmenopausal Women were presented . SurprisA dedicated session on ageing with HIV highlighted the fact that geriatricians most probably will encounter HIV survivors due to the advances made in HIV treatment over the last decades.Cancer frequency increase with age. At present most cancer treatment approaches remain tumour-centric, although frailty has been shown to predict complication rates. At present, the majority of oncology multidisciplinary team meetings (MDTs) do not consider frailty or “patient-related” factors. Early EBM in this field demonstrated incorporation of comprehensive geriatric assessment (CGA) into oncology MDTs led to adjusted management in > 70% of cases, reduced complications and reduced 90-day mortality .A recent systematic review which looked at the effectiveness of interventions to prevent pre-frailty and frailty progression in older adults also summarised current evidence and research gaps . As withAmaia Calderon-Larrañaga and colleagues have shown distinctly different patterns of multimorbidity in difference people, with significantly different sociodemographic, lifestyle, clinical, and functional profiles . This coA consensus report from the global clinical nutrition community presented the new Global Leadership Initiative on Malnutrition (GLIM) criteria for the diagnosis of malnutrition, involving a two-step approach: first screening to identify “at risk” status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition .A recent Cochrane review on interventions to improve the appropriate use of polypharmacy for older people was inconclusive, largely due to the very limited number of studies without significant bias . This reGeriatrics represents unique challenges for evidence-based medicine practice. Finbarr Martin pulled all these observations and reflections together in the Presidential Keynote Lecture: ‘twenty-first-century geriatric medicine for twenty-first-century populations’.Multimorbidity, frailty, resilience, disability are all complex concepts which take geriatric medicine beyond simple medicine. The person-centred approach in geriatrics is fundamental to ensuring we focus on the meaningful outcomes, and not be distracted by the ‘easily measurable’ alone. Luckily, there are many exciting and high-quality research and clinical improvement projects going on throughout Europe!We would suggest that strong EuGMS leadership is needed to help facilitate consensus agreements on standard definitions, methods and relevant outcomes, in collaboration with patients and the public, other specialist societies , to maximise the opportunities and benefits of doing meaningful research with the aim of working with and benefiting our patients and society at large. New technologies for example may help in empowering the older population further.Since drafting this summary a consensus statement calling for alignment of common data measurements and outcomes has been published by numerous leading researchers in geriatrics, frailty and ageing .In the meantime, the COVID-19 pandemic has affected the whole world and especially our patients. Moreover, major issues such as climate change are going to drastically affect the future, and should proactively be taken into consideration at all points. New frontiers in geriatrics have emerged and the need for strong leadership, collaboration and use of new technologies have become indispensable.


Calls for evidence-informed public health policy-making often ignore that there are multiple, and often competing, bodies of potentially relevant evidence to which policy-makers have recourse in identifying policy priorities and taking decisions. In this paper, we illustrate how policy frames may favour the use of specific bodies of evidence. For the sixth Dutch Public Health Status and Foresight report (2014), possible future trends in population health and healthcare expenditure were used as a starting point for a deliberative dialogue with stakeholders to identify and formulate the most important societal challenges for the Dutch health system. Working with these stakeholders, we expanded these societal challenges into four normative perspectives on public health. These perspectives can be regarded as policy frames. In each of the perspectives, a specific body of evidence is favoured and other types of evidence are neglected. Crucial outcomes in one body may be regarded as irrelevant from other perspectives. Consequently, the results of research from a single body of evidence may not be helpful in the policy-making processes because policy-makers need to account for trade-offs between all competing interests and values. To support these policy processes, researchers need to combine qualitative and quantitative methodologies to address different outcomes from the start of their studies. We feel it is time for the research community to re-politicise the idea of evidence use and for policy-makers to demand research that helps them to account for all health-related policy goals. This is a prerequisite for real evidence-informed policy-making. Policy-making processes in public health and healthcare involve accounting for trade-offs between competing interests and values –4. All dwhich neglect that there are multiple, and often competing, bodies of potentially relevant evidence to which policy-makers have recourse in identifying policy priorities and taking decisions”. Interest groups often present their arguments in terms of evidence-based policy, highlighting the bodies of evidence that support the course of action they advocate. What are presented as arguments about evidence are often actually contests between political priorities [According to Hawkins and Parkhurst , the funiorities .the public health community’s tendency to depoliticize the idea of evidence use, evaluating policy making processes simply by whether, how much, or how quickly pieces of evidence are taken up by policy makers” [Thus far, this distinction was often missed in the literature on evidence-informed public health policy-making , 10. In  makers” . In thei makers” . As a reBoth overtly and covertly, frames highlight certain aspects of a problematic situation, while obscuring others in order to define problems, diagnose causes, make moral judgements and suggest remedies” [selection environment for scientific arguments that underpin political positions and decisions”. Every interest group will look for the specific body of evidence that substantiates its own political standpoint [The policy science literature on ‘frames’ and ‘framing’ may be useful to shed light on this issue –14. Framemedies” . Framingemedies” . Researcemedies” , 19. Accandpoint . In otheandpoint .In this paper, we will illustrate how policy frames in public health may favour the use of specific bodies of evidence. This is based on the study of the sixth Dutch Public Health Status and Foresight (PHSF 2014) report , in whicIn this paper, we will add an epistemological and methodological dimension to this discussion about policy-making in public health . In eachThe trend scenario of the PHSF 2014 was based on analysis of historical trends and on a combination of demographic and epidemiological projections . Ageing was found to be a key factor in the trend scenario of the PHSF 2014 . By 2030These major trends in public health and healthcare in The Netherlands served as a starting point for a deliberative dialogue in three meetings with more than 100 stakeholders from a broad range of sectors  . Four soWorking with stakeholders, we framed these societal challenges into four perspectives on public health. These are entitled In the Best of Health (IBH), Everyone Participates (EP), Taking Personal Control (TPC) and Healthy Prosperity (HP) Table . A surveAs can be seen in Table Furthermore, the interpretations given to the notion of ‘quality of care’ are different in each perspective , 27. UndThese four normative perspectives have epistemological and methodological dimensions as well – in each of the perspectives, a specific body of evidence is favoured. As can be seen in Table In each perspective, different outcomes are regarded relevant. According to the IBH perspective, mean overall population measures of life expectancy, disease prevalence, recovery rates and lifestyles are crucial outcomes. Under EP, the emphasis is on differences between population groups in disabilities, employment, education and societal inclusion. In TPC, individual self-reported quality of health is the main outcome and, in HP, overall budget impact and economic growth is what matters most as an outcome.Interestingly, the outcomes relevant to three of the perspectives have been captured in the well-known Triple Aim framework for quality improvement in healthcare . In a reCrucial outcomes and preferred methodologies in one perspective may be blind spots in the evidence base for other perspectives. In the hierarchy of evidence under IBH, qualitative research is ranked very low, while in TPC this is the preferred methodology and RCTs are under suspicion and disregarded. Moreover, in the welfare theory underlying the social cost-benefit analyses in HP, socio-economic differences are non-essential . In thesObviously, some bodies of evidence may be combined with greater ease in mixed-methods research while, for other combinations, researchers need to make additional efforts. IBH had been the leading perspective for the development of clinical treatment guidelines, with an emphasis on RCTs , 17. To the relative importance given to outcomes should reflect the perspective of those who are affected. When the target audiences for a guideline are clinicians and the patients they treat, the perspective would generally be that of the patient” [The emphasis on experimental trials in the hierarchy of evidence under IBH did forestall the use of qualitative research in guidelines , 17. Howpatient” . In othepatient” .has assumed that more evidence use is inherently better evidence use. Such a belief appears to rest on an assumption that evidence works to serve a problem-solving role where all outcomes have been agreed. But such situations are the exception, rather than the rule, in policy making. As such, many evidence utilisation concepts and strategies arising from this position have typically been under-specific – failing to ask which evidence for what goals in particular” [According to Parkhurst, most past work on the use of evidence in policy-making “ticular” .The PHSF 2014 perspectives illustrate how political diversity coincides with epistemological and methodological diversity , 33. FirWe see the relation between research and policy as a two-way negotiation in which both partners learn from each other . ResearcIn health policy-making, there is clearly a need for evidence from more than one body of evidence, to inform the policy-makers, on several relevant policy goals and priorities , 36. In We feel it is time for the health research community to re-politicise the idea of evidence use in policy-making , 5, 7. OIn the PHSF 2014 report, we highlighted a number of different opportunities for policy-makers to establish links between the perspectives and their respective challenges . In this


We published rapid advice guidelines and updated guidelines for coronavirus disease 2019 (COVID-19) management on February 6, 2020, and September 4, 2020, respectively. These two guidelines vary widely in their developmental background, type of evidence, grade of recommendation and so on. We shared our experience for the development of these two guidelines to help clinical practitioners better understand and implement guidelines and to help guideline developers facilitate communication and discussion for guideline development during the pandemic. Dear Editor,https://mmrjournal.biomedcentral.com/articles/10.1186/s40779-020-0233-6#citeas) [https://mmrjournal.biomedcentral.com/articles/10.1186/s40779-020-00270-8) [Early in 2020, during the novel coronavirus infection outbreak, we published a rapid advice guideline for the diagnosis and treatment of coronavirus disease 2019 , Middle East respiratory syndrome (MERS), and influenza. Although research has reported that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, is similar to SARS-CoV (approximately 80% similar), the evidence for the possible benefits of treatment in patients with SARS or MERS disease was considered indirect because the patient populations, viruses, and possibly even drug effects were different. Therefore, the rating of the quality of evidence for all important efficacy outcomes was downgraded by two levels based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach . IndirecThe COVID-19 pandemic is a rapidly changing situation. An increasing number of research papers are being published both in China and internationally, providing research evidence for managing COVID-19, which enabled direct evidence from COVID-19 patients to be used in the development of Guideline 2. Guideline 2 finally included 75 original papers  and 33 systematic reviews or meta-analyses.During the Guideline 1 development process, 11,500 symptomatic persons were screened, 276 were identified as suspected victims of infection, and 170 were diagnosed  as having COVID-19 by the guideline working group’s clinical professionals. Frontline clinicians have accumulated valuable experience in the diagnosis, treatment and nursing of COVID-19 patients. There was no direct research evidence to inform recommendations at that time, and these experiences were assessed as “expert evidence” for our guideline development. Expert evidence was highly valued in Guideline 1 development. We used a structured form to collect this information so that it could be aggregated and presented to the guideline panel in the summary of findings. Expert evidence can be solicited by examining case reports, summaries, and reports of topics. During the consensus process, if the evidence was agreed upon by more than 70% of frontline clinicians, it was considered high-quality evidence. However, “expert evidence” was used slightly differently in the development of Guideline 2. Expert evidence would not change the direction and strength of recommendations based on direct evidence, but it could influence questions that have very limited evidence and may form an “ungraded consensus-based statement” when more than 70% of working group members in the guideline panel believed this conclusion to be valid.In the development of Guidelines 1 and 2, we adhered to the GRADE approaches and rules to assess the quality of a body of evidence , to deveAll guidelines need to be kept up to date and consistent with the best available evidence . This isGuidelines of all types should always be evidence-based. It is a common misunderstanding that evidence-based guidelines can be developed only if well- designed controlled trials exist. Recommendations are derived from a systematic review of evidence, which is the current best evidence, and guidelines in a pandemic are no exception. The guidelines should be updated with continuously emerging evidence.


Dirofilaria immitis and Brugia pahangi are vector-borne parasites found in dogs and cats, including Thailand. In order to evaluate the effects of season and environmental parameters on the prevalence of these parasites, this retrospective study was conducted in 2019. A total of 79,506 canine blood samples were examined. B. pahangi was found in 0.55% of samples  while D. immitis was detected in 0.43% . One-way ANOVA found no effect of seasonal conditions on prevalence. For B. pahangi, the parameters rainfall, relative humidity and sunshine hours showed associations with p ≤ 0.20 and were included in multiple logistic regressions resulting in adjusted odds ratios of 0.53, 1.31 and 0.55, respectively. For D. immitis, only average temperature showed p ≤ 0.20, resulting in an odds ratio of 0.42. In conclusion, Thailand has environmental parameters that do not change very much during the year, so they might not affect the prevalence of two filarial nematodes. However, the threat of B. pahangi and D. immitis should not be ignored, especially in subtropical regions where their vectors are abundant. Both owners and veterinarians should be concerned about filarial prevention and control of D. immitis and B. pahangi. Dirofilaria immitis and Brugia pahangi are vector-borne parasites in dogs and cats that have zoonotic potential and are common in tropical, subtropical and some temperate regions of the world, including Thailand1. D. immitis is well known as a causative agent of heartworm disease in dogs and cats3. Microfilariae of the dog heartworm D. immitis present a subperiodicity without clear nocturnal or diurnal peaks, where a wave pattern is apparent but microfilaria do not completely disappear from the peripheral blood. However, the physiological periodicity is unknown4. It is also known as an occasional cause of pulmonary dirofilariasis in humans5. Lymphatic filariasis, a neglected tropical disease that is caused by filarial nematodes in the genus Brugia, affects approximately 80 countries around the world, particularly in dogs, cats and humans6.Mansonia, Armigeres and Aedes are potential vectors of dirofilariasis and lymphatic filariasis7. The tropical atmosphere is the most suitable for these mosquito vectors to survive. Increasing global temperatures and humidity are advantageous to the spread of mosquitoes and are also enhancing the effectiveness of pathogen transmission through mosquito-borne diseases such as dengue, malaria and lymphatic filariasis8. For instance, there is some evidence indicating that the prevalence of mosquito-borne disease in South America and South-East Asia relates to the El-Niño phenomenon. The relationship between El-Niño and the increasing risk of these diseases can be attributed to the rise in global temperature11.Mosquitoes in the genera D. immitis reside in the pulmonary artery and can induce endothelial damage. Some cases may develop into canine eosinophilic pulmonary granulomatosis caused by the infiltration of eosinophils12. The severity of heartworm disease depends on the number of adult worms, the duration of infection and the host immune response. Adult heartworms can release vasoactive substances that result in vasoconstriction and hypoxia, which lead to pulmonary hypertension, and antigens may pass through to the lung causing eosinophilic pneumonitis13. Chronic infection leads to retrograde migration of adults to the right atrium and vena cava causing deflection of the tricuspid valve, resulting in clinical signs of right-sided heart failure14. B. pahangi infection can manifest in four ways: (1) no clinical signs with no microfilaremia; (2) no clinical signs with microfilaremia; (3) acute short duration lymph node enlargement and/or limb oedema with microfilaremia; and (4) chronic limb oedema without microfilaremia15. Experimentally infected dogs showed abscesses in the adipose connective tissue around the popliteal node and nerve-cell tumours near the sciatic nerve. In one dog, lymphatic ducts were dilated distal to the popliteal node16. Dogs demonstrated a range of clinical signs, including episodic lymphadenopathy, lymphangitis, and limb oedema similar to the clinical signs reported in humans17.Adults of 20, and no studies have been designed to monitor the environmental factors affecting the distribution of these diseases. This study evaluated the association between seasonal and environmental factors related to the prevalence of D. immitis and B. pahangi infections in domestic dogs in Bangkok, Thailand and its vicinity.Only a few studies performed in South-East Asian countries have reported the incidence and the population of animals affected by dirofilariasis and lymphatic filariasisBrugia pahangi was found in 0.55%  and D. immitis was detected in 0.43%  of 79,506 samples tested during January to December 2019. The monthly detection rate of B. pahangi and D. immitis is shown in Table B. pahangi infection was higher than that of D. immitis in all months.B. pahangi (p = 0.23) or D. immitis (p = 0.09).The prevalence by season is shown in Fig. B. pahangi and D. immitis are shown in Fig. The environmental parameters related to season, including rainfall, relative humidity, average temperature and sunshine duration, were selected based on vector and parasite biology. These parameters along with infection rates of Environmental factors, including rainfall, relative humidity, average temperature and sunshine duration, were analysed to reveal associations between infection rates and each factor using Pearson’s correlation. The results revealed no significant relation for any parameter, as shown in Table B. pahangi 0.55% and D. immitis 0.43%. Categorical analyses including crude odds ratio and 95% CI are shown in Tables Since continuous data analysis using Pearson’s correlation could not describe the association, categorical data analysis was performed by transforming the data using the average of each parameter as the cutoff: 20.38 mm rainfall, 29.78 °C average temperature, 5.52 h sunshine duration and 71.35% relative humidity, and the prevalence of D. immitis infection (p ≤ 0.20). However, three parameters were included in the logistic regression in order to estimate associations between environmental parameters and B. pahangi infection. The multicollinearity between relative humidity and rainfall was checked using the Chi-square test and the results revealed no multicollinearity between these parameters. Unfortunately, no parameter was significant using logistic regression. The adjusted odds ratio (OR) for each parameter associated with B. pahangi infection was as follows: rainfall 0.53, sunshine duration 1.31 and relative humidity 0.55.The results revealed that only average temperature showed an association with B. pahangi and D. immitis circulating in owned dogs in Bangkok and its vicinity in 2019. A large number of the samples were collected from diseased dogs, which may have influenced the prevalence recorded herein. On the other hand, no antigen detection studies were carried out to detect amicrofilaemic animals, and only those that had detectable microfilariae in blood were counted. A limitation of this study was that samples were obtained from a clinical laboratory, and thus we do not have any details about the infected dogs. In this study, the monthly prevalence of the two filarial nematodes shown in Table B. pahangi was more common than D. immitis. According to veterinarians, owners protect their pets from heartworm disease by using commercial products comprising extra-label ivermectin and its derivatives to control ticks, and these measures have been reducing the prevalence of D. immitis. In 2003, Nithiuthai reported that 10.2% of samples contained microfilaria of D. immitis  in Bangkok during 1999–200121. Unfortunately, given the lack of a prevention programme for B. pahangi, there is no medication to prevent B. pahangi infection; one of the important outcomes of this study was that the prevalence of canine lymphatic filariasis is higher than canine heartworm disease.The current study presents the prevalence of D. immitis was more prevalent than B. pahangi in weeks 17, 34 and 41. Thailand is in South-East Asia, which has a tropical savanna climate under the influence of the South Asian monsoon system. Some environmental parameters vary little throughout the year, including average temperature and humidity, thus making it difficult to associate these parameters with filarial nematode infection. There were no significant correlations between infection rate and these environmental parameters. However, sunshine duration seemed to show some correlation with B. pahangi infection rates (p = 0.19), as did relative humidity with that of D. immitis (p = 0.19). It was assumed that the longer daylight during summer affects some endocrine mechanisms in the dog, which may stimulate the female filarial worms to produce greater numbers of microfilariae4. Univariate analysis of B. pahangi prevalence revealed that three parameters showed p-values of ≤ 0.20: rainfall, relative humidity and sunshine duration, and so these were included in the multivariable logistic regression. Unfortunately, no parameter was significant in this regression; however, sunshine duration showed a positive adjusted OR of 1.31, which related to correlation. Vectors of most importance for filarial nematodes include Aedes spp. Culex spp. and Anopheles spp. and these are considered as potential vectors for D. immitis23, whereas Armigeres spp. and Manosonia spp. are considered as vectors for B. pahangi24. The OR-values of rainfall associated with B. pahangi and D. immitis prevalence were interesting: that for B. pahangi was 0.41, indicating that the rains are a protective factor, by washing floating water plants out of swamp ponds and leading to a lack of suitable places for the life cycle of Mansonia spp.25, one of its potential vectors. On the other hand, the OR-value for D. immitis was 1.26, indicating that rain is a risk factor, due to clean water being suitable for Aedes spp.23, one of its potential vectors.Our analysis showed that prevalence was not influenced by the season. Interestingly, Brugia pahangi and D. immitis are not the only two filarial nematodes reported in Thailand; other filaria include Brugia malayi26 and Dirofilaria repens27. In this study, D. repens was found in one sample in December. Microfilaria of D. repens can be differentiated morphologically as they have two nuclei in the cephalic space. Molecular diagnosis is an alternative method for identification of D. immitis and D. repens.B. pahangi and D. immitis. The prevalence of these two filarial nematodes should not be ignored, and owners and veterinarians should be educated in the prevention and control of filarial nematodes in order to decrease the prevalence of these neglected canine vector-borne diseases.In conclusion, environmental parameters in Thailand do not change much during the year, so they might not affect the prevalence of This retrospective study was conducted between January and December 2019. The results of blood examination were provided by the Vet Central Lab, which collected samples from private veterinary clinics and animal hospitals around Bangkok and its vicinity. All environmental parameters, including rainfall, relative humidity, average temperature and sunshine duration were obtained from the information service of the Thai Meteorological Department, Ministry of Digital Economy and Society. The data were the average from four stations in Bangkok: the Queen Sirikit National Convention Center, Bangkok Port, Thai Meteorological Department Bang Na and Don Mueang International Airport.D. immitis28 and B. pahangi28, respectively.A total of 79,506 EDTA-anticoagulated blood samples were collected from owned dogs and submitted to the Vet Central Lab. Buffy-coat thin blood smears were performed and stained with Wright-Giemsa stain. The positive microfilariae were examined by light microscopy. Unsheathed and sheathed microfilaria were tested for acid phosphatase activity to identify species as The prevalence of filarial worms was demonstrated using descriptive statistics with a 95% confidence interval (95% CI). The association between filarial worm infection and environmental parameters was analysed as continuous data using Pearson’s correlation. Since one week was considered as a replicate, each parameter was represented as the average per week, except rainfall, which combined all data to represent one week. If these results were not acceptable, the infection rate and other continuous data were transformed using the average of each parameter or infection rate as the cutoff and analysed using the crude odds ratio at 95% CI. The parameters showing p ≤ 0.20 were checked for multicollinearity and included in multiple logistic regression. Statistical analysis used R software version 3.5.3.


Affective Presence refers to the consistent and stable feelings that an individual tends to leave in their interaction partners. Expanding previous research on the application of affective presence to individuals in the role of leaders in teams, in this study, I examine whether leaders’ feedback behavior is related to the emergence of their affective presence. Using a multisource survey design with a sample of employees from a technology organization, as expected, results indicated that leader feedback behavior directed to the characteristics that team members should ideally have to perform well (ought self feedback) is positively related to leaders’ positive affective presence. In contrast, feedback directed to compare team members’ performance with other team members’ performance (normative cues feedback) is positively associated with leaders’ negative affective presence. As such, the study contributes to having an understanding of the etiology of affective presence in the context of teams, also informing organizational practitioners about how to manage leader influences on team members. Formally, affective presence refers to the consistent and stable feelings that a person tends to provoke with their interaction partners, which is a complementary psychological process to emotional contagion , and their average organizational tenure was 4.06 years (SD = 1.14). Team members were 71% male; their average age was 30.62 years (SD = 8.17) and their average organizational tenure 3.9 years (SD = 4.29). Teams performed executive, management, production, and service functions , and average intra-team response rate was 59%.To test the above hypotheses, I conducted a multisource survey study with employees from a technology organization. In this, leaders of different working teams answered a survey asking them about the feedback strategies they delivered with members of their teams, while an independent survey was conducted with team members to measure the affective presence of their leaders, together with leader-member interaction frequency and team members’ extraversion and neuroticism to be used as control variables. Twenty-six leaders and 143 team members participated in the study. The gender split among leaders was 73% males, their average age was 38.23 years  and directed to normative cues . According to theory on feedback, performance information delivered can also involve how well the tasks are performed in general, independent from how well employees are conducting their work behavior (r = 0.60). Leader affective presence was measured with the scale developed by Feedback behavior was measured with six items developed for the study. Leaders were asked about a series of statements about their feedback behavior directed to the team members’ ought self as a whole  = 251.08(151), p < 0.05; RMSEA = 0.07, CFI = 0.92]. Furthermore, inter-rater reliability and agreement analyses supported that team members’ ratings of leader affective presence were nested around their respective leaders and they showed strong inter-rater agreement . Descriptive, correlations and reliabilities results are presented in b = 0.37, SE = 0.15, p < 0.05), while feedback strategies directed to the normative cues were positively related to leader negative affective presence   and feedback behavior directed to the normative cues were negatively related to positive affective presence .Data were analyzed with  < 0.05) , Model 2This study supported that leaders’ feedback behavior participates in the construction of their affective presence in teams. As expected, feedback directed to the ought self was positively related to leader positive affective presence, while feedback directed to normative cues was positively related to leader negative affective presence. Although not hypothesized, asymmetrical effects were also observed, in that feedback directed to the ought self was negatively related to negative leader negative affective presence. In contrast, feedback directed to normative cues was negatively related to leader positive affective presence. I argue that such relationships are possible due to the informational meaning of leader behavior relative to their attitudes toward the relationship with team members . PositivThese results contribute to expanding theory and evidence underlying the phenomenon of leader affective presence because etiology factors that explain the emergence of this construct in the interpersonal realm are still underdeveloped. Also, the findings observed here inform practical interventions for leader development. Since leader affective presence is associated with feedback behavior, training on the delivery of information to benefit team members’ performance should be a valuable strategy to foster functional teamwork, due to the benefits of affective presence for collaboration and creative, innovative, and service performance .Limitations of the study involve the use of a cross-sectional survey design that might introduce issues on common method bias . AlthougFinally, future research should examine possible mediators between leaders’ behavior and their affective presence, other than inferences about leaders’ attitudes toward the social relationship. For example, as part of interpersonal processes, attributions of warmth and competence toward leaders might be a vehicle for the relationship between leaders’ behavior and the way they make their team members feel . For exaTo sum up, this is an initial effort to uncover the etiology of affective presence in the context of teamwork. I trust that evidence built here will contribute to the literature and practice about leader affective influences in organizations.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the Ethics committee Pontificia Universidad Católica de Chile. The patients/participants provided their written informed consent to participate in this study.HM: research problem, literature review, hypotheses elaboration, study design, data collection, data analysis and manuscript writing.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.


Chronic kidney disease (CKD) is cumulative worldwide and an increasing public health issue. Aside from the widely known protein restriction and medical therapy, less evident is the renal protection of nutrition supplements in CKD patients. This systematic review (SR), using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, aims to summarize and quantify evidence about the prevention effects of vitamin D and analogues, omega-3 polyunsaturated fatty acid (omega-3 PUFA), dietary fiber, coenzyme Q10 (CoQ10), and biotics on CKD progression. This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to examine SRs and/or meta-analysis of clinical controlled trials identified from PubMed, Embase, and the Cochrane Library. Finally, seventeen SRs were included in the qualitative analysis. The beneficial effects of these nutrition supplements in CKD patients mostly seem to be at low to very low evidence on proteinuria, kidney function, and inflammations and did not appear to improve CKD prognosis. The recommendation of nutrition supplements in CKD patients needs to discuss with physicians and consider the benefits over the adverse effects. Longer follow-up of larger randomized trials is necessary to clarify the benefits of nutrition supplements in CKD patients. Chronic kidney disease (CKD), a gradual loss of kidney function, is an increasing public health issue. Over the past decades, CKD incidence is cumulative worldwide ,2,3, parDietary management to stop CKD progress has some benefits in patients with heavy proteinuria from some large trials ,14, whicp < 0.001) [Aside from the widely known protein restriction and medical therapy, nutrition supplements have been reported to have a role in CKD prevention ,23,24,25< 0.001) . Additio< 0.001) . However< 0.001) ,27. ThusIn addition to vitamin D analogs, lower dietary acid loads  had been reported to prevent CKD progress in clinical studies ,20,24. OThe SRs and/or meta-analysis are the level I study designs to answer the intervention question in clinical practice. Nevertheless, the previous SRs on the relationship between nutrition supplements and CKD were inconsistent and the evidence certainty was lacking. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach offers a transparent and structured process for developing and presenting summaries of evidence, including its effect size and certainty, and recommendations in health care. The objective of this systematic review was to determine the effects of current and relevant SRs of nutrition supplements on renal protection in CKD patients through using the GRADE approach.This systematic reviews (SRs) was conducted and reported following the Preferred Reporting Items for SRs and Meta-Analyses (PRISMA) statement  to examiWe searched PubMed, Embase, and Cochrane CENTRAL databases for relevant SRs from the inception through October 2020. The strategy and keywords used for the systematic search were  AND . We applied a high-sensitivity and high-specificity customized filter , a sensiInclusion criteria included: (i) study design: SRs and/or meta-analysis of clinically controlled trials  designed to evaluate the influence of nutrition supplementation on renal protection in CKD patients compared to placebo, regardless of language or publish date, (ii) population: any stages of CKD patients should not need dialysis or renal transplantation at baseline, (iii) intervention: nutrition or health supplements, (iv) comparison: placebo or other treatment, (v) renal protection outcomes: a study reported at least one clinical important issue or surrogate outcome data or outcome data can be extracted from subgroup analysis was available. The critical clinical outcomes included kidney function change from baseline and the risk of progression to end-stage renal disease (ESRD); the surrogate outcomes included inflammatory factors, for instances, hs-CRP, CRP, indoxyl sulphate (IS), or p-cresyl sulphate (PCS), and oxidative stress marker, malondialdehyde (MDA). Exclusion criteria: (i) nutrition supplement that has obtained FDA approval of drug license for CKD patients, (ii) Chinese herbal medicine, (iii) studies were presented as conference abstracts, case reports, letters to editors, or in vitro studies.A piloted form of data collection was created in excel, and two authors  extracted data from the included SRs independently. Collected variables included the first author, publish year, search databases, search duration, included study design and numbers, critical appraisal tool, population, intervention (dose and frequency if available), control group, outcomes related to kidney function, and nutrition supplement duration. Data were collected from publishing papers or online supplements, from study groups or subgroups. If the author provided the original data of included controlled trials and only used the text to describe the significance of effect size rather than presented the statistical data, we further calculated the effect size by author-reported statistical methods. Similarly, if the author only describes overall appraisal results rather than the present individual outcomes-related risk of bias, we further appraise the quality of the subgroup based on the data provided in the SR. Any discrepancies on data extraction or quality assessment were discussed and reached an agreement by consulting with the third author (Chen).2I more than 50% was set as substantial heterogeneity) [We rate the certainty of included SRs using the GRADE approach as adopted for the “summary of findings” table. GRADE specified the quality of evidence to four categories—high, moderate, low, and very low. If the context of an SR comes from randomized-controlled trials, the evidence category begins as high-quality. There are five reasons to possibly rate down 1–2 grade of evidence, including the risk of bias (most information comes from studies at moderate or high risk of bias), imprecision , inconsistency  , indirecgeneity) ,35,36,37Since the included SRs, aim to evaluate the renal protection effect on the same nutrition supplement, may consist of duplicated RCTs and thus become independent, we abandoned to summarize the data by a statistical method and present the result as an SR. If standardized mean difference (SMD) was used in an SR to show the pooled outcome measure; we considered a SMD of 0.2, 0.5, and 0.8 a small, moderate, and large effect, respectively . We usedWe identified 666 articles from the electronic databases searching, excluding duplicates, irrelevant, and not fulfilled the inclusion criteria and left 13 SRs. Furthermore, we retrieved 4 SRs by hand searching from the reference lists of relevant studies, eventually included 17 SRs in this SR. Among the included SRs, 7, 2, 2, 1 and 5 studies aim to evaluate the renal protective effects of vitamin D and analogs ,40,41,42Only four clinical important outcomes , reduced proteinuria, the occurrence of ESRD, serum urea) and one surrogate outcome (CRP) reported in the five individual SRs ,43,47,48Five SRs focused on diabetic nephropathy reported 13 clinical relevant outcome data. In very low to low certainty evidence of vitamin D and analogues (established vitamin D compounds) appeared to reduce urinary albumin excretion rate (UAER) . The vitamin D and analogue effect on urine albumin creatinine ratio (UACR) varied in the included SRs. Very low to moderate certainty evidence showed no significant impact on SRs only enrolled supplement with established vitamin D compounds. SRs included RCTs with receiving newer vitamin D analogue  rather than established compounds alone suggested a significant decrease in UACR . However, the effect seems small, and the evidence was very low. In very low to low certainty of evidence suggested vitamin D and analogues reduce proteinuria 0.23–0.26 gm per 24 h . The effect on serum creatinine varied and the certainty of the evidence was very low. Only one SR reported vitamin D and analogues does not affect urine protein creatinine ratio (UPCR) and eGFR, respectively .Two SRs focused on diabetic nephropathy reported four surrogate outcome data. Very low certainty of evidence suggested Vitamin D and analogues decreased the inflammatory markers of hs-CRP, IL-6, and TNF-α , as shown in One SR of vitamin D analogues, as compared with placebo, was investigated on renal protection in CKD patients. Moderate certainty evidence showed significantly reduced proteinuria  .One SR reported two clinical relevant outcome data. Very low certainty evidence suggested that dietary fiber has no effect on Scr or serum urea . One SR Very low certainty of evidence suggested CoQ10 decreased MDA significantly  , but no Low to moderate certainty evidence suggested biotics decreased MDA, CRP and PCS significantly , but no effect on IL-6 .This section may be divided by subheadings. It should provide a concise and precise description of the experimental results, their interpretation, as well as the experimental conclusions that can be drawn.SRs through the GRADE approach recommended by the Cochrane Collaboration provides rating and strengthening the quality of evidence and has been increasingly adopted by researchers worldwide. The GRADE approach divides the quality of SRs into four evidence levels. For example, the high evidence is reliable without side effects; the moderate or low evidence is needed to consult physicians; and, the very low evidence is not recommended. In this SR and meta-analysis, we adopted the GRADE approach to evaluate the beneficial effects of nutrition supplements on CKD prevention. Our findings provided that evidence of the beneficial effects of those nutrition supplements in CKD patients mostly seems to be low to very low evidence on proteinuria, kidney function, and inflammations. Thus, it is recommended in CKD patients to consult physicians for the prescription of nutrition supplements.Vitamin D, including vitamin D2 and vitamin D3, is available for over-the-counter purchase and responsible for increasing intestinal absorption of calcium and phosphate and multiple biological effects . VitaminOmega-3 PUFA, a class of particular fatty acids with many biological functions, has been reported to or used together with diet and exercise to help lower triglyceride levels in the blood . ReviewsHigher dietary fiber and lower dietary acid loads  have been reported to reduce the risk of CKD progression ,20,24. ACoQ10, first identified in 1940, is mostly found in meat, fish, and whole grains . CoQ10 gMicrobiota dysbiosis is closely associated with many diseases related to chronic inflammations, including obesity, diabetes, cardiovascular diseases, non-alcoholic fatty liver disease, and obesity-induced CKD ,75,76. SIn summary, this study was the first and composed of seven SRs of vitamin D and analogues, two SRs of omega-3 PUFA, two SRs of dietary fiber, one SR of CoQ10, and five SRs of biotics for effect on proteinuria, kidney function, and inflammation in CKD patients. According to the GRADE approach assessment, the strength of evidence was low to very low levels for the benefits of these nutrition supplements on proteinuria and kidney function and did not appear to improve CKD prognosis. The recommendation of these nutrition supplements in CKD patients needs to discuss with physicians and consider the benefits over the adverse effects. Multicenter and large samples of RCTs with more than ten years of follow-up merit to be conducted in the future and to verify the benefits of nutrition supplements in CKD patients.


OpenStreetMap (OSM) mapathons can offer a learner-centered means for critical data literacy and visual literacy instruction. Mapathons are coordinated humanitarian mapping events in which participants use geographic information system (GIS) data and satellite imagery to create open-source maps for humanitarian support. Visual mapping is an effective learning activity because it encourages students to use big data to create a deliverable—an open-source map—that allows instructors to engage learners in data literacy and visual literacy at the highest cognitive level. OpenStreetMap (OSM) mapathons can offer a learner-centered means for critical data literacy and visual literacy instruction. Mapathons have been used as coordinated humanitarian mapping events, in which participants use geographic information system (GIS) data and satellite imagery to create open-source maps for humanitarian support. They have been used to improve coverage of under-mapped communities and support disaster relief efforts, economic assessments, and energy management analyses.HOT site to practice mapping and to learn to host mapathons. The Missing Maps site allows mapathon hosts to advertise public events and allows mappers to view information about upcoming mapathons. Examples of how libraries have hosted mapathons to support disaster relief efforts have been highlighted in the news, showcasing the work of librarians at MIT and at Columbia University.The Humanitarian OSM Team (HOT) provides free resources and training to prospective mapathon hosts. Instructors seeking hands-on mapping experience can visit the Association of College & Research Libraries (ACRL) Visual Literacy Competency Standards for Higher Education can help guide the design of cocurricular and extracurricular instruction that teaches students to critically view, use, and produce maps, and help develop appropriate learning objectives, activities, and assessments. Learning objectives for mapathons can center on one or more of the competencies established for a visually literate individual in higher education, especially understanding the “ethical, legal, social, and economic issues surrounding the creation and use of images and visual media” [Visual Literacy for Libraries: A Practical, Standards-Based Guide, a resource that includes worksheets and activities that support discussions on the ethical and social aspects of map creation and trustworthiness, further supports visual literacy instruction [The l media” . Visual truction .At Purdue, these ACRL standards and resources were used to develop data literacy instruction, and students were encouraged to consider using information from these sources to assess the quality of their map data. From one to three extracurricular mapathons have been successfully hosted each semester since fall 2017, mostly for undergraduate students in health sciences–centered and data sciences–centered learning communities. Learning communities have proved to be an effective teaching environment for the mapathons because most learning communities require student participation in extracurricular activities like mapathons, which offer synergistic opportunities for librarians and learning community stakeholders.blog for mappers. Alternatively, mapathons have been completed in fifty-minute sessions if students complete an hour of mapping prework, making them useful as cocurricular instruction methods in courses.Venues have included library spaces, computer labs, and active-learning classrooms, as well as lounge and study spaces in dorms. Mapathons can also be hosted completely online. Mapathon events have ranged in size from as few as six participants to as many as sixty participants. For example, the Purdue University Libraries 2017 GIS Day mapathon gained international participation after being highlighted on a popular Visual mapping is an effective learning activity because it encourages students to use big data to create a deliverable—an open-source map—that allows instructors to engage learners in data literacy and visual literacy at the highest cognitive level. Once students create an OSM account, they can map during mapathons or individually on their own time. Students learn to validate data sources, observe and question data gathering methods, and question data quality—practices that improve both critical data literacy and evidence-based decision making.Maps can also be used as evidence to formulate and support research inquiries. For example, what can a map tell you about community health needs? What challenges might a community face if the closest freshwater source is 100 miles away or if the community is disconnected from major road infrastructure?