Despite the clear and compelling association between social connections and well-being, the underlying mechanisms that help stave off adverse health impacts are not well understood, particularly among older adults in disadvantaged groups. Social relationships in older age may be instrumental for exchanging and gaining knowledge that further influence health and help increase awareness about misconceptions and lifestyle behaviors known to delay or reduce cognitive decline. This study used cross-sectional survey data from 147 low-income African American homebound community dwellers to investigate heterogeneity in dementia literacy profiles and its association with social connectedness. Eleven items  from a validated instrument were used to measure dementia literacy (DL). The Lubben’s social network scale was used for a social connectedness construct. We employed a 2-stage latent class modeling approach to examine heterogeneity in DL and estimate the regressions among the derived classes and the predictors . A 3-class model produced a reasonable fit and classification (entropy=0.852) of “dementia literacy patterns” labeled as (high-literacy:37%), moderate-literacy:45.2%), low-literacy:17.8%)). Social connectedness was highly predictive of class membership. A high level of social relationships increased the probability of being in the “high-dementia-literacy” class compared to the “low-dementia-literacy” class . For a unit increase in social connectedness, the odds of being in the “high-dementia-literacy” class compared to the “low-dementia-literacy” class increased by a factor of 2.2. Tailored and focused interventions to reduce social disconnectedness may also help increase dementia awareness and reduce barriers to early diagnosis.


Aging implies a higher prevalence of chronic pathologies and a corresponding increase in medication. The correct adherence and use of the medication are prerequisites for reducing risks of disease progression, comorbidity, and mortality. Medication literacy (ML) is the specific ability to safely access and understand the information available concerning medication, and to act accordingly. Currently, there are few specific instruments that ascertain the extent of ML in the general population. The aim of this work was to analyse ML in a large cohort of pharmacy customers.A total of 400 community pharmacy clients were analyzed to assess the level of ML  through the validated MedLitRxSE tool.n = 264; 66%) were adjudged not to have this ability. Statistically significant differences were found between the different age groups in terms of ML , the 51–65 and >65-year age groups having a lower frequency of adequate ML  than the rest of the age groups. A statistically significant increase in adequate ML was observed as the academic level of the clients increased . Multivariate logistic regression confirmed the influence of both variables on ML.The results showed that out of a total of 400 community pharmacy clients only 136 (34%) had an adequate degree of ML, while the rest of the clients (An inadequate ML level was found in community pharmacy clients over the age of 51, and also in those with primary or non-formal studies. Our data add to our knowledge about ML, and should pharmacists and other health professionals to adopt new strategies to prevent, or at least reduce, errors in taking medicines, thus avoiding the undesirable effects of any misuse.The online version contains supplementary material available at 10.1186/s12877-020-01881-5. Aging implies a higher prevalence of chronic pathologies and therefore an increase in medication , 2. HoweOlder patients are major users of both prescription and non-prescription medicines, and their proper use will lead to more cost-effective approaches and increase safety –7. MedicMedication literacy (ML) is the specific ability to safely access and understand the information available concerning medication, and act accordingly . AlthougA proper use of the medication includes how to administer it, when, for how long, what quantity . This inML includes skills such as interpretation and the ability to calculate doses, and cannot be measured properly by general evaluations of literacy. However, it is important to be able to assess numerical and/or documental knowledge before receiving written or verbal instructions from health professionals about preparing medication doses, the duration of treatment and any warnings . CommuniIn this study the ML of clients acquiring prescription and non-prescription medicines in community pharmacies was analyzed using MedlitRxSE questionnaire in order to the future purpose of designing new strategies that allow the pharmacist and health personnel to prevent and reduce the errors in taking medicines and thus avoid the undesirable effects of any misuse.The sample size initially calculated was to represent a population of 2500 people, since in Spain this is the average number of inhabitants per pharmacy office, with an accuracy of 5% (e = 0.05) and with a 95% confidence interval. The calculated sample size was 334 subjects, to which we added 20% to cover possible withdrawals. The final sample consisted of 400 community pharmacy clients.All 400 clients answered the validated MedLitRxSE tool  anonymouFour community pharmacies were randomly selected from 20 offices in an area in south-eastern Spain. They were located in rural and urban areas. Rural areas were defined as areas with a low population density (< 2500 habitants) and urban areas were those with a high population density (>2500 inhabitants) . Each phThe inclusion criteria considered were clients over 18 years of age, users of public or private health services who went to the community pharmacy and asked for a medicine prescribed by a doctor or an over-the-counter medicine for personal use or for someone else.All participants were informed of the study through the pharmaceutical staff attached to the community pharmacy, obtaining written informed consent in all cases. The study and protocols for recruitment were approved by the Human Research Ethics Committee of the University of Murcia  in accordance with the ‘Ethical Principles for Medical Research Involving Human Subjects’ adopted in the Helsinki Declaration by the World Medical Association .To use the MedLitRxSEs (Medication Literacy Assessment) tool, the authors were previously contacted, and they provided us with all the necessary information. A psychometric evaluation of this new assessment tool is described by authors who designed the instrument, and the Spanish version has been shown satisfactory in this respect 13). The MedLitRxSE is a tool that assesses the skills needed to manage medication properly. It consists of 14 items organized in four scenarios, of which 10 items relate to document literacy and 4 to numeracy, all with a dichotomous response . A possi. The MedIn order to understand the factors associated with ML, this qualitative variable  was converted into 2 dichotomies: inadequate and adequate ML, and a cut-off point was established to categorize ML. MedLiTRxSE does not establish a cut-off point to differentiate between adequate and inadequate medication literacy. As experts in the field we established that of the 14 possible points in MedLiTRxSE tool with 13 points we should consider an adequate ML. To achieve a higher range (adequate literacy) we assumed that of the 14 competencies evaluated by the tool, only one could fail: knowing the name of the doctor who had prescribed the drug or knowing the name of the active ingredients, both competencies from documentary medication literacy. In the case of numeracy medication literacy, we consider that when trying to know and use the doses of the drugs in an appropriate way, the requirement to consider it as adequate was greater, establishing the four questions as correct. Therefore, an adequate literacy score was established to be ≥13 points for total ML, ≥9 points for document ML, and 4 points for numeracy-ML.Univariate and multivariate analyses with logistic regression of all the variables pointed to a significant relation with the dependent variable in the bivariate analyses . Then, b2) test or Fisher’s Exact test, and non-parametric count data were compared using the Kruskal Wallis test or Mann Whitney U test. Inadequate and adequate ML were compared using bivariate analyses to determine whether there was any difference in the descriptive characteristics . Logistic regression univariate and multivariate analysis was used to examine factors associated with adequate medication literacy. A level of P < 0.05 was accepted as statistically significant. The odds ratios (OR) and their 95% confidence intervals (CI) were calculated in order to estimate relative risk. The I-square (I2) statistic with cut-off values of 73.1% and a p-value of < 0.001 was considered statistically significant.Sociodemographic data and the results of each survey were collected in a database , and statistical analysis was performed using the SPSS 15.0 software . Categorical data were compared using chi-square (X2 = 0.090). Individuals under 50 years represented 53.5% of the total while individuals over or equal to 51 years represented 46.5%.A total of 400 community pharmacy clients, including 136 males (34%) and 264 females (66%) were analyzed in this study (Table 2 = 0.003) differences: 42.5% had received only primary education or no official education, and 57.5% had secondary or university levels of education .Analysis of the different education levels pointed to statistically significant (XP = 0.180). However, an increase in the frequency of reading the leaflets did lead to a significantly higher score for mean total medication and documentary literacy, and numeracy.As regards the pharmacies where the clients’ replies were analyzed, 41% were rural community pharmacies, while 59% were in urban areas. Finally, as regards the reading of medicine leaflets, 24.8% said they never read the information provided, 28.2% sometimes and 47.0% always. There was no significant association between adequate and inadequate literacy and leaflet reading frequency .When sociodemographic characteristics and adequate- or inadequate ML were analyzed Table , Fig. 1,P = 0.019, OR = 0.592, 95% CI: 0.385–0.910). The analysis found statistically significant differences between the different age groups in terms of ML , the 51–65 and >65-year age groups having a lower frequency of adequate ML  than the rest of the age groups. A statistically significant increase in adequate ML was observed as the academic level of the clients increased .More men than women were adjudged to have and adequate level of ML . However, with regard to the number of medications, statistically significant differences are observed when comparing both study groups . A higher adequate literacy rate was observed for clients who did not take medicine (49%) than for those taking some form of medication, 1–4 medicines (31.8% and ≥ 5 medicines (7.1%) P < 0.001; OR = 0.345; 95% CI: 0.225–0.530). However, no significant statistical difference was found with respect to reading the information leaflets (P = 0.180).Similar results concerning adequate ML were found for the rural and urban pharmacies .Finally, analysis of the mean number of correct responses to the MedLitRxSE tool (14 questions) reflecting total medical literacy found an average of 10.30 ± 3.41 correct answers  in the total population analyzed (Table P < 0.001). A gradual decrease in the number of correct answers was also observed as the number of medicines consumed increased (P < 0.001). A secondary school level of education was related with the highest number of correct answers . No significant differences (P = 0.083) were associated with pharmacy location . Finally, a lower number of correct responses was observed in users that never read information leaflets compared with the clients who read always or sometimes the leaflet (P = 0.004).By contrast, a gradual decrease in the number of correct answers was observed when increasing age ) as regards the number of correct responses but this association was not confirmed when multivariable analysis was applied ; Table P < 0.001). On the other hand, a greater number of correct answers was observed in individuals with a minimum of secondary education  than in others groups. This association were confirmed when multivariable logistic regression analysis was applied ; Table P = 0.069). Documentary literacy was higher in clients who did not take medicines compared with those that did . Patients with chronic medication use was also considered a factor associated with ML , however this observation was not confirmed by multivariate analysis. However, best level of documentary literacy was recorded in pharmacy customers who always read the leaflets.Analysis of the 10 questions that reflect the extent of documentary literacy in MedLitRxSEs showed an average number of correct answers of 7.06 ± 2.51 (mean ± SD) in the total population analyzed  or the location of the community pharmacy (P = 0.154), but statistically significant differences were found as a function of age (P < 0.001), numerical literacy decreasing as the patient’s age increased and also in terms of education level (P < 0.001). The patient’s age was confirmed by multivariable logistic regression analysis  correctly answered questions by the total cohort  compared with individuals with a university education . These associations were confirmed through multivariable logistic regression analysis  patient therapy, it is not unusual for health care providers, including pharmacists, to rely heavily on written patient education materials such as the leaflets that usually accompany medicines .However, there are differences between what patients really understand and what health care providers, including pharmacists, expect or believe them to know. Patients with low reading ability have been found to be substantially less likely to understand and remember drug advice, and more likely to have trouble knowing exactly what most health professionals recommend , 19, 20.The incorrect use of medication is a major problem, not only because it diminishes the effectiveness of medicines, but also because of the high frequency of problems associated with their misuse . In thisOur result showed that only 34% of community pharmacy clients can be considered to have an adequate level of ML, which is similar to the findings of Sauceda et al.  in a popA predictive factor of adequate total, documental and numerical literacy was the educational level of participants. Moreover, in the case of numeracy, a younger age was also seen to be a predictive factor. The same factors associated with ML are also mentioned in the literature as predictors of health literacy , 30. In In view of our results, the advantages offered by using MedLitRxSE tool to analyze ML rather other health literacy questionnaires is that it allows the needs of clients, more specifically in the pharmaceutical environment, to be quickly and efficiently detected, thus improving pharmaceutical care and management of medications by the patient.The results pointed to a decrease in adequate medication literacy as the number of medications consumed by the patient increases. However, in a study carried out by Lyles et al.  no assocOur results show that the scenario with the most problems of interpretation on the part of clients was that related with identifying the part of the body to inject a medicine. To solve this problem, it would be interesting to add illustrations to help patients with low levels of literacy to improve their understanding of how medicines should be used. Indeed, a study showed that this type of illustration could reduce errors both in the dosage of the medicine and resolve doubts about the part of the body where medication should be applied, at the same time increasing the degree of satisfaction with the care received in the community pharmacy in patients with low ML showed , 36. HowIn terms of numeracy-ML, 57% answered the 4 questions correctly, unlike in the study carried out by Osborn et al. , in whicThe more frequently patients read information leaflets, the higher their score for total, numeracy and document-ML. In this sense, some authors have suggested that the habit of frequent reading is a powerful tool for improving health literacy .It should be noted that the MedlitRxSE questionnaire has not been used in a wide variety of situations. Although these cut-off points are due to expert criteria, a certain subjective charge cannot be denied as a limitation. To our knowledge, there are few instruments exclusively dedicated to measuring ML. Therefore, one of the problems with discussing the data is that it is difficult to compare our results with other studies specifically referring to ML, whether or not MedLitRxSE was used or other similar tools.In addition, the survey used in our research to measure ML does not measure the communication skills of patients, which forms part of health literacy and is essential for interaction with health professionals, with the health care system and for understanding the warnings related to medication and health .On the other hand, the original instrument was developed in the United States with a Spanish-speaking sample there. In our study, the instrument was used in a completely different context, being a limitation of our study. In the original developmental study, the instrument was validated showing that it was related to the Short Test of Functional Health Literacy in Adults (S-TOFHLA), a measure of health literacy with only a few questions that directly address medication management. Therefore, MedLitRxSE has been validated as a measure of general health literacy. It may have content validity due to the nature of the questions, however in our study we have taken into account that the measure of knowledge about drugs is only valid in the sense that it includes questions about medication management.In conclusion, the MedlitRxSE questionnaire can be considered a useful tool for measuring ML effectively and rapidly in the community pharmacy. It is a structured, easy-to-complete tool for participants and useful for evaluating the knowledge, abilities and skills necessary for managing personal medication. Their use in the present study found that community pharmacy clients over the age of 51 and those with lower levels of education have a significantly lower LD level than younger age groups and those with higher levels of education. Knowledge of patient ML would help improve communication and contribute to increasing user knowledge and understanding of their illnesses and the pharmacotherapy involved. Such knowledge would increase adherence to treatment, and the clinical outcome and safety of the same. This should encourage pharmacists as health professionals to adopt strategies and initiatives that will improve the skills and abilities necessary for managing medication, especially in the population groups mentioned, for example, by encouraging patients to read information leaflets.On the other hand, it should be noted that this analysis has allowed us to know the LA of the patients with different sociodemographic characteristics in the community pharmacies analyzed. Currently, pharmacists have access to the electronic prescription of all chronic patients who come to pick up their medication at the pharmacy. This study allows pharmacists to detect and know which group and which sociodemographic characteristics of their clients need more and more personalized attention, with more detailed explanations when drugs are dispensed, with the intention of reducing errors in taking medications.Additional file 1: Table S1. Scenarios established in the MedLitRxSE tool for Spanish drugs, with their relevant questions and their relationship with literacy and documentary literacy.


Dirofilaria immitis and Dirofilaria repens that affect dogs and humans all over the world. Serbia is considered an endemic country to both forms of dirofilariasis, although most of the population is concentrated in the north of the country. The aims of this study were to show the prevalence of D. immitis and D. repens in dogs and the seroprevalence in humans compared to previous studies in Northern Serbia. In total, 346 dog sera samples and 265 human samples were analyzed. Dog blood samples were analyzed using the modified Knott's method to check whether there were Dirofilaria spp. microfilariae and serum samples were checked by a commercial D. immitis antigen test. Human serum samples were analyzed with a non-commercial ELISA for detection of specific anti-D. immitis, anti-D. repens, and anti-Wolbachia IgG antibodies, and confirmed by western blotting. The overall prevalence for Dirofilaria spp. in dogs was 29.19%. The overall prevalence for D. immitis was 26.30%. The percentages of D. immitis and D. repens microfilaremia in dogs were 25.72 and 1.45%, respectively, while D. immitis./D. repens microfilaremia co-infections were also 1.45%. The overall seroprevalence for Dirofilaria spp. in humans was 3.77%. The overall seroprevalence for D. immitis was 1.51, 1.13% for D. repens, and for D. immitis/D. repens co-infections was 1.13%. The results indicate that D. immitis and D. repens are present in dogs and humans in the province of Vojvodina, in the northern part of Serbia. It is most likely associated with the presence of many rivers, the climate, and presence of mosquitoes in the area, so there could be a real public health risk.Dirofilariasis is a vector-borne zoonotic disease caused mainly by  Dirofilaria immitis and Dirofilaria repens. Dirofilaria immitis causes heartworm disease in canines and pulmonary dirofilariasis in humans, whereas D. repens causes canine subcutaneous dirofilariasis and ocular/subcutaneous dirofilariasis in humans. Both parasites are transmitted by culicid mosquitoes, which inoculate larva 3 into definitive hosts in both animals and humans. For that reason, dirofilariasis is considered a veterinary and public health problem , although most cases are asymptomatic  lies between Hungary, Croatia, and Romania. This northern part of the country is largely plains with a continental climate and a lot of rivers. Summers are hot and have lengthened over time due to climate change, so temperatures over 14°C usually last even through to the end of October. Winters are less and less cold and there has not been much snow during the last several winters. All this means that the mosquito season is prolonged from March to October. The air humidity during the warm period of the year is mostly high, meaning that the conditions for the development of mosquitoes are appropriate. During springtime there is a lot of rain and often in some parts of the country there are floods.Figure 2). There is also an artificial canal system called Danube–Tisa–Danube Canal. It covers the total area in Vojvodina of about 12,700 km2 and it consists of a number of canals. This Canal is a unique hydro-engineering system for flood control and hydrotechnical management, forestry, water supply, wastewater evacuation, navigation, tourism, fishing, and hunting. Besides these purposes, it also represents a substantial amount of water, convenient for development of mosquitos.In the province of Vojvodina there is the Danube river, which crosses the country from east to west, while the Tisa river flows from north to south, and there are smaller rivers all around the region  were obtained from dogs analyzed by several veterinary clinics  and 265 Dirofilaria spp. microfilariae in the blood of the animals included in the study. Morphological characteristics of microfilariae  were used in order to differentiate D. immitis and D. repens microfilariae  according to the manufacturer's instructions. There is no commercial laboratory test of any kind for D. repens in dogs.Dog blood samples were analyzed by applying the modified Knott's technique  to checkfilariae . Dog serD. immitis, anti-D. repens, and anti-Wolbachia IgG antibodies with some modifications  and 1:100 serum dilutions were used to detect the presence of anti-DiSA and DrSA IgG antibodies. Sera samples diluted at 1:40 with a recombinant form of the Wolbachia Surface Protein (rWSP) were used to detect the presence of anti-rWSP IgG antibodies. In both cases, goat anti-human IgG (H+L) conjugated to horseradish peroxidase  was used at a 1:4000 dilution. Easy Reader  was used for measuring optical densities (OD) at 492 nm. The cut-off point (OD = 0.8 for DiSA and DrSA and 0.5 for rWSP) was determined by calculating the mean value + 3 standard deviations (3SD) of 50 serum samples obtained from dogs and clinically healthy humans (negative controls) who belonged to an area free of D. immitis and D. repens. When both non-commercial ELISAs gave positive results for the same serum sample, that human sera were considered positive. Additionally, by using western blot analysis performed according to a previously described methodology (D. immitis (17–22 kDa) and for D. repens (43–70 kDa).Human serum samples were analyzed using a non-commercial ELISA for detection of specific anti-ications , 31, 32.hodology , 33–36, D. immitis, D. repens, and co-infections were manually georeferenced by GPS at the point of capture. Georeferenced positive data for both hosts are shown in the map.The ArcGIS Pro online software was used for the construction of a map of the sampling area. All layers of relevant environmental information  were included and symbolized for a better understanding of the map. All dog and human samples infected with p < 0.05.The SPSS Base 18.0 software for Windows was used for the data analysis. The descriptive analysis of the considered variables was carried out studying the proportions in the qualitative variables. To compare proportions, Chi-square tests were performed. In all the cases, the significance level was established at Dirofilaria spp. in dogs was 29.19% , 1.45% for D. repens microfilaremia, and 1.45% for D. immitis/D. repens microfilaremia co-infections . There are significant differences between the prevalence for D. immitis infected male and female dogs with a higher prevalence in male dogs, whereas the prevalence of D. repens was higher in females (p < 0.05).The overall prevalence for s 29.19% . The oveDirofilaria spp. in humans was 3.77%. These results are shown in D. immitis was 1.51, 1.13% for D. repens, and 1.13% for D. immitis/D. repens co-infections. All positive cases were detected in males with significant differences (p < 0.05) for D. immitis (1.92%) and D. repens (1.44%), but not in co-infection (1.44%). All positive samples via western blot analysis are shown in The overall seroprevalence for D. immitis between the 20–40 range and the other ranges, the seroprevalences of D. repens between the over-40 age group and the other ranges and the seroprevalences of co-infections between the 20–40 age group and the other ranges (p < 0.05).By age, there are significant differences between the seroprevalences of D. immitis and D. repens in the northeast of the country.Regarding the geolocation of the positive samples of both dogs and people on a map , all of Dirofilaria spp. species have developed limited mutual adaptation , taking into account that this region has been considered endemic for some time. Furthermore, the aim was to identify the potential risk of infection of the human population in an endemic area.The aim of the present study was to analyze the prevalence in dogs and the response to anti-D. immitis and D. repens , the previously reported seroprevalence was 22.9% for D. immitis and the presence of D. repens microfilariae was 39.34%  and co-infections (3.2%) (D. immitis infections and a decrease of an infection with D. repens in recent years (D. immitis infection between the dog population and the wild canid population. Meanwhile, D. repens was found to circulate mostly in golden jackal and red fox populations (In the current study, a prevalence of 26.30% was observed in dogs infected by s 39.34% . In Bulgnt years –23 whichulations .Dirofilaria spp. in humans was 3.77, 1.51% for D. immitis, 1.13% for D. repens, and 1.13% for D. immitis/D. repens co-infections. This is the first time these tests have been conducted in this region of Serbia. Human cases originating from D. repens have only previously been reported in the region of southeastern Serbia (D. repens and D. immitis polyproteins specific antibodies, respectively, and 2.3% in individuals with specific antibodies to both species (D. immitis, 0.2% for D. repens, and 0.9% for both parasites (D. repens cases reported (With regards to the human population, the seroprevalence for n Serbia , 40, 41. species . Similararasites . In addireported .D. immitis and D. repens in the northeast of the country are close to cities where cases of dogs and humans had already been reported (Both animals and infected people were geolocated in the immediate vicinity or in a relatively close environment of potential mosquito breeding areas, which poses a risk to those areas. The two cases of humans infected by reported  and werereported .D. immitis and D. repens are present in dogs and humans in the province of Vojvodina, in the northern part of Serbia. It is most probably associated with the presence of many rivers, the climate, and the presence of mosquitoes, so there is a real public health risk. Serology studies in humans can be very useful for indicating the exposure to Dirofilaria spp. in a healthy population in order to obtain useful data on the epidemiological scenario of human dirofilariasis in Serbia and in Europe. That exposure was confirmed in the current study. Further studies addressing the control of dirofilariasis in the dog population are needed to reduce the risk of infection in the human population.In conclusion, the results indicate that All datasets generated for this study are included in the article/supplementary material.Ethical approval was not provided for this study on human participants because People data don't require permission, everyone has verbal consent. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Ethical review and approval was not required for the animal study because the blood samples were taken during a regular blood checkup of the dogs and the consent was gained from the owners so there was no need for the ethical approval. Written informed consent for participation was not obtained from the owners because Verbal consent of client owned dogs.SS and RM designed the study and wrote the manuscript. MS, DM, IH, AP, SO, and MR performed the fieldwork, collected the data, and performed the experiments. All authors participated in the discussion of the results, corrected, read, and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer AG declared a past co-authorship with one of the authors SS to the handling editor.


Background: Systematic reviews in health professions education may well under-report struggles to synthesize disparate evidence that defies standard quantitative approaches. This paper reports further process analysis in a previously reported systematic review about mobile devices on clinical placements.Objective: For a troublesome systematic review: (1) Analyse further the distribution and reliability of classifying the evidence to Maxwell quality dimensions (beyond ‘Does it work?’) and their overlap with Kirkpatrick K-levels. (2) Analyse how the abstracts represented those dimensions of the evidence-base. (3) Reflect on difficulties in synthesis and merits of Maxwell dimensions.Design: Following integrative synthesis of 45 K2–K4 primary studies : (1) Hierarchical cluster analysis explored overlap between Maxwell dimensions and K-levels. Independent and consensus-coding to Maxwell dimensions compared  pre- vs post-discussion and (2) article abstract vs main body. (3) Narrative summary captured process difficulties and merits.Results: (1) The largest cluster (five-cluster dendrogram) was acceptability–accessibility–K1–appropriateness–K3, with K1 and K4 widely separated. For article main bodies, independent coding agreed most for appropriateness . Evidence increased significantly pre–post-discussion about acceptability , accessibility, and equity-ethics-professionalism. (2) Abstracts suggested efficiency significantly less than main bodies evidenced: 31.1% vs 44.4%, p = 0.031. 3) Challenges and merits emerged for before, during, and after the review.Conclusions: There should be more systematic reporting of process analysis about difficulties synthesizing suboptimal evidence-bases. In this example, Maxwell dimensions were a useful framework beyond K-levels for classifying and synthesizing the evidence-base. Synthesizing messy evidence in health professions education can be more art than science, more pragmatism than finesse, and more trouble apparently than it's worth. Nevertheless, exploring the evidence enough to make useful recommendations and to critique and improve the process must be better than investigatory inanition waiting for the perfect evidence-base.Whether viewed as what is probably, plausibly, or often generally true, the nature of the ‘evidence’  and the K1 = reaction, K2 = learning, K3 = behaviour, and K4 = results  been implemented across a range of contexts, populations and subpopulations, and how have those effects come about?”Petticrew , p.2 arg‘Does it work?’ becomes ‘meaningless and usually unanswerable’ (p.2) for complex interventions, and narrative reviews seek evidence to reduce uncertainty rather than to derive a precise effect-size. Even weak studies provide illumination when a field is still in development and:“evidence synthesis often is, and should be, an exercise in Bayesian decisionmaking, and reducing uncertainty, and not hypothesis testing” (p.5).‘What works best for health professions students using mobile (hand-held) devices for educational support on clinical placements?’ in an underdeveloped evidence-base. This was about a complex intervention and required versatile interpretation and classification of a mash-up of ‘whether’ (justification), ‘how/why’ (clarification), and ‘what’ (description) evidence . Co. Co31]. Narrative summary captured reflection on the difficulties in synthesis . Both reAll bar one study provided evidence for appropriateness of mobile device use to learning needs (including caregiving and patient safety aspects) , 86.7% each for acceptability and accessibility, with 73.3% and 44.4% for effectiveness and efficiency, respectively, but only just over one-quarter for equity-ethics-professionalism . For theThe largest cluster in the five-cluster dendrogram of K-levels and Maxwell dimensions was acceptability–accessibility–K1–appropriateness–K3, with effectiveness nearby, quite dissimilar from the efficiency–K4b cluster . K2a–K2bAcceptability was classified as ‘present’ significantly more post-discussion  and likewise for accessibility  and equity-ethics-professionalism .If the abstract suggested evidence of a Maxwell dimension, the main body included that evidence. The main body presented evidence for acceptability and efficiency significantly more than the abstract: 86.7% vs 66.7%, p = 0.004; 44.4% vs 31.1%, p = 0.031, respectively. For accessibility, appropriateness, effectiveness  and equity-ethics-professionalism (p = 0.250), the excess was not statistically significant.insufficient guidance about such mixed evidence and concerns about transgressing qualitative research ‘rules’,before: ill-defined outcomes and methods, requiring much translation, particularly for equity-ethics-professionalism evidence,during: much effort in reporting analysis of the process and much potential to be misconstrued.after: Combined observations about the main struggles in synthesis and analysis aggregated around the time :before:a simplified starting-point, adaptable to the intervention,before: a lens for better and wider understanding of implementation and impact, intended or otherwise,during: a structured framework for reflection, prompting deliberation to consensus about tricky evidence and its wider worth (and possible gaps), and being consistent with application of Maxwell dimensions by systematic reviews elsewhere in health services research.after: Likewise, for the list of Maxwell dimensions, main merits aggregated around the time :before:‘Does it work?’.Systematic reviews in medical education require more open discussion of difficulties in synthesizing suboptimal evidence-bases and more systematic reporting of process analysis. In the example explored here, Maxwell dimensions ,23 helpe‘Does it work?’. Besides the usual recommendation for improved reporting of primary research, BEME review 52 recommended that ‘effectiveness’-reviews extend beyond a simplistic approach of just ‘What works?’, echoing Eva  … I believe the difference [in results between poorly-designed and the best-designed studies] to be so small that to integrate research results by eliminating the ‘poorly done’ studies is to discard a vast amount of important data.”Reviewer-pairs or teams must calibrate and critique such classification tools with care to widen analytical horizons robustly. Here, deliberative synthesis of ‘whether’, ‘how/why’, and ‘what’ concepts ,18,52,53“It appears that low method quality functions more as error than as bias, reducing the confidence that can be placed in the findings but neither consistently over- nor underestimating program effects.”Wilson and Lipsey , p.420 c‘What is the effect of this complex intervention?’ [In health professions education, it is challenging to undertake systematic multi-component mixed methods reviews that attempt to arrange, interpret, and summarize evidence about ention?’ , p.2. Suention?’  an evideThere should be more systematic reporting of process analysis about difficulties synthesizing suboptimal evidence-bases in health professions education.Maxwell dimensions are potentially useful for evaluating educational interventions and synthesizing messy, variegated evidence-bases.Kirkpatrick model and Maxwell dimensions applied to such an evidence-base clustered coherently together and should be applied with critical scepticism to improve understanding and represent complexity.To improve systematicity and thoroughness of systematic reviews, especially when synthesis is tricky, reflective deliberation and supplementary analyses about the conceptual integrity and trustworthiness of ‘filtering and classification’ tools are warranted.Be aware that abstracts may well omit certain types of substantive evidence reported in the main body, thus reducing the sensitivity of title-abstract filtering.


Obstetric anal sphincter injuries (OASIs) are the most severe form of perineal trauma with potentially devastating effects on a mother’s quality of life. There are various national guidelines available for their management. The aim of this study was to review and compare recommendations from published national guidelines regarding management and prevention of OASI.We searched the PUBMED, EMBASE, MEDLINE, CINAHL and COCHRANE databases from January 2008 till October 2019 using relevant Medical Subject Headings (MeSH), including all subheadings. The guideline characteristics were mapped and methodological quality assessed with the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool by three independent reviewers. To compare the methodological quality of the guidelines, the interpretation of the six domain scores were taken into consideration. By consensus of the authors, a score of 70% was taken as a cut-off, and scores above this were considered ‘high quality’.Thirteen national guidelines on perineal trauma were included and analysed. Nine of these were specific to OASI. There is wide variation in methodological quality and evidence used for recommendations. AGREE scores for overall guideline assessment were > 70% in eight of the guidelines, with Australia-Queensland, Canada, the UK and USA scoring highest.The wide variation in methodological quality and evidence used for recommendations suggests that there is a need for an agreed international guideline. This will enable healthcare practitioners to follow the same recommendations, with the most recent evidence, and provide evidence-based care to all women globally. Approximately 90% of females suffer from some degree of perineal tear during vaginal birth . ObstetrOn a global front, the rates of OASI vary greatly. A systematic review which explored the rates of birth-related perineal trauma in low and middle-income countries showed that data were not available for most countries. The Philippines had the highest reported rate of 15%, with the lowest rate (0.1%) in Cambodia . SimilarGuidelines are defined by the Institute of Medicine as ‘statements that include recommendations intended to optimise patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options’ .The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument is the most commonly used, validated guideline appraisal tool . AlthougFew countries that have their own national guidelines on OASI. There are discrepancies and variations within each guideline, which leads to variation in obstetric practice in relation to protection of the perineum, type and frequency of episiotomy and management of OASI .The aim of this study was to assess the methodological rigour of guideline development using AGREE II and compare recommendations from published national guidelines regarding management and prevention of OASI.A search was performed in PUBMED, EMBASE, MEDLINE, CINAHL and COCHRANE databases from January 2008 till October 2019 using relevant Medical Subject Headings (MeSH) including all subheadings. Keyword search included the following: labour complications, anal canal, anal sphincter musculature, anal sphincter injuries, third degree, fourth degree, perineum, tear, laceration, disruption, rupture, trauma, disorder, incontinence, faecal, anal sphincter repair, suturing methods, end to end, overlap technique, recurrence and pregnancy after OASIS. In addition, web search engines, such as Google, were used to search for guidelines related to perineal tears and OASI.All results were reviewed, guidelines extracted and duplicates removed. National guidelines on practice related to obstetric perineal trauma, in particular OASI, were included. Guidelines from individual hospitals were excluded. The guidelines in non-English languages  were translated into English using Google Translate.Independent reviewers (NA and JR) recorded guideline characteristics including: country of origin, year of publication, principle developers, stakeholders involved, scope, consensus method, search databases, search period, endorsements and quality assessment methods.www.agreetrust.org.Four reviewers  underwent training in the use of quality assessment using the AGREE II tool from The AGREE assessment is divided into 23 core items and 2 overall assessment items. The core items are split into six domains of practice guideline quality: scope and purpose, stakeholders involvement, rigour of development, clarity of presentation, applicability and editorial independence. Each item is assessed on a 7-point Likert scale. Domain scores were calculated as recommended . This indicated a high level of intra-rater agreement in all except ‘Clarity of presentation’.Classification of perineal trauma was presented in 12.Definition of a rectal button hole tears was mentioned in six.Risk factors for OASI were discussed in 12.Prevention of OASI with perineal protection was recommended in four, while five said there was insufficient evidence to recommend it.Prevention of OASI during instrumental delivery using a mediolateral episiotomy was recommended in seven. One reported there was insufficient evidence to recommend episiotomy for all instrumental deliveries. The German and Danish guidelines only mentioned episiotomy with vacuum delivery, while forceps delivery was not mentioned.Prevention of OASI by using a warm compresses on the perineum in labour was recommended by six. Two suggested insufficient research to recommend it.Diagnosis of perineal trauma with digital rectal examination was recommended in seven. Four stated that rectal examination was only necessary in some circumstances.Repair of OASI in theatre with general or regional anaesthesia was recommended in eight. South Australia recommended that only 3b/c and fourth-degree tears require this, whereas 3a tears can be repaired in the delivery room .Nine recommended that the person conducting the OASI repair should be adequately trained.Five made specific recommendations about the repair for the anal mucosa.Separate repair of the internal anal sphincter (IAS) from the external anal sphincter (EAS) was recommended in eight. The guideline from the USA stated if the IAS can be identified it can be repaired separately or ‘as part of the distal portion of the reinforcing second layer of the rectal muscularis’, while The Netherlands mentioned this was only needed if it was possible without further exploration of the wound.Repairing a full-thickness EAS tear with overlapping or end-to-end technique was recommended in 11.Recommendations about suture type for repair were mentioned in ten.Rectal examination after completion of the repair was recommended in four.Broad-spectrum antibiotic prophylaxis at the time of repair was recommended by ten.A post-operative course of prophylactic antibiotics was recommended by three. Queensland recommended this for fourth-degree tears only and advised to consider it in third-degree tears. Three said there was insufficient evidence to recommend any antibiotics following repair.Post-operative follow-up with physiotherapy was recommended by eight. Canada stated that this was only necessary for women with anal incontinence.A post-operative course of laxatives was recommended by ten.A risk of repeat OASI in a subsequent pregnancy was described in nine.Follow-up with endo-anal ultrasound was recommended in five.Episiotomy in a subsequent delivery was mentioned in six, but the lack of sufficient evidence to recommend it was discussed.Caesarean section was recommended for women who were symptomatic of anal incontinence in a subsequent pregnancy in nine.Key recommendations were mapped.Although there was a wide variation in methodological quality and evidence used for recommendations, all guidelines scored high quality (> 70%) in at least one domain of the AGREE II tool. Eight were high quality ‘Overall Guideline Assessment’ scores and therefore were classed as ‘Recommended’. Four guidelines scored > 90% overall , 17, 19.Clinical practice guidelines are typically developed by a group of experts and healthcare professionals in the subject. Guidelines that have a small or restricted development team could introduce bias to the recommendations made. The AGREE II tool suggests that guideline development should include individuals from the relevant professional groups and also consult the patient groups affected by the guideline. On review of the development groups, a range of professionals were involved. Some consisted of doctors alone, while others included midwives, physiotherapists, colorectal surgeons and radiologists. The Dutch development team were the only group involving women who had experienced OASI and therefore scored the highest (85%) in ‘Stakeholder involvement’. Denmark (2019) and USA obtained the two lowest scores (24% and 28% respectively). This is because the guideline development team were not from a wide range of specialities, and the views of the target population had not been taken into consideration. It could be argued that all the stakeholders who would be using the recommendations from a guideline should be involved, whilst the patient population should form a vital part of the development team.All guidelines, apart from one , scored There was variation in the scope of the guidelines. This is understandable since the titles imply a variation in the content. Some are more general, looking at perineal injuries as a whole , 19, 9, The Saudi guideline had the lowest overall guideline assessment (56%). ‘Editorial independence’ (17%) and ‘Rigour of development’ (38%) were also low. When developing a guideline, it is essential to research the available evidence on the subject in order to make up-to-date and relevant recommendations. This may have been done thoroughly but the evidence for recommendations was not well documented. A clear explanation for the recommendations could help the users to weigh the level of evidence used and apply them clinically. It is also important for the user to have knowledge of the evidence used so that they can check for updates and follow accordingly. ‘Editorial independence’ analyses whether any funding bodies or conflicts of interest could have influenced the developers. Variations in the methods used to identify and assess the evidence result in variations in recommendations. When individual recommendations are reviewed it is important to note the evidence quoted and how it is interpreted. For example, the German guideline quoted Aasshiem et al.’s systematic review for warm compresses on the perineum but concluded that it ‘cannot be conclusively evaluated on account of inadequate or contradictory data’. However, the review concludes that warm compresses on the perineum decrease the occurrence of perineal trauma .Looking in more detail at the recommendations included and evidence used for each guideline the following observations were made:Classification of perineal trauma ensures a thorough evaluation of anatomy and therefore an accurate repair of the trauma. OASI missed at delivery can effect a woman’s physical and emotional recovery . All guiA rectal button hole tear is a tear of the anorectal mucosa and vagina with an intact anal sphincter which can lead to serious consequences such as a rectovaginal fistula . It may Without a digital rectal examination anorectal mucosal injury cannot be excluded . Seven oConsistent risk factors for OASI were mentioned in 12 of the guidelines but some differences were noted. Increasing birth weight and instrumental delivery were mentioned in all except the Irish guideline, probably because it was beyond their intended scope. Yet, risk factors are an important part of a guideline. They can help in counselling patients during pregnancy and delivery.In recent years there has been an increasing interest in prevention of OASI. Prevention was mentioned in ten guidelines, to varying degrees. Warm compresses were mentioned in eight; however, two suggested insufficient evidence for this. The reference used was consistently the systematic review by Aasheim et al. in reducing perineal trauma .Perineal protection was recommended in four. Five others mentioned that there were insufficient data to recommend it. This may be due to timing of production, given that some of the research recently completed may not have been available during guideline development. This highlights the time-limited nature of guidelines and the importance of reviewing them at a fixed interval.Episiotomy for instrumental delivery was recommended in nine. Two of these (German and Danish (2019)) only referred to vacuum delivery, which may be because forceps are not popularly used in those countries. There is growing evidence that episiotomy is protective of OASI in the presence of an instrumental delivery and due consideration needs to be given to this.A detailed description of repair technique for the sphincter is an essential component of a guideline on OASI. It is suggested that it is done in theatre with regional or general anaesthetic by a person who is trained in repair of OASI . These rDepending on the grade of tear, different tissues require repair. The anorectal mucosa can be repaired in a continuous or interrupted suture. The knots of the sutures can either be in the anal canal or within the tissue layers . Five deThe recommendation for EAS repair seems to be more unified. Eleven guidelines included the option for repair of a completely torn EAS with overlap or end-to-end technique. Six of these used the Cochrane review by Fernando et al. as a reference . This isUpon completion of the repair, a second digital rectal examination is recommended to confirm complete repair and also to check sutures have not inadvertently been inserted through the anorectal mucosa . This waA Cochrane review on antibiotic prophylaxis during OASI repair identified only one randomized control trial (RCT) , 25. EitThere is no evidence for a course of post-operative antibiotics. Only three guidelines recommended this, using expert opinion as evidence; another three stated there was insufficient evidence. When there is a lack of evidence it is important that this is stated to ensure the user understands the rationale for recommendations made. An expert opinion can be very valid in this situation. It is also useful to identify the gaps in research and state them in a section for future research.Other post-operative care that is mentioned are physiotherapy and laxatives. Ten guidelines recommended a course of laxatives during the post-operative period, seven of which used the same RCT evidence by Mahony et al. . ProvisiSubsequent pregnancy can pose a dilemma to mothers and clinicians, due to recurrence of tears and anorectal symptoms. Subsequent pregnancy was discussed in ten guidelines. Nine of them quoted a risk of recurrence, with a range of 3% to 8%.Five guidelines advise investigations for women during the follow-up period, including endo-anal ultrasound. The use of a dedicated perineal clinic was recommended in three guidelines, recognizing limitation of resources.Research in the role of elective episiotomy during a subsequent vaginal delivery following OASI has recently been published. D’Souza et al. concluded that mediolateral episiotomy in subsequent vaginal deliveries decreases the recurrence rate of OASI in women who have had a previous OASI by 80% . Six guiIt is important that the guidelines provide the level of, or lack of evidence, for each recommendation. Some guidelines used other clinical guidelines as a references; for example, the Queensland guideline  used theNygaard et al. recently appraised national guidelines for management of obstetric perineal lacerations  using thThe strengths of this study include its originality, search strategy, methodological design and inclusion of a variety of countries. The guidelines in non-English languages have been translated into English using Google Translate, which can lead to a bias that could be avoided with the help of a professional translator. There was reasonable agreement between the three reviewers with discrepancies resolved through discussion and reviewed by an expert (RT). All guidelines includeed were from high resource countries, which limits generalization to middle and low-resource countries. Since well-trained professionals rather than high financial resources are needed for prevention, diagnosis and treatment, the suggestion of an international guideline is pertinent.It is not possible to make recommendations of guidelines based on our analysis because of the variety of scope and purpose. There are some that have more robust development and are easier to interpret than others. And there are some that appear to have little evidence for the recommendations made. We therefore recommend a coordinated approach to development of guidelines.The users of OASIs guidelines should be aware of their development methods; guidelines developed without a standardized methodological process may lead to clinical inaccuracies. In particular, we urge clinicians to be aware of the date of publication, and the evidence that has been published since. We advocate clinicians to explore the strength of the evidence used as this may highly impact whether recommendations are appropriate for certain clinical scenarios. Furthermore, guidelines are created based on the dates the search was conducted and it may take years before the guideline is published, following the review and consultation process.We recommend guideline developers use a standardized method, such as AGREE II, using the latest evidence, together with a specific development team from many areas of clinical practice, including patient representatives. Finally, guideline review must be carried out on a regular basis to ensure it is in line with current evidence. A single universal guideline could reduce variations in clinical practice.No national guideline in this review strictly followed the standardized approach to guideline development as described in AGREE II. Given the variation in development protocol and interpretation of evidence in forming recommendations, the findings in this study justify the critical appraisal of the national OASIs guidelines and use of a tool such as AGREE II. Clinicians are advised to use current guidelines exercising awareness of guideline development, timing and available evidence used.


Dirofilaria immitis infection and, for the first time, Brugia pahangi. The occurrence of the two species was comparable. Geographic spatial distribution revealed the abundance of D. immitis and B. pahangi in the central areas at altitudes less than 400 m. However, at higher altitudes between 400 and 800 m, we found a significantly higher number of B. pahangi infections than D. immitis infections. In conclusion, D. immitis and B. pahangi were the most common filarial infections found in community dogs in Northern Thailand. Dogs might be an important reservoir for B. pahangi in that region. The population dynamics of the mosquito vector of B. pahangi across altitudinal gradients merits further study.Filariasis is emerging as a public health concern for humans, dogs, cats, and other wildlife species, and is frequently found in southeast Asian countries. The present study confirmed the species of filarial nematodes in free-roaming dogs from temple communities. Two species were found: Vsp I, the overall prevalence rates of Dirofilaria immitis (12.2% (41/337); 95% confidence interval: 9.1–16.1%) and Brugia pahangi (8.3% (28/337); 95% confidence interval: 5.8–11.8%) were determined based on 337 free-roaming community dogs from 20 districts in Northern Thailand. Microfilaremia was found in only 6.2% of dogs (21/337). Co-infection with D. immitis and B. pahangi was observed in two dogs. Of the 215 blood samples examined using a Canine Heartworm Ag Kit, only 3.72% (eight dogs) were D. immitis antigen positive. Among these eight, six dogs had occult D. immitis infections. In terms of geographic distribution, we found the abundance of D. immitis and B. pahangi in the central areas at altitudes less than 400 m to be 12.1% and 10.3%, respectively. In contrast, at higher altitudes between 400 and 800 m, a significantly higher number of B. pahangi compared with D. immitis infected individuals were observed at 14.29% and 4.1%, respectively. In conclusion, D. immitis and B. pahangi were the most common filarial infections found in community dogs in Northern Thailand. Dogs might be an important reservoir of B. pahangi in that region. Increasing awareness and concern and including proper deworming programs for community dogs should be endorsed to reduce the transmission risk. Additionally, the population dynamics of the mosquito vector of B. pahangi across altitudinal gradients deserved further investigation.Filariasis is emerging as a public health concern in tropical and subtropical areas. Filariasis is an endemic problem commonly found in southeast Asian countries. Using the PCR-restriction fragment length polymorphism (PCR-RFLP) of the ITS1 region with  Brugia malayi , Wuchereria bancrofti (bancroftian filariasis) and Brugia timori is considered a significant human health problem. Filariasis in dogs is caused by various species, e.g., Dirofilaria spp., Acanthocheilonema spp., and Brugia spp. [Filarial nematode infection is an important vector-borne disease in tropical countries. According to the World Health Organization (WHO) roadmap WHO 2020), the goal of eliminating filariasis is expected to be achieved by 2030. Filarial infections are currently common in companion animals worldwide . Specifi020, the gia spp. . Typicalgia spp. .D. immitis infection, is one of the serious types of filariasis observed in veterinary practice. Adult worms commonly live in pulmonary arteries and congestive heart failure can occur in severe cases. Dirofilaria repens and Acanthocheilonema reconditum are other [Brugia spp., such as Brugia pahangi and Brugia malayi, are known to cause lymphatic filariasis (LF), whereas B. malayi causes a serious lymphatic obstruction in humans. Whether B. pahangi is a causative agent of human disease in the natural environment is not yet known [B. pahangi in Malaysia was recently published [B. malayi, but they are the essential hosts of B. pahangi [Canine heartworm disease, re other  filarialet known . Howeveret known . A cliniublished . Dogs an pahangi .D. immitis, D. repens, A. reconditum, B. malayi, and B. pahangi. The species–specific (for D. immitis) PCR-targeting cytochrome c oxidase subunit 1 (cox1) gene has been used to confirm D. immitis infection.Currently, several methods are employed to diagnose filarial infections. The basic conventional technique generally uses microscopic examination to detect microfilariae. The microhematocrit centrifugation technique, or Woo’s test, is easy to perform, quick, and inexpensive ,12, but D. immitis, B. malayi, and B. pahangi have been reported, including different species of filarial infection [. D. immitis infection was found throughout Thailand and has a higher prevalence in stray dogs than in pet dogs [Brugia spp. infection was reported to be found mostly in the southern part of Thailand [Brugia infection in dogs has never been confirmed in Northern Thailand. The WHO recommended using a mapping method for delimiting areas requiring mass drug treatment to save resources [D. immitis and B. pahangi using spatial mapping in an effort to augment disease control efforts in animals and humans, thus reducing public health concerns.In tropical countries, including Thailand, the endemic areas for nfection ,15. D. ipet dogs . Brugia Thailand ,18. In tThailand . In addiesources ; howeverThe study area was in the province of Chiang Mai in the upper northern region of Thailand, which is considered the province with the highest dog population density in the nation . The study area was divided into three zones , including 168 males and 169 females. Inclusion criteria included age >7 months and having not received heartworm prevention medication. From each dog, 2 mL of blood was collected from either the cephalic or saphenous vein which was kept in EDTA tubes. The first 0.5 mL of blood was used for Woo’s examination for the presence of microfilaria. The remaining 1.5 mL was kept in a freezer at −20 °C for further molecular analysis.All dog owners (temple master or dog keepers) signed an informed consent form, and the treatment of the animals was approved by the Animal Care and Use Committee, Faculty of Veterinary Medicine, Chiang Mai University (R15/2562) on 12 June 2019.D. immitis antigen using a Thinka Canine Heartworm Ag Test kit  following the manufacturer’s instructions. For quality control, the blood samples were examined within 48 h after blood collection.The whole blood samples were examined for total circulating microfilariae using the microhematocrit centrifugation technique (Woo’s technique) . In addi® Blood, Macherey-Nagel, Duren, Germany) was used following the manufacturer’s instructions.Genomic DNA (gDNA) was extracted from 200 µL anticoagulated blood samples. A commercial DNA extraction kit . PCR products were analyzed on a 1.5% agarose gel electrophoresis. The positive ITS1 PCR products were then digested with five units of Vsp I  as a restriction endonuclease, according to the manufacturer’s protocol. One unit of Vsp I was used to digest 1 µg of the ITS1 PCR product for 1 h at 37 °C in a total reaction volume of 50 µL. DNA fragment analysis was conducted by 1.5% agarose gel electrophoresis, stained with RedSafe™ nucleic acid staining solution , and visualized using a GelMax™ Imager .Various diagnostic tools have been developed for the precise diagnosis of filaria infection. PCR-RFLP—which is based on a diagnostic method previously designed by Nuchprayoon et al.  and targA. reconditum and Amphiachyris dracunculoides, and primers specific for D. immitis (DI COI-F1 and DI COI-R1) to confirm D. immitis DNA in suspected occult infections. The PCR procedure was performed following previously published methods [D. immitis, B. pahangi, and B. malayi as positive controls were included in the analysis.Two other PCR techniques were used to confirm the presence of filarial DNA in the suspicious samples, including PCR of pan-filarial primers (DIDR-F1 and DIDR-R1) to discriminate between  methods  and usinD. immitis- and B. pahangi-positive samples was achieved by DNA sequencing of the 5.8s-ITS2-28S amplicons using pan-filarial primers given the clear and distinctive amplicon. The PCR product (50 μL) was purified using a NucleoSpin® PCR Clean-up Kit  and submitted for direct fluorescent dye-terminator sequencing in the sense and antisense directions by BioBasic Inc. .Species confirmation in the 10 previous D. immitis infection when positive with CHW Ag kit and/or D. immitis-DNA-positive with any molecular technique; (2) occult D. immitis infection when positive with CHW Ag kit but negative with any PCR; (3) B. pahangi infection when B. pahangi-DNA-positive with any molecular technique. Descriptive statistics summarizing the prevalence of filarial worm infection are presented as a percentage of each species. Differences in prevalence between groups or categories were analyzed using proportion tests. All statistical analyses were performed using R software [p-values < 0.05 were considered statistically significant.Diagnostic steps for identification and determination of the prevalence of filariasis are presented in software  and p-vaD. immitis isolates (Di CM329 and CM331) and five isolates of B. pahangi   and D. repens , and the sequence of Setaria digitata (EF196091) as the outgroup were included for evolution analysis. All sequences obtained in this study were submitted to the DDBJ/EMBL/GenBank database (The obtained sequences were compared with the previously deposited ones in GenBank using the BLASTn program  for specd CM337)  were usedatabase .Evolutionary analyses were conducted using MEGA X . MultiplB. pahangi and D. immitis among altitude classes using R software [p-values < 0.05 were considered statistically significant. Geographic distribution by altitude was generated from geographic information systems and GPS tracking data using QGIS software version 3.6. Notably, NASA Earth data indicates that all NASA data are available without restrictions.Geographical Information System (GIS) locations  from a mobile phone application were input to a computer. The digital elevation model (DEM) was obtained from the NASA Earth data website and used to create a raster image and to convert the model into contour lines representing altitude in the GIS application . The altitudes of the infected sites were measured using a GPS. Altitudes of the positive prevalence spots were divided into three classes modified from those used by Devi and Jauhari : below 4software  and p-vaD. immitis and B. pahangi cases were attained using a Bernoulli model and SaTScan™ v9.6 software [D. immitis and B. pahangi were classified based on the highest log-likelihood ratio (LLR), in which the likelihood function of the Bernoulli model is:Spatial cluster analyses of the positive software . Generalset to 1 . The illD. immitis antigen positive , higher than the prevalence of 8.31% for B. pahangi (28/337 dogs). However, the difference in infection rate between the two species was not significant (p > 0.05). The distributions of D. immitis and B. pahangi infection in the three zones of Chiang Mai province are shown in D. immitis and B. pahangi infection incidence was highest in the central zone at 22.96% (31/135), followed by the south zone at 22.45% (22/98). However, the prevalence rates of D. immitis and B. pahangi infection among the three zones were not significantly different (p > 0.05). Two dogs in the central zone had dual infections with D. immitis and B. pahangi. No adult D. immitis antigens were detected in the two D. immitis DNA-positive samples. Finally, an important proportion of occult heartworm infections  was distinguished  using Woo’s method and most of those were from the central zone . Of the positive . Only thnguished .The range of the percent PCV (%PCV) of dogs with positive microfilariae was 15–46%, with a mean ± SD of 32.48 ± 8.38 and a mode of 31%. Fourteen dogs with positive microfilariae  had a %PCV lower than 37%, which is considered anemic. Anemic status was categorized as mild , moderate , and severe . No icteric plasma was observed in any of the samples.D. immitis or B. pahangi. The nucleotide sequences of five isolates of B. pahangi were identical and grouped in a haplotype that showed 100% identity with B. pahangi  and B. pahangi . Howeveferences . The nuc4-554218 ).D. immitis and B. pahangi was performed to investigate the phylogenetic relationship among the different geographic regions (D. immitis clustered together in one group and were similar to D. immitis from China (EU182331), Brazil (KX932106), Iran (JX889636), Bulgaria (MN596213), and Turkey (KF273906 and HM126606). Five isolates from B. pahangi were clustered together in the same clade with B. pahangi published by Rishniw et al. [D. immitis and B. pahangi could be distinguished from B. malayi, D. repens, O. volvulus, and A. reconditum . The range of D. immitis infection was 12.05–14.29%, with the highest occurrence observed at 400–800 m . The prevalence of D. immitis was significantly higher than B. pahangi in the middle altitude class of 400–800 m, at 14.29% and 4.08%, respectively  was identified with RR at 6.69 and a clustering radius of 10.55 km. This most likely cluster was distributed in three districts: Hang Dong, Mae Rim, and Mueang. The primary cluster of B. pahangi infection was found to occur in various altitudinal areas (0 to >800 m D. immitis infection (B. pahangi. The most likely cluster of D. immitis infection (Di-1) was located in the Fang district  where the clustering radius was 9.32 km, and the RR was 4.03. Sites of positive identification of D. immitis in this cluster were distributed in the low areas at altitudes of 400 to 800 m  and size of each cluster are outlined in nfection , althougto 800 m C,D and wD. immitis infection and proven B. pahangi infection in community dogs in Northern Thailand. B. malayi was not found in Chiang Mai, although the province does have a large free-roaming dog population.The current study updates our understanding of the situation of D. immitis infection is widespread in tropical and subtropical regions and is a primary life-threatening disease of dogs and cats worldwide. The prevalence of D. immitis infection in dogs worldwide was 10.91% (95% CI = 10.18–11.65) in 2020. The prevalence of D. immitis in dogs varies across countries and continents, e.g., 22.68% in Australia, 12.07% in Asia, 11.60% in the Americas, 10.45% in Europe, and 7.57% in Africa [D. immitis infection in dogs in Thailand has been reported as 10–58% in Bangkok [Heartworm disease caused by  Bangkok ,29,30,31 Bangkok , and 6–2 Bangkok ,33,34,35B. pahangi, a lymphatic filarial worm that infests mammals, is commonly found in cats, dogs, and wild carnivores [B. malayi. Recently, five cases of clinically typical LF caused by B. pahangi were reported in suburban areas in the city of Kuala Lumpur, Malaysia [B. pahangi in Malaysia, which was identified by cyclooxygenase-1 (COX-1) PCR [B. pahangi infection in an animal in Chiang Mai. Elsewhere in Thailand, the B. pahangi infection rate range of 4–25% in dogs and cats in Bangkok has been reported [B. pahangi infections in children were reported, and Armigeres subalbatus was found to be a common mosquito in the infected areas [B. pahangi exhibits novel aspects and adaptations. For that reason, Brugia infections in humans in this region should be closely monitored, especially the environment and geographical distribution in areas with a high vector density and densely crowded human populations.rnivores , and is Malaysia . AdditioX-1) PCR . To the reported ,31,38. Ied areas . The recD. immitis cases in all altitude classes (0 to >800 m), probably due to the broad range of mosquito species, which are potential transmission vectors. Although Mansonia uniformis is an important natural mosquito vector of D. immitis in Chiang Mai [Culex pipiens quinquefasciatus, Aedes albopictus, and Ae. aegypti are additional vector species for D. immitis transmission. The majority of Aedes, Anopheles, Armigeres, and Culex mosquitoes have been found at altitudes between 300 and 900 m [Ae. albopictus is distributed in a wide range of elevations, between 300 and 1300 m, whereas Cx. quinquefasciatus has been found at elevations of 500 m and above [Mansonia species are spread across different altitudes [Mansonia species is likely to be higher in areas with floating aquatic plants.Natural infections of canine dirofilariasis enhance the risk of transmission to humans . The reliang Mai , Culex pnd 900 m . Ae. albnd above  and Mansltitudes . The numB. pahangi is considered to be a new causative agent of urban Brugia filariasis in Thailand [B. pahangi microfilariae can develop in An. quadrimaculatus and Ae. aegypti [B. pahangi microfilariae to a vertebrate host can occur via natural vectors such as Ar. subalbatus [Ar. subalbatus has also been found to be a common mosquito in infected areas and is suspected of being the main vector for zoonotic B. pahangi infection of children in Thailand [Ar. subalbatus decreases with altitude. Its preferred range is 109–330 m, but it tends to increase in areas with abundant leaf litter on the ground. However, other mosquitoes, including the genera Culex, Aedes, Mansonia, Anopheles, and Armigeres, are potential mosquito vectors of Brugia spp. [B. pahangi cases at all altitudes from 0 to >800 m. Climatic and geographic conditions, as well as environmental factors and changes in land use, may support the high prevalence of B. pahangi at low altitudes. The occurrence of more hotspots of D. immitis and B. pahangi in suburban areas of Chiang Mai, such as the Fang and Mae Rim districts (Thailand . Infecti aegypti . Developbalbatus ,45. Ar. Thailand . Chaves Thailand  demonstrgia spp.  which miistricts , could bD. immitis DNA-positive dogs did not present with adult D. immitis antigen in their blood. This may be linked to the existence of an immune complex that blocks the antigen detection process or to the low antigen secretion by adult worms [Although results of analyses of the correlation among diagnostic techniques for filariasis have so far been inconclusive ,49, a colt worms . Howeverlt worms ,52,53.B. pahangi could not be determined in this study. Last, the sampling strategy in this study was from an unknown prevalence; thus, it may pose a challenge, especially for B. pahangi, possibly contributing to an underestimation of number of samplings. However, for a follow-up study, the prevalence obtained from this study might be used and modified for a sample size determination.This study has some limitations. First, although we covered a wide range of geographical features in Northern Thailand, the results should be interpreted with caution as they cannot be generalized to all endemic settings. More variations in geographical characteristics should be included in future studies. Second, as sampling was conducted mainly among free-roaming dogs in the studied communities, information about the dogs, e.g., housing, routine drugs, and vaccination, was limited; thus, an analysis of risk factors associated with the risk of B. pahangi were found to be comparable to those of D. immitis. Both types of filarial nematodes had a high prevalence in the low altitude suburban agricultural areas. The residents of the region should be made aware that lymphatic filariasis is caused by B. pahangi. For practicing veterinarians, filarial species identification is necessary for determination of the proper heartworm treatment as well as for public health efforts related to zoonotic transmission. Spatial distribution of filariasis in consecutive areas as well as mosquito vector distribution and breeding habitats of D. immitis and B. pahangi in infected areas should be determined at finer scales to identify and implement appropriate control strategies.In this study, we covered the detection and confirmation of species of canine filarial infection in free-roaming community dogs found in Chiang Mai, Northern Thailand, using a combination of diagnostic methods. The infection rates of


The notion of ‘evidence’ circulates in two realms of current maternity care: biomedical ‘evidence-based’ obstetrics and efforts to reform conventional obstetric practices. I observed that in California's childbearing culture, ‘evidence’ is a boundary object that allows diverse actors to engage in related conversations despite fundamentally different assumptions about what evidence is or does. Sometimes these actors form productive hybrids and other times they talk past one another. This article uses recent work from the history and philosophy of science to distinguish the biomedical use of evidence, which is based on controlled experiments to prove cause and effect, from reformists' use of evidence, which foregrounds patient outcomes. Using Stengers's classification of doctors, charlatans, and curers, I discuss the role of rationality and experience in producing authoritative knowledge. Reformists' use of evidence, in effect, challenges medical power dynamics on what they perceive to be the terms of medical authority itself; in doing so, it has the potential to fundamentally alter who is the primary beneficiary of medical protocols. The challenge is continuing to use evidence in a way that doesn't simply ossify a new set of norms, but becomes increasingly capacious, flexible, specific, and patient centered. The crowd isn’t large, maybe thirty or forty people. But energy is high. Hand-drawn rainbow prayer flags wave above us, including one I drew myself, at the BirthKeepers conference the day before. The woman speaking is standing on a platform, a sparkling turquoise cape draped around her shoulders. I had just learned the day before that turquoise is the color of the birth revolution. We are gathered outside the annual conference of the American College of Obstetricians and Gynecologists (ACOG), in San Francisco, in May of 2015.‘We demand evidence-based care!’ she says. ‘Don’t induce for large babies, low amniotic fluid, or anything before forty-two weeks — acknowledge forty to forty-four weeks as the norm! Ask before you do something, episiotomies, putting your hands inside. This is my body, I get to decide!’ The speaker proudly proclaims that she is ‘just a mom’; she is also the founder of the Just a Mom League, which advocates for changes in maternity care from outside the medical profession. She later tells me the organization is for ‘everyone who’s willing to support moms as the primary decision maker regarding their body’.The politics of medical decision making might seem self-evidently related to the use of evidence — good care is evidence based, while practices not based on evidence may be harmful or unnecessary, indicative of authoritative traditions rather than what is optimal for the patient. ‘Evidence-based medicine’ (often abbreviated as ‘EBM’) has become a dominant organizing paradigm for health care and medicine in the Western world over the past two decades, yet the activists in this brief vignette used evidence as a rallying point to challenge the medical community about what is optimal and who gets to decide. Evidence is not as straightforward as it seems.In 2008, Canadian obstetrician-anthropologist Wendland published a critical medical anthropology article about evidence-based obstetrics, arguing that it undermined beneficial care for birthing women by bypassing their experience, and that of the clinician, in favor of aggregated, trial-based data that reproduced ideological biases and justified increases in cesarean section. By contrast, in my recent fieldwork on childbearing in California, ‘evidence’ was commonly marshaled to oppose obstetric conventions around medicalized birth, such as those Wendland criticizes. The idea of evidence-based medicine can be appropriated to different ends and with different relationships to the power dynamics in maternity care.Being poorly defined yet taken for granted makes evidence both confusing and powerful. In this sense, it is a boundary object , meaningTo be clear, there is a robust discussion among medical researchers about the different kinds and qualities of evidence , for which I trained and served as a doula  and actively participated in classes, community events, and professional meetings aimed at doulas, midwives, nurses, doctors, childbirth educators, and childbearing people. I also conducted interviews with various people from these groups and followed articles in the popular press about maternity care. As I describe elsewhere , the BayBeing a practicing doula and anthropological researcher required juggling the practical and ideological commitments associated with each role. Since doulas tend to participate in what I call ‘reformist’ circles and efforts, I am more familiar with this perspective, though I endeavored to balance things out by, for example, regularly writing for a university medical blog and attending conferences aimed at nurses and doctors. In any case, from my feminist position as both anthropologist and doula, ‘neutrality’ was never a goal. In the Bay Area, birth reformists are a professionally heterogeneous group with varying ideological commitments and degrees of investment, and include actors as diverse as parents, doulas, midwives, obstetricians, nurses, scientists, and activists . These reformists marshal claims about evidence-based practice to push back against hospital interventions from surgery to pharmaceuticals, arguing that existing medical practice is based on litigation, profit, and outdated social conventions, not science see .Although ‘evidence’ is on the surface an epistemological term, reformists deploy it in a political way to contest broader power dynamics, sometimes with the tone of activist underdogs challenging a patriarchal establishment. Reformists’ dissatisfaction with the politics of medical practice and knowledge production includes critiques of litigation, liability, and the ‘pharmaco-insurance-research industrial complex’. Science studies scholar Sociologists There are two ways that evidence can be a boundary object, lacking consensus yet enabling cooperation. The first concerns the kind of evidence that is being used and its relative quality. In EBM this is typically illustrated as a pyramid: randomized controlled trials (RCTs) are the ‘gold standard’ of evidence in contemporary biomedical systems, with systematic reviews of RCTs at the very top . BeneathMy argument takes place on a different level that is concerned with underlying epistemological paradigms. These go unarticulated even as reformist and biomedical use of evidence blends and blurs. Evidence as a concept is naturalized as self-evident and ahistorical in both orientations. Its general association with science lends it moral and epistemological potency; among those concerned with maternity care, it was implicitly understood that no one could be ‘against evidence’. Yet significant practical and political differences stemmed from how evidence was understood. In what follows, I first describe how I saw ‘evidence’ being used by reformists to shift paradigms of knowledge and practice. Then I work closely with Stengers’s ideas to trace how contemporary understandings of evidence came into being through social processes of consolidating authority; dominant understandings consider evidence as offering proof of cause, whereas marginalized understandings point to empirical outcomes. Finally, I consider the contemporary interactions between the different concepts of evidence, referencing Stengers’s concept of ‘curers’ to consider what further ‘evidential diversity’ might look like. Given the ubiquity and centrality of evidence not only in obstetrics but in medicine generally, what ‘counts’ is a high-stakes issue, consequential for everything from everyday doctor visits to whether insurance will cover potentially life-saving treatments labeled ‘experimental’. Being more explicit about epistemological underpinnings and their genealogies can, I suggest, improve maternity care, and potentially have even broader impact.‘Midwifery is the only intervention ever proven to reduce prematurity!’ exclaimed Missy Cheyney, the medical anthropologist and home-birth midwife speaking at the 2012 Midwives Alliance of North America (MANA) conference. MANA is the most inclusive professional midwifery organization, comprising hospital-based, home-birth, certified, licensed, and traditional midwives; Cheyney was speaking about the MANA Statistics Project, which collects data about births attended by midwives, primarily occurring in homes or birth centers. Her small stature belied her larger-than-life presence, as she urged the audience of mostly midwives to enroll in the MANA Stats Project, an online birth registry that collects de-identified birth data from clients who consent to participate. MANA’s Division of Research began collecting data through an online system in 2004 and the total sample size numbered more than one hundred thousand cases by 2016 (MANA n.d.-b). This registry would enable researchers who applied for access to the data set to study and make claims about safety and risk in midwife-led births at home and in birth centers, as well as to supplement and critique the obstetric canon offered by the biomedical research industry. Existing databases do not accurately capture planned home and birth center births in most states, which also makes funding such research challenging.This dynamic speaker enumerated many of the findings that were emerging from the studies underway and the resulting claims: more than 70 percent of women delivered not laying on their backs , and 50 percent had little to no perineal damage, suggesting a possible connection between delivery position and perineal tearing. She reported the rate of cesarean section for women who went into labor intending a home or birth center birth (5 percent) and described very high rates of exclusive breastfeeding at the six-week visit (98 percent). She elaborated a careful discussion of how to represent transfers to the hospital in the statistics. In her opinion, the data showed ‘What we’re doing right’, and that ‘Midwifery works!’ She lamented the spread of dominant US models of obstetric care to other countries — ‘low resource nations are attempting to emulate our broken system’ — and mentioned partner initiatives such as the Home Birth Consensus Summit, letting audience members know where they could get a PDF pamphlet of abstracts of all known research on home birth.Beginning with that MANA conference, which was the first I attended during my preliminary fieldwork, I noticed the phrase ‘evidence based’ used ubiquitously by those concerned with maternity care, including pregnant people and parents, obstetricians, researchers, midwives, doulas, childbirth educators, and community activists, both those I met in person and those whose writings I found online. In my fieldwork encounters, the ideas of evidence and evidence-based practice were used to reassure, persuade, advertise, lend legitimacy, and consolidate surety among those inclined to agree. They were used to challenge (or justify) protocols and to justify  controversial decisions, which could potentially include all decisions in the fraught cultural landscape of childbearing! It was only later that I learned about the term’s particular usage in contemporary medicine, which led me to consider the longer history of evidence and its role in legitimating scientific knowledge. Below, I give a few illustrations to set the stage for the genealogical claims that follow.EvidenceBasedBirth.com, to which I was referred frequently. For prospective parents, it offers a newsletter and free access to reports describing key studies or summarizing research on a particular topic, suggesting that parents ‘print them and bring them to your appointment to talk with your provider’ (Dekker n.d. -b). For professionals, the site runs an ‘academy’ offering training, certification, and continuing education credits. It also includes a blog and shop with branded goods. The website was founded by Rebecca Dekker, PhD, a nurse who cites her own negative birthing experience as catalyzing her realization that standard American maternity care is not based on research and, in fact, is shown by research to be harmful to healthy birthing women (Dekker n.d.-a). She aims to ‘[put] the evidence back in the hands of the people who need it the most: birthing people and their families’, instead of having it be ‘locked away in medical journals’ (Dekker n.d.-a). The reports she synthesizes often reinterpret data around hot-topic issues, such as induction and ‘overdue’ babies (One of the most obvious examples is the website ’ babies . Dekker Arguably the first evidence-focused reformist effort was the Mother Friendly Childbirth Initiative (MFCI), drafted in 1996 and updated in 2015, a consensus document MANA calls ‘ahead of its time’ (MANA n.d.-a). The MFCI has five principles — normalcy of the birth process, empowerment and autonomy [for the birthing person], doing no harm, and taking responsibility [for the practitioner] — and ten steps to implement them (Improving Birth n.d.). Regional, state, and national organizations support the initiative, notably the Coalition for Improving Maternity Services. A key facet in reformists’ use of evidence is the idea that much existing hospital birth protocol is not standardized or based on empirical evidence about patient outcomes. Many common hospital practices are critiqued for not being evidence-based — often by citing research suggesting that they are, in fact, detrimental to patient experience and outcomes — including episiotomies , continuous fetal monitoring, routine use of pitocin (a contraction-stimulating drug), inducing labor for babies that are ‘overdue’ or ‘getting too big’, directed pushing in which the birthing person is told when to ‘bear down’, routine use of the lithotomy position (lying on one’s back), and removing newborns to the nursery.A recent initiative aligned with the MFCI principles is the California Maternal Quality Care Collaborative (CMQCC), founded in 2006 at Stanford University School of Medicine together with the State of California in response to rising maternal mortality and morbidity rates and racial disparities . CMQCC hLocally, Natural Resources is a prominent brick-and-mortar resource center and store in San Francisco that offers classes, trainings, and support groups. One of its emails explains that:When prenatal education and maternity care are not patient-centered , it is possible that the risks of labor and birth interventions may not be fully disclosed. In many hospital environments, inductions and cesarean births occur more frequently than statistically medically-necessary. The hospital prenatal courses are educating you from the hospital model of labor, birth, and perinatal care which is actually sometimes based on ‘the way it’s always been done’ rather than the most current and valid research about what supports normal and healthy labor and birth. (email dated 24 March 2016)Natural Resources describes its own classes as ‘committed to patient-centered, evidence-based, empowered, fully-informed, and individualized education and labor/birth planning’ (email dated 24 March 2016). The collapsing together of these qualities is typical of the way I saw reformists refer to evidence, as though evidence were necessarily centered around patient experience or promoting empowerment, as opposed to an implicit doctor- or institution-centric, disempowering norm. Many critical histories and social studies point out how hospital practices evolved to suit doctors’ convenience and support a power structure in which they wield authority  is precisely the work of contemporary charlatans, who do not belong in the experiment-oriented medical profession because they make claims about ‘what happened’ without attempting to prove why. Medicine has been ill-suited to applying science’s explanatory powers. The epistemic culture of obstetrics would do well to move beyond differentiating its knowledge from ‘mere’ midwifery, as it has done historically. The hybridity and dialog between midwifery and obstetrics that has begun over the past few decades due to the efforts of reformists is, I argue, just such a process. Reformist agitation to link clinical practice and outcomes-based research does focus on curing, and it seems to me that one could generally substitute ‘outcomes based’ for ‘evidence based’ in reformist discourse. The evidence-based obstetrics The Skeptical OB, falls in line with this prediction. Such defensiveness will be especially an issue, Reformists’ appeals to evidence are claims to rationality, as opposed to superstition, intuition, magic, emotional intelligence, faith/belief, or other kinds of nonauthoritative knowing often associated with midwifery, especially historically . A ratioThe invocation of rationality via evidence parallels the professionalization of American midwives in the late 1990s, during which the formulation of professional credentials, licensure, and accreditation legitimated midwives’ inclusion as medical practitioners. Since then, they have effected significant change from within the medical profession. It was this projected ability to change the establishment, and thereby improve things for the majority of women, that tipped the debate in favor of those who wanted to professionalize, against those who were concerned with whether professionalization would hamper midwives’ independence and devalue the spirit and artistry of midwifery. While American midwifery and obstetrics are not nearly as integrated as they are in many other Western countries, the inclusion of midwifery in hospital settings and its increasing professional legitimation has reshaped American maternity care. The recent hospital proliferation of family birth centers and birthing suites, expanding beyond labor and delivery wards, and of baby-friendly hospitals in which the newborn is not removed to a nursery, is at least partially in response to pressure from consumers attracted to the more ‘personal care’ a midwife offers.This ‘personal care’ reflects an orientation around the birthing person’s perspective, which is the fundamental difference between curing and proving. What would happen if cure and care, which are necessarily centered on the patient, were integrated with RCTs and experimental practice, which are shaped by an epistemic history in which care is irrelevant to producing knowledge? Perhaps it would raise the question of whether outcomes can ever be objective or neutral. In much EBM, patients are only conceived of as having preferences that might be factored into clinicians’ decision making, not as experiencing care or being in a position to comment on its effectiveness, much less decide what the problem is that needs attention . ‘Outcomes’ are often referenced statistically, such as lowered rates of maternal death or cesarean section, which — while certainly not against the interests of birthing people — are also not patient-centric in the more qualitative sense in which power dynamics are altered.  Shifting attention from knowledge production to outcomes could highlight the experience of childbearing people, but it doesn’t necessarily do so, and there is reason to value experimental knowledge production for its own sake. Disaggregating the two genealogies of evidence — cure and proof — could allow for more specificity in how power and knowledge interact in birth.and partial contributor to medical knowledge can the imagined neutrality of medical research be confronted effectively, allowing other suppressed evidence to be brought to light’ (emphasis added). She also notes an obstacle to doing so: in the medical literature, writing on birth at present is too easily polarized between a stubbornly naive ‘birth works’ model, on the one hand, and the fearful and technocratic ‘a chance to cut is a chance to cure’, on the other. … These discourses are at cross-purposes. Appearing in different journals, they preach only to the converted, although both are also marketed to the pregnant consumer of health care. Neither group creates a world the other recognizes as real. , 227I propose that consolidating an authoritative understanding of evidence is not in the interest of optimizing maternity care for the benefit of childbearing people. Rather, in making the concept of evidence more capacious — articulating its diverse forms, expanding the types of evidence that are considered valid, and thinking through the kinds of benefits and situations to which each is applicable — maternity care might not merely allow for these differences but draw strength from them see . WendlanWhile in some ways the ‘evidence wars’ I have described reproduce these silos, in other ways evidence, boundary object that it is, creates a bridge between worlds. Articulating the multiplicity within the bridge is a step towards maternity care that benefits a greater diversity of birthing people. In As a next step, what if evidentiary practice were expanded to include the nonrational? Interestingly enough, some EBM assertions of the importance of clinician expertise sound similar, as they advocate for the role of ‘intuitive and experiential thinking, which characterize expert judgment’ , 420. Th