Every day there is criticism about lack of evidence on traditional, complementary, and integrative medicine (TCIM). But is this narrative evidence-based? Are we really missing research about TCIM? Or are we just not looking correctly at the evidence? Evidence maps are a useful method with the dual function of synthesizing available evidence on a specific topic and identifying knowledge gaps. This article presents a six-step evidence map methodology along with recently published TCIM evidence maps, including one related to COVID-19. TCIM evidence maps are useful instruments to inform decision-making for policymakers, health practitioners, and patients. Every day there is criticism about lack of evidence on traditional, complementary, and integrative medicine (TCIM). This lack of evidence was a common topic in the narratives of over 15 000 health care professionals . But is In 2019, the World Health Organization (WHO) Global Report on Traditional and Complementary Medicine  revealedSince 2002, the WHO Traditional Medicine Strategy  has beenOverall, TCIM evidence production has increased significantly over the last 20 years. During the regional meeting “Advancing towards Universal Health, Contributions of Traditional and Complementary Medicine,” organized by the Pan American Health Organization (PAHO) in 2017 in Managua, Nicaragua, the PAHO/WHO Latin American and Caribbean Center on Health Sciences Information (BIREME/PAHO/WHO) presented a proposal for creation of a Virtual Health Library (VHL) specialized in TCIM. During the meeting, delegates from various countries proposed the creation of a TCIM Collaborative Network for the Americas as a technical cooperation response to the demand from PAHO Member States for reliable sources of scientific evidence on TCIM .https://mtci.bvsalud.org/en/). The sheer number of studies creates a challenge for anyone navigating this saturated field. The VHL TCIM is a thematic virtual library that aims to promote the visibility, access, use, and publication of scientific, technical, and educational content that will contribute to promotion, development, and integration of TCIM into health care services and systems in the Americas through stakeholder collaboration.Currently there are over 1 million bibliographic references in the VHL TCIM , brought together a group of researchers and experts in the field to develop clinical evidence maps on TCIM. The objective of this article is to present the six steps of evidence map methodology and recently published TCIM evidence maps, including one related to COVID-19.Evidence mapping allows different types of evidence integration, as well as graphical or dynamic representations, through interactive online databases, which facilitates interpretation of results and may also include information about quality analysis and effects . These cThe first map developed by BIREME/PAHO/WHO was about the clinical effectiveness of ozone therapy, with a medical focus, revealing a need to widen its use. After this experience, the organizations involved in the project deliberated about the areas for the following maps, considering their application in the Brazilian health system. The seven practices selected are included in the National Policy of Integrative and Complementary Practices prioritized by the Ministry of Health of Brazil: traditional Chinese medicine , medicinal plants and phytotherapy, yoga, meditation, reflexology, oral ozone therapy, and shantala (infant massage). Because of the large number of studies in each area, the working groups decided only to include systematic reviews about each of the practices in these evidence maps.We report the methods and results according to PRISMA guidelines  and the TCIM evidence map methodology can be described considering six steps, each with a set of activities .https://mtci.bvsalud.org/en/evidence-map. These maps include over 800 systematic reviews, 500 interventions, and 400 outcomes . TCIM evidence maps are all available from the TCIM Evidence Map website In relation to level of confidence, we applied AMSTAR 2 and found studies with high, moderate, and low levels of confidence. Regarding evidence quality, the majority of TCIM evidence maps presented positive effects—although lack of effect was also attributed, as well as a few negative effects—analyzed using different methods by each systematic review. All this information is available on the TCIM Evidence Map website and is easy to access for policymakers, health professionals, and patients.Due to the challenges and urgency brought by the development of the COVID-19 pandemic, the Ministry of Health of Brazil, BIREME/PAHO/WHO, CABSIN, and the TCIM Network teamed up to develop a specific evidence map to describe different TCIM interventions and report health outcomes that could help in times of COVID-19. The main objective of this evidence map was to systematize scientific evidence in order to support professionals, managers, and researchers in the construction of documents and actions related to TCIM in the response to the pandemic.This evidence map includes 126 controlled clinical studies and reviews that are arranged in a graphic platform and distributed across 62 interventions and 67 clinical outcomes divided into immunological response, complementary clinical management, and mental health .Until now, there is no evidence of specific treatments for COVID-19. This work synthesized evidence for researchers and health professionals duly trained in the use of complementary therapies in the management of symptoms, especially in the dimensions of mental health and mild symptoms. Most antiviral activity findings described refer to respiratory viruses in general, not specifically to SARS-CoV-2; these may guide new research but do not necessarily support a therapeutic protocol recommendation .Evidence maps represent a broad grouping and repository of evidence published in indexed scientific journals, from various countries, to contribute to evidence-informed practices and also to respond to the ongoing pandemic. There is much evidence about TCIM that still needs to be gathered.There are several different ways to do evidence mapping , but usuThe aim of making all TCIM evidence maps available through an interactive platform at the VHL TCIM is to facilitate policymakers, health practitioners, and patients’ access to this information. In each map, it is possible to access different interventions, outcomes, and effects in order to promote TCIM evidence-based decision-making. Every map presents the number of studies in each category, areas with gaps, and level of confidence (based on AMSTAR 2) for each included study, so researchers can also identify areas that still require research.In these times of uncertainty, we would like to have all the cause-effect answers that Western medicine promises , as wellWe understand that evidence maps can only provide a broad overview of research, and the TCIM evidence maps cited will not be able to answer more refined questions, such as the most adequate TCIM application method, differences between health services, adequate training for practitioners, patient access, and self-application effects. But we believe future research, including qualitative research and case studies, is needed to answer these questions and is very important for TCIM-related evidence development.Evidence maps provide an easy visualization of valuable information on TCIM for policymakers, health practitioners, and patients, in order to promote evidence-based complementary therapies in line with the WHO Traditional Medicine Strategy 2014–2024 .RPSP/PAJPH and/or PAHO.Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the


We accidentally detected a subclinical wandering spleen on preoperative ultrasonography in a cat with gastrointestinal lymphoma. If the spleen is not in the normal position, the wandering spleen should be considered. We accidentally detected a subclinical wandering spleen on preoperative ultrasonography in a cat with gastrointestinal lymphoma. If the spleen is not in the normal position, the wandering spleen should be considered. Displacement due to twisting of the spleen is occasionally observed.2A 12‐year‐old male castrated mixed‐breed cat was examined for a 5‐day history of lethargy, anorexia, and vomiting. The cat had no relevant medical history, and it received routine vaccinations. On physical examination, its weight was 3.2 kg, rectal temperature was 37.5℃, and heart rate was 160 beats/min. Its general appearance was quiet, alert, and responsive. The cat had a body condition score of 3 .No abnormalities were found in the complete blood count. Biochemical analyses revealed abnormalities such as increased activities of alanine aminotransferase  and aspartate aminotransferase ; increased concentrations of total protein , albumin , glucose , and urea nitrogen ; and decreased concentrations of sodium , chloride , and potassium . The urinalysis results were unremarkable. Radiography of the thorax and abdomen revealed no abnormalities. Abdominal ultrasonography showed no apparent thickening of the intestinal wall but partial thickening of the muscularis (muscularis to submucosa ratio of 1:1) and swelling of the mesenteric lymph nodes (22 × 11 mm).Inflammatory bowel disease and lymphoma were suspected, but at the request of the owner, symptomatic treatment was performed with subcutaneous infusions of Ringer's acetate solution (50 ml/kg), famotidine , and metoclopramide . The cat showed repeated improvement and worsening of clinical signs for 2 weeks. The results of the tests performed during this period showed that the activity of feline pancreas‐specific lipase  had increased and the concentration of cobalamin  had decreased. The concentrations of total T4  and folic acid  were normal. The tests were performed in a commercial veterinary medical laboratory.On the 14th day, since there was no complete improvement in clinical signs, we decided to perform a full‐thickness biopsy of the intestinal tract by laparotomy. The cat was hospitalized, and an intravenous infusion of Ringer's acetate solution (10 ml/kg/h) was started. On the second day of hospitalization, all biochemical analysis items that were abnormal at the first visit were normal; only the serum amyloid A concentration  was increased. Blood coagulation tests showed a low prothrombin time , a prolonged activated partial thromboplastin time , and an increased concentration of fibrinogen . The D‐dimer concentration  was normal. Abdominal ultrasonography revealed no improvement in the thickening of the muscularis or swelling of the lymph nodes. Furthermore, the spleen, which was normal until the previous day, was displaced to the right side of the abdominal cavity  and ceftriaxone sodium hydrate  were administered for 3 days until discharge. During this period, the spleen was observed on ultrasonography, and there was no displacement from the normal position. Histopathological examination revealed a low‐grade gastrointestinal lymphoma. On the 25th day of hospitalization, anticancer therapy with prednisolone  and chlorambucil  was initiated. In addition, administration of cobalamin  was initiated for hypocobalaminemia. No displacement of the spleen was observed at this point either. Currently, 6 months have passed since the laparotomy, but no displacement of the spleen has been observed, and the gastrointestinal lymphoma is also in complete remission with tapering prednisolone  and chlorambucil.3Many wandering spleens in humans are generally diagnosed by clinical symptoms, such as abdominal pain, ultrasonography, or computed tomography.In humans, the wandering spleen is often found in the pelvis, although sometimes it may remain in the left upper quadrant and simply have an abnormal rotation. Ligamentous laxity can be acquired due to conditions such as splenomegaly or pregnancy; however, it is often congenital.There have been reports of generalized lymphoma in humans with a wandering spleen, wherein the wandering spleen was displaced in the pelvis, and the cause of displacement was unknown.The treatment of wandering spleen in humans is generally surgical due to the risk of torsion. Splenectomy is selected for cases with splenic infarction, and splenopexy or gastropexy is selected for those without splenic infarction.4We accidentally detected a subclinical wandering spleen on preoperative ultrasonography in a cat with gastrointestinal lymphoma. The findings of our study strongly suggest that this case had a congenital laxity or lack of ligaments that support the spleen. To the best of our knowledge, this is the first report of a wandering spleen in a nonhuman mammal, a cat.The authors declare no conflict of interest.MY contributed in writing—original draft preparation and supervision. MN is the primary clinician. Both authors have read and agreed to the published version of the manuscript.In Japan, there are no ethics committees available for private animal hospitals. Nevertheless, this study was conducted according to the ethical codes of the Japan Veterinary Medical Association. The samples obtained in this study were used after obtaining written consent from each dog owner.The samples obtained in this study were used after obtaining written consent from each dog owner.


Childhood nephrotic syndrome is widespread in pediatric nephrology. In most cases, it needs hospitalization for patient management. An increasing number of studies report that proper nursing care could promote the rate of treatment and improve post-treatment prognosis. Clinical nursing pathways refer to innovative nursing modes with high-quality, excellent efficacy, and low costing treatment. There are reports on how nursing methods that utilize data combine with clinical nursing pathway to enhance nephrotic syndrome care in kids. However, the results remain controversial. Therefore, it is necessary to conduct this study to systematically explore how evidence-based nursing combined with clinical nursing pathway plays a role in nephrotic syndrome care among children.This study protocol will conduct a comprehensive search on MEDLINE, Cochrane Library, CINAHL, EMBASE, Scopus, Chinese National Knowledge Infrastructure, WanFang, and Web of Science electronic databases to identify relevant research articles from inception to April 25, 2021. Studies in both English and Chinese languages are used for this study. This study protocol will analyze randomized controlled trials that investigated the role of evidence-based nursing combined with clinical nursing pathway to care for nephrotic syndrome in children. Two authors will independently screen the search results, select suitable studies for inclusion, extract the characteristics and outcome data of the selected studies, and evaluate the risk of bias based on standard Cochrane methodology. Any discrepancies will be resolved by consensus.The present study will summarize high-quality evidence to systematically explore how a nursing model based on evidence combined with clinical nursing pathway influences the caring of children with nephrotic syndrome.The present study will summarize the direct and indirect evidence to judge whether evidence-based nursing combined with clinical nursing pathway can improve the treatment and post-treatment prognosis in children with nephrotic syndrome.This study does not require an ethical approval.https://osf.io/bcrdk/).April 25, 2021.osf.io/bcrdk/ ( Nephrotic syndrome is also the second most encountered kidney-related condition in pediatric nephrology clinic. In general, based on the preliminary response to corticosteroid therapy at inspection, children with nephrotic syndrome are typically categorized as steroid-sensitive nephrotic syndrome and steroid-resistant nephrotic syndrome. The categorization is based on the International Study of Kidney Disease in Children studies during the 1970s, which indicated that regardless of morphological variations on kidney biopsy, the response to corticosteroid and additional immunosuppressive treatments is the most critical prognostic indicator in nephrotic syndrome. Therefore, as long as therapy remain responsive, kids with steroid-sensitive nephrotic syndrome exhibit outstanding prognosis with more than 95% improbability to advance to the final phase of kidney disease.Nephrotic syndrome is a commonly occurring kidney disease in children. It is prevalent all over the world, with an incident rate of 1.5 of 16.9 patients for every 100,000 kids and a prevalence of 16 patients for every 100,000 children.,7 A previous study showed that adopting a mental health clinical nursing pathway to help patients with malignant tumors can effectively reduce the suicidal intentions in patients and enhance their life standard. As the body of knowledge associated with nursing based on evidence grows and as nursing practice becomes increasingly reliant on actual, reliable scientific evidence from the patients, the conventional limited empiricism nursing model is evolving into a novel nursing concept. Few studies have reported the impact of utilizing nursing models based on evidence combined with clinical nursing pathway to care for children with nephrotic syndrome. However, the results are controversial. Thus, the current study will systematically explore the role of evidence-dependent nursing combined with clinical nursing pathway to care for nephrotic syndrome children.Clinical nursing pathway is widely considered as a means that provide useful knowledge regarding distinct patients and their treatment, including the provision of straightforward assistance in clinical settings. Therefore, it is an innovative high-quality nursing mode with excellent efficacy and affordability.2The present study aims to explore the role of evidence-based nursing combined with clinical nursing pathway to care for children with nephrotic syndrome.33.1 and it has been listed on the Open Science Framework .The present study will be performed as per the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols,3.2Ritu3.3Children  with a confirmed diagnosis of nephrotic syndrome will be included; there will be no restrictions on gender, race, and country.3.3.1Patients in the experimental group must receive evidence-based nursing intervention combined with clinical nursing pathway. Meanwhile, patients in the comparisons group must only receive evidence-based nursing intervention, clinical nursing pathway only, or no nursing intervention, except evidence-based nursing intervention combined with clinical nursing pathway.3.3.2The major outcomes included duration of hospitalization, hospitalization fees, and the satisfaction level of patients.3.3.3This protocol study will include randomized control trials investigating the role of combining evidence-based nursing and clinical nursing pathway to treat nephrotic syndrome children.3.43.4.1A comprehensive search will be performed on MEDLINE, Cochrane Library, CINAHL, EMBASE, Scopus, Chinese National Knowledge Infrastructure, WanFang, and Web of Science electronic databases to identify relevant studies from their inception to April 25, 2021. Articles published in both English and Chinese will be selected. The search terms given below will be combined using Boolean logic  to identify relevant studies: “clinical pathway,” “evidence-based nursing,” “nephrotic syndrome,” “randomized controlled trial,” and “RCT.”3.4.2This study protocol will go through the reference lists of all selected primary studies and review articles to obtain other related references.3.53.5.1A couple of authors will autonomously study the titles/abstract obtained through electronic and manual exploration. Afterwards, the complete text of each study will be further scrutinized to identify relevant studies. The present study will resolve discrepancies in judgement by consensus and discussion. The flowchart of searching and screening studies will be presented in Figure 3.5.2A pair of independent authors will extract all relevant information from each study through a generalized data extraction form. The following items will be extracted from individual studies: appropriate characteristics of the studies , intervention characteristics , population characteristics , and outcome measures. All discrepancies in judgement will be resolved through consensus and discussion.3.5.3 This study will resolve discrepancies in judgement by consensus and discussion.A pair of independent authors will evaluate the bias risk in the included studies. The procedure will be based on the Cochrane Risk of Bias Tool.3.5.4This protocol study will analyze the continuous data according to mean differences or standardized mean differences and 95% confidence interval, while the dichotomous data will be analyzed using the relative risk and 95% confidence interval.3.5.5In cases of missing data, the corresponding authors will be contacted to collect the lost data.3.5.6I2 statistic to evaluate statistical heterogeneity across studies. It is intended to consider a heterogeneity level of above 50% as substantial or high, in which case the random-effects model will be utilized; otherwise, the fixed-effects model will be adopted.This study protocol will utilize the 3.5.7We will intend to repeat the analyses while excluding studies at high risk of bias to evaluate the robustness of our findings if applicable.3.5.8It is also planned to devise and assess a funnel plot to investigate any plausible small study and publication bias where applicable. It is also intended to evaluate for asymmetry through Egger's test.4 The primary reference was local and foreign-associated studies and the explicit settings of the patients in the chosen group. The application of the nursing model must be performed strictly in accordance with the devised strategy. Afterwards, the completed section should be specified, while the incomplete section institutes the primary content of the subsequent nursing phase. Clinical nursing pathway aims to enhance the quality of treatment for patients by enabling multidisciplinary partnership and leading health care practitioners with evidence-based treatment strategies. The present study will summarize high-quality evidence to systematically explore how nursing based on evidence combined with clinical nursing pathway to care for children with nephrotic syndrome, besides facilitating the development of clinical guidelines, nurses can use the work done here as a reference. To the best of the author's knowledge, this study is the first to evaluate the role of evidence-based nursing combined with clinical nursing pathway when used to provide care for children with nephrotic syndrome.The clinical nursing pathway involves the devising and application phases. In a previous research, a specialized nursing team devised a nursing path which included the senior level to the visiting physician, head nurse, and nurses.Conceptualization: Xia Yu.Data curation: Xia Yu, Cai-Yan Han.Investigation: Cai-Yan Han.Formal analysis: Xia Yu, Cai-Yan Han.Funding acquisition: Cai-Yan Han.Methodology: Xia Yu, Cai-Yan Han.Project administration: Cai-Yan Han.Resources: Cai-Yan Han.Software: Xia Yu.Validation: Xia Yu, Cai-Yan Han.Visualization: Xia Yu, Cai-Yan Han.Writing – original draft: Xia Yu, Cai-Yan Han.Writing – review & editing: Cai-Yan Han.


Little is known about whether these domains are assessed or accounted for in DHIs.Digital health interventions (DHIs) are increasingly being adopted globally to address various public health issues. DHIs can be categorized according to four main types of technology: mobile based, web based, telehealth, and electronic health records. In 2006, Norman and Skinner introduced the This study aims to explore how DHIs assess and evaluate the eHealth literacy model, describe which health conditions are addressed, and which technologies are used.We conducted a scoping review of the literature on DHIs, based on randomized controlled trial design and reporting the assessment of any domain of the eHealth literacy model. MEDLINE, CINAHL, Embase, and Cochrane Library were searched. A duplicate selection and data extraction process was performed; we charted the results according to the country of origin, health condition, technology used, and eHealth literacy domain.We identified 131 unique DHIs conducted in 26 different countries between 2001 and 2020. Most DHIs were conducted in English-speaking countries , delivered via the web , and addressed issues related to noncommunicable diseases  or mental health . None of the interventions assessed all six domains of the eHealth literacy model. Most studies focused on the domain of health literacy , followed by digital , basic and media , and information and scientific literacy . Of the 131 studies, 7 (5.3%) studies covered both health and digital literacy.Although many selected DHIs assessed health or digital literacy, no studies comprehensively evaluated all domains of the eHealth literacy model; this evidence might be overlooking important factors that can mediate or moderate the effects of these interventions. Future DHIs should comprehensively assess the eHealth literacy model while developing or evaluating interventions to understand how and why interventions can be effective. DHIs can be defined as “health services delivered electronically through formal or informal care. DHIs can range from electronic medical records used by providers to mobile health  apps used by consumers” [eHealth or DHIs in their title or abstract has consistently increased over the past 20 years, starting from 65 in 2000 to 11,395 in 2019, reaching a total of 6720.In the last 20 years, digital health or eHealth has emerged as an important research field. At the intersection of medical informatics, public health, and business, eHealth refers to the use of “health services and information delivered or enhanced through the Internet and related technologies” . Technolnsumers” . On PubMSome systematic reviews and meta-analyses have described the effectiveness of DHIs in addressing various public health problems, such as somatic diseases , or healIn 2006, Norman and Skinner  proposedeHealth literacy scale (eHEALS), which has been one of the most adopted and cited, with 449 citations on the Journal of Medical Internet Research page and more than 1320 results on Google Scholar . The last domain of the eHealth literacy model, scientific literacy, involves the ability to allocate health-related findings in the right context by systematically understanding the “nature, aims, methods, applications, limitations, and politics” of building knowledge [Strictly related to the concept of eHealth is computer or technology literacy, which is the capability to use new technologies and software and the ability to access electronic health information . Recent nowledge ,8,25,26,nowledge -29.According to the developers of the eHealth literacy model, the six domains can be grouped into two main categories: analytic  and context-specific . The analytical category refers to a set of competencies that can be applied to a wide range of information sources, whereas context-specific categories include competencies that can only be applied to a specific problem in a specific context . For exaArguably, researchers developing DHIs should always take into account the domains of computer or technology literacy and health literacy, as these are potential pathways for more effective and equitable interventions . Health eHealth literacy and identified only four systematic reviews [However, to what extent are these assumptions tenable? In other words, is the eHealth literacy model purely conceptual or does it find a concrete application in DHIs? To the best of our knowledge, there are no systematic reviews that specifically discuss the application of the complete eHealth literacy model in DHIs. When we were developing the search strategies for this project, we searched for existing systematic reviews in PubMed and PROSPERO databases with the keyword  reviews -36. Howe reviews , underse reviews , older a reviews , or collWe followed the scoping review framework by Arksey and O’Malley , which eThe main review question, based on the eHealth literacy model, was “To what extent are DHIs assessing the 6 domains of the eHealth literacy model?” More specifically, we wanted to answer the following research questions: What domains of the eHealth literacy model  are assessed and reported in the literature? What health conditions have been investigated? What technologies are used?We searched four electronic databases that cover most of the medical and public health literature: MEDLINE, CINAHL, Embase, and Cochrane Library.eHealth literacy model, digital health, and the study design for interventions. The eHealth literacy model concept entailed terms such as health literacy, literacy, computer literacy, information literacy, basic, functional, scientific, media, information, computer, health, eHealth, literacy, literate, illiteracy, and illiterate. The second concept, digital health, expanded on the above and entailed keywords, such as telemedicine, internet, mobile, phone, digital, medium or media, mHealth, eHealth, telemedicine, and computer, based on other systematic reviews recently conducted by one of the authors [We used a predefined search strategy, encompassing keywords and medical subject headings to cover three main concepts:  authors ,38,39. T authors . The seaIn addition, we used the reference list of identified systematic reviews on the topic to identify other potentially relevant studies.We followed the Joanna Briggs’ Institute’s PCC (Population-Concept-Context) framework ,42 to deThe screening process consisted of two stages: title and abstract as well as full-text screening. The first stage involved 2 reviewers (MEB and MB) and one research assistant, who independently screened all records identified by the searches. This task was completed using a web-based application for systematic reviews, Rayyan . The intFor each retrieved record, 2 authors (MEB and MB) extracted the following information into a Microsoft Excel spreadsheet: first author name, year of publication, article title, journal, and number of trial registry (if available), principal investigator name (if available), country of the first author or of the principal investigator (if available). This information was used to identify and map articles pertaining to the same study. In the full-text stage, we also extracted text to verify whether the record included a digital component, was based on a randomized controlled design, focused on specific health conditions, and measured and reported results related to one of the domains of the eHealth literacy model .When multiple records were available for one study, we chose the country of origin of the first author or of the principal investigator listed in the study protocol; we chose the year of publication of the first published article available.mobile-based, including mobile apps, text messages, and interactive voice response, exclusively designed for mobile or other handheld devices; (2) web-based, including those designed for being accessed via computer, explicitly labeled as web- or internet-based, online, and e-learning, delivered through bespoke websites or social media outlets, such as social networking sites —social media are web-based apps that can be accessed via different devices connected to the internet, including smartphones [telehealth, comprising telerehabilitation, telemedicine, or other interventions focused on distributing services and information via electronic information and telecommunication devices [EHRs, focusing on EHRs that are defined as “a repository of patient data in digital form, stored and exchanged securely, and accessible by multiple authorized users” [hybrid.On the basis of the information extracted, we categorized studies according to the domains of the eHealth literacy model . We also inductively categorized the studies according to the health conditions described. When multiple conditions were reported, we categorized the study as having multiple conditions. Finally, we inductively categorized the interventions according to four main types of technology: (1) rtphones ,44,45;  EHRd users” . Telehead users” ,48. WhenThe first author and a research assistant independently completed the classifications; in case of inconsistencies or disagreements between the classifications, the fourth author acted as a third reviewer and resolved the disagreements through discussion. All the authors agreed with the final categorization.We performed a descriptive analysis of the characteristics of the included papers and reported the results by year of publication, the country of origin of the study authors, eHealth literacy domain, health condition, and type of technology used.The electronic database search yielded 4135 records. The selection process is summarized in the PRISMA  flow diagram shown in As shown in The studies were conducted in 26 countries . Most stIn the following sections, we have reported the results according to our research objectives, whereas a table with the detailed characteristics of the selected studies is provided in Of the 131 studies included, none assessed or measured all six domains of the eHealth literacy model. Most of the studies  focused on one of the six domains of the eHealth literacy model; only 5.3% (7/131) of studies reported the assessment of two domains, namely health literacy and digital or computer literacy. Most of the studies that reported on one literacy domain  focused on health literacy , followed by digital or computer literacy , basic or functional literacy , media literacy , information literacy , and scientific literacy .A large number of studies  discussed interventions addressing NCDs, such as hypertension, obesity, end-stage kidney disease, type 2 diabetes, chronic kidney disease, heart disease , fibromyalgia syndrome, and asthma. Of these 61 NCD-focused studies, 3 (5%) also discussed mental health topics, and 1 (2%) covered sexual and reproductive health. The second most covered category of health conditions was mental health , including depression, eating disorders, mental and behavioral disorders, anxiety, and suicide prevention. Other topics included health education , such as health promotion, health communication, patient provider communication and literacy, aging and maternal and infant health , sexual and reproductive health, and substance use . The remaining 11.4% (15/131) studies covered a variety of health topics.With regard to the technologies used, most studies included web-based interventions 68/131, 51.9%), followed by mobile-based , telehealth  EHRs , and hybrid interventions . Examples of web-based technology included e-learning portals for specialized training ,51, expe.9%, follAmong web-based interventions (n=68), most focused on NCDs , mental health , and health education topics . Mobile-based interventions (n=40) followed a similar pattern, with approximately half of the studies focusing on NCDs  or other health topics . Most telehealth , EHR , and hybrid  interventions focused on NCDs.This is the first scoping review examining the extent to which DHIs have assessed, accounted for, and reported any of the six domains of the eHealth literacy model by Norman and Skinner . We idenGlobal North, that is, from English-speaking countries including the United States, Australia, and the United Kingdom. A few studies have been conducted in countries of the Global South, such as Africa, Latin America, or South East Asia. This finding is consistent with that reported in a recent scoping review on digital health innovations [Global South has been previously reported in the literature [Most of the evidence comes from the ovations  and in aovations , which sterature -72, yet terature ; howeverterature ,73. Thirterature ,75. AnotOur findings showed that none of the 131 selected DHIs conducted in the last 20 years accounted for or assessed all six domains of the eHealth literacy model. Although these interventions were included because they assessed at least one domain of the model, only 5.3% (7/131) of studies included the assessment of more than one domain. These 7 studies assessed only digital and health literacy. Our study also shows that most DHIs have assessed and evaluated health literacy  among inThere are numerous explanations for these findings. First, researchers specialized in DHIs might not be familiar with or might have ignored the original model, even though the seminal paper by Norman and Skinner  and the Although intervention designers should aim to develop content that is understood by people with low functional literacy ,83, thisAnother important finding was that few identified DHIs assessed digital literacy (n=26). Not assessing digital literacy is based on the assumption that all participants are equally able to use technology and are able to make sense of the information delivered. This assumption might not be tenable in all contexts, and it does not allow researchers to understand whether participants appropriately received the intervention. In other words, health literacy is context-specific and varies according to different situations and topics. Arguably, health and digital literacy might act as moderators of intervention effects and not including these factors might underestimate or overestimate intervention effects .The limited assessment of digital literacy in DHIs also raises some ethical considerations in terms of equity and social justice, as these interventions tend to attract highly educated, healthy, and digitally literate individuals who have easy access to technology, leaving out less-educated and poorer segments of the population, who may be most in need of the interventions themselves ,85. ThisAnother reason for the absence of a comprehensive and accurate assessment of the six domains of the eHealth literacy model might be due to the fact that this assessment will be unfeasible and daunting for the participants. Holding constant the basic or functional literacy , assessing all six domains using existing scales for media, scientific, health, digital, and information literacy would require longer questionnaires that will take more time to complete, which might discourage participation in these studies. For example, one of the most used instruments to assess digital literacy is the relatively short (8 items) eHEALS . HoweverThis scoping review showed that the selected DHIs published in the last 20 years focused mostly on NCDs, delivered via web- or mobile-based platforms. This is consistent with the findings of a few recent scoping reviews focusing on research on DHIs for behavior change ,94 or inTo the best of our knowledge, this is the first scoping review that systematically examined evidence pertaining to the application of the eHealth literacy model by Norman and Skinner  in DHIs.This review suggests that future DHIs should focus more on the assessment of the eHealth literacy domains when developing a DHI, especially the domains that are assessed the least, such as scientific, media, basic, and information literacy. Even though assessing all domains of the eHealth literacy model might be unfeasible, it would allow researchers to account for factors that might moderate or mediate the effects of the interventions on the targeted health outcomes.Future systematic reviews should be conducted to examine the effects of DHIs on various health outcomes identified in this review by anticipating subgroup or sensitivity analyses comparing different types of intervention, delivery modes, and most importantly different levels of health literacy or digital literacy.


Investments to promote sustainable land-use within critical river catchment areas are often undertaken to provide benefits to society. Investments generally aim to protect or restore ecological infrastructure—the underlying framework of ecosystems, functions and processes that supply ecosystem services—for multiple benefits to society. However, the empirical evidence base from studies across the world on both mechanisms and outcomes to support these assumptions is limited. We collate evidence on the benefits of ecological infrastructure interventions, in terms of ecosystem services provided to society, from three major South African water-providing catchments using a novel framework. In these catchments, millions of US Dollars' worth of investments have been made into ecological infrastructure since 1996. We ask the question: is there evidence that ecological infrastructure interventions are delivering the proposed benefits? Results show that even in catchments with substantial, long-term financial investment into ecological infrastructure, research has not empirically confirmed the benefits. Better baseline data collection is required, and monitoring during and after ecological infrastructure interventions, to quantify benefits to society. This evidence is needed to leverage investment into ecological infrastructure interventions at scale. Investment at scale is needed to transition to more sustainable land-use to unlock greater benefits to nature and people. There hEcological infrastructure interventions aim to provide multiple ecosystem services to society , as wellIn the last decade, more than 80 countries committed to restore over 30 million hectares of degraded land by 2020 under several UN frameworks , requiriIn South Africa, a nation with water security challenges, the government has invested in restoring ecological infrastructure with the focus of augmenting water provision and creating jobs . Here, w. 2. 2.1The Berg, Breede and uMngeni catchments are nationally important, water-stressed strategic water source areas  figure . Strateg. 2.2Our approach to assessing the evidence base in these three catchments included three phases. The first included the development of an ‘ecological infrastructure intervention – ecosystem services' (EII-ES) framework which we used to hypothesize the effects of ecological infrastructure interventions on ecosystem processes and services. The second stage included a literature review of peer-reviewed and grey literature in these three catchments. Lastly, we integrated the hypothesized EII-ES framework with the evidence from the literature review using causal loop diagramming principles. We discuss each of these phases in detail below.. 2.2.1We developed a framework within which the effects of different types of ecological infrastructure interventions on ecosystems processes and services were hypothesized . To do tSeveral assumptions were made to establish the direction of impacts: (i) that the interventions will result in natural ecosystem recovery, the extent of which depends on probable chance of success of the intervention , (ii) th. 2.2.2There has been substantial financial investment into ecological infrastructure interventions in the Berg, Breede and uMngeni catchments in South Africa in comparison to other catchments ,18. Thern = 106) and 56% specifically mentioned a benefit in terms of ecosystem service delivery (n = 69). Of these 69 papers/reports that specifically mentioned a benefit, 74% explained the process behind this (i.e. how the intervention affected ecosystem service delivery) (n = 51). These 69 papers/reports were selected for further, detailed analysis.The total papers/reports for each site were: Berg (1029), Breede (502) and uMngeni (113). These were given an initial screening for relevance . Three hundred and ten papers and reports were selected for further analysis. Approximately 58% of studies were from the three catchments, approximately 11% elsewhere in South Africa, and approximately 20% in the rest of the world . The pubIn the more detailed analysis, the specific ecological infrastructure interventions of these 69 papers/reports were recorded, as well as the ecosystem process and/or ecosystem services investigated. This resulted in 393 cases of reported benefits of investing in ecological infrastructure. It is important to note that sometimes the linkages were implied and not explicit. For example, because the concept of ecological infrastructure, and even ecosystem services, is relatively new ,23, manyn = 12), ecosystem properties and processes (n = 34) and ecosystem services (n = 19) were generated. Next, the 269 cases relating to ecosystem services were extracted for further analysis . The terminology for the ecosystem services framing was based on Boerema et al. [From the 393 cases, lists of ecological infrastructure interventions , processes and ecosystem services using systems thinking and causal loop diagramming principles . This wa. 3. 3.1For the EII-ES framework, we identified 17 different types of ecological infrastructure interventions and assessed the chance of success and relative cost of each intervention for the study catchments . There iWe hypothesized the impacts of these 17 interventions on 14 different ecosystem services for the study catchments . The rea. 3.2From the literature review, we identified 12 broad groups of ecological infrastructure interventions, which partly mapped out onto the 17 types from the EII-ES framework , but witThe 12 types of ecological infrastructure interventions identified from the literature can be divided into four main categories in terms of their targeted impacts: the first are those that aim to restore native plant biomass , the second are those that target reducing alien plant biomass , the third are those that target sediment retention and influence system hydrology  and the fourth are those that aim to impact fauna, by providing habitat, or restoring abiotic cues .Of the 12 broad types of ecological infrastructure interventions, invasive alien plant clearing, establishing buffer zones and the general ‘restoration' category had the largest evidence base, with more than 25 cases investigating their benefits . In most. 3.3et al. [Using the systems dynamic model, we show that five of these ecological infrastructure interventions (and two of the four categories described above) are implemented at the interface of a native versus alien biomass dynamic feedback loop . Woody aet al. ). This n. 3.4The key results from the three analyses are summarized as follows. Our novel EII-ES framework hypothesized that 40% of ecosystem services were likely to either increase, or increase together with no change, 25% were hypothesized to either increase or decrease depending on the context, while 24% and 11% were hypothesized to not change, or decrease together with no change, respectively. This differed for the literature review, where the vast majority of cases (96%) showed increases in ecosystem service provision. This suggests a bias, whereby only the ecosystem services thought to increase are investigated or considered in research. Only 4% of studies reviewed involved direct measurements, while 5% were modelled, and the vast majority were conceptual (91%). The quality of the evidence was relatively high for 71% of empirical and modelling studies. There was little overlap between the interventions considered in the EII-ES framework and those that emerged from the literature (seven types were in common). The systems dynamic model highlighted some important knowledge gaps, revealing that the benefits of ecological infrastructure investments were only empirically measured on five ecosystem services as well as biodiversity, whereas the impacts on ecosystem properties are considerably better quantified.. 4Overall, the results suggest that the state of the ecological infrastructure interventions evidence base is empirically limited, and this has important implications. In terms of sustainable land-use, it appears that in these three South African catchments, ecological infrastructure interventions are mostly based on sound ecological principles; however, the empirical evidence on process and outcomes is lacking. This makes it difficult to sustain good management practices and investments into ecological infrastructure. We discuss the results and their implications further here, in three subsections: §4.1. The state of the ecological infrastructure interventions evidence base, §4.2. The importance of local, empirical studies and §4.3. The evidence base to leverage investment.. 4.1We aimed to establish whether there is evidence available that ecological infrastructure interventions are delivering the proposed benefits in three well-invested and researched South African catchments. The main finding of this review is that the evidence for the benefits of ecological infrastructure interventions in these catchments is mostly propositional. Although most of the research shows positive benefits, 91% of this research to date has been conceptual. This result is similar to that of an international review on economic evaluation of wetland restoration that concluded that the understanding of the value achieved is ‘tentative' . The staIn the more-established field of ecological restoration , where clear methods and indices exist for monitoring and evaluation, a global review found that the number of empirical evaluations has grown substantially, as have those that assess ecological functions . HoweverAlthough the ecological infrastructure investment evidence-based is limited for these three catchments, in most cases ecological infrastructure interventions were found to be beneficial. A review of nature-based solutions in the United Kingdom also found that, while there is a clear evidence base linking certain interventions to human well-being, there is no comprehensive mapping of multiple positive and negative outcomes for different contexts . Therefo. 4.2The complexity of ecosystems and the social contexts in which they are embedded implies that benefits of ecological infrastructure investments are likely to be highly context-specific . TherefoThe systems dynamic model constructed in this study for a ‘generalized South African ecosystem' demonstrates complexity through the interconnectedness of each property and process in the ecosystem. It highlights how an investment that targets a single ecological infrastructure intervention in isolation  is unlikely to be successful in a complex, fire-adapted ecosystem. The complexities of fire-adapted ecosystems  means that holistic approaches  are critically important for successful ecological infrastructure interventions ,41. One . 4.3To leverage investment into ecological infrastructure for more sustainable land-use, a better understanding of financial returns as well as investor preferences has been cited . In SoutCould the lack of empirical evidence at a local scale be hindering potential large-scale private sector investment that is currently missing in South Africa, and globally? Despite significant public sector funding, the overall value and scale of investments into ecological infrastructure in South Africa is considered small relative to that required ,45. Inve. 5The results of this study support five main conclusions: (i) The evidence base for the benefits of investing in ecological infrastructure is empirically weak for three of the most invested-in South African catchments. (ii) There is a need for better baseline data collection, and monitoring during and after ecological infrastructure interventions to establish evidence for the benefits. (iii) We recommend that governments make funding available to support focused, applied and local empirical research to build an evidence base for the benefits of ecological infrastructure investments globally. (iv) Private sector investment could potentially complement and relieve constrained public sector funding; however, evidence of financial returns is required. (v) Finance to be able to implement ecological infrastructure interventions at scale could bring greater benefits to nature and people through more sustainable land-use.Click here for additional data file.


This issue of Campbell Systematic Reviews includes the first two evidence and gap maps (EGMs) to be published by the Campbell Collaboration. The first is a map of 396 studies of the impact of agroforestry on agricultural productivity, ecosystem services and human well‐being , copublished with the International Initiative for Impact Evaluation (3ie). The other EGM is of 166 studies on the effectiveness of interventions for people with disabilities in low‐ and middle‐income countries , which has just one outcome rather than set of outcomes. The EBPM is also an exception in being one of the maps that report what the evidence says .Approaches vary in terms of presentation of maps as well. Some use visualisation, like 3ie and Campbell, whereas others only present findings as descriptive reports such as the Global Evidence Mapping Initiative and the Collaboration of Environmental Evidence.Campbell has a long‐standing track record of being one of the pioneers in synthesising and promoting the dissemination of high‐quality, unbiased evidence and helping our readership to understand why standards and principles in evidence‐making matters. This devotion goes into the setting of conduct and reporting standards for evidence mapping. Campbell EGMs include a visual presentation of the evidence as a matrix. Most usually, the matrix shows intervention categories (rows) and outcome domain (columns). The map may have additional dimensions capturing study or intervention characteristics, such as study design, location and population sub‐group, which can be applied as filters. The map is interactive: users click on entries to see a list of studies, and on study names to access a database record for the study. Campbell has produced and innovated in maps to a range of research questions.1.They can be applied to a range of research questions such as of studies of effects, prevalence, implementation and barriers or facilitators.2.The type of evidence included in the EGM depends on the research questions. A mega‐map  is the most important—and often the most difficult—part of developing an evidence map.4.The secondary dimensions may comprise study design, population, region, country and can be used as filters for relevant evidence.5.Stakeholder consultation, particularly consultation with the funder(s), is an important stage in developing the map—most notably the framework.6.The title of the EGMs should define the scope of the map.7.EGMs have a broader scope than systematic reviews and the scope is defined by PICOS.8.The reports are always accompanied by plain language summaries to facilitate research use.9.It is desirable to have a maintenance plan to update maps annually.Priority points to consider for EGMs are as follows.Campbell has been working with different stakeholder agencies on innovations in evidence mapping. As already mentioned, we have worked on maps with different scopes: EGMs, mega‐maps and the map of maps. Whilst most maps to date are effectiveness maps, we have also produced maps of process evaluations for interventions for people experiencing homelessness, and one of tools, methods and metrics for studies analysing nutrition‐agriculture linkages. Country evaluation maps capture all evaluations of socioeconomic interventions in a single country—such maps are ongoing for Kenya, Uganda and the Indian state of Karnataka. There is also a map of just effectiveness studies for India.As intended, maps are used in various ways. The child welfare mega‐map was used by UNICEF in its decision to fund an EGM of violence against children. The homelessness maps commissioned by the Centre for Homelessness Impact are being used as the basis for three systematic reviews. The Uganda Country Evaluation Map is being used in the planning process by the Office of the Prime Minister.Do you have an interesting idea, topic or suggestions for an EGM? We would love to hear your thoughts. You can also register with us to join the innovation!


To provide guidance for the management of mood disorders, both depressive and bipolar disorders, based on scientific evidence supplemented by expert clinical consensus.It is the EIT responsibility to monitor a patient's physical health and the effects of anti-psychotic medication for at least the first 12 months.The update has been developed in a consistent manner to the 2015 guideline. The composition of the working group has remained largely the same as has the process to evaluate the evidence and synthesise the findings. To approach the update, the working group identified areas within the 2015 guideline where significant changes had occurred, for example the development of new therapies or where thinking and practice have changed and new ideas have emerged. Recommendations were reviewed in light of any new findings and evidence. As only some sections of the 2015 guideline have been updated/revised, the time taken to develop the update has been considerably shorter. Public consultation and peer review informed the final version.This led us to review the mechanism in the team for arranging and reviewing these investigations.The mood disorders clinical practice guideline update addresses both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework supplemented by expert clinical consensus.


The DHLI was directly and significantly correlated with age, subjective social perception, sense of coherence, and well-being (p < 0.001). The average digital literacy was higher in men than in women, in students older than 22 years, and in those with greater satisfaction with online information (p < 0.001). The COVID-DHLI-Spanish is useful for measuring the digital literacy about COVID-19 in Spanish-speaking countries. This study suggests gaps by gender and socioeconomic perception.Digital health literacy influences decision-making in health. There are no validated instruments to evaluate the digital literacy about COVID-19 in Spanish-speaking countries. This study aimed to validate the Digital Health Literacy Instrument (DHLI) about COVID-19 adapted to Spanish (COVID-DHLI-Spanish) in university students and to describe its most important results. A cross-sectional study was developed with 2318 university students from Spain, Puerto Rico, and Ecuador. Internal consistency was measured with Cronbach’s alpha and principal component analysis. Construct validity was analyzed using Spearman’s correlations and the Kruskal–Wallis test. The internal consistency of the questionnaire was good for the global scale  as well as for its dimensions. A total of 51.1% ( The current COVID-19 pandemic has provoked an avalanche of digital information, to the point of being considered an infodemic by the World Health Organization. The large amount of information available can be overwhelming for citizens and even counterproductive if false, incomplete, or inadequate information is accepted as real. The citizen who receives the information must have sufficient elements to interpret it in its context, discriminate it, and use it for better health performance, in order to limit the spread of the disease and promote a culture of care [The World Health Organization defines health literacy as “the personal characteristics and social resources necessary for individuals and communities to access, understand, evaluate, and use information and services to make decisions about health” . In thisOn the other hand, low digital health literacy has been associated with higher mortality , hospitaDuring the pandemic, the use of digital social media such as Facebook, YouTube, and Twitter, among others, became the main source of information search ; worldwiAccording to other authors, the digital literacy on COVID-19 in young adults has important limitations, despite their constant use of digital media ,17. LikeIn order to better manage the ability to use information, discriminate it, and take advantage of it for the benefit of health, it is necessary to strengthen digital health literacy. One of the first steps for this is to have valid instruments that will allow us to evaluate the level of digital health literacy related to COVID-19 . From thIn recent years, several instruments have been developed to measure digital health literacy . One of To our knowledge, there have been no previous studies evaluating the validity of a digital literacy scale in a Spanish-speaking population. The purpose of this research was to evaluate the validity of the DHLI scale for digital literacy related to COVID-19 adapted to Spanish and to analyze the main characteristics of the digital literacy around COVID-19 in university students. The novelty of this study is to have a digital health literacy measurement instrument adapted and validated for Spanish. From this instrument, it will be possible to carry out research that evaluates the digital literacy on COVID-19 in the Spanish-speaking population.https://covid-hl.eu, accessed on 21 February 2022), a research network on DHL related to COVID-19 in university students, which includes researchers from 50 countries including the authors of this article. This article analyzes the adaptation and validation into Spanish of the DHLI questionnaire of digital literacy applied by the COVID-HLI consortium [This study was designed within the framework of the COVID-HL research consortium  was measured with the Spanish translated version of the Digital Health Literacy Instrument (DHLI) used by the global COVID-HL Consortium  and desiThe methodology proposed by van der Vaart  was follSex: Male/female/diverse;Age: Categorized into under 22 years old and over 22 years old;Country of origin: Spain, Puerto Rico, Ecuador;Subjective social perception: Refers to the social position of the student. This is based on the MacArthur methodology developed by Adler , in whicSubjective well-being: Subjective well-being was measured with the World Health Organization (WHO) well-being scale . It consA survey that also contained the following variables was administered:Cronbach’s alpha was used for the analysis of the internal consistency of the scale and each dimension. For the validation of the content of each dimension, a principal component analysis and a varimax rotation were used to examine the theoretical fit of the five dimensions.p-value of less than 0.05 was considered significant.To measure the construct validity, the characteristics or theoretical concepts that would be related to better digital health literacy such as age, subjective social perception, sense of coherence, anxiety about the future and well-being in the last two weeks were considered. Spearman’s correlations with these variables were calculated, and a ® version 15.0 software .In addition, Kruskall–Wallis non-parametric mean tests were performed to observe differences in the digital health literacy scale between sociodemographic variables. Data were analyzed using Statan = 1161) of the students corresponded to universities in Spain, 39.54% (n = 917) to Ecuador, and 10.29% (n = 241) to Puerto Rico. n = 1624), with age less than or equal to 22 years , coming from majors related to Life Sciences and Health , and who were studying at the undergraduate level . On a scale of one to 10, 26.61% (n = 617) of the undergraduates rated themselves as having a social status of 7. A total of 19.97% (n = 463) of the students reported having a chronic condition. Overall, there were no significant differences in sociodemographic characteristics between countries  was good for the global scale  as well as for each of its dimensions, except for the privacy dimension, which presented a Cronbach’s alpha of 0.45 (95% CI 0.67). p < 0.001, suggesting that there was sufficient correlation between each component of each dimension to be able to perform the analysis. The Kaiser Meyer Olkin sample adequacy measure was 0.86, suggesting that the sample was large enough for the analysis.Principal component analysis presented a chi-square with 2105 degrees of freedom of 8479.45 and The DHLI scale translated into Spanish presented a direct and significant correlation with age, subjective social perception, sense of coherence, and well-being in the last two weeks; in contrast, an inverse and significant correlation was obtained with the presence of anxiety about the future .n = 946) of the respondents were found to have sufficient digital literacy, 40.1% (n = 742) had problematic digital literacy, and 8.8% (n = 162) had inadequate digital literacy.The mean for digital health literacy was 2.94, with a standard deviation (SD) of 0.57. The dimension that presented the highest scores was privacy protection with a mean of 3.40 ± 0.54, while the self-generated content dimension presented the lowest mean of 2.81 and SD of 0.60. According to these findings, 51.1% (p < 0.001). There were also significant differences in age, with those aged younger than 22 years having lower DHLI scores than those aged 22 years or older . Similarly, higher DHLI scores were found in those who were studying for their master’s and doctoral degrees compared to undergraduate students . Additionally, those who were very satisfied with COVID-19 related information found on the Internet had significantly higher DHLI scores than those who were dissatisfied .The current COVID-19 pandemic has highlighted the importance of digital health literacy. Digital health literacy includes access to appropriate information, discrimination of messages, and care- and prevention-oriented decision making ,9. HealtThe young adult population is one of the main consumers of digital information , and at The current study analyzes the validity of the DHLI adapted to Spanish (COVID-DHLI-Spanish) to evaluate the digital health literacy related to COVID-19. The COVID-DHLI-Spanish achieved a Cronbach’s alpha of 0.69, which demonstrates a good internal reliability of the overall scale; moreover, the internal consistency was adequate for each of its dimensions, except for the privacy dimension, which obtained a Cronbach’s alpha of less than 0.5. This was similar to what was found in the validation of the original van der Vaart and Drossaert scale . The relThe DHLI scale adapted to Spanish also showed a significant correlation with age, subjective social perception, anxiety toward the future and well-being in the last two weeks, which implies adequate construct validity. This is consistent with a previous study conducted in South Korea that found appropriate construct and discriminant validity for the same questionnaire . It is kIn the present study, slightly more than half of the young adult university students had sufficient digital literacy, meaning that only one in two university students had adequate digital literacy; given the context in which the study was applied, this is concerning. A total of 40.1% had problematic digital literacy, and 8.8% had inadequate digital literacy, which is similar to findings from other studies worldwide . In GermAdditionally, this study found higher COVID-19 related digital literacy scores in men, as reported in other studies . AlthougSimilarly, master’s or doctoral level students presented better digital health literacy scores, which would be explained by their better background knowledge to discern the information available in digital media and social networks, and which has been corroborated by other studies ,46. LikeThis study has some limitations, one of which is that it was not possible to carry out a concurrent validation, since there were no other scales available in its class that were adapted and validated in Spanish. Likewise, it was not possible to evaluate the validity of the scale for the different ethnic groups that inhabit the countries included in the study. Similarly, the data collection was carried out in a young adult population that regularly attended public and private universities, so there may be a bias in the information. Although it is a multicenter study, the sample was at convenience, so the population was not representative of all young university students in the three countries included. In this study, no other additional results on the associations and effects of digital literacy on health in the context of COVID-19 are presented. This analysis is part of a subsequent article.The main advantage of this research is that it is a study that includes a population from three Spanish-speaking countries, and it is the first of its kind to analyze the validity of a scale from the digital health literacy related to COVID-19 adapted to Spanish. Previously, the same original Dadaczynski, Orkan and Rathmann  questionThe digital health literacy has proven to be a key determinant to promote decision-making, behaviors, and actions in favor of health in times of pandemic. The present study aimed to analyze the validity of the DHLI scale on COVID-19 adapted to Spanish in university students and to describe its main results. The COVID-DHLI-Spanish was found to be a valid and reliable instrument to measure digital health literacy in relation to COVID-19 in Spanish-speaking populations. The authors recommend using the DHLI questionnaire adapted to Spanish to monitor and evaluate the digital health literacy in relation to COVID-19 as a valid instrument for Spanish-speaking countries.Better digital health literacy supports sound decision-making and is associated with better health outcomes in the context of COVID-19, both individually and collectively. In this study, we observed that barely one in two university students had adequate or sufficient digital literacy on COVID-19, which is worrying, given that they are frequent users of social networks, and who, in turn, can influence the decision making by other individuals, be they colleagues, friends, family members, etc. On the other hand, this study found significant differences in digital health literacy by sex, age, and socioeconomic perception, suggesting socioeconomic and gender inequalities in relation to digital health literacy. These findings show the need for public health policies and health promotion strategies focused on strengthening the digital health literacy in the university population and in the Spanish-speaking population in general, guaranteeing equity in access to information and in the skills to manage, discriminate, and apply information to health.


Remote robotic-assisted endovascular interventions require real-time control of the robotic system to conduct precise device navigation. The delay (latency) between the input command and the catheter response can be affected by factors such as network speed and distance. This study evaluated the effect of network latency on robotic-assisted endovascular navigation in three vascular beds using in-vivo experimental model. Three operators performed femoral, carotid, and coronary endovascular robotic navigation blinded from the hybrid room with the prototype remote-enabled CorPath GRX system in a porcine model. Navigation was performed to different targets with randomly assigned network latencies from 0 to 1000 ms. Outcome measurements included navigation success, navigation time, perceived lag , and procedural impact scored by the operators . Robotic-assisted remote endovascular navigation was successful in all 65 cases . Guidewire times were not significantly different across the simulated network latency times. Compared to 0 ms added latency, both the procedural impact and perceived lag scores were significantly higher when the added latency was 400 ms or greater (< 0.01). Remote endovascular intervention was feasible in all studied anatomic regions. Network latency of 400 ms or above is perceptible, although acceptable to operators, which suggests that remote robotic-assisted femoral, carotid or coronary arterial interventions should be performed with network latency below 400 ms to provide seamless remote device control. Robotic-assisted endovascular interventions have multiple advantages compared to conventional, manually performed interventions. They play a significant role in reducing occupational hazards for the operator, such as radiation exposure and orthopedic complications due to heavy lead aprons , 2. WithThe feasibility of percutaneous coronary intervention (PCI) from long geographic distances has been previously described in both animal models and humans –5, but tDuring remote robotic-assisted navigation, the operators use joysticks to manipulate the endovascular devices. Real-time response of the system is required to carry out precise navigation between the remote and local sites, which highly depends on network performance. The effect of network latency during coronary artery navigation and PCI has been demonstrated, but no data is available on its effect, when robotically navigating in the peripheral arterial system. This preclinical study aims to evaluate the effect of network latency on robotic-assisted endovascular navigation in coronary, lower extremity and extracranial arteries using an in vivo experimental model.The CorPath GRX  is a robotic system, FDA-cleared for coronary and peripheral vascular interventions and CE-marked for neurovascular interventions. The robot allows the operator to deliver and navigate guidewires, rapid exchange devices and guide catheters via joystick control. The system is compatible with commercially available 0.014-inch guidewires and standard rapid exchange (RX) balloons and stent delivery systems. The bedside component includes a single-use sterile cassette, which advances, retracts, and rotates the guidewire and the guide catheter, advances and retracts the RX device. This cassette is attached to a robotic drive that can advance and retract the guide catheter with its forward and backward movements. With the use of the advanced cassette, the system is also capable of manipulating microcatheters. The robotic drive is supported by the extended reach arm, which is mounted on the bedside rail.The operator sits in a radiation-shielded interventional cockpit and navigates the devices via the control console. The control console consists of a touchscreen and three joysticks for RX device, guidewire and guide catheter manipulation.The present study utilized a remote prototype modification of the CorPath GRX system, which allowed the physical separation of the remote and local nodes, while connected via the institutional network. The robotic control unit and drive were connected to a target computer  that each utilized a grandmaster clock and global positioning system antenna for synchronization of the control unit with the robotic drive. In this study the in vivo model, robotic arm, and bedside technician were located in a hybrid interventional suite , while the operators were navigating the endovascular interventional devices from the control room (“remote”), facing away from the hybrid room Fig. .Fig. 1LaThe remote workstation includes monitors that display angiographic images, reference images, and hemodynamic data, similar to a typical CorPath GRX case. A telepresence system  was used to communicate via live audiovisual streams of the operating room, operational field, and remote workstation.Network latency was simulated by delaying robotic commands in the remote prototype modification of the CorPath GRX System. Simulated latencies ranged from 0 to 1,000 ms and were additive relative to the low (but nonzero) native latency of the institutional network.The procedure was performed in a domestic cross, female swine weighing 49.1 kg. The animal procedure was conducted under a protocol approved by the Institutional Animal Care and Use Committee.The animal underwent standard anesthesia procedure by a clinical veterinarian and the access site was prepared and draped. Right common femoral access was gained, and a 6 French sheath  was placed in the contralateral common femoral artery under fluoroscopy guidance . Femoral arterial robotic navigation was performed with a 0.014″  or 0.018″ wire  and a 0.027″ microcatheter . For the external carotid arterial approach, a 7F Envoy guide catheter (90 cm)  was placed in the ostium of the left common carotid artery with a 0.014″ wire  and a Renegade Hi-Flo microcatheter . For coronary arterial navigation, a Q3.5 guide catheter  was placed in the ostium of the left coronary artery with a 0.014″ wire.Angiography was performed in each vascular bed after the sheath was placed in the ostium of the target vessel, and based on the angiography, navigational targets were defined. These targets were a distal deep femoral branch, lingual artery, branch of the facial artery, and the diagonal branch of the left anterior descending coronary artery.A vascular surgeon, a neurosurgeon, and an interventional cardiologist participated, and performed femoral, external carotid and coronary arterial navigation, respectively. Each operator has completed > 20 endovascular robotic cases in both ex-vivo and in-vivo cases. Their task was to robotically navigate the guidewire from the tip of the guide catheter to the preselected targets. After the navigation to a target was completed, the wire was retrieved in the tip of the guide catheter, and the run was repeated.During different runs, randomly assigned robotic command delays (latencies) were added to the system ranging from 0 to 1000 ms . LAN connection includes an intrinsic command and image delay, which was incremental to the injected latency times. Operators were blinded to latency times. The first four runs were performed with 0 ms added latency, then random latencies were added to each run, up to 19 runs total per navigational target.After finishing the endovascular navigational tasks, devices were removed, the access site was closed, and the animal was euthanized.The success of guidewire navigation was defined as the ability to navigate the guidewire from the tip of the guide catheter to the preselected target. For each run, guidewire times were measured. After every run, operators scored the perceived latency and the procedural impact on a scale from 1 to 5. Perceived latency was scored by the operators according to the following scale: 1 = imperceptible; 2 = noticeable but minor; 3 = noticeable; 4 = noticeable and major; 5 = too long. Procedural impact was scored by the interventionalist according to the following scale: 1 = no impact; 2 = minor impact (acceptable performance); 3 = noticeable impact ; 4 = significant degradation ; 5 = unacceptable to complete. Data were analyzed across the three vascular beds, and also separately by making two groups: peripheral  and coronary.n) and percentage (%), continuous variables are summarized as mean and standard deviation (SD). A Kruskal–Wallis test was conducted to determine if wiring times, perceived latency scores and procedural impact scores were different for among the injected latencies. P for trend was obtained from a Wilcoxon-type test for trend to evaluate the trend in perceived latency and procedural impact scores. Results were considered significant when p-value was < 0.05. Post-hoc tests for comparing added latency of 0 ms with added latencies up to 1000 ms were performed with the Man-Whitney test. STATA statistical software  was used for statistical analysis.Categorical data are presented as count . Mean wire navigation time for femoral, carotid target no. 1, carotid target no. 2 and coronary target were 131 ± 84.25, 26.26 ± 29.66, 104.9 ± 84.25 and 70.22 ± 65.18 s, respectively. Across the range of latencies studied, there was no significant difference and no trend observed in navigational times within each vascular bed.p = 0.006 and p = 0.002, respectively)  and the perceived latency (p = 0.038) scores. When analyzing the scores between the peripheral and the coronary navigation, a tendency of higher scores was seen with the longer added latencies but the difference was not significant . Operators reported a minor impact on their performance with latencies of 400 ms or above. Network latency of 400 ms and above was reported to be perceptible but acceptable. These results suggests that remote robotic-assisted femoral, carotid, or coronary arterial interventions should be performed with network latency below 400 ms to provide seamless remote device control.Available upon request.


Embase.com during the development of evidence summaries supporting first aid guidelines. We aimed to achieve a balance among recall, specificity, precision, and number needed to read (NNR).The aim of this project was to validate search filters for systematic reviews, intervention studies, and observational studies translated from Ovid MEDLINE and Embase syntax and used for searches in PubMed and Reference gold standards were constructed per study type derived from existing evidence summaries. Search filter performance was assessed through retrospective searches and measurement of relative recall, specificity, precision, and NNR when using the translated search filters. Where necessary, search filters were optimized. Adapted filters were validated in separate validation gold standards.Search filters for systematic reviews and observational studies reached recall of ≥85% in both PubMed and Embase. Corresponding specificities for systematic review filters were ≥96% in both databases, with a precision of 9.7% (NNR 10) in PubMed and 5.4% (NNR 19) in Embase. For observational study filters, specificity, precision, and NNR were 68%, 2%, and 51 in PubMed and 47%, 0.8%, and 123 in Embase, respectively. These filters were considered sufficiently effective. Search filters for intervention studies reached a recall of 85% and 83% in PubMed and Embase, respectively. Optimization led to recall of ≥95% with specificity, precision, and NNR of 49%, 1.3%, and 79 in PubMed and 56%, 0.74%, and 136 in Embase, respectively.Embase.com.We report validated filters to search for systematic reviews, observational studies, and intervention studies in guideline projects in PubMed and  Embase.com. These filters have been translated, with minor adaptations, and used in our organization in the absence of properly validated search filters specifically designed for use in PubMed and Embase.com [The development of evidence-based practice guidelines is a time-consuming process . Evidencbase.com .Search filters are standardized combinations of search terms (indexing terms and/or free text words) to identify records with a specific feature, in this case aspects of study design . Other eThere are typically two ways of composing a gold standard. One way is to hand-search a set of records  . The recEmbase.com for future use in guideline development projects, thereby aiming to find a balance between recall and specificity.Given its recently obtained ISO 9001:2015 certification for the development of systematic reviews and evidence-based guidelines, CEBaP strives for a continuous quality improvement of its processes . The curEmbase.com syntax [The systematic review filters tested were translated from existing filters from SIGN, designed for Ovid MEDLINE and Ovid Embase, to PubMed and m syntax   with a specificity of ≥45% .In case our search filters did not reach the desired level of recall (≥85%) and specificity (≥45%) in both PubMed and Embase, we attempted to optimize them by looking for additional relevant search terms to be included in the filters. These were searched for in the indexing terms and title, abstract, and keywords of studies that were included in the reference gold standard but not retrieved when combining the original search with the search filter. Both the original search filters and newly optimized alternative search filters were then tested in an independent validation reference gold standard retrieved from a distinct set of first aid–related evidence summaries. The use of an independent validation gold standard is important, as this gives a more reliable estimate of how the filter performs in a real-world application and thus increases the generalizability of results .The reference gold standard consisted of 77 systematic review references, collected in 33 evidence summaries on different first aid topics. An overview of the evidence summaries can be found in The reference gold standard consisted of 70 systematic review references, collected in 35 evidence summaries . When usThe systematic review filter's performance was considered sufficient  for use in first aid guideline projects. Therefore, the filter was considered validated, and no further optimization was pursued.The reference gold standard consisted of 116 intervention study references, collected from 21 evidence summaries . Using tThe reference gold standard consisted of 103 intervention study references, collected from 21 evidence summaries . AdditioThe performance of the intervention search filter was considered insufficient. Further optimization by analyzing indexing terms, titles, abstracts, and keywords of missed reference gold standard records led to two optimized search filters , Table 1In the independent validation reference gold standard, consisting of 73 intervention study references from 18 evidence summaries , the oriThe adapted filter performed better with respect to recall and identified 69 out of 73 records, with recall of 95%, specificity of 49%, and precision of 1.3% . NNR usiThe independent validation reference gold standard consisted of 70 intervention study references, identified from 18 evidence summaries . The oriThe adapted intervention study search filter, on the other hand, identified 68 out of 70 records and had a recall of 97%, specificity of 56%, and precision of 0.91% . NNR wheAlthough NNR increased when using the adapted filter and the recall of the original filters was already high in the validation samples, the increased yield in gold standard records in our view justifies the altogether modest increase in records to screen.The reference gold standard consisted of 83 observational study references, collected in 21 evidence summaries . When usFor Embase, the reference gold standard contained 77 observational study references, originating from 22 evidence summaries . AdditioThe observational study search filter was considered sufficiently effective for use in first aid guideline evidence summaries. No further optimization was attempted.The production of 490 evidence summaries for a total of three first aid guidelines took approximately 3,045 working hours, of which approximately 822 hours were dedicated specifically to screening records retrieved with systematic literature searches at the title and abstract level. The current project aimed to increase time-efficient screening of potentially relevant papers in future first aid guideline projects by optimizing (where necessary) and validating methodological search filters that were used on an ad hoc basis in prior guideline projects. Search filters for systematic reviews and observational studies were considered sufficiently effective, whereas those for intervention studies were optimized to satisfactory levels for guideline project purposes. Theoretically, using these search filters could decrease the total screening time by approximately 42% if all searches were performed using a search filter. In practice, this yield will be less, as we aim for search filters to be used judiciously  and depending on the yield of the search without the use of the filters.The current study has limitations. First, the filters evaluated in this paper were specifically tested on searches of evidence summaries used for first aid guideline projects. First aid is a thematically broad area of health , 27. DivEmbase.com. Lee et al. compared several systematic review search filters, including the original Ovid MEDLINE and Ovid Embase version of the SIGN filter slightly adapted and tested by us [When comparing our results to those of others, it is clear that accurate identification of systematic reviews is of interest to many. Nevertheless, we are, to our knowledge, the first to validate search filters for systematic reviews for use in PubMed and ed by us . Our fined by us . The SIGed by us –33. The Several authors have published validated methodological search filters for identification of randomized controlled trials, such as the Cochrane Highly Sensitive Search Strategy , 30, 34.Embase.com are among the first to be validated and demonstrate an acceptable performance for use in guideline projects.Search filters for observational studies are much less studied than filters for systematic reviews or randomized controlled trials. The ISSG Search Filter Resource mentions several observational study filters for use in Ovid MEDLINE and Ovid Embase, but generally with untested performance . A recenFuture research should aim to design and validate similar search filters for other scientific databases , for which validated study design filters are scarce .Embase.com. The filters show an acceptable balance between recall and specificity for use in guideline projects, in particular in the field of first aid, but may be useful in other domains as well.To conclude, this work has validated methodological search filters for systematic reviews and observational studies and optimized methodological search filters for intervention studies in PubMed and


Streptococcus agalactiae (GBS) harboring novel ST1656 IE without AV involvement. Our patient presented with manifestations of various serious systemic and intracardiac complications, requiring early surgery, but ultimately died from non-cardiogenic causes. This case emphasizes the importance of treating MVA as a dangerous sequela of IE, of performing transesophageal echocardiography to make its accurate diagnosis and institute early surgical intervention, and of considering GBS as a rare but important causative agent of IE in elderly patients with comorbidities.Mitral valve aneurysm (MVA) is a rare but life-threatening valvular pathologic entity most commonly associated with infective endocarditis (IE) of the aortic valve (AV). We describe a diabetic patient with ruptured anterior MVA secondary to capsular genotype V  Mitral valve aneurysm (MVA), a saccular outpouching of the mitral leaflet toward the left atrium (LA), is rare but can be a fatal sequela of active or previous aortic valve (AV) infective endocarditis (IE), causing aneurysmal rupture and systemic embolization –3. HowevA 69-year-old man was admitted to our hospital for lethargy. He reported a 1-month history of repetitive watery diarrhea before admission. He had no history of prior cardiac disease but did have a history of hypertension and alcoholism. On admission, physical examination results were as follows: blood pressure, 76/51 mmHg; mild hypothermia: 36.0°C; tachycardia, 115 beats/min; and grade 4/6 holosystolic murmur at the cardiac apex. He was drowsy, but neurologic examination was unremarkable. A collapsed jugular vein and cool skin were noted. The electrocardiogram revealed sinus tachycardia. The chest radiograph was unremarkable. Laboratory testing revealed elevated inflammatory markers; severe thrombocytopenia; acute renal failure (RF); and elevated levels of liver enzymes, blood glucose, hemoglobin A1c, and brain natriuretic peptide, suggesting systemic inflammation. Transthoracic echocardiography (TTE)Streptococcus agalactiae strains , meeting a modified Duke criterion for a diagnosis of IE. On day 5, semi-urgent cardiac surgery was performed following a multidisciplinary team discussion. Surgical findings included a large mass of vegetations on the A1 scallop of the MV with extensive valve destruction, which formed an aneurysm through which two ruptured perforations had occurred  . Color Doccurred . We confoccurred . Neverthoccurred . Microbioccurred . Based oA summarized illustration of the case presentation is provided in To our knowledge, we describe here, the first case of native MV IE caused by a GBS genotype V/ST1656 strain without AV involvement. Subsequently, the patient developed MVA secondary to GBS IE concurrent with various fatal intracardiac and systemic complications, eventually died despite aggressive antimicrobial and surgical management. Our case may provide four important clinical suggestions.First, we describe a case of MVA secondary to IE without AV involvement.MVA is a rarely encountered echocardiographic finding, identified in <0.3% in the TEE setting –3. AV IESecond, our case of MVA revealed various serious intracardiac complications requiring early cardiac surgery.MVA can be manifested in various ways, ranging from an asymptomatic presentation to fatality due to complications.Aneurysmal rupture and systemic embolization are the most common complications of MVA . AlthougAs the third clinical suggestion, TEE was found most suitable for the definitive diagnosis of MVA, detection of its complications, and surgical planning in the present case.TEE is of significant diagnostic value in detecting intracardiac complications such as MVA and leaflet perforation, compared to TTE   and intracardiac complications  requiring early surgery. Our case raises three clinical challenges for GBS IE.The first clinical challenge is the management of GBS IE.Staphylococcus aureus IE. Factors associated with mortality in GBS IE include HF , neurological impairment , and RF   , cliniciThe second clinical challenge is to consider GBS IE in the differential diagnosis.In general, GBS, which commonly colonizes human genital and gastrointestinal tracts, is known as the leading cause of neonatal sepsis and meningitis . RecentlThe third clinical issue concerns the importance of the new clone of GBS identified in our case.n = 19, including our clones) (n = 4) from Japan/Australia, Ib/ST10 (n = 4) from Japan, V/ST1 (n = 3) from Japan/Australia, and VIII/ST1 (n = 2) from Japan. Therefore, the genotype V/ST1656 from both GB125–2 (blood) and GB125–3 (PML) in our case seems to be a very rare clone. The serotype III/ST19 clone is highly virulent and associated with very severe GBS IE even in healthy adult patients  , 2. The patients . Since oWe describe a fatal case of MVA secondary to GBS IE, complicated by variable intracardiac and systemic complications, requiring early surgical intervention.MVA is a rare but potentially fatal sequela of IE. Therefore, it is imperative to detect MVA early and perform surgery expediently. TEE is useful for an accurate diagnosis and optimal surgical planning. Therefore, clinicians should be aware of this rare valvular anomaly and should not hesitate to perform TEE in patients with potential IE. In addition, our case highlights the clinical significance of bearing in mind GBS IE as a rare cause of severe IE.The original contributions presented in the study are included in the article/The authors confirm that written informed consent for submission and publication of this case report, including the images and associated movie, has been obtained from the patient's family.HYamam contributed to the clinical design and concept. HYamam and HYamad acquired the clinical data. TM and MG performed microbiological analyses. YI performed pathological analyses. HYamam and TT interpreted the data and drafted and revised the manuscript. All authors discussed, read, and approved the manuscript and its submission for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.