Podoconiosis is a type of elephantiasis characterised by swelling of the lower legs. It is often confused with other causes of tropical lymphedema and its global distribution is uncertain. Here we synthesise the available information on the presence of podoconiosis to produce evidence consensus maps of its global geographical distribution.We systematically searched available data on podoconiosis in SCOPUS and MEDLINE from inception, updated to 10 May, 2019, and identified observational and population-based studies reporting podoconiosis. To establish existence of podoconiosis, we used the number of cases reported in studies and prevalence data with geographical locations. We then developed an index to assess evidence quality and reliability, assigning each country an evidence consensus score. Using these summary scores, we then developed a contemporary global map of national-level podoconiosis status.There is evidence of podoconiosis in 17 countries  and consensus on presence in six countries . We have identified countries where surveillance is required to further define the presence or absence of podoconiosis. We have highlighted areas where evidence is currently insufficient or conflicting, and from which more evidence is needed.The global distribution of podoconiosis is not clearly known; the disease extent and limits provided here inform the best contemporary map of the distribution of podoconiosis globally from available data. These results help identify surveillance needs, direct future mapping activities, and inform prevention plans and burden estimation of podoconiosis. The global distribution of podoconiosis is uncertain. With our current understanding of its distribution still incomplete, many of the countries suspected to be endemic for podoconiosis are based on expert opinion and lack published evidence of confirmed cases. In this study, we used multiple data sources and health metrics to identify countries with presence and absence of podoconiosis with appropriate uncertainties. After assembling a database of different evidence types we constructed a weighted score for each country called ‘evidence consensus scores’. We used these scores to measure the certainty of the presence and absence of podoconiosis. The maps produced help to identify evidence gaps and uncertainties in the current global distribution of podoconiosis. Countries with evidence of podoconiosis are mostly clustered in Africa, and a few in Asia and Latin America. We have also identified countries with indeterminate status on the presence and absences of podoconiosis. These countries are characterised by weak health systems and multiple co-endemic diseases causing lower leg swelling, potentially leading to misdiagnosis of podoconiosis. Given these challenges, we recommend intensified disease surveillance and active case searching be implemented in areas where evidence is lacking. Podoconiosis is a neglected tropical disease (NTD) caused by long-term exposure to red clay soil –3. The dIn 2011, the World Health Organization (WHO) included podoconiosis on its list of other NTDs. CurrentDespite increased global interest towards podoconiosis, its geographical distribution remains largely uncertain. Historically, podoconiosis has been reported in 32 countries globally, but there is uncertainty about its current distribution due to the lack of comprehensive surveillance. Three cThe misdiagnosis of podoconiosis is a particular challenge given the absence of point-of-care diagnostic tests, combined with scarce knowledge of the disease among health workers in many endemic countries. Misdiagnoses not only under-estimate the distribution and prevalence but may also over-estimate the burden of the misdiagnosed condition, with implications for population-at-risk estimates and programme monitoring. Thus, the joint lymphatic filariasis (LF) and podoconiosis mapping in Ethiopia conducted in 2013 reduced Mapping the global distribution of a condition is a prerequisite for effective strategy and programme design. Estimating the global burden and population at risk of podoconiosis requires clear understanding of its geographical limits and a list of affected countries. We aimeth May, 2019. Additional publications were identified from the reference lists of identified papers. The detailed search strategy and complete systematic review has been reported previously[Data sources included systematic peer-reviewed literature, conference proceedings and abstracts. We also used the information provided by Price’s monograph, which creviously. We updareviously, 30.We searched for studies that reported the epidemiology of podoconiosis. In May 2019 we searched SCOPUS and MEDLINE for all relevant studies that reported podoconiosis occurrence, prevalence, and incidence or case reports. We used the following search terms; “podoconiosis” OR “mossy foot” OR “non-filarial elephantiasis”. No time or language limits were applied. We hand-searched the reference lists of all recovered documents for additional references. Abstracts of all reports were read and full papers retrieved for those appearing to fulfil selection criteria. Publications were eligible for inclusion in the evidence consensus if they reported the presence of podoconiosis regardless of the type of diagnostic approach used to detect cases.The methodology used for generating the geographical limits of podoconiosis was adapted from previous studies on dengue and the In order to quantify evidence consensus, a weighted scoring system termed “evidence consensus” was developed , 29. ThiWe used a map developed by WHO and a monograph written by Price as a genet al. as a gold standard diagnosis for podoconiosis, as this is the only approach that satisfactorily eliminates other potential aetiologies. Articles using the Sime et al[From the literature database we assessed case reports based upon the contemporariness of the data included as well as the diagnostics used to confirm podoconiosis cases. If the article contained evidence from between 2000 and 2019 a +3 score was given, while if it was between 1990 and 1999 +2 was scored and for those before 1990 +1 was given. The contemporariness of podoconiosis literature was based on the different eras of podoconiosis research. Pre-1990 studies are mostly marked based on rapid survey of people with lower leg swelling. Studies conducted between 1990 and 1999 used some form of test, whereas those studies conducted between 2000 and 2019 utilised some form of clinical algorithm including history, physical examination and disease specific tests. This has been included in the supplementary material. A variety of diagnostic methods have been described in the literature. We used the clinical algorithm developed by Sime ime et al approachFor each country, we added the number of cases reported in all studies included. We checked the sources of data to avoid double counting of cases. When two different studies reported cases from the same source, the original study was used to identify the case numbers. Articles/locations reporting more than 30 cases were given a score of +6, those with >15 and ≤30 were scored +4, those with >5 and ≤15 were scored +2 and those with ≤5 cases were scored 0.We attempted to account for the impact of possible misdiagnoses and underreporting by assigning countries with no evidence of podoconiosis cases a score representing the evidence for absence. This score integrated three components: diagnosis, surveillance, and sociodemographic development. Each ranged from 0 to 1 and was weighted equally.The diagnosis score was intended to reflect the likelihood of misdiagnosis of podoconiosis as other causes of lymphedema ), based on the distributions of these conditions and their prevalence relative to podoconiosis. We calculated the ratio of podoconiosis to each other cause of lymphedema from selected lymphedema surveys –19, and We measured diagnosis score and surveillance score based on the Healthcare Access and Quality (HAQ) Index values, assuming lower levels of diagnostic capacity and surveillance in countries with lower levels of personal health-care access and quality index. The HAQ Index was developed by the Global Burden of Disease (GBD) to track national healthcare access. The indThe surveillance score was equal to the diagnostic capacity factor . This score was intended to indicate low surveillance capacity, assuming lower levels of surveillance in countries with lower levels of personal health-care access and quality.The sociodemographic index was intended to represent the propensity for podoconiosis based on socio-demographic index. The Socio-Demographic Index (SDI) is a comThe absence score was calculated from the sum of the diagnosis score, surveillance score and sociodemographic development score and was highest for countries co-endemic for leprosy, LF and TU, with lower levels of the HAQ Index, and lower levels of socio-demographic development, 35.By scoring the evidence categories mentioned above individually and then combining their respective scores, we were able to calculate ‘‘evidence consensus,” a measure of how strongly the combined evidence collection supports a podoconiosis-present or podoconiosis-absent status. To derive an overall country evidence consensus score, the scores for all evidence categories were summed, and then divided by the maximum possible score and multiplied by 100. Consensus was defined as either consensus (± 100), very strong (±75% to ±99%), strong (±50% to ±74%), moderate (±25% to ±49%) presence or absence, indeterminate (0% to 24%), or weak evidence of absence (-1% to -24%).https://www.naturalearthdata.com/)[The base map of the global administrative areas was downloaded from the Natural Earth (ata.com/). All mapIn Africa, 12 countries with podoconiosis presence were identified, with complete consensus in six . The evidence in these six countries comes from local surveys and some nationwide mapping conducted in Ethiopia, Rwanda and Cameroon –19. In fIndeterminate status was established for the Democratic Republic of Congo (DRC), although podoconiosis was reported to be present in Price’s monograph. HoweverMost parts of southern and northern Africa, including Tunisia, Libya, Egypt and Western Sahara were classified within the ‘strong evidence of absence’ category, where the disease has either never been reported or has been eliminated, as it occurs in Algeria, Morocco and Tunisia. Fig 4)Fig 4)In Asia, two countries with podoconiosis presence were identified (India and Indonesia). In India there is very strong evidence for presence, whereas in Indonesia there is moderate evidence for presence. In India, we have identified two published articles and one conference proceeding reporting on podoconiosis –45. Two In Latin America there are three countries  with moderate evidence for presence of podoconiosis. In Brazil, while Price reported two cases in São Paulo, anotherIn the rest of the world, most countries had very strong evidence or complete consensus for podoconiosis absence. There are sixteen countries with weak evidence of absence including Puerto Rico. Although neither WHO nor Price indicated the presence of podoconiosis, a publication dated 1922 mentioned the presence of podoconiosis in Puerto Rico. The remWe have assembled available data on podoconiosis from multiple sources and synthesised them through an evidence consensus framework, providing the first comprehensive list of countries endemic for podoconiosis with varying levels of certainty. The maps generated provide information on the known limits of podoconiosis, and identify areas in which podoconiosis status is uncertain and requires additional information. These results have several implications for future work on podoconiosis; from estimating its global burden and limits, to targeting resources for control and case management, as well as prioritizing areas for surveillance and research.We identified evidence of podoconiosis in 17 countries and consensus on presence in six. We have used supplementary information including the presence of confounding diseases weighted by the HAQ Index and SDI, which enabled us to identify countries with weak surveillance capacity and presence of confounding diseases which need further investigations.Three countries with consensus on presence  have already mapped the distribution of podoconiosis –19. The India, Indonesia and Brazil are also among the countries with evidence of presence of podoconiosis. Given the large populations of these countries, their inclusion will have a substantial impact on the estimated population at risk globally. Taking this into account, we aim to apply an evidence consensus approach at the subnational-level in these countries, to identify whether the disease is localized or widespread throughout them. A fine-scale approach will help us to develop a robust and credible estimate of the global burden of podoconiosis and enable a tailored approach to mapping and burden estimation.We identified ten counties with strong or moderate evidence of podoconiosis. These countries could be categorised as a second priority group in terms of mapping and evidence generation. All have historical evidence of podoconiosis presence reported in the peer-reviewed literature and Price’s monograph. In this category, Burundi is the only country in which an extensive market-based survey was conducted by Price. The surIn ten countries , podoconiosis status was indeterminate. Neither WHO nor Price indicated the presence of podoconiosis in these countries, with noThe data and analysis presented herein are the first of their kind for podoconiosis. We have compiled the largest dataset available globally for podoconiosis. In addition, we have used other sources of data and evaluated potential for misclassification based on the surveillance capacities of countries and the epidemiology of confounding diseases. Hence we employed the most comprehensive approach to determine the list of countries endemic for podoconiosis. We acknowledge several limitations to our approach, however, that are important to the interpretation of the results and their future applications.In this study, we focused on determining the presence or absence of podoconiosis at the country level. From previous work, the distribution of podoconiosis within a country has proven to be heterogeneous and we recognize the need for detailed  information for in-country planning and intervention, 52. OngIn Latin America we identified only one case report from Brazil, making There is a marked difference in the availability of occurrence data globally. From all the occurrence data, 79.2% were recorded from Cameroon and Ethiopia alone. This clearly indicates that there is marked variation on research on podoconiosis. Although this may not affect the current analysis, it may have implication on future analysis using the current database. Follow up analysis should account for clustering of surveys from such few countries. In addition, this implies the need for strengthening surveillance and research in other endemic countries.The evidence consensus approach used here has several strengths such as the utilization of multiple sources of data including published literature and health metrics which measure or approximate surveillance and health system capacities. We used this method because podoconiosis is one of the most neglected tropical diseases and there is very limited understanding of its presence and absence worldwide. Integrating health system metrics into the scoring system enabled us to give an indication of the uncertainty associated with the lack of data in many countries. This approach, however, does not capture the spatial heterogeneity in the potential distribution of the disease within countries. Thus, in countries where there is high consensus of podoconiosis presence, the disease may in fact be limited to certain areas. We are addressing the problem of spatial heterogeneity in a subsequent research study, which will build upon the outcomes of present study. Finally the evidence consensus approach doesn’t provide any evidence of prevalence or burden, but could help to guide further studies to help elucidate these. The evidence consensus work presented here will be important for future work. The evidence consensus maps developed here can be integrated into a geospatial modelling framework intended to ascertain the global burden of podoconiosis. Prevalence models can be informed by the evidence consensus maps presented here.In conclusion, we provide empirical evidence of the occurrence of podoconiosis and a list of countries endemic for the disease. Countries with the highest evidence consensus are the countries which should be targeted for further research, surveillance and initiation of prevention and control programmes. Mapping should be done in these countries to determine the in-country distribution and limits of podoconiosis which are critical for programme-level decision making. Some coS1 Appendix(DOCX)Click here for additional data file.


Escherichia coli, a common member of the human gut microbiota belonging to the Enterobacteriaceae family, is the causative agent of the majority of urinary tract infections (UTIs). The gut microbiota serves as a reservoir for uropathogenic E. coli where they are shed in feces, colonize the periurethral area, and infect the urinary tract. Currently, front line treatment for UTIs consists of oral antibiotics, but the rise of antibiotic resistance is leading to higher rates of recurrence, and antibiotics cause collateral damage to other members of the gut microbiota. It is commonly believed that incorporation of the American cranberry, Vaccinium macrocarpon, into the diet is useful for reducing recurrence of UTIs. We hypothesized such a benefit might be explained by a prebiotic or antimicrobial effect on the gut microbiota. As such, we tested cranberry extracts and whole cranberry powder on a human gut microbiome-derived community in a gut simulator and found that cranberry components broadly modulate the microbiota by reducing the abundance of Enterobacteriaceae and increasing the abundance of Bacteroidaceae. To identify the specific compounds responsible for this, we tested a panel of compounds isolated from cranberries for activity against E. coli, and found that salicylate exhibited antimicrobial activity against both laboratory E. coli and human UTI E. coli isolates. In a gut simulator, salicylate reduced levels of Enterobacteriaceae and elevated Bacteroidaceae in a dose dependent manner.The opportunistic pathogen  Klebsiella pneumoniae, Proteus mirabilis, and Staphylococcus aureus, the opportunistic pathogen Escherichia coli accounts for the majority (>65%) of reported cases [E. coli (UPEC) which can colonize the perineal area and subsequently infect the urethra and urinary tract [E. coli and related organisms, but increasing rates of antibiotic resistance have led to reduced efficacy of these drugs, and concomitant increase in the rate of recurrence [Urinary tract infection (UTI) is the most prevalent infection observed in humans, affecting 150 million people annually worldwide [ed cases . The humry tract , 4. Fronajority >5% of repcurrence , and evecurrence . The norcurrence , 10, 11.E. coli-specific vaccines or small molecules that target virulence factors like adhesion, which appears essential for the ability of E. coli to infect the urinary tract [There has been substantial research in expanding treatment options for UTIs beyond broad-spectrum antibiotics. This has led to the development of ry tract , 13. Furry tract . These dVaccinium macrocarpon. While clinical trials exploring the beneficial effect of cranberry consumption on UTI recurrence and symptomologies show mixed results [in vitro experiments have reported antimicrobial or antiadhesive properties of phenolic components of cranberry against E. coli [As an alternative strategy, there has been an interest in exploring nutritional interventions which may decrease UTI recurrence rates and/or symptoms by reducing the natural reservoir of potentially UPEC. A popular remedy is the consumption (in the form of concentrate or juice) of the American cranberry,  results , several E. coli , 16. Mor E. coli .Enterobacteriaceae, which could be uropathogenic. Here, cranberry components showed both promising prebiotic and modest antimicrobial activity, so we explored specific phenolic and non-phenolic cranberry components for anti-E. coli activity in monoculture. Candidates with attractive therapeutic activity profiles were tested in a human gut simulator seeded with a human gut microbiota. Cranberry-derived salicylate reduced Enterobacteriaceae in this model, while protecting core gut commensals.In this study, we sought to expand upon previous reports by broadly testing cranberry extracts and whole cranberry powder in a human gut microbiome-derived community in a gut simulator. We hypothesized that the reported, though inconsistent, reduction in UTI recurrence rates could be explained by cranberry-induced modulations on the gut microbiota community and a resulting reduction of Enterobacteriaceae. Thus, to determine the effect of cranberry consumption on the human gut microbiota composition, we treated stool communities each day for five days with 1 mg/mL phenolic-enriched or phenolic-deficient cranberry extracts or whole cranberry powder in a gut simulator. Because microbiota composition naturally varies between individuals [Enterobacteriaceae (0.0% relative abundance Enterobacteriaceae) or with a sample with a high level of Enterobacteriaceae (15.7% relative abundance Enterobacteriaceae); Enterobacteriaceae level in the stool samples was determined by 16S rRNA gene sequencing. Enterobacteriaceae normally constitutes a small proportion of the healthy human gut microbiota at 0.1–1% relative abundance [We hypothesized that cranberries, through prebiotic or antimicrobial activity, may alleviate UTI recurrence by reducing the host’s reservoir of UTI-causing ividuals , we seedbundance . Both saEnterobacteriaceae, the phenolic-enriched extract significantly increased Bacteroidaceae (p = 0.028) while treatment with phenolic-deficient extract and whole cranberry powder increased the relative abundance of Bacteroidaceae approximately three-fold as compared to untreated controls  and stabilizes over time as the relative abundance of Bacteroidaceae increases (p = 0.011). Importantly, whole cranberry powder significantly reduced the relative abundance of Enterobacteriaceae (p = 0.0093) to a greater extent than control (Porphyromonadaceae populations (p = 0.0019), and was able to maintain high levels of Bacteroidaceae over time, similar to the control. The phenolic-deficient extract significantly increased Porphyromonadaceae (p = 0.025) and stabilized Enterobacteriaceae to levels observed in the control  was determined for salicylate and β-resorcylate and found to be 1 mg/mL for both compounds against E. coli MG1655.To explore potential antimicrobial activity of cranberry constituents against ompounds  were tesEnterobacteriaceae in a human gut microbiota community, a gut simulator inoculated with human stool was treated each day for five days with 1X MIC salicylate or β-resorcylate dissolved in dimethyl sulfoxide (DMSO). DMSO can be used as a terminal electron acceptor and can cause Enterobacteriaceae blooms [Enterobacteriaceae relative abundance were calculated before treatment and after five days of treatment. In previous experiments , compared to a 9.9% reduction by β-resorcylate (p = 0.0060) and a 0.8% reduction in control vessels (p = 0.89), as compared to pre-treatment levels , 0.1X MIC (0.1 mg/mL), or 0.01X MIC (0.01 mg/mL) salicylate. Following five days of treatment, salicylate exhibited a dose dependent response against Enterobacteriaceae , compared to 0.1X MIC , 0.01X MIC  and the control  (Enterobacteriaceae titers as CFU/mL (Enterobacteriaceae titers of 1X MIC treatment were about one log lower than in control vessels (p = 1.8E-07). Treatment with 0.1X MIC salicylate significantly decreased titers by one-half log (p = 2.1E-06), but 0.01X MIC treatment did not decrease titers significantly (p = 0.12); control titers did not change over time (p = 0.64)  and Lachnospiraceae (p = 0.036) populations  . In ordes CFU/mL . The fin = 0.64) . Furtherulations .E. coli isolates, the MICs for a panel of 12 isolates sourced from UTI patients were determined. The isolates were from patients treated with a broad array of antibiotics, yet all exhibited similar MICs to salicylate as E. coli MG1655, ranging from 0.5–2 mg/mL  for anaerobic respiration and successful competition over strictly anaerobic members of the gut microbiota [Enterobacteriaceae bloom can further promote the immune imbalance and exacerbate the inflammatory status of the gut epithelium [Enterobacteriaceae-induced inflammation. Furthermore, a consistent increase in Bacteroidaceae populations was a notable outcome of salicylate and whole cranberry powder treatment on human gut microbiota populations. We have previously shown that Bacteroidaceae are negatively correlated with depression, which may be due to their ability to produce the neurotransmitter gamma-Aminobutyric acid (GABA) [While a decrease in diseases . Gram-ne pathway , 25. Intcrobiota . Dysbiosithelium . Thus, id (GABA) .Bacteroidaceae and reducing Enterobacteriaceae levels in the gut microbiota. While several compounds likely act synergistically in the cranberry to drive in vitro microbiota compositional changes, we identify cranberry-derived salicylate as a beneficial modulator of the human gut microbiota.Taken together, our studies suggest that ingestion of components from the American cranberry modulate the microbiota in a manner that may be beneficial by enriching The Northeastern University Institutional Review board  approved the collection of feces from human subjects. Written consent was obtained from donors.2, 85% nitrogen at 37°C. Samples were aliquoted (1 mL) in 20% glycerol and stored at -80°C.Stools were collected at Northeastern University following an Institutional Review Board-approved protocol (number 08-11-16). Briefly, one fresh stool sample was collected from each healthy adult donor (n = 26) using stool collection vessels (Medline Industries). Donors were not currently taking antibiotics and had not taken antibiotics for at least two weeks at the time of collection. Using the attached scoop, a sample of the stool was immediately placed in 9 mL pre-reduced PBS (24 hours in anaerobic chamber) to total approximately 10 mL of slurry in 50 mL collection tubes (Fisher Scientific). The stool slurry was homogenized in a Coy Anaerobic Vinyl chamber  in 5% hydrogen, 10% COGIFU Anaerobic Medium broth  was prepared according to the manufacturer’s instructions and then diluted and buffered as follows to yield greater population diversity . DeionizWhole cranberry powder, the phenolic-enriched and phenolic-deficient extracts, and cranberry fractions were prepared from a mixture of cranberry cultivars, primarily the Stevens variety. Whole cranberry powder was prepared by grinding cranberries frozen in liquid nitrogen into a powder.To prepare the phenolic-enriched extract, whole cranberry powder was solubilized in deionized water; to prepare phenolic-enriched fractions from concentrate or pomace, cranberry concentrate or ground pomace were solubilized in deionized water; juice was not further solubilized. Solubilized cranberry material or juice was filtered with a 0.7um GMF filter (Thermo Titan 3 30mm Filter (0.7μm GMF Membrane)) and injected into the Flash Chromatography System (Agilent Flash Purification System (971-FP) together with the Biotage SNAP Cartridge (KP-C18-HS 120g)). The following gradient was used for elution of oligosaccharides and phenolic compounds with water (A) and 0.1% acetic acid methanol (B) as mobile phases: 0–10 min 100% A; 10–20 min 85% A; 20–30 min 100% B. The 15% methanol fraction and the 100% methanol fraction which contained phenolic compounds were collected respectively in glass bottles. The 100% methanol fraction was further applied onto the LH-20 column . The liquid sample was allowed to flow into the bed, then 10–20ml of deionized water as starting mobile phase was added to the bed and flowed through making sure the sample solution was completely washed into the bed. Ethanol (25%) was used to elute and collect the phenolic-enriched fraction. The composition of the phenolic-enriched extract is reported in The 44 fractions or pure compounds were commercially purchased based on cranberry composition or prepared from cranberry juice powder, cranberry concentrate, and cranberry pomace .−6 in deoxygenated medium was inoculated into the vessel chambers and then media was pumped at 0.101 mL/minute so that 145.44 mL was replaced every 24 hours. The microbial population established for 48 hours prior to treatment interventions. Treatments were administered every 24 hours for five days by dosing directly into each chamber vessel. Phenolic-enriched and phenolic-deficient extracts and whole cranberry powder were dosed at 1 mg/mL; β-resorcylate was dosed at 1X MIC (1 mg/mL) and salicylate was dosed at 1X MIC (1 mg/mL), 0.1X MIC, or 0.01X MIC. Sampling was conducted before and after treatment interventions. The average relative abundance change was calculated by averaging the percent relative abundance change of a given taxa in each replicate from before treatment intervention to after treatment intervention. Samples were stored at -80°C for sequencing and plated on pre-reduced MacConkey agar using sterile glass beads to calculate the CFU/mL of Enterobacteriaceae. Plates were incubated anaerobically for 48 hours. All experiments were performed at 37°C in an environment containing a gas mixture of 85% Nitrogen, 10% CO2, and 5% Hydrogen. The phenolic-enriched or deficient extracts and whole cranberry powder were tested on stool from two different donors in duplicate (low Enterobacteriaceae sample) or triplicate (high Enterobacteriaceae sample). All β-resorcylate and salicylate treatments were performed on stool from a single donor in duplicate (β-resorcylate) or triplicate .A modified simulator of the human intestinal microbial ecosystem (SHIME)  was usedwww.mrdnalab.com, Shallowater, TX, USA) on an Ion Torrent PGM. The V4 variable region was amplified using PCR primers 515/806  in a single-step 30 cycle PCR with the HotStarTaq Plus Master Mix Kit . The following conditions were used: 94°C for 3 minutes and 30 cycles of 94°C for 30 seconds, 53°C for 40 seconds and 72°C for 1 minute, followed by a final elongation step at 72°C for 5 minutes. A proprietary analysis pipeline  was used to process the data. Barcodes and primers were removed and then sequences with less than 150 bp were removed. Sequences with ambiguous base calls or with homopolymer runs greater than 6bp were removed. The sequences were denoised. Operational taxonomic units (OTUs) were generated and chimeras were removed. OTUs were defined by 97% similarity and were taxonomically classified against a database derived from RDPII (http://rdp.cme.msu.edu) and NCBI (www.ncbi.nlm.nih.gov).Sequencing was performed by MR DNA  method was used to quantitatively measure the ompounds  against E. coli MG1655 was grown overnight in LB broth . The overnight culture was diluted 1:100 and grown aerobically to OD600 0.5 at 37°C. Cranberry compounds were solubilized in 100% DMSO (10 mg/mL). Compound solutions were diluted to 200 μg/mL in LB broth. The OD600 0.5 culture was diluted 1:100 and added in 1:1 ratio with the compound solution. Cultures were incubated aerobically at 37°C overnight. OD600 was read on a BioTek Synergy H1 microplate reader and percent inhibition was calculated by comparing the OD600 of the treated cultures to the OD600 values of the untreated culture.To test the activity of cranberry components, a single colony of E. coli MG1655. The culture (OD600 0.5) was diluted 1:500 into a 1:2 dilution series in LB broth of salicylate or β-resorcylate  and incubated aerobically or anaerobically overnight at 37°C. The MIC was calculated as the lowest drug concentration with total inhibition of visual growth.The MIC of soluble cranberry compounds that inhibited growth by 20% or more was calculated against E. coli isolates sourced from patients treated with antibiotics for UTIs were obtained from Dr. Anne Stapleton at the University of Washington. Twelve isolates were randomly chosen for MIC testing Click here for additional data file.S2 TableMethods used were previously described .(DOCX)Click here for additional data file.


Lean Six Sigma is a set of techniques intended to improve processes by greatly reducing the probability that errors will occur. The Lean Six Sigma approach was used to engage staff and clinicians in standardizing the assessment of patient health literacy in an academic safety net clinic.Clinicians were surveyed, and a chart review was conducted to attain baseline information regarding the uniformity of health literacy assessment and documentation in the clinic. A workgroup used the survey data and Lean Six Sigma quality improvement tools to determine the root cause, which was the lack of standardization.To address this root cause, a standardized process for health literacy assessment in the clinic was developed; an assessment tool was selected, support staff were trained, and the new process was initiated. A support staff focus group was conducted, and a second clinician survey was disseminated to gauge perception of the new health literacy assessment and documentation processes. Quantitative data were collected to assess the coverage achieved by the new processes. Monthly reporting and staff feedback sessions were conducted to ensure continued efficacy of the protocol.Standardized assessment and documentation processes were effectively implemented using the Lean Six Sigma approach in an academic safety net clinic. Providers and rooming staff were satisfied with the new processes. Rooming staff input and buy-in were critical to successful implementation.HLRP: Health Literacy Research and Practice. 2019;3(1):e25–e30.][Our findings suggest that Lean Six Sigma tools and methodologies can be appropriate for health care quality improvement and process standardization in an academic safety net clinical setting. A growing body of evidence supports the role of Lean Six Sigma (LSS) tools and processes for the assessment, design, and implementation of the quality improvement in the health care industry. This study explored the use of LSS on the standardization and documentation of health literacy assessment of patients in an academic safety net clinic. Findings suggest that LSS is an appropriate method of standardizing assessment and documentation of health literacy in this clinical setting. Health literacy is the degree to which people have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions , and it Table 1). The clinic is part of an Accountable Care Organization and is a Level 3-Certified “Patient Centered Medical Home” (PCMH), meaning that the health care organization is structured to coordinate patient care through a variety of clinicians across the continuum of care  is a top health care accreditation organization. To achieve accreditation as a PCMH, organizations must demonstrate that they have met NCQA standards and guidelines, which includes the assessment of patient health literacy. Through research of the staff chart review for the Internal Medicine Center accreditation application, it was discovered that clinicians were not assessing patient health literacy in a standard fashion. This was brought to the attention of faculty clinicians during a monthly faculty meeting, and the faculty decided that improving health literacy assessment (HLA) and documentation was a priority. Faculty clinicians, resident clinicians, rooming staff, and research staff volunteers formed a health literacy workgroup with two Process Engineers from the Quality Improvement Department to guide the group effort. The Process Engineers had achieved Lean Six Sigma Green Belt Certification. Because this is a Quality Improvement initiative, no institutional review board approval was needed for this initiative.Lean Six Sigma methods and tools are the standard system-wide approach to process improvement and were selected to address these issues .Lean Six Sigma is a performance improvement methodology that incorporates effectiveness to reduce variation in an existing process. The health literacy workgroup aimed to develop and test methods to standardize HLA and identify patients with low health literacy. The focus of this report is to describe Lean Six Sigma methods that may be used to implement HLA in similar settings.The project was organized, and a project team was assembled. The customer and business objectives  were defined and validated by all “customers” of the process. The customers in this case were the clinicians and clinical staff, specifically medical assistants and nurses responsible for rooming patients in the clinic. This phase began in December 2016.Table A) via email and about one-half of those responded. Responses indicated that 8% of clinicians were assessing patient health literacy. From 1 month's completed office visits, a sample of patient charts were selected at random and a review was conducted by the health literacy work-group research staff. The chart review found that only 3 of 50 (8%) clinicians documented an HLA and that a variety of tools designed by the clinicians themselves were being used. The health literacy workgroup determined that the electronic medical record's (EMR) built-in HLA tool was not a validated instrument and that it was too time consuming to be practical in a clinical setting. Also, due to an internal technical issue, not all clinicians had access to this tool in the EMR. The group decided to select a different tool.All clinicians were surveyed about HLA use , a visual tool for documenting business process from beginning to end, was used by the workgroup. Although the existing process involved clinicians conducting the HLA, the group determined that it would be more appropriate for rooming staff to be responsible for patient HLA.The SIPOC  is intended to clarify what the customers of the process value and then translate the information into quantifiable metrics. The VOC included the clinician survey data and rooming staff input collected at workgroup meetings. During the development of the VOC table, the workgroup concluded that the HLA was valuable to clinicians, should not offend patients, and should not be an imposition to rooming staff work flow. Goals for the project based on the VOC were (1) complete HLAs for 80% of new patients, (2) ensure the HLA took less than 5 minutes to complete, and (3) develop an accessible standardized process for documentation of results.A tool called the voice of the customer  data were collected to validate the problem's existence. The aforementioned survey indicated that a small percentage, approximately 8%, of clinicians stated that they were consistently conducting HLAs. To further validate the problem's existence, two additional research staff used the same measurement system and sampling approach as the earlier chart review. They verified baseline findings that only 3 of 50 (6%) charts contained documentation of an HLA and that the HLA tools and documentation were inconsistent. The measure phase was completed in February 2017.In February 2017 the workgroup invited clinicians from the Family Medicine Center, a similar residency clinic to discuss their experiences with their prior temporary HLA implementation. The Family Medicine Center clinic is located on the same campus as the Internal Medicine Center clinic but serves children as well as adults. Data and process information were examined during a brainstorming session to determine the critical root causes of the problem, which included a lack of access to a standardized tool and a lack of accessibility of patient HL scores. Root causes were validated through observations of rooming procedure by health literacy workgroup members and became the basis for which solutions were developed.Solutions were implemented to specifically address the critical root causes. Potential risks included the possibility that patients would react poorly to the HLA questions. Rooming staff felt that patients would be receptive but were empowered to skip the HLA if it seemed that administration would negatively affect patient satisfaction.Table C). Clinical staff and physicians were given an educational manual about administering the BRIEF, which included information such as standardizing methods of questioning patients, how to respond if the patient declined, and how to score the assessment. Rooming staff were trained in interactive group sessions by research staff on the use of this tool.Another potential risk included rooming staff neglecting to perform an HLA due to time constraints. To address the root causes, the workgroup (including rooming staff) selected a validated HLA instrument called the Brief Health Literacy Assessment (BRIEF) . The BRIInternational Statistical Classification of Diseases and Related Health Problems, 10th revision code  conducted HLAs while rooming the patient and would alert physicians of the low assessment results by entering low health literacy scores in the “chief complaint” of the patient's chart. Physicians would then document low health literacy in the patient chart by adding an ion code  for low Two weeks into the pilot, a focus group moderated by research staff was conducted to gauge perceptions of the HLA process and tool among the rooming staff . Thematic analysis was used to analyze responses. Nurses and medical assistants (the clinic's rooming staff) perceived the process and the administration of the patient HLA positively. The group's opinion was that patients also received the assessment favorably.Table D). About 40% of clinicians responded, and 64% of those that had seen patients indicated that their awareness of the patient's health literacy score altered the way in which they interacted with the patient.Three weeks into the pilot phase, a second email survey was disseminated to clinicians (Internal Medicine Center's Information Technology and Analytics Reporting division constructed a report that tracked HLA smart phrase use in the clinic. This report is provided monthly to the health literacy workgroup research staff for evaluation. In month 1 of the pilot, 85% of patients were properly assessed, and 81% of the patients had the score documented properly. In month 2 of data collection, 91% of patients were properly assessed, and 63% of the patients had the score documented properly. Approximately 24% of assessed Internal Medicine Center patients were found to have low health literacy. The HLA completion and documentation rates exceeded project goals, implying that the pilot process properly addressed the critical root causes, and the health literacy workgroup determined to continue with this process.A training plan was developed to address each functional group: rooming staff, residents, and faculty. The plan included “new knowledge and skill requirement,” “estimated length/format,” “owner,” “start date,” and “completion date.” Once all functional groups received training, the process was implemented permanently.Along with the roll out, controls were put into place to ensure the new process is maintained and to protect against backsliding. Health literacy workgroup research staff receives monthly reports documenting completed HLA surveys for the practice. The new HLA process will be revisited via faculty meetings if less than 80% of appropriate patients are being screened. The control phase was implemented immediately with the roll out of the pilot and is ongoing.The Lean Six Sigma data-driven, process-improvement methodology provides meaningful results and customer satisfaction. This project aimed to explore methods to overcome barriers to the implementation of a standardized HLA practice. Clinician and clinical staff engagement throughout the planning and pilot project was a key factor in successfully implementing an HLA protocol. It is important to involve the customers of the process and also those who work most closely within the process to ensure sustainability. The Internal Medicine Center's HLA process and HLA documentation process was designed using qualitative analysis, survey, and focus group assessments. Lean Six Sigma methodology was instrumental in the successful roll out, assessment of, and sustainability of this project.Although the implications for health literacy screening scores are dependent on how they are used in the clinical setting, the use of Six Sigma methodology and the inclusion of “customers” in the design and implementation of a standardized HLA process and a standardized HLA documentation process were found by this assessment to be valuable. Further research should be conducted on the use of Lean Six Sigma tools in standardizing processes associated with patient HLA and health literacy documentation.


Dirofilaria infection nor treated against mosquitoes with insecticides or/and filarioid worms with macrocyclic lactones. Dirofilaria infection was examined with a modified Knott’s test for microfilariae, DiroCHEK®, for the presence of D. immitis antigen, as well as by multiplex and conventional PCR. Altogether, 77 (22.4%) dogs living in 58 settlements of 17 counties were found to be infected with one or both Dirofilaria species based on the PCR techniques. Twenty-eight (8.1%) and 38 (11.1%) dogs were infected with D. immitis and D. repens, respectively. Coinfections were recorded in 11 samples (3.2%) collected in 11 locations of 8 counties. The results confirmed that both dirofilarioses are endemic in dogs and the eastern areas of the country are hyperendemic for heartworm disease. Temperature showed a significant association with the prevalence of D. immitis  but not with that of D. repens . The prevalence of neither D. immitis  nor D. repens  showed a significant correlation with precipitation. The number of yearly growing degree days (GDD) based on the lifecycle of Dirofilaria in mosquitoes ranged between 3.73 and 7.57 for the Hungarian districts. The GDD showed a significant positive association with the prevalence of D. immitis  and a non-significant positive relationship with that of D. repens .Between April and September 2017, blood samples were collected from 344 randomly selected dogs older than 1 year in 180 settlements of 19 counties in Hungary. The dogs lived exclusively outdoors, had never travelled and had neither been examined for  Dirofilaria immitis, can cause life-threatening heartworm disease (other name cardiopulmonary dirofilariosis) worldwide , in accordance with the manufacturer’s instructions.Serum samples were tested for the presence of Dirofilaria spp. and 16S rRNA of D. immitis were used, respectively . Multiplex and conventional PCR reactions targeting fragments of 12S rDNA of both Dirofilaria generations based on the growing degree days (GDD) was calculated following the method described by Genchi et al.  samples collected in 11 locations of 8 counties ; the infected dogs lived in 35 settlements of 16 counties  and D. repens (p = 0.044)  spatial aggregation was found for the pooled data of both species. Temperature showed a significant association with the prevalence of D. immitis  but not with that of D. repens . The prevalence of neither D. immitis  nor D. repens  showed a significant correlation with precipitation. The number of yearly GDD-based life cycles of Dirofilaria in vectors ranged between 3.73 and 7.57 for the Hungarian districts  and a non-significant positive relationship with that of D. repens .Altogether, 77 out of the 344 dogs from 58 settlements of 17 counties were found to be infected by one or both  in 11 3.% samplesD. repens infections had occurred in Hungary between 1879 and 1951  cluster was found only in a region where D. repens was the most frequent filarioid parasite in mosquito samples collected in a 3-year surveillance programme between 2011 and 2013 . Taking into account the previous report about Dirofilaria infections in the country  than that found in earlier serological  dogs in our study. Trájer et al.  cluster in the eastern part of Hungary where the first autochthonous case was diagnosed. It can be stated that this area is hyperendemic for heartworm disease. We assume that more D. immitis-infected local dogs facilitated the spreading of this nematode species there than in the other part of the country. It cannot be excluded definitively that D. immitis had also been present in the country before the twenty-first century because no epidemiological surveys had been carried out and no reliable diagnostic methods were available earlier. However, it is more plausible that D. immitis has only recently been introduced to Hungary because neither microfilariae nor adult worms of D. immitis had been found in local dogs  using temperature data for the period 2008 through 2017. We obtained a higher estimate for the number of Dirofilaria generations per year. This can be explained by the increasing temperature due to global warming. Another possible reason for the differences might be the distinct sources of the applied meteorological datasets. The risk period for Dirofilaria transmission is seasonal in Hungary, with peaks in the summer, when the temperature is especially sufficient to facilitate the extrinsic incubation of Dirofilaria in vectors. We are aware of the fact that environmental temperature along with adequate moisture is one of the key factors in the epidemiology of dirofilariosis as others have stated (Medlock et al. More than a decade ago, Genchi et al.  used temBoth dirofilarioses are endemic in Hungary, and heartworm disease is more prevalent in the eastern areas of the country. This study further confirms the significant circulation of these filarioid parasites in the local domestic dogs. We assume that the administration of broad-spectrum chemoprophylactic products with endoparasiticidal and/or ectoparasiticidal activity for 8–12 months each year would assist in preventing these pathogenic and zoonotic parasitic infections. Further systematic monitoring studies are required to better understand the environmental risk factors and to identify the competent mosquito vectors in the epidemiology of local dirofilariosis. Particular attention should be paid to stray and shelter dogs.


Aphanizomenon flos-aquae (AFA) and cyanotoxins, presenting exposure risk. The authors conducted a systematic literature review using a GRADE PRISMA-p 27-item checklist to assess the evidence for toxigenicity of AFA in both fresh waters and BGAS. Studies have shown AFA can produce significant levels of cylindrospermopsin and saxitoxin in fresh waters. Toxicity studies evaluating AFA-based BGAS found some products carried the mcyE gene and tested positive for microcystins at levels ≤ 1 μg microcystin (MC)-LR equivalents/g dry weight. Further analysis discovered BGAS samples had cyanotoxins levels exceeding tolerable daily intake values. There is evidence that Aphanizomenon spp. are toxin producers and AFA has toxigenic genes such as mcyE that could lead to the production of MC under the right environmental conditions. Regardless of this ability, AFA commonly co-occur with known MC producers, which may contaminate BGAS. Toxin production by cyanobacteria is a health concern for both recreational water users and BGAS consumers. Recommendations include: limit harvesting of AFA to months when toxicity is lowest, include AFA in cell counts during visible blooms, and properly identify cyanobacteria species using 16S rRNA methods when toxicity levels are higher than advisory levels.Previous studies of recreational waters and blue-green algae supplements (BGAS) demonstrated co-occurrence of  Aphanizomenon flos-aquae (AFA) is naturally present in fresh-water sources and has been harvested as dietary blue-green algae supplements (BGAS) in the U.S. since the 1980s [Aphanizomenon spp. form the most common and noxious type of harmful cyanobacteria blooms (CyanoHABs), which have potentially dire consequences for environmental and human health [Cyanobacteria, also known as blue-green algae, are photosynthetic bacteria that occur in many fresh and salt water environments around the world. Some cyanobacteria species are toxigenic; they have the potential to produce toxins that can harm people, pets and wildlife. he 1980s . AFA is n health ,4. The pn health ,5, and hn health . While tn health . Previoun health ,11,12. Mn health . These e50) and tolerable daily intake (TDI), or thresholds for daily reference doses (RfD). Under the Clean Water Act (CWA) 304(a) the Environmental Protection Agency (EPA) recommended a threshold for RfD concentrations of cyanotoxins to protect human health while swimming or participating in other recreational activities in and on the water [Cyanotoxin guidelines were established by the World Health Organization (WHO) in 1999 . Work ishe water . States he water . States he water . The epihe water . In addihe water . Because of incidents attributed to toxic CyanoHABs, the WHO and the EPA recommended that risk assessment plans and safety levels include cyanobacteria as an environmental parameter to be monitored and assessed. Swimmers can involuntarily swallow water while swimming, and harm from ingestion of recreational water is comparable to that of drinking water with the same toxin content . For recAphanizomenon flos-aquae in order to evaluate the risks posed to recreational water users and dietary BGAS consumers. The aim of this systematic review is to determine the strength of evidence for the toxigenicity of Aphanizomenon spp. are known to produce a variety of cyanotoxins, including ANTX, CYN and STX [Aphanizomenon spp. produce toxins in eutrophic conditions; studies suggest that nitrogen limitation may increase the extracellular release of toxin in CYN-producing cultures. The release of toxins through the cell membrane has been linked to NorM MATE proteins encoded by genes cyrK (for CYN toxins) [sxtM (for STXs) [Aphanizomenon spp.Some species of cyanobacteria are considered toxigenic, meaning they carry the genes responsible for producing various toxins that are classified by mode of action into hepatotoxins , neurotoxins , and skin irritants . Several and STX ,18,19. A toxins) ,19,20 anor STXs) . Extrace50 of ANTX is 200–250 µg/kg body weight in rats [ANTX is a naturally occurring organophosphate. Toxicity of ANTX has been well documented since the 1960s . It is a in rats ,25. ANTX in rats , binding in rats . This “d in rats . Symptom in rats . Dependi in rats . There a in rats .Cylindrospermopsis raciborskii detected in Australia, Hungary [Umezakia natans in Japan [Anabaena bergii in Israel [Raphidopsis curvata in China [Aphanizomenon ovalisporium in Australia and Israel [50  in mice was determined to be approximately 4–6 mg/kg [CYN is a naturally occurring liver toxin that is found typically in warm tropical waters but, has a presence worldwide. CYN is found in cyanobacteria such as  Hungary , and the Hungary ; Umezakiin Japan ; Anabaenn Israel ; Raphidoin China ; and Aphd Israel ,33. CYN d Israel . In addid Israel . P-450 md Israel . CYN hasd Israel . The LD5–6 mg/kg . The EPA–6 mg/kg . The kid–6 mg/kg . The cri–6 mg/kg .Microcystis, Planktothrix (Oscillatoria), Anabaenopsis, Cylindrospermopsis and Aphanizomenon [50 by the intraperitoneal route is approximately 25–150 µg/kg of body weight in mice; the oral LD50 (by gavage) is 5000 µg/kg of body weight in mice, and higher in rats [MCs are a class of cyclic peptides, typically containing seven amino acids. Those found in freshwater are predominantly produced by species of izomenon . This grizomenon . MCs are in rats . With an in rats . The pro in rats ,5,16. Be in rats . The EPA in rats . It is w in rats ,42; ther50 based on previous mice studies, via this route of exposure has been estimated to be 50 µg/kg body weight [Another toxin produced by AFA is saxitoxin (STX), a paralytic shellfish poison (PSP) found in both marine and freshwater environments. The term saxitoxin can also refer to a class of more than 50 structurally related neurotoxins (known collectively as “saxitoxins” or STXs). Humans and other animals are commonly poisoned by STXs after they are taken up by filter-feeding bivalves and crustaceans, which ingest and concentrate the toxin within their tissues and organs . STX-rely weight . Currenty weight . Humans y weight . AFA is naturally present in freshwater sources . CyanoHAAphanizomenon spp. show evidence for moderate to high toxin production particularly with MCs, CYN , ATX , and STXs  [Aphanizomenon spp. carry toxigenic genes and produce ATX, CYN, MCs and STXs in varying degrees, uncertainty exists over whether AFA has the genes for toxigenicity and if it does, whether it produces toxins in differing environmental conditions. In 2015, genome analysis by Šulcius et al. revealed the presence of non-coding sequences belonging to ANTX gene cluster that indicates AFA may have contained genes responsible for the production of cyanotoxins [Dolichospermum circinale and AFA) but by small numbers of Microcystis cf. aeruginosa and Planktothrix rubescens that co-habited the blooms sampled [mcyE gene responsible for MC toxin production [Microcystis aeruginosa is likely. This cyanobacterial co-occurrence also supports findings by Palus et al. in 2007, where cyanobacterial blooms were found to be most intense between August and September, producing the highest concentrations of MC toxins seen in the study [Microcystis aeruginosa and AFA were the most dominant cyanobacteria present within the blooms during periods of high MC concentration [Throughout the literature AFA has demonstrated the ability to produce ATX, CYN, MC, and STXs under certain conditions and in certain geographical areas. Overall the  toxins) ,17. Whil sampled . AFA wasoduction . Since Aoduction , contamihe study . Microcyntration , making Aphanizomenon spp. [Aphanizomenon gracile is highly correlated with CYN concentrations in the lakes and was suspected to be the major producer of the detected CYN toxin [Aphanizomenon var klebahnii was identified in 2009 in the Czech Republic as a potential producer of CYN toxins [More direct evidence for AFA toxigenicity was found in the following studies. In 2007 Fastner et al. detected measurable amounts of CYN toxin in 21 German lakes with high concentrations of non spp. ,49. CYN non spp. . The maxnon spp. . AphanizYN toxin . This waYN toxin . CYN-synYN toxin . The strYN toxin . In 2007YN toxin ,28,50. AN toxins . ANTX waN toxins . The birN toxins . In addiN toxins .C. raciborskii as potential producers of STX, while confirming A. gracile did, in fact, produce STX [In addition to CYN and ANTX, there was evidence of STX when AFA was the dominant species in the Montargil Reservoir, Portugal . To confduce STX . It was duce STX .Dietary supplements are largely self-regulated, although there are some safeguards in place following the passage of the 1994 Dietary Supplement Health and Education Act (DSHEA) by the United States Congress and its implementation by the Food and Drug Administration (FDA) .The harvesting of cyanobacteria for production as dietary supplements has recently come under scrutiny, as the production of these BGAS suffer from less strict quality controls than other food products or pharmaceuticals. In addition, BGAS are marketed internationally and sold widely over the counter and via the Internet. Although insufficient evidence exists, BGAS are reported to have beneficial health effects including weight loss, increasing alertness and energy, and mood elevation for people suffering from depression . In chilMicrocystis aeruginosa is a regular occurrence together in blooms with AFA [M. aeruginosa regularly coexists with AFA it can be collected inadvertently during the harvesting process, resulting in MC contamination of BGAS [For nearly 30 years, AFA has been harvested for blue-green algae supplements and constitutes a significant portion of the health food supplement industry in North America . AFA is with AFA . Because of BGAS . In 1996 of BGAS . MCs wer of BGAS . Microcystis spp., and recommends that genetic testing be done to identify the organism responsible for MC production [Spirulina spp. are generally regarded as safe within the BGAS industry as of this time [l-alanine (BMAA) [Saker et al. (2007) supports the findings that many AFA-based BGAS may be contaminated with MC-producing strains of oduction . Previouoduction . Althougoduction . In 2012oduction . Of all oduction . Spirulihis time . Only AFhis time . In 2015his time . While shis time ,61, neithis time . In 2017his time . Toxic shis time . Some ste (BMAA) . Dietarye (BMAA) .Microcystis or Planktothrix, and toxin testing for MC >10 μg/L, ANTX >20 μg/L, CYN >6 μg/L, and STX >100 μg/L [Aphanizomenon spp. in their list of potentially toxic cyanobacteria, e.g., toxigenic taxa include Anabaena, Microcystis, Planktothrix, Nostoc, Coelosphaerium, Anabaenopsis, Aphanizomenon, Gloeotrichia, Woronichinia, Oscillatoria, and Lyngbya [Cyanotoxin advisories and guideline values vary from state to state, and not all states have advisory and guideline values. To date, fifteen states have included recreational guideline values for cyanotoxins as part of their response protocol. The EPA currently lists Oregon’s options for recreational water guidance/action level as public health advisory over >100,000 cells/mL of “toxigenic species”, or >40,000 cells/mL of 100 μg/L . CurrentAphanizomenon spp. as a known toxin producer specifically for cyanotoxins: CYN , ANTX (7–47%), and STXs (7–35%) [Aphanocapsa spp. dominated total CyanoHABs during periods of maximum MC concentration in Sardina, Italy [mcyE gene, and did not produce ANTX or STX [Aphanizomenon spp. STX gene cluster may be biogeographically differentiated by county [M. aeruginosa or A. gracile [There is evidence to support  7–35%) . In 2017 (7–35%) . Environ5% . In 2X or STX . Gkelis y county . In IrelmcyA gene was detected in all AFA dietary supplements tested, which could be attributed to contamination by other toxic cyanobacteria such as Microcystis spp. [mcyE gene [The first report of CYN in AFA was reported by Preussel et al. in Germany, 2006 through LC-MS/MS analysis and detection of PCR products of gene fragments . In 2007tis spp. . SimilarcyE gene . Aphanizomenon spp. of this genus have only been described morphologically [Aphanizomenon and distinguish them as separate species [The evidence for production of ANTX, CYN, MC, and STX, by AFA is of increasing concern, given that AFA occurs with high frequency in freshwater ecosystems throughout the U.S., and is regularly and increasingly used as a dietary supplement. Not only is AFA abundant in CyanoHAB events, but it appears to survive well in poor growth conditions as well, even at low temperatures . AFA proogically . No phyl species . AFA mayAphanizomenon spp. for AFA and therefore their findings cannot be confirmed or used as evidence to support the presence of toxin production by AFA [Aphanizomenon such as A. gracile, which is a known toxin producer [One finding of this review is the large amount of uncertainty that exists over the potential for AFA to carry toxin genes and produce toxins. Several earlier studies have misidentified n by AFA ,65. Withproducer ,66. In aproducer . Previouproducer  and Humpproducer , have seproducer  to develAphanizomenon in two studies [Aphanizomenon or M. aeruginosa [Aphanizomenon spp. have shown a moderate to high production of toxins. Cyanobacteria blooms are commonly a mixture of toxic and non-toxic genotypes, and associated toxin concentrations can be highly variable both spatially and temporally ,68. Addi studies ,65. AFA-ruginosa ,41,59. OAphanizomenon due to the potential for cross-contamination among species, and lack of regulation and testing among dietary supplements. Further investigation is warranted to improve our understanding of the effects that AFA dietary supplements have on consumers [Microcystis spp. from Upper Klamath Lake should be followed by laboratory cultivation and subsequent toxicological analyses to provide information on the toxicity of cyanobacterial contaminants [The presence of toxins in recreational waters and BGAS production environments remains a public health concern when CyanoHABs are present, with elevated levels of MCs being found and increasing reports of illness. Accumulated evidence from the peer-reviewed literature suggests that AFA carries toxigenic genes and has the potential to produce toxins under the right environmental conditions. Toxin production of cyanobacteria is highly variable, both within and between blooms and given the timing or seasonality of the bloom . Evidenconsumers . Surveysaminants . The following recommendations are based on the most current global studies (2000–2017) to inform public health, regulatory and natural resource management agencies regarding AFA toxicity to make the most informed decisions. These signs will help to educate and alert the public of the potential health risks associated with recreational water use during CyanoHABs. This step is particularly important for recreational users with small children or dogs. It is recommended that signs be posted at first visual confirmation of scum, while cell counts and/or toxicity analyses are underway. This action would reduce the risk of exposure to cyanotoxins.The majority of studies indicate that cyanobacteria produce most toxins under environmental conditions, which are most favorable for their growth (warmer summer months). When temperature and light requirements are optimal for toxin production, AFA may produce more MCs than during times with less than optimal temperature and light . This maIt has been demonstrated that AFA has the potential to produce toxins, and should be included in the cell counts of toxigenic cyanobacteria for public health advisories related to CyanoHABs. Ending exclusion of AFA from CyanoHAB advisory criteria would lead to increased frequency and duration of public health advisories and would reduce the risk of exposure to cyanotoxins. This may be evaluated and revised after additional evidence. The EPA’s cyanotoxin guidelines were established under scientific rigor based on existing knowledge from published peer-reviewed scientific evidence on the adverse human health effects of toxins, criteria methodologies, and recreation-specific exposure parameters, reviewed by the Health and Ecological Criteria Division, Office of Science and Technology Office of Water, U.S. . The heaPrior to 2007, several research studies had misidentified another toxin-producing cyanobacteria species for AFA. Previous attempts to differentiate toxigenic from non-toxic strains of the same species using microscopic methods have failed. Therefore, it is not recommended to identify species of cyanobacteria using only microscopic methods. During CyanoHABs events when cyanotoxin levels are above health advisory guideline values, advanced molecular methods such as 16S rRNA PCR should be used to determine specific strains of toxigenic cyanobacteria. This information would help to focus analysis for cyanotoxins and inform future evaluation of cyanobacteria toxigenicity.Further research would provide an evidence base to improve recommendations for recreational and BGAS guidance values. It should be noted whether there is a visible algal bloom (include picture) at the time the sample is taken in addition to recording other environmental factors such as temperature (ambient and water), pH, and whether it is raining/snowing. Protocols for sample collection, preparation and storage should be evaluated for improvement. Both microscopic evaluation and ELISA testing should be done regardless of cell count. Cell count and ELISA results should be recorded and compared across time to note any predictive environmental factors for increased toxicity and to definitively prove whether AFA is a toxin producer. Molecular techniques should be employed to detect toxicity genes. This work will help to either confirm or refute the presence of toxin producing genes and better understand the risks associated with AFA in recreational waters and dietary supplements.A systematic review of the peer-reviewed literature was conducted per the preferred reporting items for systematic review and meta-analysis protocol  method. The GRADE method rates the quality of evidence presented in research studies for evaluation. Evidence is assessed based on five factors: risk of bias, imprecisions, inconsistency, indirectness of evidence and publication bias. The quality of evidence is rated on the following scale: “High Quality”, “Moderate Quality”, “Low Quality” and “Very Low Quality.” Randomized control trials are considered “High Quality” evidence but, can be downgraded if there is a serious risk of bias in the study. Additionally, observation studies begin as “Low Quality” evidence and can be upgraded due to large effect size (Relative Risk or Odds Ratio > 2), presence of a dose response or the presence of confounders against bias. The methodology is widely used and accepted by numerous organizations including the WHO. Articles were assessed, and tables were produced using the online GRADEpro toolkit, summary of findings table.


More than one in four older adults (OA) in the US fall each year and 20 to 30% suffer moderate to severe injuries such as head trauma or hip fractures. Falls are both a medical and financial burden that can be significantly reduced by lifestyle interventions. One of the main strategies to help reduce these statistics is evidence-based fall prevention classes which help to build muscle, improve balance, and increase participants’ confidence in fall control. A goal of the Arkansas Geriatric Workforce Enhancement Program (HRSA grant U1QHP28723) is to deliver community-based programs that improve health outcomes and quality of life. Evidence-based preventive health training is a major way to meet this goal. Two of these evidence-based trainings are Tai Chi (TC) and A Matter of Balance (AMOB), multi-week classes that help to improve balance and reduce fall risk. This study took place at scheduled community-based classes, where demographic and balance data were obtained. The aim was to determine the difference in the balance of community-dwelling OA as measured by Balance Tracking System® before and after AMOB and TC courses. Both groups showed positive changes in their mean balance percentage with the AMOB class having a higher Mean ± SD (24.3 ± 21.0) vs. the TC participants (4.0 ± 29.7). The One-Way Analysis of Variance showed statistically significant difference in the AMOB class over those in the TC class, F  = 5.280, p < 0.05. The Cohen’s d = 0.789 indicates a large effect between the two groups.


Patients with idiopathic Parkinson’s disease (IPD) require long-term care and are reported to use complementary and alternative medicine (CAM) interventions frequently. This CAM-specific clinical practice guideline (CPG) makes recommendations for the use of CAM, including herbal medicines, acupuncture, moxibustion, pharmaco-acupuncture, and qigong (with Tai chi) in patients with IPD. This guideline was developed using an evidence-based approach with randomized controlled trials currently available. Even though this CPG had some limitations, mainly originating from the bias inherent in the research on which it is based, it would be helpful when assessing the value of the CAM interventions frequently used in patients with IPD. Idiopathic Parkinson’s disease is a chronic neurodegenerative disease which presents progressive loss of dopaminergic neurons in substantia nigra. Generally, long-term medical care is often required after first diagnosis of IPD. The prevalence of IPD rises with age but there could be geographic difference in the prevalence among 70–79-year-old population between Asian countries and North America–Europe countries . BecauseThis CAM-specific CPG for IPD was developed to provide reliable recommendations for health care professionals and patients based on current best clinical evidence on the benefits and harms of CAM interventions.The scope covered in this guideline contained any modalities which are originated from outside of conventional biomedicine and can be used together with main-stream medical practice . In the Figure 1). In September 2016, the society organized a steering committee to oversee the development of the guideline, a development committee to synthesize the evidence and draft the CPG, and an advisory committee to review the proposed CPG. The steering committee included six society members, the development committee was multidisciplinary and consisted of four disease specialists, five methodology experts, one statistician, and one economic analysis specialist. The advisory committee included seven KM physicians working in primary and secondary care and recommended by the Society of Stroke on KM and two KM physicians recommended by the panel of physicians at the Guideline center for KM.This CAM-specific CPG for IPD was developed by the Society of Stroke on KM . The strength of the recommendations was graded according to the level of evidence and its clinical importance, such as the risk and benefit of the intervention and its value to the patient, as A, B, C, D, or GPP (Table 2). Based on the level of evidence and strength of the recommendations, a draft recommendation for each clinical question was prepared by the development committee.Multiple members of the development committee selected the literature, extracted the relevant data, and performed the risk of bias assessment and meta-analysis. Any disagreement was resolved by group discussion. The evidence for each clinical question was qualitatively and quantitively synthesized. In case of multiple clinical trials using the same specific intervention such as specific type of herbal medications or acupuncture, clinical questions for specific interventions were generated through panel discussion and synthesized too. Levels of evidence and the strength of the recommendations were then evaluated using the GRADE approach . Validat1. A questionnaire concerning the initial draft of the recommendations was prepared, and a panel of nine multidisciplinary experts was established on the recommendation of the advisory committee. The experts on the panel were asked to grade their degree of agreement with each recommendation on a nine-point Likert scale . A median value of ≥7 indicated that agreement was reached and a median value <7 implied disagreement that required a further round of the Delphi process. The expert panel answered two rounds of questionnaires, after which the final recommendation for the CPG was drafted (Supplementary Table 1). The Guideline center for KM then approved the final draft of the CPG to be implemented by the end of 2018.The Delphi method was used to achieve formal consensus between experts and clinicians and required all contributors to complete an on-line web surveyThis clinical question was intended to assess the overall clinical evidence for combination therapy using herbal medicines of any type and anti-parkinsonian agents. Although inclusion of multiple prescriptions when assessing the clinical evidence for herbal medicine is controversial, it is considered necessary at the present stage. In addition, the benefits and risks of treatment are similar between the herbal medicines available, and there was a consensus among the group of experts that the values and preferences for these medicines are similar. After assessing the overall evidence for herbal medicine regardless of the type of prescription, we evaluated the clinical evidence for several herbal prescriptions that have been evaluated in previous clinical trials using the following clinical questions in below sections.Supplementary Table 2.1).Seventy-five studies (including 5430 patients with IPD) that evaluated the UPDRS total score were included. The score was significantly lower in the combination therapy group than in the anti-parkinsonian monotherapy group . The results of 44 RCTs (including 3100 patients with IPD) that evaluated the UPDRS part I score for mentation, behavior, and mood favored combination therapy . Fifty-nine RCTs (including 4311 patients with IPD) that evaluated the UPDRS part II score for activities of daily living found a significant difference between the combination therapy group and the anti-parkinsonian drug monotherapy group . Seventy RCTs (including 4909 patients with IPD) that evaluated the UPDRS part III score for motor examination were included, and combination treatment achieved better results . When the UPDRS part IV score for motor complications was assessed, the results of 40 studies (including 3078 patients with IPD) indicated a significant difference in favor of combination treatment . The PDQ-39 summary index was assessed in 20 studies (including 1490 patients with IPD). The MD in the summary effect estimate for the PDQ-39 summary score was 9.29  in favor of combination therapy. Twenty-seven RCTs (including 2043 patients with IPD) included information on the concomitant dose of levodopa. The SMD in levodopa consumption was -0.77  when the group that received combination therapy was compared with the group that received anti-parkinsonian drug therapy alone, suggesting that lowering the dose of levodopa in the combination group was more effective. Forty-nine RCTs (including 3463 patients with IPD) included an assessment of adverse events; the RR for total incidence was estimated to be 0.44  in the group that received combination therapy when compared with the group that received anti-parkinsonian drug therapy alone. However, the overall level of evidence for these analyses was assessed as low, and the results of future studies will have a significant impact on the degree of confidence in the summary effect estimates. A combination of herbal medicine and anti-parkinsonian drug therapy should be considered in patients with IPD; however, the strength of this recommendation may change according to the outcomes of future research . The evidence in this section suggests a comprehensive recommendation for combination therapy using various herbal medicines and anti-parkinsonian drugs .Rehmannia glutinosa, Paeonia lactiflora, and Polygonum multiflorum. Four RCTs (including 289 patients with IPD) that compared Bosin-yanggan-sigpung-bang and levodopa combination therapy and levodopa monotherapy were included. The MD in the summary effect estimate for the UPDRS total score was -11.39  and the SMD for consumption of levodopa was -1.04 , which suggests a statistically significant difference in favor of combination treatment. There was no significant difference in the incidence of adverse events between the two groups. The levels of evidence for the UPDRS total score and the dose of levodopa were inadequate (Supplementary Table 2.2).Bosin-yanggan-sigpung-bang has been one of the most frequently evaluated herbal medicines in clinical trials and consists mainly of Concomitant administration of Bosin-yanggan-sigpung-bang herbal medicine and anti-parkinsonian drug therapy may be considered in patients with IPD (strength of recommendation: C/level of evidence: insufficient).Cornus officinalis, P. multiflorum, and Salvia miltiorrhiza. Ten studies that were included in the analysis were used to answer this clinical question. The summary effect estimates for the UPDRS total score  and PDQ-39  were in favor of combination therapy. The RR for the overall incidence of adverse events was 0.46 .Bosin-hwalhyeol-cheobang contains mainly Concomitant use of Bosin-hwalhyeol-cheobang herbal medicine and anti-parkinsonian drug therapy may be considered in patients with IPD (strength of recommendation: C/level of evidence: moderate).Lycium chinense, C. officinalis, P. multiflorum, S. miltiorrhiza, and Buthus martensi. Three studies could be included in the analysis. When comparing combination therapy and levodopa monotherapy, the MD for the UPDRS total score was -15.40  and the MD for the PDQ-39 was -7.05  in favor of combination therapy. The overall level of evidence was moderate. None of the studies included information on adverse events (Supplementary Table 2.4).Bosin-hwalhyeol-tonglag-cheobang is mainly composed of Concomitant administration of Bosin-hwalhyeol-tonglag-cheobang herbal medicine and anti-parkinsonian drug therapy may be considered in patients with IPD (strength of recommendation: C/level of evidence: moderate).R. glutinosa, L. chinense, Loranthus parasiticus, and Gastrodia elata. Three studies could be included in the analysis. The summary effect estimates for the UPDRS part II score for activities of daily living  and those for the UPDRS part III score for motor examination  favored combination therapy. The MD in the summary effect estimates for the amount of levodopa used was 0.05 . The estimated incidence of total adverse events favored combination treatment . The level of evidence was low (Supplementary Table 2.5).Sugji-pyeongjeon-tang is a herbal prescription that consists mainly of Concomitant use of Sugji-pyeongjeon-tang herbal medicine and anti-parkinsonian drug therapy should be considered in patients with IPD (strength of recommendation: B/level of evidence: low).Supplementary Table 3.1).This clinical question was intended to assess the overall clinical evidence for combination therapy with acupuncture and anti-parkinsonian medications regardless of type of acupuncture intervention. After addressing this clinical question, we assessed the clinical evidence for the frequently used acupuncture interventions in the following clinical questions. Twenty-one RCTs were included. A meta-analysis of clinical trials comparing combination treatment with acupuncture and anti-parkinsonian drug therapy with anti-parkinsonian drug therapy alone suggested that combination therapy had better overall clinical effectiveness than anti-parkinsonian drug therapy alone . In addition, there was a statistically significant difference in the Webster scale score  in favor of combination treatment. The UPDRS total score suggested that combination therapy with acupuncture and anti-parkinsonian drug administration was more effective in improving symptoms than anti-parkinsonian drug therapy alone . Only two studies reported adverse events, with no serious adverse events occurring in either study. The overall level of evidence is low, and future studies will have a significant impact on the degree of confidence in the summary effect estimates. This section suggests a comprehensive recommendation for various acupuncture interventions, and recommendations for individual type of acupuncture are suggested below (Concomitant use of acupuncture and anti-parkinsonian drug therapy should be considered in patients with IPD (strength of recommendation: B/level of evidence: low).Acupuncture points such as GB20, LR3, GB34, LI4, GV20, KI39, LI11, GV16, BL10, BL40, GB6, GV1, and PC6 can be considered for use in acupuncture.Supplementary Table 3.2).Seven RCTs were available to address this clinical question. The anti-parkinsonian therapy used in the control groups was a fixed combination of levodopa and benserazide in all cases. Significant improvement in the Webster scale score  was observed in favor of combination therapy when compared with the fixed combination as monotherapy. Adverse events were only reported in two of the seven studies. There were no serious adverse events in either of these studies. The level of evidence from the literature is low and the results of future studies are likely to have a significant impact on the degree of confidence in the summary effect estimates .Supplementary Table 3.3).In three RCTs, electroacupuncture and anti-parkinsonian drugs were compared with anti-parkinsonian drug therapy alone and there was no significant difference in overall clinical effectiveness , Webster scale score , or UPDRS total score  between the two groups. However, the level of evidence was low and the results of future studies are likely to have a significant impact on the degree of confidence in the summary effect estimates (Concomitant use of electroacupuncture and anti-parkinsonian drug therapy may be considered in patients with IPD (strength of recommendation: C/level of evidence: low).If the patient’s chief complaints are tremor and rigidity, electroacupuncture should be applied carefully so as not to trigger overstimulation.Supplementary Table 3.4).Three RCTs were available to answer this clinical question. The fixed combination of levodopa and benserazide was used as the anti-parkinsonian drug therapy in all the control groups. There was significant improvement in the Webster scale score  in favor of combination therapy. There was no description of the adverse events that occurred in any of the studies. The level of evidence in the literature is insufficient but combination treatment is recommended based on the clinical experience of the development committee .Supplementary Table 4.1).Five studies (including 293 patients with IPD) were included in the comparison of the effectiveness of moxibustion with that of other interventions in terms of the UPDRS total score. The UPDRS total score was lower in the moxibustion group than in the control group . Three RCTs (including 174 patients with IPD) were included in the assessment of the UPDRS part III score for motor examination, and a significant difference was observed in favor of moxibustion . Only one study reported adverse events and none of the studies reported side effects. The overall level of evidence was low. Although moxibustion could potentially be a treatment for patients with IPD, there is a lack of concrete evidence for its efficacy and safety (Moxibustion may be considered in patients with IPD (strength of recommendation: C/level of evidence: low).Care should be taken not to cause adverse events by excessive stimulation if the main symptoms are tremor and rigidity.Supplementary Table 4.2).Only one RCT could be included in the analysis to answer this clinical question. Sixty patients with IPD were included in this study and the UPDRS total score was assessed by comparing the combination of direct moxibustion, acupuncture, and anti-parkinsonian drug therapy with anti-parkinsonian drug monotherapy alone. The UPDRS total score was significantly improved in the combination group in comparison with the anti-parkinsonian drug monotherapy group . There was no description of adverse events in this study. The level of evidence is low; however, summary effect estimates may change according to the findings of future research. Care should be taken to avoid adverse events by excessive stimulation if the patient’s main symptoms are tremor and rigidity . Care should be taken not to cause adverse events by excessive stimulation if the patient’s main symptoms are tremor and rigidity.Supplementary Table 4.3).One RCT would be included in the analysis to answer this clinical question. There was no significant difference in the UPDRS total score between combination therapy and a fixed combination of levodopa and benserazide . No information on adverse events was available. The overall level of evidence is low. Care should be taken not to cause adverse events by excessive stimulation if the patient’s main symptoms are tremor and rigidity (Concomitant treatment with Moxa-stick moxibustion and anti-parkinsonian drug therapy may be considered in patients with IPD (strength of recommendation: C/level of evidence: low).Care should be taken not to cause adverse events by excessive stimulation if the patient’s main symptoms are tremor and rigidity.Supplementary Table 4.4).One RCT comparing a combination of warm-needling acupuncture and swallowing exercises with swallowing exercises alone was included in the analysis to address this clinical question. The total effectiveness rate was significantly higher in the combination treatment group  but there was no report on adverse events. The overall level of evidence was low .One RCT was available to address this clinical question. When comparing a combination of bee venom acupuncture and anti-parkinsonian drug therapy with anti-parkinsonian drug therapy alone, there was a significant difference in UPDRS total score in favor of combination therapy. One participant reported an itching event after bee venom acupuncture. The overall level of evidence was insufficient, but the development committee decided to make a GPP recommendation based on the prevalent use of this treatment modality in current clinical practice and the opinion of the expert committee.Concomitant treatment with bee venom acupuncture and anti-parkinsonian drug therapy is recommended in patients with IPD (strength of recommendation: GPP/level of evidence: insufficient).Supplementary Table 5).One RCT could be included in the analysis to answer this clinical question. There was no significant difference in the total effectiveness rate between a combination comprising Puerarin pharmaco-acupuncture and anti-parkinsonian therapy and single anti-parkinsonian drug therapy alone . No adverse events were reported. The overall level of evidence was insufficient, but the development committee decided to make a GPP recommendation based on the prevalent use in current clinical practice and the opinion of the expert committee (Concomitant treatment with pharmaco-acupuncture and anti-parkinsonian drug therapy is recommended in patients with IPD (strength of evidence: GPP/level of evidence: insufficient).Supplementary Table 6.1).Two RCTs (including 141 patients with IPD) were included to answer this clinical question. The group of patients that received combination therapy  had a better UPDRS part III score for motor examination  and a better Berg balance scale score . In addition, the combination therapy group showed better results in several domains on the Parkinson Disease Sleep Scale-2, including sleep quality , motor symptoms at night , symptoms of Parkinson’s disease at night , and disturbed sleep  compared with the groups without qigong. However, the overall level of evidence was low .Supplementary Table 6.2).Three RCTs (including 216 patients with IPD) were included for evaluation of this clinical question. When compared with exercise or stretching movement, Tai chi had a better effect on the UPDRS part III score for motor examination  and Berg balance scale score . In addition, there was a significant decrease in the number of falls recorded in the Tai chi training group . However, the overall level of evidence was low (Tai chi can be considered in patients with IPD (strength of recommendation: B/level of evidence: low).This evidence-based CPG on CAM interventions for IPD outlines the currently available evidence and makes recommendations for the commonly used CAM interventions, i.e., herbal medicines, acupuncture, moxibustion, pharmaco-acupuncture, and qigong (with Tai chi). This CPG mainly addresses combination treatment using individual CAM interventions and anti-parkinsonian drug therapy because of the current lack of clinical evidence for use of CAM interventions alone. In this sense, CAM interventions need to be considered for concomitant use only until new and conclusive evidence of their efficacy as monotherapy emerges. In addition to this, about CAM interventions usage, communication between physician and patients is very important to prevent potential adverse events, which should be reminded when CAM interventions get started .The development committee acknowledges that this CPG has several limitations, the most important one being that the overall level of evidence for each intervention as assessed by GRADE approach is low or insufficient because of the high risk of bias introduced by methodologic problems and inaccuracies arising from the small numbers of participants in the included studies. Indeed, there could be considerable publication bias because most of the relevant studies were performed in Asian countries. Additionally, we did not intend to limit target population of this CPG but most clinical studies included only Asian population who showed different characteristics in ages, sex, and region across the studies. Second, most of the recommendations focus on the overall benefit and harm of combination treatment with CAM interventions and antiparkinsonian drugs. CPGs that focus on specific symptoms or long-term complications related to IPD need to be developed in the future. In addition, this CPG dose not include detailed information on the methods for usage of individual CAM interventions, which would be updated in the future CPG. Third, this CPG is based on evidence for combination treatment with CAM interventions and anti-parkinsonian drug therapy. As already mentioned, there is no clear evidence regarding whether individual CAM interventions are effective and safe enough to be recommended in this CPG. Therefore, in principle, we recommend that most CAM interventions be used in combination with conventional anti-parkinsonian drug therapy at this stage. Third, there was no participation of consumer groups in the Delphi process, which means that no patient perspectives or preferences were taken into account in the development of this CPG. Fourth, no cost or economic analysis was performed. Finally, only limited interventions were assessed in this review. As we described in the “Materials and Methods” section, interventions which were frequently used in Asian countries were included for this CPG. Actually, frequently used CAM modalities are reported to be different between countries  so otherRigorous RCTs for individual CAM interventions with adequate statistical power should be conducted, especially in the United States and Europe. The safety and effectiveness of CAM as monotherapy and when used as part of combination therapy should be evaluated in the IPD population. Comparative ranking between included CAM modalities would be helpful which can be suggested through indirect comparison using network meta-analysis method. A consumer group should be included in the Delphi process when updating this CPG in the future. Inclusion of a cost-effectiveness analysis should also be considered when updating this CPG. Finally, when clinically implementing recommendations of the interventions included in this CPG outside Korea, physicians and patients need to consider accessibility and feasibility of the interventions in their medical environment and context.Development of this guideline was funded by the Ministry of Health & Welfare through the Korea Health Industry Development Institute. None of the members of the Society of Stroke on Korean Medicine or members of each committee and expert panel that participated in the Delphi process has any conflicts of interests in this research.This guideline will be updated in 2020. In the future update, various CAM interventions not covered in this guideline will be included.K-HC, T-HK, SK, W-SJ, S-KM, C-NK, S-YC, C-YJ, S-HL, TC, JJ, JC, ML, and EC participated in the CPG development committee and devised the CPG development project. K-HC, T-HK, SK, W-SJ, S-KM, C-NK, S-YC, C-YJ, and S-HL involved in the clinical question development. TC, JJ, JC, and ML conducted systematic literature searching and conducted electronic Delphi surveys. T-HK, TC, JJ, and JC conducted evidence synthesis and made draft of the recommendations. T-HK drafted this manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.