Simulation results demonstrate that the presented algorithm achieves great improvements in both the accuracy of identifying conflicting data and that of fusing conflicting data.There is continuously increasing interest in research on multi-sensor data fusion technology. Because Dempster’s rule of combination can be problematic when dealing with conflicting data, there are numerous issues that make data fusion a challenging task, including the exponential explosion, Zadeh Paradox, and one-vote veto. These issues lead to a great difference between the fusion results and real results. This paper applies the idea of analyzing distance-based evidence conflicts, introduces the concept of vector space, and proposes a new cosine theorem-based method of identifying and expressing conflicting data. In addition, this paper proposes a new data fusion algorithm based on the degree of mutual support between beliefs, which is based on the Jousselme distance-based combination rule proposed by Deng  The DS theory uses a collection to construct the general framework of an uncertainty reasoning model rather than using the specific probability to describe the uncertainty. By establishing the corresponding relation between hypotheses and collections, the uncertainty of hypotheses can be transformed into the corresponding collections. Under the circumstances that In the field of multi-sensor data fusion, the DS theory is a popular method to express and fuse the uncertainty information, and is especially suitable for decision level fusion. However, the appearance of conflicting evidence results in a series of problems when conducting fusion using the DS theory. Zadeh discovered that simply using Dempster’s rule of combination to deal with highly conflicting data will produce some counter-intuitive results. This is known as Zadeh’s Paradox . In addiThis paper applies a distance-based idea to deal with evidence conflict and introduces the concept of vector space. On this basis, we propose a cosine theorem-based method that can effectively identify and explicitly express the conflicting data. On the basis of the above, we propose a new multi-sensor data fusion algorithm based on the degree of mutual support between beliefs, which can solve the data conflict.The rest of this paper is organized as follows: in Section 2, we introduce the background and related work. The cosine theorem-based method for identifying and expressing conflicting evidence is described in Section 3. Section 4 provides the data fusion algorithm based on the degree of mutual support between beliefs on the basis of Section 3, and simulation verification is performed in Section 5. In Section 6, we present the concluding remarks for this paper, as well as the outlook of our future work.2.1, Θ2,…, Θn}. We can define P(Θ) as the set of all possible combinations of all the elements, which is denoted as P(Θ) = {Ø, {Θ1},{Θ2},…,{Θn}, { Θ1∪Θ2}, { Θ1∪Θ3},…, Θ}. We define a function m from P(Θ) to  such that:The DS theory uses Θ to denote a set of mutually exclusive and independence hypotheses about some problem domain. Thus, Θ is composed of all the possible answers to a question and is called the sample space or frame of discernment, which is indicated as Θ = {Θm is called the basic probability assignment (BPA), the quantity m(A) represents the measure of belief that is committed exactly to hypothesis A, and A is called the focal element If m(A) > 0.Then, function m1, m2 are two basic probability assignments of discernment frame Θ, for ∀ A⊆Θ, and the combination of m1, m2 is given by the following formula, which is called Dempster’s rule of combination:K is called the normalization constant, and such that:Note that However, the conflict data brings a challenge for the application of the DS theory. Many researchers have been researched the conflict data of the evidence theory, there has been no clear definition. Here, we introduce a simple and intuitive definition of the conflict data.(The notion of conflict): in DS evidence theory, the conflict between two reliabilities can be qualitatively expressed as a source of evidence strongly supports a hypothesis, but another source of evidence strongly supports an alternative hypothesis, and the two assumptions are incompatible.In fact, the degree of conflict between the evidences can also be said the degree of mutual support. If the degree of conflict is small, it means conclusions of the evidence can support each other; otherwise, it means they cannot support each other. There have been some improvements and schemes resolving conflict data problems when using Dempster’s rule of combination. The existing research can be approximately classified into two aspects: one is the improvement of the analysis, judgment, and expression of conflict evidences, and the other is the amelioration of the fusion algorithm for conflicting data.2.1.As the fusion of conflicting data can be problematic when using Dempster’s rule of combination, it is very important to reasonably and effectively judge the degree of data conflict. There have been various studies on this topic.2.1.1.K computed by Dempster’s rule of combination. It can be observed from the formula that K is calculated by the sum of the products of every two BPAs of completely conflicting propositions B and C. This is called the conflicting coefficient, the value of which can partly reflect the proportion of uncertain information caused by conflicting evidence. However, it has been proven from practical experience that there is no direct relationship between the value of K and the conflicting relation of two pieces of evidence. Thus, it is unreasonable to measure the degree of conflict between pieces of evidence using quantity K.The earlier analysis of conflicting data was based on the quantity 2.1.2.et al. introduced the notion of vector space for evidential theory to propose a conflict expression method based on the distance between the pieces of evidence  is defined as follows:(Pignistic probability function) : SupposeA| indicates the number of elements in A. The Pignistic probability of the subset A is:Here, |m to the Pignistic probability is called the Pignistic probability transformation. Pignistic probability can effectively reflect the belief assignment of a given hypothesis, because it takes into consideration the influence of the inclusion relation between hypotheses on the probability.The transformation from basic probability assignment 2.1.4.On the basis of Pignistic probability-based conflict expression methods, Liu proposed using the concept of using the gambling credibility distance to express the degree of conflict . The gamE1, E2 and E3 under discernment frame Θ:The following shows the basic probability assignments for pieces of evidence A, B and C of this example are singleton sets and have no intersection. Thus, the Pignistic probability is the same as the belief assignment result. We can see that the degrees of conflict for the two methods are the same. However, even though the maximum difference in Pignistic probability between E2 and E1 equals that between E3 and E1, it is observed that on the condition that the belief assignment result for A of E3 remains the same, the belief assignment result for B increases. Thus, E3 is approximately closer to E1, and the degree of conflict is smaller than that between E2 and E1.According to the concept of the gambling credibility distance, 2.1.5.a priori on a specific dependence assumption between the sources.Destercke and Burger  proposedConflict k for sets should be such that:a priori assumption about sources dependence and only consider such assumptions as possible additional information.In particular, they do not make any 2.1.6.Lefèvre and Elouedi  proposed2.1.7.Klein and Colot  used the2.2.Nowadays, researchers at home and abroad mainly focus on two aspects of fusion algorithms: improving Dempster’s combination rule and modifying the evidence source model.2.2.1.When the pieces of evidence are highly conflicting, Dempster’s combination rule normalizes the conflicting data directly without a reasonable belief assignment, which leads to unreasonable results after data fusion. In view of this problem, some researchers have proposed new combination rules.m(Θ). This removes the regularization process of the original combination rule , the angle between PignisticVectors will be , and the corresponding cosine values should be . When the angle is 0°, the cosine value is 1, which infers that the two pieces of evidence are fully supported. When the angle is 90°, the cosine value is 0, which means the degree of conflict is the largest. As the cosine function is monotonically decreasing in the domain T, PignisticVector m2 = T. We find that cos = 1 through E1 and E2 are different.Using m2 (Θ) = 1, it means E2 does not know the concrete reliability allocation results. According to the uncertainty principle of retaining unknown information in maximum entropy theory, the result of m2 (A) = 0.5, m2 (B) = 0.5 is reasonable.The above result seems like violating the analysis principle of the conflict data. But, due to PignisticVectors are the same. Under these conditions, we could calculate the cosine of the initial reliability allocate results and without the mixed set. Then, comparing the value of cosine with the cos(PignisticVector). If these two values are pretty inconsistent, we consider that the procedure of reducing the dimension is not necessary. The cosine could be calculated just by the initial reliability allocation results.Inevitably, the existence of mixed set also can lead to situation that the 4.In Section 3, the method for computing the degree of support between pieces of evidence was defined. To make further efforts, an evidence fusion algorithm is proposed based on the degree of support, which is calculated using the cosine of the pieces of evidence. The constructed correlation matrix considers the relativity among pieces of evidence. As a result, the proposed algorithm has a stronger ability to eliminate conflict between the pieces of evidence.According to the obtained masses, the presented algorithm calculates the angle between the pieces of evidence, which is the metric for the degree of support between them. Then, we calculate the mean value of the weighted credibility by using Deng’s method. Finally, we apply Murphy’s method to fuse the data and obtain the fused masses. On basis of the results, we can consider whether it is necessary to add new evidence or perfect the frame for the discernment.k data sources. After calculating the degrees of support, the correlation matrix can be constructed as follows:Using Expression S, the elements on the diagonal are the degrees of support, which are all equal to 1. The sum of all the elements in row i is the degree of support for evidence i. The support vector for k pieces of evidence is shown in the following expression:In the correlation matrix Sup, Sup (i) indicates the degree of support for evidence i, where a larger value indicates greater similarity. To obtain reasonable weights for the pieces of evidence, Expression In Crd(i) can be used as the weight of evidence im, and the average credibility can be obtained as:Obviously, there is It’s important to note that the proposed algorithm adds up all the elements in a row, including the elements on the diagonal . This is different from Deng’s method, which does not include the diagonal elements. Intuitively, the result calculated by our method can better reflect the real support degree of the mutual evidence.m1, m2 and m3, and the correlation matrix S:For example: suppose that there are three evidences m1 is completely conflict with m2 and m3, and the degree of evidence conflict between m2 and m3 is also great. With the method proposed by Deng et al., the weight of m1 is 0, and the weights of m2 and m3 both are 0.5. This is unreasonable.In this example, the evidence The main steps of the algorithm are shown below.(1)n-dimension to the n-dimension. With the use of the cosine theorem, the degrees of support for the pieces of evidence will be obtained, after which correlation matrix S is constructed.Calculate the correlation coefficients and construct correlation matrix S. After the Pignistic transfer process, the number of credibility assignments will decrease from 2(2)Calculate the support vector and credibility assignments for the pieces of evidence. By using Expressions (3)Calculate the weighted mean of the credibility assignments by using the obtained degrees of support and credibility values. The transferred credibility assignments can be calculated using Expression (4)Fuse the obtained credibility by using the Dempster’s combination rule and Murphy’s method. In Murphy’s method, the evidence’s mass is just reformed by averaging. Here, we reform the mass using a weighted mean, which not only benefits from the advances of Murphy’s method in dealing with conflicting pieces of evidence with a high calculation speed, but also takes into account the correlation between pieces of evidence.(5)Under the Open World and Close World Assumption, make the decision based on the data fusion results.th, it is difficult to make the decision. In particular, the value of th is set based on the actual situation. In order to make the decision, under the Close World Assumption, we need increase the number of evidences. And under the Open World Assumption, we need to add new assumptions in the frame of discernment.As we all know, the high conflict of the data is equivalent to the great difference of the reliability allocation on the same assumption. Because we adopt the evidence weighted average fusion method in this paper, there is maybe a potential problem. If the difference of the reliability allocation, which is obtained after the fusion operation of the high conflict data is less than the preset difference threshold The flowchart of the process is given in Pseudo random code is shown below:Input: 1.m1, m2, m3,…mk), reliability allocation results of k pieces of evidence in the sample space Θ = {Θ1, Θ2,…, Θ3};Mass 1−m(ϕ) // Pignistvector i is the Pignistic probability vector of i, transited from a 2n-dimensional vector to an n-dimensional vector 3:End for 4:For eachi ∈ k , j ∈ k 5:cos=<PignisticVectori,PignisticVectorj>|PignisticVectori|×|PignisticVectorj| // get the angle of two PignisticVector 6:End for 7:Sup[i]=∑j=1kcos // Sup[i] indicates the degree of support for evidence i 8:SumSup=∑j=1kSup[i] // SumSup is the degree of support for all the evidence, prepared for normalization 9:Crd[i]=1SumSupSup[i] // normalized 10:MAE(m)=∑i=1kCrd(i)*mi // MAE(m) is the weighted average credibility of the original reliability 11:t = Murphy(MAE) // using Murphy’s method to average the credibility 12:If (t > th) // t is the incompatibility computed above 13:Then 14:Make decision 15:Else if (isCWA = 1) 16:Then 17:add more evidence to make the decision 18:Else 19:add new elements to the frame of the discernment 20:end procedure5.5.1.The proposed method defined a new way to measure the conflict between pieces of evidence, and also the degree of support. It is essential to the method, so it is necessary to validate whether it is reasonable to show the conflict level.A, B}, there are two pieces of evidence with the credibility assignments shown below:x denotes the credibility of hypothesis A, and the credibility of hypothesis B is 1−x. With an increase in x, the degree of support between the two pieces of evidence is as shown in x-axis is the results of the reliability allocation. The y-axis is the similarity of the evidences E1 and E2.Given the discernment frame Θ = {x increases from 0 to 0.5, the degree of support increases from 0.7071 to 1.0. In contrast, in the interval , the degree of support decreases with an increase in x, and the cosine curve line is symmetrical with x = 0.5. The change is reasonable to show the relativity between pieces of evidence.As shown in E1 and E2 are as follows:When the conflict level is large, to simulate this situation, we assume that the credibility values of The obtained degree of support is shown in x. The cosine curve increases from 0 to 1 when x increases from 0 to 1. The variation trend is reasonable and meaningful to show the degree of support.BPAd based on the Jousselme Distance, difBetP based on Pignistic probability, and ConfDegree based on the proposed method. In [1, Θ2,…, Θ20}, and the credibility assignments for pieces of evidence E1 and E2 are as follows:A is contained in Θ, and Θ is a changeable set. First, we set A = {Θ1}, then, adding a new element to subset A each step until A = {Θ1, Θ2,…, Θ20}. The change process of set A has shown in Next, we discuss a comparison simulation of the three methods for measuring conflicts: thod. In , the sitA, the conflict between two pieces of evidence is shown in With the increase in the elements in A, the conflict level changes according to the different A. It is apparent in Step 1 to Step 5 that the credibility assignments of E1 in set {Θ1, Θ2, Θ3, Θ4, Θ5} gradually increase, and the degree of conflict decreases. Then, after Step 5, as the elements increase, the credibility assignments of E1 in set {Θ1, Θ2, Θ3, Θ4, Θ5} gradually decrease, and the conflict increases. These results prove that this is also an effective and reasonable way to measure the conflict between pieces of evidence.With an increase in the elements in subset Compared to the two existing methods, the proposed method is similar in the change trend of Jousselme’s method, and the two methods are more reasonable for showing the conflicts. Moreover, the amount of calculation needed for the proposed method is lower than that for Jousselme’s method. The method based on the Pignistic probability has a very low computational complexity. However, it does not show the increasing trend after Step 8, which shows that it is not sensitive to the change in the conflict between pieces of evidence.5.2.To verify the rationality and validity of the proposed fusion method based on the degree of support, we use the example in  to test A, B, C}. There are five different kinds of sensors to observe the object. They are a CCD sensor (S1), sound sensor (S2), infrared sensor (S3), radar (S4), and ESM sensor (S5). Now, there is an object that belongs to A, and the pieces of evidence obtained from the five kinds of sensors are as follows:Assume that there are three objects in a target recognition system. Thus, the discernment frame is Θ = {S2) is abnormal, which may cause wrong fusion results. In this situation, the perception of the sound sensor  applying the degree of support to develop a flexible and effective new way to deal with the index explosion problem and (2) improving the weighted mean step and considering additional influence factors.


The development of evidence-based guidelines is a key step in ensuring that maternity care is of a universally high standard. To influence patient care national and international guidelines need to be interpreted and implemented locally. In 2011, the Royal College of Obstetricians and Gynaecologists published guidelines for the management of reduced fetal movements (RFM), which can be an important symptom of fetal compromise. Following dissemination it was anticipated that this guidance would be implemented in UK maternity units. This study aimed to assess the quality of local guidelines for the management of RFM in comparison to published national standards.Cross-sectional survey of maternity unit guidelines for RFM. The guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool and scored by two independent investigators. Two national guidelines were used as standards to evaluate unit guidelines.Responses were received from 98 units (42%); 12 units had no guideline. National guidelines scored highly using the AGREE II tool but there was wide variation in the quality of individual maternity unit guidelines, which were frequently of low quality. No guidelines incorporated all the recommendations from the national guideline. Maternity unit guidelines performed well for clarity and presentation but had low scores for stakeholder involvement, rigour of development and applicability.In contrast to national evidence based guidance the quality of maternity unit guidelines for RFM is variable and frequently of low quality. To increase quality, guidelines need to include up to date evidence and audit standards which could be taken directly from national evidence-based guidance. Barriers to local implementation and resource implications need to be taken into consideration. Training may also improve the implementation of the guideline. Research is needed to inform strategies to realize the benefits of clinical guidance in practice. The presence of fetal movements (FM) is a well-recognised sign of fetal viability and vitality . In contth Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) reviewed 422 antepartum stillbirths and found suboptimal care in 45% of cases [th CESDI report dates from 1999, these findings were echoed in a regional Confidential Enquiry of stillbirths in 2010–11 [The 8of cases ; more thof cases . InadequTwo related studies, in the UK and Australia/New Zealand describe a wide variation in obstetric and midwifery practice in the management of RFM ,12. ThisClinical guidelines are one means to improve and standardise clinical care; they are defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” . Their rThis study aimed to systematically assess the quality of guidelines for the management of RFM in individual maternity units and whether this equates with the standard of national guidelines. To ensure robust and reproducible assessment of guidelines the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool was used to evaluate all guidelines .Two hundred and thirty five maternity units across the UK were asked by letter for either an electronic or paper copy of their guideline for the management of RFM in May-July 2013. Ethical approval was not required as this work was a service evaluation. In addition, two national evidence-based guidelines were identified by internet searches  using the AGREE II tool which has been used previously in maternity care ,22. The Data, including overall scores and domain scores for the guidelines were collated and analysed using Microsoft Excel. The agreement between both appraisers’ (AH and SJ) assessments was compared on 20% of the samples using Cohen’s Kappa coefficient. The relationship between the overall score and the total of the domain scores were calculated by Pearson’s correlation coefficient. Descriptive statistics were used to describe the domain and overall scores; unit guidelines and national guidelines were compared using Mann–Whitney U-test . A p value of <0.05 was accepted as statistically significant.Of the 235 units contacted, a response was received from 98 (42%). Of those respondents, 12 (12%) did not have a guideline. Seven (8%) of the 86 guidelines received were out of date and 10 (12%) had no review date. No guideline contained all 12 key recommendations from the RCOG Guideline, the median number of recommendations included in unit guidelines was 7  but more variable results for the individual domains ranging from fair (K = 0.25) to very good (K = 1.00). For both investigators, the Pearson’s correlation coefficient between the total domain scores and overall score was 0.94 indicating a very strong relationship between the overall assessment and the sum of the individual components.Both the RCOG and ANZSA guidelines received the maximum overall score of 7 and the majority of individual components scored >5 Table . The ANZWhen assessing individual units scores differed greatly, but some patterns were apparent. In the first domain, ‘scope and purpose’, the majority of scores were above average quality (≥4). Unit guidelines usually specifically stated the objective of the guideline, but lost points due to a lack of description of to whom the guideline is meant to apply. Guidelines that scored poorly in this domain had either omitted the section or there was insufficient detail. Overall, the ‘stakeholder involvement’ domain was of average quality, but there was a wide range of scores Table . High scThe ‘rigour of development’ of unit guidelines was poor, with most units having a low score. None of the unit guidelines explicitly stated a strategy to obtain evidence and few referenced relevant research. Critically, 41% of guideline did not reference national evidence-based guidelines in lieu of a novel literature search. Although a review date was usually included, points were frequently lost because there was rarely a procedure for updating the guideline. In contrast, national guidelines stated an explicit strategy for generating evidence and had a comprehensive reference list.‘Clarity of Presentation’ was the highest scoring domain and was the biggest collective strength of all the guidelines with no difference between national and unit guidelines; almost all units highlighted the key recommendations for practitioners. In contrast, ‘applicability’ was one of the lowest scoring domains, with both national and unit guidelines neither identifying barriers or facilitators to their implementation nor resource implications. Nevertheless, some high-scoring guidelines provided supporting materials to aid dissemination such as patient information leaflets. All unit guidelines scoring the lowest possible score of 2 for ‘editorial independence’, most likely because in the UK healthcare is publicly funded implying that there are no directly competing interests.To address deficiencies in the care of women presenting with RFM identified by CESDI and national surveys of practice regarding RFM, ANZSA and RCOG produced guidelines released in 2010 and 2011 respectively ,20. The The AGREE II tool had good agreement between investigators with comparable Kappa values of 0.3-0.96 to earlier studies  and a veThe area where unit guidelines performed the weakest was the “rigour of development” domain. There was little description of methodology to obtain evidence and a significant minority of units (41%) did not refer to national guidelines positively or negatively. More worryingly, 13% of units directly contradicted the high-grade evidence obtained from systematic reviews and meta-analyses. This raises the question whether following detailed, transparent guideline development the evidence should remain constant and its applicability be adapted to local settings with relevant knowledge of resources and an ability to identify barriers to change. Since maternity units are not mandated to adopt national guidance, they are instead encouraged to adapt it using local stakeholder groups. Development of guidelines is a resource intensive exercise, requiring expertise and service-user involvement, searching and synthesis of the evidence which is then contextualised. Critically, our study showed that stakeholder involvement and applying guidance to practice were amongst the weakest areas of unit guidelines. Therefore, it could be argued that local resources could be much better employed involving service users, assessing barriers to implementation and adapting guidance to their local situation rather than synthesising evidence.Although guidelines are not intended to mandate clinical practice, they should maintain the quality of care and remain consistent with evidence-based recommendations . Thus guUltimately, the difference between national and local guidance may explain why evidence from clinical research does not produce the desired improvements in outcome for the wider population. Here, less than 30% of guidelines recommended ultrasound assessment of fetal growth, liquor volume and umbilical artery Doppler after the first presentation with RFM and 53% after recurrent RFM despite evidence that women with recurrent RFM are at increased risk of stillbirth, that these investigations best identify poor pregnancy outcome and that this approach reduces perinatal mortality ,28. To aThis evaluation has shown that unit guidelines for the management of a common presentation in maternity care were of variable quality, and were of a significantly lower standard than national guidelines. This may adversely affect care for women presenting with RFM. Unit guidelines need to be improved in specific areas, particularly stakeholder involvement and incorporating the relevant research identified by national guidance and applying those findings to the local situation.


Very low quality (VLQ) evidence translates into very low confidence in the balance of risk and benefits based on the estimates drawn from the body of evidence. Consequently, this assessment highlights gaps in the research evidence, i.e. knowledge gaps, for important clinical questions. In this way, expert guideline panels identify priority knowledge gaps that, arguably, should inform the research agenda and prioritize scarce research economical resources. The extent to which the research agenda reflects the knowledge gaps identified in clinical practice guidelines is unknown.A systematic evaluation of the Endocrine Society (ES) clinical practice guidelines portfolio from 2008 to 2014 was conducted with the objectives to identify (1) recommendations in the ES clinical practice guidelines based on VLQ evidence reflecting knowledge gaps in endocrinology, and (2) active research designed to address these gaps by searching the clinical trial registry, clinicaltrials.gov, using terms describing patients (diseases), interventions, comparison, and outcomes.In 25 ES guidelines, we found 660 recommendations, of which 131 (20 %) were supported by VLQ evidence. Clinical trialists are attempting to answer 28 (21 %) of these knowledge gaps by performing 69 clinical trials.The research enterprise is addressing one in five knowledge gaps identified in clinical practice recommendations in endocrinology. These findings suggest an inefficiency in the allocation of very scarce research economical resources. Linking the research agenda to evidence gaps in clinical practice guidelines may improve both the efficiency of the research enterprise and the translation of evidence into more confident clinical practice. The Endocrine Society (ES) has created clinical practice guidelines to aid clinicians in the care of patients with endocrine disorders. In 2005, the ES adopted the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Group system –4. The GA recent study showed that low to very low quality evidence, largely derived from small observational studies, supported most endocrinology guideline recommendations , 6. To tWe conducted a systematic evaluation of the available ES clinical practice guidelines to identify clinical recommendations that are based on VLQ evidence and that potentially reflect knowledge gaps in endocrinology. Using the ES guideline web site, we identified and retrieved all ES clinical practice guidelines issued from 2008 to 2014 –38. For Because of problems with classification, some recommendations based on VLQ evidence should not have been graded as they represent best practice statements in which there is no sensible alternative. In this sense, best practice recommendations are thought to do substantially more good than harm (or vice versa) and therefore no one would consider doing a study to definitively establish the answer to the implicit question . ExampleWe then identified the research questions relevant to these knowledge gaps in terms of patients, interventions, comparisons, and outcomes (PICO). For each VLQ evidence item, we drafted a research question that a clinical trial could answer using the PICO format  , 35, 39.We then searched the clinicaltrials.gov database for active studies  addressing the questions identified from the guidelines. Since 2000, this registry has emerged as the most complete including trials from 188 countries. A clinical trial was deemed eligible if it addressed the PICO question with at least one of the necessary outcomes. For each eligible clinical trial, we extracted the study design, source of funding, year of entry, and the sample size. Although we did not look for publication of results, we excluded trials completed 5 or more years prior to the date of guideline publication. Reviewers working independently searched the clinical trial registry until 100 % agreement, a point reached after searching for 20 questions. A single reviewer completed the search for the rest of the questions.We performed a descriptive analysis and summarized continuous variables as mean (SD) and presented percentages in cases of categorical variables.We identified 25 Clinical Practice Guidelines from the ES with 660 recommendations, of which 209 32 %) were supported by VLQ evidence –32. Afte % were sActive research was identified for 28 21 %) of these 131 recommendations represented by 69 clinical studies ; the least dealt with were gaps in the evidence for care of patients with diabetes, obesity, and cardiovascular disease  from the grading of the strength of recommendation . FurtherWe are also aware that, even though panels may be the best way to identify research gaps, it could be easily argued that this does not automatically mean that trials should be conducted in those areas, e.g. the needed studies might be prohibitively expensive, research gaps might be difficult to study, or the science field is not developed enough to support the conduct of clinical trials. On the other hand, panels choose areas of clinical relevance to formulate recommendations. Often, these represent ongoing practice, which is unlikely to be supported solely by mechanistic hypotheses or basic science data. While we do not know the extent to which our findings apply to other areas of medicine, they may very well represent a trigger to examine the research pipeline and improve the quality and relevance of the evidence. A functional pipeline connecting evidence to recommendations and back can ultimately better support decision making by patients, clinicians, policy makers, and funding agencies.Researchers are addressing only one in five knowledge gaps identified in clinical practice recommendations in endocrinology. Linking the research agenda to evidence gaps in guidelines may improve both the efficiency of the research enterprise and the translation of evidence into practice by increasing the value and reducing the waste in research.


Health management involves a variety of activities that include daily decisionmaking. Two types of decisions deserve attention: one that enables the manager to choose a specific direction (scenario A) and another that enables the manager to act and sometimes correct existing pathways or processes in order to improve quality of care (scenario B).When a specific direction (scenario A) is chosen, it is prioritized in relation to the other possibilities. In this context, modern concepts of health economics may help in choosing the best option. Health economics states that available resources must be deployed efficiently. Efficient allocation of resources involves not only monetary but also scientific issues. The goal should be to choose the practice that is both clinically and cost-effective. In regards to scenario B, quality tools and concepts should be applied to guarantee the uniformity and high performance of processes (“doing things right”).scenario A, EBM offers scientific background and points out more effective practices. It also helps health care providers to evaluate the strengths and limitations of costeffectiveness studies and how to apply the results to real-world health services. In scenario B, EBM merges with clinical quality improvement tools to create the concept of Evidence-based quality improvement (“doing the right things right”). When health care providers do the right things right, quality of care and clinical outcomes are improved. The cycle is completed by continuous performance measurement, adjusting actions according to the best evidence available at a given moment. This synergy between management and EBM could be described as “doing the right things even better.”How could evidence-based medicine (EBM) help clinicians in the decisionmaking process? EBM, which gained strength in the 1990s, seeks to integrate the best scientific evidence available into daily clinical practice. In patient care, this can be expressed as “doing the right things.” However, defining the right things is a hard task given the huge amount of information available. The number of published papers in electronic databases grows progressively and continuously. For this reason, being aware of scientific methodology can help clinicians interpret and select high quality studies that are more applicable to their practice. In In cardiology, a vast amount of scientific evidence is available. For example, a quick search via PubMed using the Medical Subject Headings term cardiology retrieves about 163,000 articles. As a consequence, one should expect a similar availability of studies focused on quality improvement that could benefit patients, also considering physician experience and patient expectations.,3. However, few studies on this subject have been published so far, especially on a national basis.Through initiatives from the Institute of Healthcare Improvement and national and international Cardiology Societies, as well as performance indicators demanded by hospital accreditation agencies , health services have created a support structure to monitor practice and design projects for continuous quality improvement in this issue shows several challenges and actions implemented at a private hospital with a mixed clinical staff during an 8-year follow-up. It emphasizes the role of management and care leadership commitment, clinical staff engagement, organizational culture, knowledge of care process, and continuous monitoring of indicators. This current theme issue on cardiology at einstein features articles that address a wide variety of topics in cardiology and bring together information that is both relevant and of high scientific quality. We hope that you benefit from this issue. Enjoy your reading.The article “Effect of implementing an acute myocardial infarction guideline on quality indicators”


Accounts of evidence are vital to evaluate and reproduce scientific findings and integrate data on an informed basis. Currently, such accounts are often inadequate, unstandardized and inaccessible for computational knowledge engineering even though computational technologies, among them those of the semantic web, are ever more employed to represent, disseminate and integrate biomedical data and knowledge.Semantic EvidencE), an RDF/OWL based approach for detailed representation of evidence in terms of the argumentative structure of the supporting background for claims even in complex settings. We derive design principles and identify minimal components for the representation of evidence. We specify the Reasoning and Discourse Ontology (RDO), an OWL representation of the model of scientific claims, their subjects, their provenance and their argumentative relations underlying the SEE approach. We demonstrate the application of SEE and illustrate its design patterns in a case study by providing an expressive account of the evidence for certain claims regarding the isolation of the enzyme glutamine synthetase.We present SEE (SEE is suited to provide coherent and computationally accessible representations of evidence-related information such as the materials, methods, assumptions, reasoning and information sources used to establish a scientific finding by adopting a consistently claim-based perspective on scientific results and their evidence. SEE allows for extensible evidence representations, in which the level of detail can be adjusted and which can be extended as needed. It supports representation of arbitrary many consecutive layers of interpretation and attribution and different evaluations of the same data. SEE and its underlying model could be a valuable component in a variety of use cases that require careful representation or examination of evidence for data presented on the semantic web or in other formats. Scientific evidence, as a concept, can be defined as information that is relevant to assess the likelihood that a particular scientific idea is correct. Representation of the corresponding evidence is therefore key to evaluating hypotheses and assessing claims contained in scientific articles, databases or any other repository of scientific information. Biomedical knowledge is often highly context-dependent and based on evidence obtained from the skilful combination and evaluation of individual results, involving, among other aspects, a range of model organisms, diverse experimental and computational techniques, different forms of interpretation, and various inference schemes. Consequently, all those aspects - the materials, methods and information sources used, the observations made, the reasoning employed and the context-specific assumptions made - are important for comprehensive evidence accounts. Likewise, when data, often from disparate sources, is integrated to study complex biological systems an account of the evidence that was used to infer a model's properties and those of and among its components is critical for correct and transparent understanding of that model.Scientific findings are now routinely published as resources on the World Wide Web. Besides electronic versions of natural language texts more and more information from both new and legacy sources becomes available through databases  and web Semantic EvidencE), an RDF/OWL based approach for providing detailed, extensible and computationally accessible accounts of evidence even in complex settings. SEE is designed to enable the fabric of observations, methods, assumptions, and inferences examined by researchers to evaluate the evidence for a claim to be formally represented along with their sources using semantic web techniques. Evidence is captured in terms of the argumentative structure of the supporting background for a claim i.e., by a coherent representation of claims, of the entities the claims are about, of the argumentative relations between the claims and of claim provenance. SEE accommodates nested layers of interpretation and attribution and different evaluations based on the same data. We demonstrate its application in a case study that is typical for the task of collecting, representing and evaluating evidence for systems biology approaches such as genome-scale metabolic network reconstruction by providing an expressive account of evidence for the location of the enzyme glutamine synthetase.Here we introduce SEE  a formal representation of scientific claims, their provenance and the argumentative structure used to justify them by other claims, (ii) a formal representation of claim content and (iii) a coherent integration of the two. SEE relies on an abstract model for the representation of claims, provenance and argumentative structure specified in the Reasoning and Discourse Ontology (RDO), a lightweight OWL vocabulary developed for this purpose. Claim content e.g., F graphs  which enAfter outlining general requirements and design principles for representation of evidence we describe the RDO. We then demonstrate the application and design patterns of the SEE approach in a case study generating an expressive representation of evidence reported in the literature for the location of the enzyme glutamine synthetase.We posit two design principles for the representation of evidence and explain their rationale in the following:DP1: Representation of evidence amounts to representation of claims and argumentative structure.DP2: Evidence relations in the sense of "A is evidence for B" obtain between the things being claimed.Accounts of evidence are directed towards the justification of scientific claims. The SEE approach is based on the notion that scientific claims put forward possible, more or less likely scenarios and outcomes - states of affairs  - as beiWe derive two additional requirements:DP3: A researcher's assessment of the evidence for a finding usually includes evaluation of which materials and methods were used, what kind of data was obtained and which properties were observed, inferred or assumed to establish the finding. Consequently, a representation of the materials, methods, data items and other elements forming the subject of a claim should be part of a computationally accessible evidence representation. In RDF and OWL the subject of a claim, a state of affairs, must be expressed, using appropriately defined resources, as (one or more) triples and axioms, respectively. It follows then, in accordance with DP2 that in an RDF/OWL-based representation of evidence that includes claim subjects the representation of evidential relationships should operate between claim subject representations, i.e. between sets of RDF-triples and/or OWL-axioms.DP4: Representation of claims and hence representation of evidence must take into account claim provenance, in particular through which source and by which agents the claims were made. Knowing which agent made the claim is crucial for evaluating independence and reproducibility. Tracking the original source of a claim provides a natural reference point for all subsequent representations of the claim and its supporting background and for re-evaluation of the claim within the original context in which it was communicated.We therefore identify as minimal components for modelling evidence elements representing (i) scientific claims and the argumentative structure used to justify them by other claims, (ii) the subjects of the claims i.e. that what is claimed with regard to a subject of inquiry, (iii) the agents making the claims and arguments, (iv) the sources in which claims were originally made e.g., the original scientific articles or database records.Based on the foregoing we developed an abstract model for representation of evidence in terms of claims, their argumentative structure and their provenance. It is specified here as the Reasoning and Discourse Ontology (RDO) using the Web Ontology Language (OWL). This section outlines the core classes and properties of RDO. Full, formal specification of all RDO constructs is provided in the ontology file provided as additional file what is claimed - is communicated in some linguistic form, often as part of a more comprehensive report  authored by the agents. Claims are usually justified by other claims the subject of which has been accepted as true, usually on the basis of yet other claims. RDO  represent particular claims made by particular agents on a particular occasion that a particular proposition, the subject of the claim, is true. Propositions, in our model, are represented by the class proposition and taken to represent the semantic content of contextualized lexical entities formulated in some natural or artificial language [text. Further core classes are report representing accounts intended to accurately describe an event or situation. Thus, scientific journal articles or database records as typical sources of assertions are examples of a rdo:report. Agent is used to represent individual persons, corporate bodies or information processing devices as roleplayers in the creation of reports or assertions. RDO specifies various properties to represent the relations between instances of these classes .The typical scenario that underlies the constructs defined in RDO is the following: Agents  make claims on particular occasions  about a subject of inquiry. The subject of the claim - i.e. O Figure  rests onlanguage . The lexs Figure . In partWe applied SEE to generate a computationally accessible, expressive and extensible account of evidence gathered in the literature regarding a claimed source of the enzyme glutamine synthetase (GS). We have chosen this particular test case because obtaining reliable information on location of enzyme activities is a subject area of particular importance for systems biology approaches such as the reconstruction of cell-type specific  or organMeister 1985' in the following) authored by Alton Meister which asserts in the second paragraph of the text, among other things, that the enzyme glutamine synthetase (GS) was isolated from rat liver. This assertion is based, by way of citation, on the contents of another article by Tate, Leu and Meister [Tate 1972' in the following). In Tate 1972 the isolation of GS from rat liver is reported. The finding is reported to be based on an investigation which involved, among other things, extraction of rat livers, protein purification and γ-glutamyl hydroxamate synthesis (γ-GHS) assays. In the following we show how this context is formalized using the SEE approach to yield a detailed formal account of the evidence presented through these articles for rat liver as source of GS. In doing so, we illustrate various design patterns used in SEE for representing the relevant items. For clarity assertion instances will be indexed as A1, A2, and so forth.Starting point is our evaluation of a scientific journal article   providing its digital representation. The second paragraph of Meister 1985 constitutes a report_part. It is expressed as the English language text as which it is written and which is represented as an instance of text. The original text is linked to it via the data property has_lexical_structure. Meister's claim that glutamine synthetase was isolated from rat liver contained in this paragraph is represented by an instance of assertion (A1) labelled as '! some GS-enzyme isolated from some rat liver ! AM' to indicate the assertion subject in a concise, human readable manner . A1 is related to a corresponding instance of proposition identifying the subject of the claim, to an instance of agent representing Alton Meister, and to said report part by the properties asserts, is_assertion_made_by and is_assertion_made_in, respectively.Figure assertion instance which is linked to the source assertions by is_directly_inferred_from and linked to the same proposition instance as the source assertions by asserts. Each assertion can be linked to its corresponding agents and reports. Application of this design pattern to our case study is shown in Figure is_directly_inferred_from and by sharing the same proposition instance via asserts.Claims which reiterate previous findings are represented as assertions on the same subject made by the respective agents. Formally, the reiterating claim is represented as an assertion instances and is_directly_inferred_from relations with additional links to represent assertion subjects and provenance  is essentially based on asserting that (A3) there is a biological sample (labelled 'sample-1') which has GS-activity, that (A4) any GS-activity is borne by some GS-enzyme and that (A5) sample-1 was isolated from some rat liver  it was input to a particular assay (labelled assay-1), that (A7) this assay produced a particular result, data item 1, and that (A8) this data item is a measurement of some GS-activity. A8, in turn, is justified by asserting that (A9) the data item is output of assay-1, that (A10) this assay was a γ-GHS assay, and that (A11 & A12) this type of assay is suited to measure GS-activity. Some assertions are not further justified, either because they reflect factual descriptions in Tate 1972 , represent general assumptions of the authors (A11) or are expressions of terminological domain knowledge . A5 exhibits a similar justification trail, as shown in Figure The argumentative structure within and across the publications is represented as a series of e Figure . The assy, that A any GS-aThe prevalent pattern in SEE for recording individual and logically relevant steps of an investigation is for any such step to link its outcomes , the techniques used to produce these outcomes, and their objectives as exemplified in the composite assertions comprising assertions A9-A12 and A15-A20 Figure . In A9-Aassertion instances described so far is complemented by a structured representation of what is asserted in each assertion, the assertion subject. To this end each assertion instance is linked to a corresponding proposition instance the IRI  of which identifies a named RDF graph. This graph provides a structured representation of the assertion subject using appropriately defined resources .To generate the graph representations of the assertion subjects, the natural language expressions of the assertions identified in the assertion and corresponding proposition instances are directly derived from the graph representation of the assertion subject (see methods section). In particular, the label "related_to some Bsome A " is used for proposition instances that represent statements of the form "some A related to some B" by applying the design pattern described above.Labels of Meister 1985 and Tate 1972 reports is the result of the interpretation by another agent (Christian Bölling - CB). This can be explicitly represented in SEE using its familiar design pattern for propositions and assertions. For example, the claim that Tate et al. indeed assert that the assay they performed was a γ-GHS assay in their 1972 publication can be represented as an assertion instance in its own right, made by another agent, CB . It is linked to the corresponding proposition via asserts and the assertions made by Tate et al. via is_directly_inferred_from. We describe two semantically different patterns to make this connection. In pattern 1 assertion A30 is linked to assertion A2  activity (EC 2.3.2.2) . The γ-GHS assay works by measuring the formation of L-γ-glutamyl hydroxamate rather than glutamine . Tate etThe test case evidence representation that was created using the RDO constructs and design patterns was evaluated in terms of its potential to answer, within the confines of the case study, a list of competency questions reflecting different aspects of the evidence a researcher investigating glutamine synthetase knowledge would be interested in:Q1: Which locations of GS have been asserted?Rat liver.Q2: Where has rat liver GS been reported?The Meister 1985 and Tate 1972 reports.Q3: Do the assertions made in these reports pertain to independent observations?No. Meister's assertion is based on Tate et al.'s assertion. Moreover, some of the authors of the two reports are identical.Q4: Is there experimental evidence and where is it described?Yes. In the Tate 1972 report.Q5: Which observations and techniques were used for establishing rat liver as GS source?1. extraction of a protein sample from rat liver (technique: TLM purification)2. that sample has GS-activity (technique: γ-GHS assay)Q6: Did Tate et al. really make these observations and conclusions? Who created this account of their findings?Christian Bölling.Based on the SEE design patterns, these questions could be formulated as SPARQL  queries The following evidence-related information can be queried exploiting property chains and other axioms defined for the RDO constructs:- all assertions which are directly or indirectly used to infer a given assertion- all assertions made in a given report- all assertions made by a given agent- all assertions on the same subject- all agents making assertions on a given subjectFor the corresponding queries see additional file SEE offers a tangible interpretation of the concept of evidence in terms of the argumentative structure of the supporting background for a claim. It rests on the disctinction between claims as such (assertion), their subjects (proposition) and the linguistic form in which these subjects are communicated (text). As a consequence of this design evidential relations (as in "A is evidence for B") can be represented consistently as relations between assertions. This means that statements of the form "this dataset / experiment / publication / method is evidence for B" are regarded as figurative expressions. Instead, the relation between a dataset, an experiment or a publication and the state of affairs it is claimed to be evidence for is represented indirectly through relations between assertions the subjects of which relate to the entities in question. The advantage of this design is that it enables a coherent representation not only of extensive argumentative networks but also of arbitrary many layers of consecutive interpretations and alternative evaluations of the same observations or information sources. RDO offers clear, formally defined types and relations for representing claims, their subjects, their linguistic representations, related information sources and agents on the basis of well established concepts from epistemology and the philosophy of language ,25,33,34is_directly_inferred_from property and its transitive superproperty is_inferred_from. This allows for a coherent representation of different argument forms and larger rhetorical structures which can be mapped onto their underlying assertions.SEE represents argumentative structure at its foundational level of premises being used to infer a conclusion using the SEE aims to capture arguments as they are presented in their sources rather than to evaluate their quality or to categorize them. How conclusive an argument is will typically depend on agent background knowledge or application-dependent requirements. The SEE design enables users to evaluate evidence according to their own, possibly domain- and application-specific criteria.SEE-based accounts could also be used alongside specified rules, or argument forms considered as acceptable by individual researchers or within specific domains of inquiry which could then be leveraged to automatically infer new assertions on the basis of the already asserted information.With regard to the extraction of assertion subjects and a specific argumentative structure from a natural language text SEE relies in its current form on a heuristic approach leveraging expert domain knowledge to identify assertions and formalize them in OWL. As OWL is a subset of first order logic there may be statements from natural or artificial languages which cannot directly be translated into OWL, constraining the formalization of assertion subjects in SEE. It is, however, not clear which actual limitations arise from this theoretical constraint for the representation of evidence in specific use cases. The test case presented here suggests that within a specified domain of discourse, using appropriate constructs and design patterns, the relevant contents of the statements made originally in a context-rich narrative format such as a scientific journal article can be adequately formalized.Formalization of natural language statements is an important prerequisite for computational approaches to data evaluation. For applications that can forego this need the statements can be represented in their original form as texts or referenced by links to the original information sources. Both are by default designed to be provided in SEE as reference points for evaluation.The presented design patterns make SEE-based accounts of evidence extensible. This design is in line with the open world assumption on which RDF and OWL as knowledge representation languages operate. The particular argumentative structure and level of detail presented in the case study are based on heuristics reflecting domain-specific requirements to understand how an enzyme was characterised. This representation can be extended or shortened as required. For example, details on the protein purification process performed by Tate et al. or indeed any other detail that becomes relevant for the evaluation of the presented evidence could be appended to the existing assertions. Likewise, as we have demonstrated, alternative views and conclusions can be accommodated. On the other hand, for applications which only require information on claim provenance, only the source publications of the main claims could be represented.Evidence type schemes provide a useful shorthand categorization of research techniques used to establish a claim. SEE could be aligned with any categorization of research techniques and hence evidence type scheme to characterise the evidence for an assertion. Essentially, SEE provides a platform to define custom, extensible evidence types and apply them as needed. For example, the evidence for rat liver as a source of GS in the test case could be characterised as "experimental evidence" as "based on a direct assay" as "based on a γ-GHS-assay" or as "based on a γ-GHS assay, protein purification involving Sephadex chromatography, and samples from Sprague-Dawley rats" depending on the level of accuracy desired.The flexibility and extensibility of the SEE approach may also be useful to characterise evidence where several techniques have been combined to establish a scientific result or evidence is characterised in combination with claim provenance. We illustrate this with a comparison to the Gene Ontology (GO) evidence codes which are meant to reflect the type of work or analysis described in the cited reference which supports the GO term to gene product association . GO evidRepresentations which use SEE or its underlying model could be productive in a variety of use cases requiring careful examination or recording of evidence, e.g.,- providing supporting background information for biomedical knowledge bases,- creating digital abstracts of research publications,- adding a claim-level perspective on research publications which could be used by publishers, in bibliographic databases and in personal bibliography managers,- providing open linked data which can be integrated on an informed basis using varying, application specific evidence criteria.The SWAN biomedical discourse ontology  developeThe central focus of the SEE approach is to provide a formalized account of evidence as claims, their subjects and their argumentative structure using clearly defined concepts and semantics. From this perspective SEE and related works may be seen as complementary: The basic notion of a report part in RDO could be complemented with AO's rich set of selectors as pointers to various elements of scientific reports. Recent alignment of the Citation Typing Ontology (CiTO) and SWAN produced a consolidated set of constructs to characterise bibliographic references . PotentiClaims made in scientific research communications are usually embedded in a contextually and rhetorically rich narrative and attenuated by expressions of epistemic modality . Adding Semantic EvidencE) is an approach to represent scientific evidence in terms of the argumentative structure of the supporting background. The presented case study suggests that SEE is capable to provide a computationally accessible account of evidence even in complex settings. SEE enables a coherent representation of evidence-related information such as the materials, methods, assumptions, reasoning and information sources used to establish a scientific finding by adopting a consistently claim-based perspective on scientific results. SEE allows for extensible evidence representations, in which the level of detail can be chosen as needed and existing accounts can be extended. Its design permits representation of arbitrary many layers of consecutive interpretation and attribution as well as different evaluations of the same data. SEE is specified as an RDF/OWL based approach for integration with other semantic web resources and linked open data environments but its underlying model can also be used in other knowledge engineering and knowledge representation approaches.SEE  and agents (linked via rdo:is_assertion_made_by). If "P" is the proposition label and "A" is the agent label, the assertion is labelled as "! P ! A". Multiple propositions are concatenated by " AND ". Multiple agents are separated by a space symbol. For our case study, author names are further abbreviated by their initials. The rationale of this nomenclature is that it allows to quickly understand what is asserted and who asserts, maintains a clear connection between assertion and proposition, maintains a connection to the formal representation of the assertion subject and singles out assertions as being labelled with a leading exclamation mark.We have adopted the following nomenclature for labelling L Syntax  are usedThe authors declare that they have no competing interests.CB and MW conceived the conceptual elements of the SEE approach and developed the abstract model underlying the RDO. CB implemented the RDO in OWL, developed the design patterns and formulated the test case representation with contributions by MW. CB, MW and HGH evaluated several development versions of the design patterns and resulting representations. HGH supervised the research. CB drafted the manuscript. All authors read and approved the final manuscript.rdo_owl.txt. Full, formal specification of all RDO constructs. This version is also available at http://purl.org/see/rdo/1.0. The latest version of RDO is available at http://purl.org/see/rdo.Click here for filegsexample_owl.txt. Representation of the argumentative structure and axioms involving the entities used to model the case study in OWL format.Click here for filegsexample_propositions_trig.txt. Named graph representations of assertion subjects.Click here for filegsexample_sparql.txt. SPARQL queries for the case study representation.Click here for fileSEE_MP_comparison_note.pdf. A short comparison of central concepts in the SEE and MP (Micropublications) models.Click here for filemappings.pdf. Mappings of constructs in the case study representation to other biomedical ontologies.Click here for file


Survivorship care plans (SCPs) are written treatment summaries and follow-up care plans that are intended to facilitate communication and coordination of care among survivors, cancer care providers, and primary care providers. A growing number of guidelines for the use of SCPs exist, yet SCP use in the United States remains limited. Limited use of SCPs may be due to poor quality of these guidelines. The purpose of the study was to evaluate the quality of guidelines for SCP use, tools that are intended to promote evidence-based medicine.Appraisal of Guidelines for Research and Evaluation, 2nd edition), a tool developed by an international group of scientists to advance the quality of clinical practice guidelines. To promote consistency with extant studies using the AGREE II instrument and to clearly and unambiguously identify potentially useful guidelines for SCP use, we also summarized AGREE II scores by strongly recommending, recommending, or not recommending the guidelines that we evaluated.We conducted a comprehensive search of the literature using MEDLINE/PubMed, EMBASE (Excerpta Medica Database), and CINAHL  published through April 2014, in addition to grey literature sources and bibliographic and expert reviews. Guideline quality was assessed using the AGREE II instrument : Guidelines were generally unambiguous in their recommendations that SCPs should be used. Guidelines scored lowest on applicability : Few guidelines discussed facilitators and barriers to guideline application; advice and tools for implementing guidelines were vague; and none explicitly discussed resource implications of implementing the guidelines.Guidelines often advocated survivorship care plan use without justification or suggestions for implementation. Improved guideline quality may promote survivorship care plan use.The online version of this article (doi:10.1186/s13012-015-0254-9) contains supplementary material, which is available to authorized users. The transition from cancer treatment to follow-up care is often challenging for the nearly 15 million cancer survivors in the United States . SCP useLimited SCPs use in practice may relate, in part, to poor quality of guidelines for SCP use. Guidelines are tools that are intended to promote the use of recommended practices. High-quality guidelines reflect the perspectives of relevant stakeholder groups; provide clear guidance for implementation; are based on empirical evidence, explicit in their methods of development, critically reviewed by experts, and free from conflicts of interest; and are specific and unambiguous . EvidencThe purpose of this study was to assess the quality of guidelines for SCP use. Results may offer perspective on why SCP use has been limited to date. If the quality of guidelines for the use of SCPs is low, then developing clearer, less ambiguous guidelines may represent a first step toward promoting SCP use. If the quality of guidelines for the use of SCPs is high, then efforts may need to focus on multifaceted interventions to promote the implementation of guidelines for SCP use in practice.For the purposes of this study, we used the IOM’s definition of guidelines: “statements that include recommendations intended to optimize patient care” .A broad range of literature was gathered to identify guidelines for the use of SCPs. The following electronic databases were searched for references to guidelines related to SCPs published through April 15, 2014: MEDLINE/PubMed (1946–2014), EMBASE (Excerpta Medica Database) (1947–2014), and CINAHL  (1981–2014). In addition to the databases for indexed scientific publications, we searched grey literature sources, including websites of professional organizations and guidelines groups , a tool developed by an international group of scientists to advance the quality of clinical practice guidelines [Guidelines evaluated in the study included recommendations regarding topics other than SCP use. Since the purpose of this study was to evaluate the quality of guidelines for SCP use, we did not abstract data regarding recommendations that did not relate to SCP use. To extract data from guidelines related to SCP use, SB developed a data extraction form  and 16  are limited in their applicability to SCPs; evidence of benefits, risks, and alternatives is limited. As such, these items were excluded from analysis. DC, LD, and SB worked together to revise item 12 (“There is an explicit link between the recommendations and the supporting evidence.”); in light of limited empirical evidence regarding SCPs, DC and LD interpreted item 12 as “Evidence is described, and recommendations follow from it”.SB conducted the final scoring, according to the instrument protocol, by adding together DC and LD’s respective ratings for items in each domain and standardizing the total score out of 100%.strongly recommended, guidelines receiving an overall assessment of 50% or greater were recommended. and guidelines that neither received a standardized score of 50% or greater on all domains nor received an overall assessment of 50% or greater were not recommended.The AGREE II manual does not provide guidance regarding how to interpret scores. To promote consistency with extant studies that have used the AGREE II instrument ,18, we aTable Table Scope and purpose criteria relate to the objectives of the guideline, health questions to be addressed, and target population(s) . The aveStakeholder involvement criteria relate to whether guidelines were developed with input from appropriate stakeholders and reflect the views of intended users . On averRigor of development criteria relate to methods of gathering and synthesizing evidence considered during guideline development, processes of guideline development, and methods for updating the guideline . Only thClarity of presentation criteria include the following: the recommendations are specific and unambiguous and key recommendations are easily identifiable . On averApplicability criteria relate to facilitators and barriers to implementing the guideline’s recommendations, strategies for implementing the guideline’s recommendations, and resource implications of implementation . Of all Editorial independence criteria relate to ensuring lack of bias in the development of the guideline . The aveOverall guideline quality was low. Scores ranged from 8%  to 67% . Only fiOverall, AGREE II domain scores suggest that the quality of guidelines for SCP use is low. This finding is consistent with that of other studies that have shown poor quality of guidelines in cancer care . GuideliThe lack of clarity was underscored by the challenges of abstracting guideline data. Two investigators abstracted data, and a third reconciled abstractions. In multiple instances, the independent abstractions led to two reasonable but distinct interpretations of the guidelines. That two informed individuals could develop such distinct interpretations of one guideline suggests that busy clinicians may have difficulty culling relevant information that is consistent with their peers’ practices. This lack of guideline clarity may partly explain limited and inconsistent SCP use in practice ,35.As we suggested might be the case in the introduction, the poor quality of guidelines for SCP use may contribute to limited and inconsistent SCP use in practice ,8. ClearMany of the guidelines included in this study scored highly in some, but not all, domains. Efforts to promote SCP use may benefit from combining elements from multiple guidelines into a single clear, unambiguous resource. SB, JW, LD, and colleagues are currently synthesizing information from the guidelines that scored highest in each AGREE II domain in this study to create a “meta-guideline” for SCP use that practitioners may reference to facilitate their decision regarding adopting SCPs and, should they adopt SCPs, to facilitate their implementation. By leveraging the work of existing guidelines, this effort represents an efficient approach to facilitating practitioners’ decisions around SCP adoption and implementation.Study limitations should be considered when interpreting results. The search was conducted by a librarian with expertise in systematic reviews; however, the search may have excluded some guidelines. For example, we excluded guidelines that were not published in English. And although the AGREE II instrument is a useful tool for evaluating guideline quality, it has limitations. In particular, it does not offer guidance for interpreting scores. Our criteria for strongly recommending, recommending, or not recommending guidelines were intended to promote consistency with extant studies using the AGREE II instrument ,18 and tAnother challenge of AGREE II relates to applying criteria across several guidelines. Scores are intended to be based on a guideline’s quality irrespective of other guidelines’ quality. However, as scoring proceeds, reviewers’ evaluations of guidelines becomes biased by familiarity with previously scored guidelines. The quality of future AGREE II evaluations may benefit from randomizing the order in which each reviewer evaluates guidelines to average out the effects of increased familiarity.Our findings indicate that the quality of guidelines for SCP use is poor. Guideline quality may be improved with more behaviorally specific information regarding methods for effective SCP implementation. Organizations that develop cancer-related guidelines may promote quality by incorporating AGREE II into their formal practice guideline programs, as many other guideline-developing organizations have successfully done .


Wandering spleen is a rare clinical entity, and its chronic torsion of the vascular pedicle result in splenic vein occlusion leading to gastric varices. Here, we present a case of wandering spleen complicating gastric varices in a 40-year-old female. Three-dimensional CT (3D-CT) clearly showed the disruption of the splenic vein at the origin of the vascular pedicle and collateral development of the gastric varices. The patient was electively treated with laparoscopic splenectomy. Difficulty of prediction of the splenic vein recanalization to improve the varices was the reason for the use of splenectomy versus splenopexy. The varices were successfully diminished 3 months after the surgery. After review of cases of complicating gastric varices in the literatures, splenectomy is still a secure way to treat an adult patient with wandering spleen with complicating gastric varices. Wandering spleen is characterized by extensive mobility and displacement of the spleen from its normal position. The incidence is quite rare, with less than 0.9% in several series of splenectomies, having two peaks - in childhood and in adult females aged 20 to 40 years being of reproductive ages with suggested etiology of congenital anomalies in the development and acquired laxities of the supporting structures, respectively ,2. Chron3/μl. Physical examination revealed a well-defined, mobile, firm, and tender 12-cm mass in her hypogastric region.A 40-year-old female presented to our hospital with acute onset of abdominal and back pain 2 weeks after a spontaneous abortion. She had occasionally experienced similar episodes of the abdominal symptoms, which subsided spontaneously, for 10 years after a Caesarean delivery. On further inquiry, she gave a history of exploratory laparotomy due to an idiopathic abdominal pain 20 years ago in which the ectopic spleen was identified. She denied nausea, vomiting, and tarry stools. Laboratory data were unremarkable except for a reduced platelet count of 11.1 × 10Abdominal ultrasound examination showed a parenchymatous organ in her lower abdomen. Contrast-enhanced abdominal CT disclosed absence of the spleen in the normal position and an enlarged spleen presented in the lower abdomen. It was connected with the elongated vascular pedicle which showed a whirled appearance of splenic vessels and surrounding fat, indicating torsion of the wandering spleen Figure a-c. HomoElective laparoscopic surgery was done with placement of three trocars at the sub-umbilicus, suprapubic, and the middle of the upper abdomen 2 weeks after the consultation. Intraoperatively, the enlarged spleen was found in the lower abdomen, and there was no anchorage to the retroperitoneum and left phrenicus. The gastrosplenic ligament and splenic hilus were fused and elongated to suspend the spleen and turned 1,440° (Figure Wandering spleen is a rare clinical entity, and its complication with gastric varices is even rarer ,4. The gThe definitive treatment for wandering spleen is surgery, since non-operative treatment is associated with a complication rate as high as 65% . In caseThere were few reports discussed about appropriate surgical management with chronic torsion of the vascular pedicle complicating gastric varices. We reviewed cases of gastric varices secondary to wandering spleen including our case in the literatures Table . Of 14 cSplenopexy would be an appropriate surgical option when recanalization of the splenic vein was certainly established. However, splenectomy is still a secure way to cure the gastric varices secondary to wandering spleen.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Dirofilaria repens and D. immitis are filarioid helminths with domestic and wild canids as main hosts and mosquitoes as vectors. Both species are known to cause zoonotic diseases, primarily pulmonary (D. immitis), ocular (D. repens), and subcutaneous (D. repens) dirofilariosis. Both D. immitis and D. repens are known as invasive species, and their distribution seems associated with climate change. Until very recently, both species were known to be nonendemic in Austria.Dirofilaria sp. in dogs and humans in Austria are analysed, together with analyses of mosquito populations from Austria in ongoing studies.Metadata on introduced and possibly autochthonous cases of infection with Dirofilaria sp. in humans (30 cases of D. repens—six ocular and 24 subcutaneous) and dogs (approximately 50 cases—both D. immitis and D. repens) were most likely imported. However, occasionally infections with D. repens were discussed to be autochthonous (one human case and seven in dogs). The introduction of D. repens to Austria was confirmed very recently, as the parasite was detected in Burgenland (eastern Austria) for the first time in mosquito vectors during a surveillance program. For D. immitis, this could not be confirmed yet, but data from Germany suggest that the successful establishment of this nematode species in Austria is a credible scenario for the near future.In Austria, most cases of D. repens in mosquito vectors indicate that D. repens presumably invaded in eastern Austria. Climate analyses from central Europe indicate that D. immitis also has the capacity to establish itself in the lowland regions of Austria, given that both canid and culicid hosts are present.The first findings of  Dirofilaria repens and D. immitis (Spirurida onchocercidae)  in southern and eastern Europe, Asia Minor, central Asia, and Sri Lanka . The. TheDirod humans . It is tri Lanka . More thri Lanka –5. Howevri Lanka . CompareD. immitis is responsible for canine and feline cardiopulmonary dirofilariosis [D. immitis filariae [D. immitis but are asymptomatic in most cases [Dirofilaria, showing no or only nonspecific clinical signs [lariosis . Canine filariae . Besidesst cases . Cats aral signs .D. immitis is the causative of human pulmonary dirofilariasis, but this parasite was recently also associated with ocular dirofilariasis [D. immitis is distributed in temperate, tropical, and subtropical areas of the world. In Europe, the main distribution is located in Mediterranean regions, where high prevalences in dogs are observed, and in several areas, both D. repens and D. immitis coexist . In untt . Thirtyhttps://www.cia.gov/Library/publications/the-world-factbook/fields/2144.html), the first cases of D. immitis were described in four dogs in Switzerland in 1995 [D. repens north of the Alpine Arc were documented in 11 clinically asymptomatic dogs from the south of Switzerland in 1998 [D. repens and D. immitis have been documented more frequently in recent years, and autochthonous findings in dogs as well as mosquitoes are reported in new areas where both filarioid species were not known as endemic before [D. repens was documented in most central European areas prior to D. immitis.In central Europe  autochthonous findings of D. repens and D. immitis in dogs (definite hosts), humans , and mosquitoes (vectors) in Austria are summarized .Published as well as unpublished cases of imported and autochthonous documentations of mmarized . PublishD. repens were reported in Austria, 16 (53%) in male patients and 14 (47%) in females  dogs were female and 16 were male (62%). In only five cases (19%) of the monoinfections did symptoms like skin nodules lead to the diagnosis of dirofilariosis. In all other cases, the pathogens were found incidentally or during travel screening. Fifteen (58%) of the dogs infected with D. repens (including mixed infections with D. immitis) had previous travel activity to countries neighboring Austria known to be endemic for D. repens . Seven (27%) of the monoinfections were reported in Austrian dogs whose travel activity remained unclear. However, an epidemiological study conducted in eastern Austria documented the findings of microfilariae of D. repens in one of eight dogs in Gänserndorf (Lower Austria) and six of 90 dogs in Neusiedl (Burgenland) by PCR and Knott test [Overall,  Austria . Excludiott test . All potD. immitis were documented in 25 dogs in Austria  prior to infection; no case was suspected to be an autochthonous infection from Austria.Filarioid helminths of the species  Austria . Of 16 dD. repens and D. immitis infections were examined in three dogs, all of which had reported travel activity. Microfilariae were observed in the blood of four dogs, without further differentiation of the parasites to species level.Mixed n = 36; unpublished data) and western Austria  were screened for the presence of filarioid helminths. However, to date, neither D. repens nor D. immitis have been observed in Austrian foxes or other possible wild hosts.Blood samples of foxes from eastern , Culiseta annulata, Culex pipiens complex, Anopheles maculipennis complex, An. algeriensis, and Ochlerotatus caspius are potential vectors for D. repens [D. immitis in Austria are Coquillettidia richardii, Ae. albopictus, Oc. caspius, Ae. vexans, An. maculipennis complex, Cx. pipiens complex, and Cx. modestus [Currently, 46 mosquito species are known to be present in Austria . Of thes. repens ,17,21–23D. repens in Austria was detected in mosquitoes in 2012 for the first time in a nationwide mosquito surveillance and monitoring program [D. repens was examined in pools of An. algeriensis in Rust and An. maculipennis complex in Mörbisch, both in the federal state of Burgenland, bordering Hungary , the transmission of (i) the presence of one mosquito species capable of transmitting the parasites, and (ii) the presence of a minimum number of dogs infected with adult helminths that produce microfilariae.D. repens and D. immitis are part of the Austrian Culicidae species inventory. The two most common mosquito species in Austria, Ae. vexans and the Cx. pipiens complex, may readily act as potential vectors of these pathogens [In Austria, competent mosquito vectors for the transmission of both athogens .Dirofilaria in Austria. It is estimated that 581,000–600,000 dogs live in 511,000 households in Austria, with a human population of 8,579,747 . Most of these dogs are kept in the house; outdoor and/or kennel keeping is uncommon in this country. This circumstance might delay the introduction and establishment of the nematodes and might be the reason why they are to date not autochthonous in Austria, while this is the case for neighboring countries.The number of infected dogs might be the limiting factor for the establishment of D. immitis) is most probable. Both the heartworm predictive model (based on growing degree days) and the Dirofilaria development units show parts of eastern Austria  as suitable for the introduction and/or establishment of D. repens as well as D. immitis [The above-mentioned preconditions are themselves influenced by several factors like human behavior with respect to pets  and wildlife , globalization, and climatic factors . Several immitis . More deD. repens in one human, seven dogs, and two mosquito species indicate that this parasite is becoming endemic and establishing itself in Austria. However, a stable establishment of D. repens is still to be seen, as all these cases were documented within a relatively short time span. D. immitis does not appear to be endemic in Austria, but with regard to observations in the neighboring countries (particularly Hungary and Slovakia) it will probably become established in the near future. Therefore, regular monitoring of the mosquito population as well as the wild carnivore population is of urgent need.The  autochthonous findings of D. repens in mosquito vectors indicate that D. repens presumably invaded into eastern Austria in recent times. Veterinarians and medical physicians should be aware of possible autochthonous cases with these neglected pathogens in Austria. However, further monitoring of mosquitoes is necessary to observe the expansion of the distribution of D. repens and the possible invasion by D. immitis in Austria.The first findings of D. repens in mosquitoes, as well as potential autochthonous cases in dogs and humans, suggest that this parasite is establishing itself in Austria.Autochthonous findings of D. immitis is only associated with travel activity, and the parasite is not (yet) endemic in Austria.Until now, D. repens and D. immitis in dogs in recent years makes it clear that veterinarians should also consider these parasites in the diagnosis of Austrian dogs without prior travel activity.The increase of cases with both D. repens and D. immitis is necessary to evaluate the possible establishment of both parasites in the future.Mosquito surveillance and observation of canid wildlife hosts for the presence of Genchi C, Kramer LH, Rivasi F (2011) Dirofilarial infections in Europe. Vector Borne Zoonotic Dis 11:1307–17. doi: 10.1089/vbz.2010.0247.Morchón R, Carretón E, González-Miguel J, Mellado-Hernández I (2012) Heartworm Disease (Dirofilaria immitis) and Their Vectors in Europe—New Distribution Trends. Front Physiol 3:196. doi: 10.3389/fphys.2012.00196.Otranto D, Dantas-Torres F, Brianti E, Traversa D, Petrić D, et al. (2013) Vector-borne helminths of dogs and humans in Europe. Parasit Vectors 6:16. doi: 10.1186/1756-3305-6-16.Silbermayr K, Eigner B, Joachim A, Duscher GG, Seidel B, et al. (2014) Autochthonous Dirofilaria repens in Austria. Parasit Vectors 7:226. doi: 10.1186/1756-3305-7-226.Simón F, Siles-Lucas M, Morchón R, González-Miguel J, Mellado I, et al. (2012) Human and animal dirofilariasis: the emergence of a zoonotic mosaic. Clin Microbiol Rev 25:507–44. doi: 10.1128/CMR.00012-12.