Rhizoma coptidis and Shen-Ling-Bai-Zhu-San), improved blood glucose and lipid control. This pilot observational study investigated whether YH1 affects microbiota, plasma, and fecal bile acid (BA) compositions in ten untreated male patients with type 2 diabetes (T2D), hyperlipidemia, and a body mass index ≥ 23 kg/m2. Stool and plasma samples were collected for microbiome, BA, and biochemical analyses before and after 4 weeks of YH1 therapy. As previous studies found, the glycated albumin, 2-h postprandial glucose, triglycerides, total cholesterol, and low-density lipoprotein cholesterol levels were significantly improved after YH1 treatment. Gut microbiota revealed an increased abundance of the short-chain fatty acid-producing bacteria Anaerostipes and Escherichia/Shigella. Furthermore, YH1 inhibited specific phylotypes of bile salt hydrolase-expressing bacteria, including Parabacteroides, Bifidobacterium, and Bacteroides caccae. Stool tauro-conjugated BA levels increased after YH1 treatment. Plasma total BAs and 7α-hydroxy-4-cholesten-3-one (C4), a BA synthesis indicator, were elevated. The reduced deconjugation of BAs and increased plasma conjugated BAs, especially tauro-conjugated BAs, led to a decreased glyco- to tauro-conjugated BA ratio and reduced unconjugated secondary BAs. These results suggest that YH1 ameliorates T2D and hyperlipidemia by modulating microbiota constituents that alter fecal and plasma BA compositions and promote liver cholesterol-to-BA conversion and glucose homeostasis.Our previous clinical trial showed that a novel concentrated herbal extract formula, YH1 ( Rhizoma coptidis (RC) and Shen-Ling-Bai-Zhu-San (SLBZS). Modern pharmacological research has identified that the major chemical constituents of RC are alkaloids, and berberine serves as its main bioactive alkaloid with antidiabetic, antidyslipidemic, antiobesity, antibiotic, antioxidant, and anti-inflammatory activities [Clostridium spp. Metagenomic and metabolomic studies demonstrated that the antidiabetic effect of berberine was mediated by the inhibition of deoxycholic acid (DCA) biotransformation by Ruminococcus bromii [Traditional Chinese medicine (TCM) has been an excellent resource for developing new medications for metabolic disorders, such as type 2 diabetes (T2D), since ancient times . Increastivities . Howevertivities . Previoutivities . In additivities ,7,8,9. AThere are bidirectional interactions between gut microbiota and BA synthesis . Gut micEnterobacter and Escherichia/Shigella, resulting in reduced plasma glucose and lipid levels [SCFAs, including acetate, propionate, and butyrate, are well-known to induce GLP-1 secretion from gut L cells, and thus indirectly regulate glucose homeostasis by promoting insulin secretion and reducing pancreatic glucagon secretion . SLBZS wd levels . A dailyd levels , YH1 tred levels . This su2; (4) Received dietary and exercise education from a nutritionist for at least one month; (5) HbA1c ≥ 6.5%; (6) LDL-C ≥ 130 mg/dl; (7) Agreed to take 6 g of YH1 three times per day for 4 weeks.We conducted this pilot observational study in the TCM clinics of the Taoyuan branches of Chang Gung Memorial Hospital from January 2020 to December 2021 . This study was approved by the Committee on Research Ethics of the Chang Gung Memorial Hospital in Taiwan (No: 201901022B0A3). All participants provided written informed consent prior to participation. Eligible participants were male outpatients with T2D and hyperlipidemia who were not receiving treatment and consented to taking 6 g of YH1 [2; (7) stressful situations, including diabetic ketoacidosis, nonketotic hyperosmolar diabetic coma, severe infection, or surgery in the previous month; (8) Mental illness; (9) Addiction to tobacco, alcohol or other drugs; (10) Hemoglobin-related disease or chronic anemia; (11) Underlying conditions that could lead to poor compliance; (12) Severe organ disease, including cancer, coronary artery disease, myocardial infarction, or cerebrovascular diseases; (13) Consecutive use of antibiotics, probiotics, or weight loss drugs for more than 3 days within the 3 months prior to participation in this study; (14) Uncontrolled hypertension (blood pressure ≥ 160/100 mmHg); (15) Chinese medicine treatment in the past month.Patients were excluded if they met any of the following criteria: (1) Type 1 or other specific type of diabetes; (2) Female sex; (3) Use of oral hypoglycemic agents or insulin within the past month; (4) Use of lipid-lowering agents within the past month; (5) Serious gastrointestinal (GI) tract diseases, such as peptic ulcers or GI tract bleeding; (6) Hepatic insufficiency with alanine aminotransferase (ALT) > 108 U/L or renal insufficiency with estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 mAll participants were instructed to maintain their eating habits and lifestyles during the study period, and dietary recalls were obtained to document usual dietary intake by the same nutritionist before and 4 weeks after YH1 treatment. Patients were evaluated for medication history, Bristol Stool Form Scale (BSFS), Constipation Assessment Scale (CAS), prescription adherence to YH1, and adverse events at 0 and 4 weeks. Additionally, physical examination parameters, including body weight, BMI, waist circumference, blood pressure, and heart rate, were measured. Fecal specimens were collected at home, with a clean stool collection container with a spoon attached to the lid, prior to and upon conclusion of YH1 treatment. Stool samples were stored in the freezer immediately after collection, transferred to the laboratory in the frozen state within 3 days, and stored at −80 °C before analysis. In addition, blood samples were collected while fasting and 2 h post-breakfast for assessment of metabolic and biochemical parameters before and 4 weeks after YH1 treatment. A standardized breakfast containing a Chinese omelet with pork chop and a slice of pan-fried radish cake  was provided at 0 and 4 weeks to avoid the effect of different foods on BA profiles. ® DNA Kit  in accordance with the manufacturer’s protocol. Genomic DNA was amplified by PCR with primers targeting the 16S rRNA V3-V4 region, with a product size of 460 bp. The detailed protocol for PCR and sequencing has been described in a previous study [For stool microbiome analysis, we conducted DNA extraction, polymerase chain reaction (PCR) amplification, and 16S rRNA sequencing, as previously described . Total bus study . Brieflyus study . Subsequus study  algorithus study . Measureus study  via DESeus study  normalizFasting plasma glucose (FPG), 2-h postprandial glucose (2hPG), and glycated albumin were measured at weeks 0 and 4. Homeostatic model assessment of insulin resistance (HOMA-IR), β-cell function index (HOMA-β), lipid profiles, C-reactive protein (CRP), as well as hepatic and renal function were assessed at the beginning and end of the study. Furthermore, 2-h postprandial blood samples were collected for measurement of 2hPG and stored at −80 °C until analyses of plasma BA profiles, 7α-hydroxy-4-cholesten-3-one (C4), and fibroblast growth factor 19 (FGF19), before and after YH1 therapy. C4 and FGF19 serum biomarkers were indicators of BA synthesis and an index of the negative feedback loop involved in BA metabolism, respectively.Plasma and fecal sample preparation and analysis of BA by a UPLC–MS/MS system  covering 15 major BA species are described in Protocol S1. The full term of each BA and its abbreviation are presented in the table of Protocol S1. We assessed the total and individual concentrations of the 15 BAs, as well as the ratios of classified BAs, including ratios of 12α-hydroxylated BAs  to non-12α-hydroxylated BAs ; primary  and secondary BAs ; and glyco- plus tauro-conjugated  to unconjugated BAs .For plasma C4 analysis, 300 μL methanol was added to 100 μL plasma samples for liquid–liquid extraction. Samples of the mixture were incubated on ice for 30 min and then centrifuged to precipitate protein at 12,000 rpm for 30 min at 4 °C. The supernatant was transferred to a sample vial and analyzed in an LC–MS system  in negative atmospheric pressure chemical ionization (APCI) mode with multiple reaction monitoring. The chromatographic separation was achieved on an Acquity HSS pentafluorophenyl (PFP) column  at 25 °C with mobile phase A (25% acetonitrile with 0.1% formic acid) and mobile phase B (methanol). The flow rate was set to 0.3 mL/min. The gradient profile was as follows: 70% B for 1 min; linear gradient 70–75.7% B, 8 min; 75.7–100% B, 1 min; and 100% B, 2.2 min. The column was then re-equilibrated for 3 min. The parameters of MS were as follows: corona was 1 μA, desolvation gas flow was 800 L/h at 600°C, and cone gas flow was 150 L/h at 150 °C. System operation and data acquisition were controlled using Mass Lynx software and targeted metabolic data were analyzed by TargetLynx . In addition, serum FGF19 was measured by using commercially available enzyme-linked immunosorbent assay kits  according to the manufacturer’s instructions.p < 0.05 (*) were considered statistically significant, and p < 0.01 (**) was considered highly significant.IBM SPSS statistical software  was used for nonparametric analysis and verification. Measurement data are presented as the median , and categorical data are described by numbers. The Wilcoxon signed-rank test was used to detect differences in gut microbial features , plasma and fecal BA levels, and clinical outcomes between baseline and post-treatment measurements. Fisher’s exact test was performed to assess categorical variables. Spearman’s test was used for correlation analyses, not only between the percentage change in C4 and FGF19, but also between the gut microbiome and host metabolome or clinical parameters. All statistics were performed using a two-tailed test. Values of Ten male patients with hyperglycemia and hyperlipidemia who agreed to take 6 g of YH1 three times per day for 4 weeks were recruited for the study, and no participants dropped out. Prescription adherence of all patients was above 80%, and no participant was excluded from the data analysis. Participants were aged 38 to 57 years, with a median age of 48 years. The median duration of diabetes was 2.0 years, with a range from 0.5 to 14.0 years. Previous medications prescribed to treat chronic diseases included hypouricemic agents (sulfinpyrazone and benzbromarone) taken by two patients for a long time, four antihypertensive drugs taken by three participants , antihistamines (levocetirizine and denosin) used by two people, and silymarin used by two individuals. Participants continued to take the above medication without dosage or medication changes during the study.Anaerostipes  and Escherichia/Shigella , but reduced abundances of Parabacteroides , Bifidobacterium , and Romboutsia , after YH1 therapy , Parabacteroides merdae , Oscillibacter ruminantium , and Bacteroides caccae . Collectively, our microbiome analysis indicated that, although YH1 did not significantly alter the richness and diversity of gut microbiota, specific gut bacteria showed prominently different abundances at the genus and species levels after 4 weeks of YH1 treatment. YH1 enriched SCFA-producing bacteria, including Anaerostipes and Escherichia/Shigella, and inhibited BSH-active clones, such as Parabacteroides, Bifidobacterium, and Bacteroides caccae.Stool samples were collected from the participants before and after 4 weeks of YH1 treatment. Microbiota profiles were investigated using 16S rRNA sequencing. Microbial community variation, as indicated by Chao1 and Shannon indices (α-diversity), was slightly decreased after YH1 treatment without a significant difference a. Princi therapy c. YH1 re therapy d includip= 0.013). The median percentage of CDCAs  also increased prominently from 41.9 to 56.7% (p = 0.007). However, the median percentage of secondary BAs, including DCAs , LCAs , and UDCAs , significantly decreased from 33.7 to 24.1% (p= 0.007), 2.3 to 1.5% (p= 0.037), and 6.9 to 3.2% (p= 0.005), respectively. Therefore, the ratios of CAs/DCAs and CDCAs/DCAs both increased significantly after YH1 treatment, indicating that YH1 reduced the production of secondary BAs.In this study, plasma and stool samples were collected from ten patients at baseline and 4 weeks after oral administration of YH1. The changes in 15 types of plasma BAs are shown in p= 0.047), with the median concentration increasing from 827.1 to 1073.2 nM. Similarly, the median concentration of non-12α-hydroxylated BAs significantly increased from 1036.9 to 2037.8 nM at the end of YH1 treatment (p= 0.005). Levels of primary BAs in plasma increased significantly (p= 0.005), with the median concentration increasing from 1118.4 to 2354.2 nM, whereas levels of secondary BAs did not change. Conjugated BA levels were significantly elevated (p= 0.005), with a median increase from 1261.4 to 2872.0 nM. Interestingly, levels of both glyco- and tauro-conjugated BAs were strikingly elevated, and the increase in tauro-conjugated BA levels was significantly greater than that of glyco-conjugated BA levels after YH1 treatment. Therefore, the median ratio of G/T-BAs decreased from 10.7 to 4.2 (p= 0.005), and a decline in the G/T ratio was observed in both primary and secondary BAs. Furthermore, the median unconjugated BA level decreased from 545.0 to 289.2 after treatment (p= 0.047). The ratio of different classifications of plasma BAs before and after YH1 treatment are presented in p= 0.005). The ratio of conjugated to unconjugated BAs also increased prominently, with a median increase from 2.0- to 7.0-fold (p= 0.007), suggesting that YH1 inhibited the deconjugation of conjugated BAs by modulating the gut microbiome. Regarding the change in BA classification after YH1 treatment from baseline , the levp = 0.017), with the median concentration increasing from 1914.5 to 3200.5 nM. C4 levels were also markedly elevated (p= 0.037), but plasma FGF19 levels showed no significant change before and after YH1 treatment (p = 0.025). Intestinal FXR regulated the production of FGF19, a hormone that travels via enterohepatic circulation with a negative feedback effect of hepatic CYP7A1 activity on BA and lipid metabolism. A lower FGF19 concentration suggested less activation of intestinal FXR signaling, thus leading to increases in BA biosynthesis and plasma C4 levels after YH1 treatment.reatment . Howeverp= 0.047). However, there were no significant differences in total stool BAs or the ratios of different classifications in feces , without hypoglycemic episodes. The median 2hPG level also declined from 158.0 to 117.5 mg/d (p= 0.007). However, no significant changes were found in FPG, HOMA-IR, or HOMA-β scores at the end of this study. Regarding the parameters of lipid metabolism, the 4-week YH1 treatment resulted in significant reductions (p < 0.01) in total cholesterol, LDL-C, and TG levels compared with the baseline values (p= 0.07), with a median decrease from 49.5 to 39.5 U/L. However, neither inflammatory marker (CRP) levels nor renal function was significantly different after YH1 treatment in this study. Regarding the assessment of bowel movements, there were no significant changes in CAS or BSFS scores during this study. Adverse GI events were found once in two patients, experiencing mild nausea and bloating, respectively. The remaining eight patients did not experience any side effects during this trial. The severity of the above GI events was below grade two, as measured by the Common Terminology Criteria for Adverse Events  grading system. YH1 treatment was temporarily paused for one day when the two participants reported discomfort, and treatment was resumed once symptoms were resolved without other medical intervention. No patients experienced hypoglycemia during this study.Changes in various clinical parameters before and after four weeks of YH1 treatment are shown in e values . AlthougEscherichia/Shigella abundance represented a positive correlation with elevated TLCA  in plasma. Parabacteroides was negatively correlated with plasma TCDCA  and tauro-conjugated BAs , but positively correlated with LDL-C levels . In addition, Bifidobacterium was negatively correlated with TDCA  and tauro-conjugated secondary BAs  in plasma. Therefore, a decrease in Parabacteroides and Bifidobacterium abundances led to an increase in plasma levels of tauro-conjugated BAs and a decrease in LDL-C levels. At the species level, the reduction in Parabacteroides distasonis abundance also showed a positive correlation with decreased LDL-C levels , and the decrease in Parabacteroides merdae abundance was positively correlated with decreased plasma unconjugated BA levels . The decrease in Oscillibacter ruminantium abundance was positively correlated with reduced FPG levels , and negatively correlated with both elevated HOMA-β scores  and stool TLCA levels . In brief, YH1 significantly inhibited some microbiota in the gut, especially Parabacteroides and Bifidobacterium, which were related to the changes in BA composition, as well as in the clinical parameters.There were some correlations between YH1-responsive microbiota and BAs or clinical outcomes. At the genus level, the increase in 2. YH1 increased the abundances of SCFA-producing bacteria Anaerostipes and Escherichia/Shigella and reduced the abundances of Parabacteroides, Bifidobacterium, Romboutsia, Oscillibacter ruminantium, and Bacteroides caccae. Similarly, metformin improved T2D by modulating the microbiota, such as increasing the abundance of Escherichia/Shigella and decreasing that of Romboutsia, Oscillibacter, Bacteroides, and Parabacteroides [Oscillibacter abundance, and GLP-1 receptor agonist increases Anaerostipes abundance [This pilot observational clinical study is the first to report that 4 weeks of oral YH1 treatment alone significantly alters the stool microbiome and increases levels of conjugated BAs, especially tauro-conjugated BAs, in plasma and stool. These changes could effectively improve glycemic levels and lipid profiles for middle-aged, T2D male patients with LDL-C ≥ 130 mg/dl and BMI ≥ 23 kg/mteroides . Other abundance . TherefoClostridium spp. Therefore, BSH activity was decreased, leading to an accumulation of TCA in the intestine, thus acting on FXR receptors and affecting lipid metabolism [Ruminococcus bromii to attenuate DCA biotransformation [Parabacteroides merdae and Bifidobacterium spp., but enriched species such as Parabacteroides distasonis. Our study proved that YH1 decreased BSH-expressing microbiota, such as Bifidobacterium, Parabacteroides merdae, Parabacteroides distasonis, and Bacteroides caccae, elevating the ratio of conjugated to unconjugated BAs. Interestingly, we found that YH1 treatment decreased the G/T ratio of BAs, which was not reported in a previous clinical trial [Bacteroides and Parabacteroides, exhibiting different deconjugating activity between tauro- and glyco-conjugated BAs [Bacteroidetes, was more selective for tauro-conjugated BAs than glyco-conjugated BAs [Parabacteroides and Bacteroides caccae. Furthermore, YH1 treatment increased the ratio of primary to secondary BAs in plasma, but the levels of primary unconjugated BAs (CA and CDCA) were not elevated. As the abundances of 7α-dehydroxylated bacteria, such as Clostridium (clusters XIVa and XI) and Eubacterium, did not show significant changes in this study and these bacteria can metabolize only unconjugated-BAs [Although YH1 contained berberine, the changes in microbiota and plasma BAs after YH1 treatment were partially different from those observed after a single berberine compound treatment in previous studies ,9,30. Prtabolism ,30. A clated BAs . Similarated BAs ,32. Therated-BAs , the redated-BAs . Our stuAnaerostipes, as well as Escherichia/Shigella, and both are butyrate-producing strains in the intestine. Through SCFA receptors, gut microbiota-derived SCFAs have roles in GLP-1 release, insulin secretion, and regulation of energy expenditure [Anaerostipes and Escherichia/Shigella-derived SCFA levels that target receptors in gut L cells. This results in improvements in GLP-1 secretion and hyperglycemia, without any side effects of hypoglycemia. Conjugated BAs were associated with less activation of intestinal FXR signaling, so less negative feedback regulation promoted CYP7A1 activity with elevation of plasma C4 levels in our study. This led to liver cholesterol-to-BA conversion and hyperlipidemia reduction. Hence, this clinical research on YH1 could support the therapeutic mechanisms of TCM in improving metabolic diseases by modulating the gut microbiota and BAs found in animal studies [BAs regulate glucose, lipid, and energy homeostasis mainly through nuclear FXR and TGR5, and have pathophysiologic roles in obesity, T2D, dyslipidemia, and nonalcoholic steatohepatitis ,35. In aenditure . Collectp = 0.009), with a median decrease from 4.4 to 2.7. According to the previous literature, a TG/HDL-C ratio > 3.5 is linked with higher risks of cardiovascular disease and coronary heart disease-related death. It is anticipated that the future annual incidence of diabetes will increase two-fold for individuals with a TG/HDL-C ratio > 3.5 [Comparing our previous clinical trial  with theio > 3.5 ,37. Nineio > 3.5 ,39. ThisThis study has the following limitations. First, the sample size was small, and participation in our study was limited to males only. Females were excluded to avoid blood contamination of fecal samples during the menstrual period and to avoid sex differences in the microbiota and BA compositions. The standardized breakfast was provided in this study to prevent different diet-related BA secretion, and dietary records of patients were monitored by the same nutritionist during the study. Therefore, we controlled and minimized variables that could affect gut microbiota and BA composition to make our findings more reliable. Larger randomized controlled trials are warranted to confirm these pilot results. Future research that enrolls women together with men could determine if the influences of YH1 on gut microbiota and BA are universal or gender specific for patients with T2D and hyperlipidemia. Second, this study enrolled middle-aged, overweight or obese patients with treatment-naïve T2D and hyperlipidemia in Taiwan. The results may not be applicable to individuals in different stages of T2D or other racial/ethnic populations. Finally, the 4-week study period was relatively short. Longer treatment periods are required to evaluate the long-term effects of YH1 on microbiota and BA metabolism. Notwithstanding these limitations, our study still provides important evidence that YH1 can manage T2D and hyperlipidemia by regulating the microbiome and BA composition.Anaerostipes and Escherichia/Shigella-derived SCFAs might further improve hyperglycemia by regulating the release of GLP-1 in gut L cells. The detailed and complicated mechanism of YH1 requires more clinical and basic research in the future.We found that YH1 improved T2D and hyperlipidemia, by potentially inhibiting some gut bacteria with specific phenotypes of BSH, resulting in reduced deconjugation abilities. This led to elevated levels of conjugated BAs, especially tauro-conjugated BAs in plasma and stool. Consequently, YH1 potentially inhibited the activity of intestinal FXR, thereby decreasing hyperlipidemia by reducing negative feedback regulation and promoting the conversion of hepatic cholesterol to BAs. In addition, increased levels of conjugated BAs plus


Global Evidence-to-Policy (E2P) Summit. This summit brought together different stakeholders from all WHO Regions to identify common challenges, share lessons learned, and provide recommendations to support evidence-informed decision-making as a catalyst for policy and societal changes.In response to the challenges created by the COVID-19 pandemic to the role of evidence in policymaking, the World Health Organization (WHO) in collaboration with the Pan American Health Organization (PAHO) convened the first The E2P summit was organized by the Evidence-Informed Policy Network (EVIPNet), a global initiative with strong experience in promoting the use of evidence in policymaking.an EVIPNet Americas regional meeting to discuss the processes for using scientific evidence for the COVID-19 pandemic response and the challenges faced in translating this knowledge into policies in Latin America and the Caribbean (LAC). The event contributed to strengthening the EVIPNet Americas network. Three different panels were convened that provided insights into the use of evidence during the COVID-19 pandemic, experiences of Ministries of Health, and shared strategies and mechanisms for institutionalizing the use of evidence. The panels and participants shared important insights and lessons from different institutions in different countries . They reflected on several experiences of encouraging the use of evidence by public institutions to effectively respond to the COVID-19 pandemic, such as the need to better communicate evidence, to strengthen the relationship between evidence producers and decision makers, and for greater capacity-building in non-pandemic times to ensure better preparedness.As part of the Summit, PAHO convened Call for ActionEVIPNet Americas and PAHO have used their experience in supporting LAC countries to encourage collaboration between stakeholders and to use evidence better in responding to the COVID-19 pandemic see . The E2PConceptualization: L.R., C.M., J.B. and T.P., Writing – original draft: C.M., E.C., J.B., T.P., M.H., AND L.R., Writing – review & editing: M.M., D.F., L.K., R.B., C.C., C.V.M.A., and S.G. All authors reviewed and agreed with this final version of the paper.No individual data was used for this manuscript. The resources mentioned are all publicly available under the URLs reported in the table.This commentary did not have any source of funding.The author is a staff member of the Pan American Health Organization. The author alone is responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the Pan American Health Organization.The authors have declared that no competing interests exist. Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Pan American Health Organization.


Neurotology is a rapidly expanding field of knowledge. The study of the vestibular system has advanced so much that even basic definitions, such as the meaning of vestibular symptoms, have only recently been standardized.To present a review of the main subjects of neurotology, including concepts, diagnosis and treatment of Neurotology, defining current scientific evidence to facilitate decision-making and to point out the most evidence-lacking areas to stimulate further new research.This text is the result of the I Brazilian Forum of Neurotology, which brought together the foremost Brazilian researchers in this area for a literature review. In all, there will be three review papers to be published. This first review will address definitions and therapies, the second one will address diagnostic tools, and the third will define the main diseases diagnoses. Each author performed a bibliographic search in the LILACS, SciELO, PubMed and MEDLINE databases on a given subject. The text was then submitted to the other Forum participants for a period of 30 days for analysis. A special chapter, on the definition of vestibular symptoms, was translated by an official translation service, and equally submitted to the other stages of the process. There was then a in-person meeting in which all the texts were orally presented, and there was a discussion among the participants to define a consensual text for each chapter. The consensual texts were then submitted to a final review by four professors of neurotology disciplines from three Brazilian universities and finally concluded. Based on the full text, available on the website of the Brazilian Association of Otorhinolaryngology and Cervical-Facial Surgery, this summary version was written as a review article.The text presents the official translation into Portuguese of the definition of vestibular symptoms proposed by the Bárány Society and brings together the main scientific evidence for each of the main existing therapies for neurotological diseases.This text rationally grouped the main topics of knowledge regarding the definitions and therapies of Neurotology, allowing the reader a broad view of the approach of neurotological patients based on scientific evidence and national experience, which should assist them in clinical decision-making, and show the most evidence-lacking topics to stimulate further study. Neurotology is a medical discipline that explores the interface between otorhinolaryngology and neurology, comprising the clinical evaluation and treatment of sensorineural hearing and balance disorders. In recent years, new knowledge and new test modalities have been incorporated into neurotology. In order to gather the scientific evidence of neurotology into an easily accessible and succinct document, the ABORL-CCF, through its Department of Neurotology, developed the Neurotology Forums project to present to doctors who treat neurotological diseases an organized meeting of scientific evidence, facilitating the management of the neurotological patient.This text was the result of the I Neurotology Forum, held with the leading specialists in the field in Brazil on September 2, 2017. Prior to the meeting, the texts had been written based on a literature review to gather scientific evidence divided by topics. For this first Forum, the topic definitions and therapies was chosen. In addition to a literature review, contact was made with the Barany Society, which authorized the official translation of the concepts defined in the world consensus of the international classification of vestibular diseases,The texts written by the experts were then screened by the other Forum participants a few weeks in advance. Each author presented their text on the day of the meeting and, after debating them among those present, the texts were finalized by consensus. The texts were then grouped and standardized. On October 27, 2018, at a final meeting with representatives of the Neurotology training services in the country, the text was read again, and minor final adjustments were made. The recommendations of this first Forum, based on the literature, are objectively described and summarized in this article. For further reading, the reader may refer to the Forum text published in full on the ABORL-CCF website.Resolution of the Federal Council of Medicine 1718/2004, ratified by ABORL-CCF at the ABORL-CCF Ordinary General Meeting).The physician must respect the legal determinations and guidelines dictated by the Federal Council of Medicine (CFM) and ABORL-CCF. The teaching of private medical acts in any form of knowledge transmission to non-medical professionals, including those pertaining to advanced life support, except remote emergency care, is prohibited until optimal resources are reached .The medical report with diagnosis is the exclusive competency and prerogative of the physician, who is responsible for diagnosing the diseases and prescribing treatments, whereas the other professionals will act only within the scope of their respective legislations, according to the jurisprudence of the Superior Courts. People who perform acts of diagnosis of diseases and prescription of treatments should be reported to the authorities for illegal practice of Medicine, a crime provided for in the Penal Code with penalties ranging from six months to two years in prison .Considering the increasing complexity of medical problems, it is essential the team of physicians and other health professionals, such as nurses, pharmacists, physiotherapists and speech therapists, respect the limits of their competencies, prerogatives and their strict professional scope  vertigo is the sensation of self-motion when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement. The term encompasses false spinning sensations (spinning verti- go) and also other false sensations like swaying, tilting, bobbing, bouncing, or sliding (non-spinning vertigo).(Non-vertiginous) dizziness is the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion.external vertigo, oscillopsia, visual lag, visual tilt, and movement-induced blur.Vestibulo-visual symptoms are visual symptoms that usually result from vestibular pathology or the interplay between visual and vestibular systems. These include false sensations of motion or tilting of the visual surround and visual distortion (blur) linked to vestibular  failure. There are five vestibulo-visual symptoms: Unsteadiness, directional pulsion, balance-related near-fall, and balance-related fall.Postural symptoms are balance symptoms related to maintenance ofpostural stability, occur- ring only while upright . There are four postural symptoms: Clinical history is the main tool in the search for patient diagnosis. According to the Bárány Society, vestibular syndromes have been classified into 3 distinct groups: acute, episodic, and chronic.These are characterized by the abrupt onset of vestibular symptoms that persist for days or weeks, commonly associated with nausea, vomiting, gait unsteadiness, movement intolerance and presence of nystagmus. After the initial peak of symptoms, there occurs improvement during the first week and gradual recovery over weeks to months. AVS may occur spontaneously, following trauma or exposure to toxic agents, among others.These present as recurrent episodes of vestibular symptoms lasting from seconds to hours. The inter-crisis period may be asymptomatic or maintain some degree of milder dizziness in relation to the crises.They are characterized by the persistence of vestibular symptoms over a long period of time. The main diagnoses are persistent postural-perceptual dizziness (PPPD), chronic idiopathic unilateral vestibulopathy, persistent unilateral vestibulopathy after vestibular neuritis, unilateral vestibulopathy secondary to vestibular schwannoma, unilateral vestibulopathy after medical procedure, chronic bilateral vestibulopathy. Other diagnoses: CANVAS, posterior fossa tumors.•Calcium channel antagonists: sedative action, as they antagonize slow calcium channels and also because they have antihistamine action on H1 receptors. In addition to these effects, peripheral vasodilation action is described.They may be prescribed in the acute phase of vestibular diseases for symptomatic relief. Their use should be as short as possible so as not to impair the vestibular compensation and avoid unwanted side effects. The main classes of medications and their mechanisms of action are:B.Level of Evidence: recommended.•Antihistamines: vestibular sedatives with anti-cholinergic and antihistamine effect on H1 receptor. They can be used in acute vertigo, for the relief of nausea and vomiting,Degree of recommendation: Level of Evidence: B.recommended.•Benzodiazepines: vestibular sedatives because they potentiate the inhibitory action of GABA. They may also be used in acute vertigoDegree of recommendation: B.Level of Evidence: recommended.Degree of recommendation: •Betahistine: it is a histaminergic modulator acting as a weak H1 agonist and a strong H3 heteroreceptor antagonist. Its action in the labyrinth involves mechanisms that facilitate fluid circulation in the stria vascularis via the precapillary sphincter, thereby reducing endolymphatic pressure.14They are indicated for symptom control and prophylaxis of new crises of vertigo. The main medications in this class and their mechanisms of action are:A.Level of Evidence: recommended.•Ginkgo biloba EGb761 Extract: it is an herbal medicine, consisting of two active fractions: flavonoids and terpenoids. It has antiplatelet, antioxidant, antihypoxemic, anti-free radical, and antiedema actions in both the central nervous system and the inner ear.16Degree of recommendation: B.Level of Evidence: recommended.Degree of recommendation: They are used for the prophylaxis of vestibular migraine crises and Meniere’s disease and treatment of PPPD. The start of the therapy should be gradual to assess possible adverse reactions and treatment should be continued for at least 6 months after symptom control. Withdrawal, when indicated, should also be gradual to avoid withdrawal reactions by the patient.There are at least seven types of neurotransmitters involved in the transmission of vestibular system impulses. The top seven are glutamate, acetylcholine, GABA, dopamine, norepinephrine, histamine and serotonin. Most antidepressant medications work by modulating the action of serotonin. Serotonin receptors are found in the peripheral vestibular system and the vestibular nucleus in the central nervous system.•Prophylaxis of vestibular migraine crises: Nortriptyline , Amitriptyline , Venlafaxine .•Prophylaxis of Meniere's syndrome crises: Sertraline , Escitalopram .•Treatment of persistent postural-perceptual dizziness: Sertraline , Paroxetine , Imipramine , Fluvoxamine , Milnacipran , Fluoxetine , Citalopram .Listed below are the recommendations of each antidepressant according to the diagnosis:They are used in the treatment of vestibular paroxysms and prophylaxis of vestibular migraine crises and in the control of tinnitus. The start of the therapy should be gradual to assess possible adverse reactions. Withdrawal, when indicated, should also be gradual to avoid withdrawal reactions by the patient.Anticonvulsants are classified according to their site of action and potency: enhancers of GABA-mediated synaptic inhibition , sodium channel blockers , calcium channel blockers , inhibitors of glutamate synaptic receptors (lower the excitability threshold). The most commonly used are carbamazepine, oxcarbazepine, topiramate, valproate, gabapentin and lamotrigine.•Treatment of vestibular paroxysm: Carbamazepine , Oxcarbazepine , Gabapentin , Phenytoin , Valproic Acid .•Prophylaxis of vestibular migraine crises: Topiramate , Valproate , carbamazepine , Gabapentin , Lamotrigine .Anticonvulsants with their degree of recommendation, according to diagnosis, are listed below:20•Diuretics: they can be used to treat Meniere’s disease, with cases being assessed individually. Although several experimental and radiological studies demonstrate the reversal of hydrops with the use of diuretics, the mechanism of action of these medications is still much discussed.They help control vestibular symptoms, fluctuating hearing, aural fullness and tinnitus in patients with Meniere’s disease.C.Level of Evidence: optional.Degree of recommendation: These are distinct therapeutic procedures for vestibular rehabilitation exercises. While rehabilitation exercises, such as Cawthorne-Cooksey or Brandt-Daroff protocols, aim at mechanisms of neuronal plasticity such as adaptation, habituation and sensory substitution, otoliths repositioning maneuvers aim to effectively release and reposition otoliths out of the endolymphatic duct and ampoule and back to their physiological utricular position. They should be carried out by the doctor to resolve the positional vestibular symptoms in BPPV.A.Level of Evidence: strong.•Maneuvers for the posterior canal:•Maneuvers for the lateral canal - canalithiasis (geotropic variant):•Maneuvers for the lateral canal - cupulolithiasis (apogeotropic variant):•Maneuvers for the anterior canal: these were not discussed in the forum since anterior canal BPPV is a very rare and uncertain diagnosis and its pathophysiology is not well understood.•Complications of repositioning maneuvers: severe complications are rare but should not be underestimated. Observation of the patient’s risk factors, and the use of appropriate techniques help to prevent them, and their performance under medical supervision is necessary for the treatment. The main complications are severe vertigo crisis, with nausea, vomiting and sweating, with frequent need for medication, conversion to another semicircular canal , requiring an adequate diagnosis of the new affected canal with indication of another therapeutic maneuver, intracanalicular otolith obstruction  requiring reversal of position, osteoarticular and vascular cervical lesions, and endolymphatic hydrops.32Degree of recommendation: Used to control vestibular symptoms in Meniere’s disease and to recover rapidly progressive sensorineural hearing loss. Gentamicin application is reserved for the treatment of Meniere’s disease unresponsive to clinical treatment. Because of the possibility of hearing loss, cochlear function should be monitored. Intratympanic corticosteroid therapy can be used for sudden sensorineural hearing loss, immune-mediated inner ear diseases, and rapidly progressive sensorineural hearing loss, as primary, combined, or rescue therapy to oral corticosteroid therapy.34Level of evidence: B (vertigo control) and C (hearing loss).recommended.Degree of recommendation: •Traditional: vestibular adaptation exercises intensify vestibular-ocular reflex gain and tolerance to head movements, improve gaze stability, vestibulo-visual interaction during head movements, and postural stability in conflicting sensory environments. Sensory substitution exercises seek to intensify residual vestibular function and replace the reduced or absent vestibular function with alternative strategies of gaze stabilization and static and dynamic postural control. On the other hand, habituation exercises aim to desensitize the movements and/or positions that trigger vestibular symptoms through repetitive stimuli.It is a physiological form of treatment of peripheral and/or central vestibular symptoms, allowing patients to perform their usual activities to the best of their capacities. It is based on eye, head and body exercise protocols. The exercises use vestibular adaptation mechanisms, substitution of sensory or motor strategies and habituation to accelerate vestibular compensation and regain body balance.36A.Level of Evidence: strong.•With platforms: the use of platforms may be a therapeutic option included in the vestibular rehabilitation protocol. Platforms are equipment where the individual remains in an upright position, being submitted to body stability challenges caused by movements in the mid-lateral or anteroposterior direction or with flexion and extension of the ankle. There are studies showing more significant improvement in the Dizziness Handicap Inventory (DHI) and body sway scores in patients treated with the platform, compared to conventional vestibular rehabilitation.Degree of recommendation: C.Level of Evidence: recommended.•Vibrotactile substitution: the use of vibrotactile substitution equipment may be a therapeutic option included in the vestibular rehabilitation protocol. It is a technique that accelerates central compensation through vestibular rehabilitation by substitution. It consists of placing a vibrating device on the patient, most commonly an adjustable waist belt, which consists of a main unit, responsible for detecting movement sways, and four vibratory units, located in the anterior, posterior, right lateral and left lateral positions,41Degree of recommendation: B.Level of Evidence: recommended.•Virtual Reality: aims to recreate environmental changes by stimulating sensory systems to adjust the reflexes involved in postural control and balance strategies.Degree of recommendation: B.Level of Evidence: recommended.•Neuromodulation: vestibular rehabilitation through neuromodulation may be performed in patients with peripheral or central chronic vestibular dysfunction for at least 1 year who have performed and completed previous vestibular rehabilitation therapy protocol with limited results, and whose symptoms and limitations to perform activities of daily living still persist.Degree of recommendation: B.Level of Evidence: recommended.Degree of recommendation: Procedures that may be used in selected cases of disabling vertigo refractory to clinical treatment. Labyrinthectomy is limited to patients with socially useless hearing, while vestibular neurectomy is one of the options for patients with useful hearing.C.Level of Evidence: optional.Degree of recommendation: The purpose of the procedure is the symptomatic control of patients who are refractory to the clinical treatment of Meniere’s disease. However, no class or scientific society was found that adopted a recommendation for this subject. The procedure becomes an individual option of each professional, considering the characteristics of the case.C.Level of Evidence: optional.Degree of recommendation: It is a treatment option for the control of vertigo symptoms and is only indicated for patients with disabling symptoms of superior semicircular canal dehiscence (SSCD) syndrome. There is still no evidence to determine the most effective surgical technique. A systematic review published in 2017C.Level of Evidence: optional.Degree of recommendation: It is a safe surgical treatment indicated for the management of patients with perilymphatic fistula, as long as its diagnosis is established.Level of Evidence: C.recommended.Degree of recommendation: The large amount of information presented in this article is a demonstration of the advancement of neurotology in recent years. The authors hope that this review may help the physician to understand, approach and treat patients with vestibular symptoms.The authors declare no conflicts of interest


This study compared the reliability, construct validity, and respondents’ preference of the Chinese version of 8-item eHEALS (C-eHEALS) and 21-item DHLI (C-DHLI) in assessing older adults’ electronic health  literacy using a mixed-methods approach. A web-based, cross-sectional survey was conducted among 277 Chinese older adults from September to October 2021, and 15 respondents were subsequently interviewed to understand their preference of scale to use in practice. Results showed that the internal consistency and test-retest reliability of both scales were satisfactory. For the construct validity, the C-DHLI score showed stronger positive correlations with having Internet use for health information and higher educational attainments, occupational skill levels, self-rated Internet skills, and health literacy than the C-eHEALS score. In addition, younger age, higher household income, urban residence, and longer Internet use history were only positively correlated with C-DHLI score. Qualitative data suggested that most interviewees perceived the C-DHLI as more readable than C-eHEALS for its clear structure, specific description, short sentence length, and less semantic complexity. Findings revealed that both scales are reliable tools to measure eHealth literacy among Chinese older adults, and the C-DHLI seemed to be a more valid and favored instrument for the general Chinese older population based on the quantitative and qualitative results. The Internet is now well integrated into our daily lives. It has become the most readily accessible resource for obtaining health information, bringing many opportunities for self-care . As the Electronic health  literacy, first mentioned by Norman and Skinner in 2006, is defined as the ability of individuals to seek, find, understand, and appraise health information from electronic resources and apply such knowledge to addressing health problems . The rolThe most widely used tool for eHealth literacy assessment is the 8-item eHealth literacy scale (eHEALS) developed by Norman and Skinner in 2006, which measures one’s perceived ability or self-efficacy to use the Internet for health information . The eHEAlthough eHEALS is the most used instrument to measure eHealth literacy, some concerns have been raised. First, it was developed in 2006, and since then a drastic change on the Internet has been observed, including a more advanced technology and increased popularity of social media. Some scholars criticized its insufficient ability to capture the vibrant Internet characteristics  in more recent years . Indeed,Compared to eHEALS, the DHLI measures both Health 1.0 and interactive Health 2.0 aspects  . MoreoveDue to the different emphases and characteristics of eHEALS and DHLI, more investigations are needed to compare their applicability and relevancy in assessing Chinese older adults’ eHealth literacy in practical settings. In addition to examining the reliability of the C-DHLI and C-eHEALS, the present study expanded research on eHealth literacy assessments by examining their construct validity. Typically, construct validity is established by presenting correlations between a measure of a construct and some other measures that should, theoretically, be associated with it  or had no association it  . In the First, inequalities in demographics and socioeconomic status can have great influence on older adults’ eHealth usage and eHealth literacy . The IntIn addition, given that eHealth literacy capabilities can be seen as important personal resources, it is also necessary to understand respondents’ personal preferences about the measurements. The present study will utilize qualitative interviews to determine respondents’ perceptions of the two scales. Such approach can provide important information for understanding respondents’ preferences regarding the scales used in research and clinical settings .Based on the above, the purpose of this study was to compare the reliability, construct validity, and respondents’ perceptions of the C-eHEALS and C-DHLI using a mixed-methods approach. It is expected that findings of the study would help to identify a valid and reliable instrument for assessing eHealth literacy among Chinese older adults.Sojump (a major platform for online surveys in China). Participants self-administered the online questionnaire after giving their informed consent, which took around 15 min to complete. After two weeks, approximately 20% of them were randomly selected and invited to complete another questionnaire which consisted of the two eHealth literacy scales again. No incentives were given to the participants.A web-based cross-sectional survey was conducted among Chinese older adults from September to October 2021. A non-probability, convenience sample of older adults above 55 years of age in 30 provinces and municipalities of mainland China was recruited. The inclusion criteria of the participants were: (1) being aged 55 or over, (2) having Internet use experience, and (3) having cognitive ability to complete a self-reported survey. Eligible participants were invited to participate in the web-based survey via social networking sites . The online questionnaire, which included the informed consent and study questionnaire, was accessed through a hyperlink or a QR code of Socio-demographic characteristics included the respondents’ information about age, gender, types of residence, education, occupation (currently or before retirement), and monthly household income.Internet use-related factors included respondents’ Internet use history (years), self-rated Internet use skills (response options from 1 = “Poor” to 5 = “Excellent”) and Internet use for health information .eHealth literacy was assessed by two instruments: the 8-item C-eHEALS and the 21-item C-DHLI. As introduced before, in the C-DHLI, respondents were asked how often they experience specific situations or how difficult they find it to perform specific tasks by searching for health information from the Internet. The 4-point Likert scale has response options ranging from “1 = very easy” to “4 = very difficult” or from “1 = never” to “4 = often”. Scores need to be reversed, and a higher score represents a higher level of eHealth literacy. In this study, the three optional items about protecting privacy were not included in the validation analysis due to low completion rates . AnotherHealth literacy was assessed by a 14-item health literacy scale (HLS-14) developed by M. Suka et al., which contains three dimensions: functional, interactive, and critical . The resAfter the web-based survey, participants who had shown interest in taking part in the follow-up qualitative study were invited to provide their contact information. Those with various socio-demographic backgrounds were randomly selected and approached by one research team member for their consent to be interviewed. During the interviews, their perceptions and preference for the two eHealth literacy scales were asked and recorded  ,31. A toEthical approval was obtained from the Survey and Behavioral Research Ethics Committee of the Chinese University of Hong Kong (No. SBRE-21-0005).Descriptive statistics regarding respondents’ socio-demographic characteristics, Internet use behaviors, eHealth literacy scores on two scales, and health literacy were described by mean ± standard deviation (SD) for continuous variables  and number (percentage) for categorical variables.Internal consistency of both scales was assessed by Cronbach’s coefficient alpha. A threshold of 0.7 was considered acceptable, a value >0.8 indicated good internal consistency, and a value >0.9 indicated excellent internal consistency . Test-retest reliability was calculated by the interclass correlation coefficient (ICC), with values less than 0.5, between 0.5 and 0.75, between 0.75 and 0.9, and greater than 0.90, indicating poor, moderate, good, and excellent reliability, respectively .Based on the theoretical and empirical evidence, nine a-priori hypotheses were used to evaluate the construct validity of the C-DHLI and C-eHEALS as follows. The process of construct validation test used in this study followed the methodology in examining scale construct validity used in many previous studies ,35,36.H1: Older age would be negatively associated with eHealth literacy among Chinese older adults.H2: Higher educational attainments would be positively associated with eHealth literacy among Chinese older adults.H3: Urban residence would be positively associated with eHealth literacy among Chinese older adults.H4: Higher occupational skill levels would be positively associated with eHealth literacy among Chinese older adults.H5: Higher household income would be positively associated with eHealth literacy among Chinese older adults.H6: Longer Internet use history would be positively associated with eHealth literacy among Chinese older adults.H7: Higher self-rated Internet skills would be positively associated with eHealth literacy among Chinese older adults.H8: Having used Internet for health information would be positively associated with eHealth literacy among Chinese older adults.H9: Higher health literacy would be positively associated with eHealth literacy among Chinese older adults.One-way analyses of variance (ANOVA) were used to analyze responses for C-eHEALS and C-DHLI scores, with age category, types of residence, education, occupation, household income, Internet use history, self-rated Internet skills, and using the Internet for health information as group factors, followed by LSD post-hoc tests. In addition, Pearson or Spearman correlations were also used to test the above hypotheses for the effect size and direction.The qualitative data were transcribed and translated into English. We used inductive thematic analysis to analyze the interview data related to the respondents’ preference decisions . The autThe characteristics of respondents are presented in p < 0.001).Sixty-two participants completed the C-eHEALS and C-DHLI again two weeks after baseline. The internal consistency of both scales was good, with both Cronbach’s alpha of 0.94. For the test-retest reliability, both C-eHEALS and C-DHLI showed excellent test-retest reliability on their total scores by 0.92 and 0.94 of ICC between baseline and two weeks later (p < 0.001). Specifically, the functional literacy dimension (ρ = 0.402) of health literacy showed a moderate positive correlation with C-DHLI scores but no significant correlation with C-eHEALS. Nevertheless, age (r = −0.217) showed a weak-to-moderate negative correlation with C-DHLI scores; unban residence (ρ = 0.240), higher occupational skill levels (ρ = 0.298), and longer Internet use history (ρ = 0.346) also showed a weak-to-moderate positive correlation with higher C-DHLI scores (p < 0.001).As shown in p < 0.01) and occupational skill levels  were weakly correlated with higher C-eHEALS scores. Other variables showed no significant correlations with C-eHEALS scores.For C-eHEALS, higher self-rated Internet skills (ρ = 0.242), having used the Internet for health information (ρ = 0.328), and higher health literacy (ρ = 0.391) were weakly-to-moderately correlated with higher C-eHEALS scores; higher educational attainments  preferred to use the C-DHLI, labeled B6–B13. Two (13.3%) did not give an explicit choice and were labeled C14–C15. Through an iterative process, the data were saturated on two themes: item readability and content comprehensiveness, that influenced respondents’ preference to use a particular scale.As shown in A1, A2, and A3) stated the items in both C-eHEALS and C-DHLI were easy to read and understand. With regards to their demographic characteristics, they generally had higher education attainment, higher household income, urban residence, longer Internet use history, having used the Internet for health information, and higher C-eHEALS and C-DHLI scores. They had no difficulty answering both scales; thus, the scale’s brevity  became the main reason for their choice.The scale’s readability is one of the most important factors affecting respondents’ preference for which scale to use. For the five interviewees who preferred the C-eHEALS, three interviewees .”[Interviewee A2]A4 and A5) found both scales quite difficult to understand and answer by themselves, especially Interviewee A5 who could hardly answer both scales without the other’s help. They picked the C-eHEALS only due to its fewer item numbers. They had lower education and household income, town or village residence, short Internet use history, and had never used the Internet for health information. Their eHealth literacy scores on both scales were low.However, two other interviewees  and item 5  of the C-eHEALS.Of the eight interviewees who preferred to use the C-DHLI in practical settings, most stated the C-DHLI was easier to understand as it had more “I have difficulty distinguishing the items of C-eHEALS and feel some of them quite similar. Thus, when answering the questions, I just roughly choose an option. But for the C-DHLI, I can tell the difference between items with specific scenarios, so I can exactly understand what this scale would like to ask.”[Interviewee B10]less semantic complexity and shorter length of the C-DHLI’s items as reducing their burden in answering the scale. Additionally, Interviewee B7 also emphasized the higher readability of C-DHLI than C-eHEALS, not only about the items but also about item options,In addition, some—particularly those with lower education  and shorter Internet use history—described “C-DHLI’s items are shorter, easier, and more straightforward. Moreover, the answer options of C-DHLI regarding difficulty or frequency are more objective and easier to answer than eHEALS’s options about the agreement.”[Interviewee B7]C14 and C15) did not give an explicit preference for either scale. They explained that they rarely used the Internet for health information and eHealth literacy was unimportant in their daily life. They commented the C-DHLI is relatively easier to understand but more time-consuming.Another two interviewees  than C-eHEALS. The C-eHEALS was more favored by those who can easily understand it for having fewer items (and therefore being less time-consuming) than the C-DHLI.The quantitative results showed that both C-eHEALS and C-DHLI had good internal consistency and test-retest reliability in Chinese older adults. The result was consistent with the findings of a Korean study which validated the Korean version of DHLI and eHEALS in older adults  . As founr = 0.402, p < 0.001) while not significantly associated with the C-eHEALS score. Some previous studies have criticized the weak relationship between one’s self-efficacy and actual performance on eHealth use [Overall, the C-DHLI demonstrated better construct validity than the C-eHEALS in the older Chinese population. Specifically, all nine hypotheses were fulfilled in the C-DHLI, and five of them were fulfilled in the C-eHEALS. In addition, for the five hypotheses fulfilled in both scales, the correlations between C-DHLI and the hypothesized factors  were stronger than such with the C-eHEALS scores. As stated before, the disparities in social structure, digital divide, and health literacy are related to older adults’ eHealth literacy, which would further exacerbate health disparities . Based oalth use ,17. AlthThe results from the qualitative data confirm that a clear difference of eHealth literacy levels exists within older individuals, potentially influenced by their socio-demographic characteristics and Internet use history/skills . RespondThis study confirmed the reliability and validity of the two eHealth literacy instruments in Chinese older adults. However, as mentioned before, as the digital health technologies have advanced a lot in recent years , refinement of the instrument is therefore warranted, for example, to capture the characteristics of online interactions. In addition, the C-DHLI, as a newly developed instrument, has been translated into Chinese in 2021 by our research team and validated in 277 Chinese older adults for the first time. More evidence regarding its psychometric properties in larger and more representative samples in China is also needed. There are several limitations of the study that should also be noted. First, the present study was a web-based survey with the sample being Chinese older adults who voluntarily participated in this study. Selection bias may exist as the participants were older adults who had experience with the Internet and were more likely to be interested in accessing health information online. Second, reporting bias  may exist as the questionnaire was self-reported and self-administered. Third, nine a-priori hypotheses were used to examine the construct validity in the present study, which is often considered less powerful than criterion validation. However, with strong theories and specific expectations, it is possible to acquire substantial evidence that the measurement instrument is measuring what it purports to measure .To conclude, the Chinese versions of eHEALS and DHLI were reliable in assessing eHealth literacy, but the C-DHLI was more valid than the C-eHEALS among Chinese older adults. In addition, qualitative results showed that the C-DHLI was more favored by respondents with different backgrounds, due to its clear structure, specific descriptions, shorter sentence length, and lesser semantic complexity. The C-eHEALS was preferred by people who can easily understand it due to its brevity . The findings suggest that the C-DHLI may be more applicable to general older populations in China for eHealth literacy assessment; the C-eHEALS can be considered in certain elderly groups  in daily practice. In addition, the refinement of the eHEALS is still strongly recommended to capture the evolution of digital health technologies over time.


Ultrasonography is currently used in investigating many vascular diseases, especially for guiding vascular access. The objective here was to summarize the evidence from Cochrane systematic reviews (SRs) on the effects of ultrasound-guided vascular access as an intervention approach. Review of SRs, conducted in the Division of Vascular and Endovascular Surgery of Universidade Federal de São Paulo. A broad search was conducted in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed the effects of ultrasound guidance as a therapeutic approach towards performing any vascular access. The key characteristics and results of all the reviews included were summarized and discussed. Three SRs on venous access at all ages and one review on arterial access in pediatric participants were included. There was low to moderate certainty of evidence that ultrasound increased the success rate from the first puncture and the overall success rate of the procedure; and reduced the total rate of perioperative and postoperative adverse events, number of punctures, time needed to achieve success and rate of failure to place catheters. Evidence of low to moderate quality showed that ultrasound-guided vascular access seems to reduce the total rate of perioperative and postoperative complications/adverse effects, number of punctures, time needed to achieve success and rate of failure to perform venous catheterization in adults and arterial punctures in children. There is a lack of information regarding ultrasound-guided arterial puncture in adults. Further studies are still imperative for reaching solid conclusions, especially regarding arterial ultrasound-guided access. In the United States, over 15 million central vascular catheter-days occur in intensive care units per year.,,Over recent decades, ultrasound has been used as a possible aid for diagnostic purposes, including in bedside examinations and for possibly avoiding complications in various procedures.,,Although there are some practical guidelines that make recommendations regarding standard use of ultrasound to guide venous catheterization, up to 40% of doctors are resistant to using this evidence in their practice.Despite the large amounts of money that have been invested in research on this topic, the relevance of ultrasound-guided vascular access as a therapeutic approach is still a matter of debate, especially in relation to arterial puncture. Because the use of ultrasound as an additional intervention may be a reasonable alternative for improving the results relating to many types of vascular access, it is imperative to assess the effects of ultrasound-guided access through well-conducted randomized controlled trials.The aim of this study was to identify and summarize the evidence from Cochrane systematic reviews (SRs) regarding ultrasound-guided vascular access, in an overview.This was a review of Cochrane systematic reviews conducted in the Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, Brazil.Full Cochrane SRs published in the Cochrane Database of Systematic Reviews (CDSR) were included, without restrictions regarding date of publication. Withdrawn or outdated versions of SRs and protocols for SRs were considered not relevant.We considered all participants who underwent a vascular access procedure, both males and females, of all ages, without any restriction regarding the site of puncture.We considered SRs that assessed any vascular access technique, such as the Seldinger technique, as an intervention, if comparison with ultrasound-guided access was made in at least one of the study arms.We considered any patient-relevant clinical or laboratory outcomes, as assessed by the authors of the SRs included.We conducted a sensitive systematic search in the Cochrane Database of Systematic Reviews  on July 3, 2018. We used the following MeSH terms and all related variants in the titles, abstracts and keywords: “vascular access devices”, “endovascular procedures”, “ultrasonography”, “ultrasonography, Doppler” and “ultrasonography, interventional”. The detailed search strategy is presented in Two researchers (GAA and RLGF) independently evaluated the titles and abstracts to analyze whether the SRs fulfilled the inclusion criteria. Any disagreement was resolved by consulting other authors . The SRs were selected and summarized by two authors (GAA and RLGF).The results from the search and the SRs included were presented as a qualitative synthesis (descriptive approach).,,,Our search strategy retrieved 221 references and, after screening the titles and abstracts, 11 SRs were preselected. After assessing the full texts, four reviews fulfilled the inclusion criteria and were included in the qualitative synthesis.The latest versions of all the SRs included were published between 2011 and 2016. Details regarding the characteristics of the interventions, comparisons and outcomes and the certainty of evidence are presented in The objective of this systematic reviewReal-time 2D ultrasound guidance significantly decreased the overall risk of catheter placement failure  and the risk of catheter placement failure on the first attempt . Use of ultrasound guidance correlated with notably fewer attempts/catheter placements (mean difference (MD) -0.35; 95% CI -0.54 to -0.16).A meaningful reduction in the time required for successful vein puncture, from the time when the skin was anesthetized, was found with real-time ultrasound guidance .Real-time ultrasound guidance was found to significantly decrease the risk of carotid artery puncture  and led to a significant reduction in the risk of hematoma . There were no differences between patient groups regarding the risk of pneumothorax or hemothorax .There are benefits from the use of real-time 2D Doppler ultrasound guidance with regard to the number of catheters successfully inserted on the first attempt. There was lower risk of arterial puncture and hematomas and less time was taken for successful vein puncture.This systematic reviewAccording to the review authors, almost all of the studies selected for the review had high risk of bias, and the meta-analysis had substantial heterogeneity. The results were presented as comparisons of landmark versus 2D ultrasound, and landmark versus Doppler ultrasound.Use of 2D ultrasound improved the overall success rate by 12% , with no difference between use of Doppler and use of 2D ultrasound. However, the quality of this evidence was very low, due to uncertainty regarding the analysis on data from Doppler ultrasound.The 2D ultrasound reduced the number of attempts needed to succeed , with very low quality of evidence. Only at the first attempt was it found that Doppler ultrasound had better results , with low quality of evidence.The time taken for successful cannulation was lower with use of 2D ultrasound , with very low quality of evidence. There was no evidence of difference in this outcome using Doppler ultrasound , with moderate quality of evidence.Use of 2D ultrasound reduced the total number of perioperative and postoperative complications by 71% . However, the quality of evidence was very low. There was no difference when Doppler ultrasound was used instead of 2D ultrasound, but the quality of this evidence was also low.Inadvertent arterial puncture was reduced by 72% through use of 2D ultrasound . Use of 2D ultrasound reduced significant hematoma formation by 73% . However, the quality of the evidence was very low. For Doppler ultrasound, this outcome was described in only one trial, thus making statistical analysis impossible.The results relating to other complications such as thrombosis, embolism, hemomediastinum and hydromediastinum, hemothorax and hydrothorax, pneumothorax, subcutaneous emphysema and nerve injury were better (decrease of 66%) through use of 2D ultrasound , with moderate quality of evidence. In Doppler ultrasound trials, these outcomes were not reported.This systematic reviewSimilarly to the review by Brass et al.,For subclavian/axillary vein cannulation, the quality of the evidence was low regarding the overall success rate. There was no evidence that use of 2D ultrasound or Doppler ultrasound-guided puncture techniques made any difference in this outcome . However, for femoral vein catheterization, a small increase in the overall success rate was reported  with moderate quality of evidence.For subclavian/axillary vein cannulation, there was no evidence of any difference between landmark and 2D real-time puncture ultrasound regarding the number of attempts needed to succeed . However, the quality of the evidence was very low. For femoral vein catheterization, this outcome was reported in only one trial.There was no evidence of any difference in the time taken to achieve successful cannulation for the subclavian/axillary vein , but the quality of the evidence was low. For femoral vein catheterization, only one trial could be analyzed.There was no evidence of any difference in success at the first attempt  regarding subclavian/axillary vein cannulation, with high quality of evidence. However, ultrasound used during puncture of the femoral vein increased the rate of success at the first attempt , and the quality of the evidence was high.For subclavian/axillary vein cannulation, use of 2D ultrasound or Doppler ultrasound-guided puncture techniques did not show any difference in the total perioperative and postoperative complication rate , although the quality of the evidence was very low. For femoral vein catheterization, this outcome was reported in only one trial.For subclavian/axillary vein cannulation, real-time ultrasound significantly reduced the risk of arterial puncture , but the quality of the evidence was low. No evidence of any difference was found in relation to femoral vein catheterization . However, the quality of the evidence was low.Real-time ultrasound significantly reduced the risk of hematoma in subclavian/axillary vein cannulation , with moderate quality of evidence. None of the trial authors reported this outcome for femoral vein catheterization.Regarding use of 2D ultrasound or Doppler ultrasound-guided puncture techniques for subclavian/axillary vein cannulation, the study did not find evidence of any difference in this outcome . However, the quality of the evidence was very low. Likewise, for femoral vein catheterization, no evidence of any difference was found , and the quality of the evidence was low.2D ultrasound improves the safety and quality, compared with an anatomical landmark technique for the subclavian or femoral vein, but the results are uncertain.Ultrasound guidance may be useful not only for central venous access, but also in arterial and peripheral cannulation.Ultrasound guidance was found to significantly increase the success rate of cannulation at the first attempt  and increased successful radial artery cannulation within the first two attempts . The quality of the evidence was moderate for both outcomes. However, ultrasound guidance did not significantly improve the rate of successful cannulation in comparison with palpation .The review authors were unable to perform a meta-analysis on the time taken for successful cannulation and the number of cannulas used. The number of attempts required for successful cannulation was presented in two studies, but no meta-analysis was possible.The review authors did not conduct a sensitivity analysis. However, results regarding the need for assistance from another operator (i.e. the primary operator failed when attempting to insert the cannula and asked for help) were presented in one of the studies. A rate of 30.6% was reported in the ultrasound group, versus 33.7% in the palpation group .The rate of complications such as hematoma was significantly reduced when using 2D ultrasound guidance during radial artery cannulation . The quality of the evidence was moderate. No studies reported any data on ischemic damage.There is evidence of moderate quality to support the use of ultrasound guidance for radial artery cannulation. Improved success rates at the first and second attempts were identified, along with lower complication rates, compared with the other techniques. Improved success rates at the first try may be more pronounced among infants and young children.The overall analysis on the reviews included suggested that use of 2D ultrasound-guided vascular access provided benefits, compared with use of anatomical landmarks and the palpation technique alone.Reduction in the total rate of perioperative and postoperative complications/adverse effects was found in one of the reviews in relation to internal jugular vein catheterization using 2D ultrasound. Hematoma formation was reduced through application of ultrasound in all of the four SRs included. However, none of these reviews addressed the impact of use of ultrasound on patient discomfort and mortality. Nor did they evaluate the impact of different types of devices (e.g. point-of-care versus standard devices) and the skill with which these instruments are applied.The major limitation of this overview was the small number of reviews included. Another limitation was that one of the reviews was out of date in the sense that it did not evaluate the evidence using the GRADE approach.Nevertheless, all of the reviews included suggested that use of ultrasound for guided vascular access provided various benefits, compared with use of anatomical landmarks (vein puncture) and palpation (artery puncture) alone.,,,,,,,,,,Some of the most recent clinical practice guidelinesEven with limitations regarding the quality of evidence, all of the four Cochrane reviews included in this overview showed that ultrasound guidance for vascular access provided some benefits. There is a lack of information regarding ultrasound-guided arterial puncture in adults. Therefore, further well-designed and well-conducted studies from which solid conclusions can be reached are still imperative, especially regarding arterial ultrasound-guided access. Additional evidence with high certainty regarding ultrasound guidance for venous and arterial puncture is needed in order to build up a robust body of evidence in this setting.


As eHealth and use of information and communication technologies (ICT) within healthcare becomes widespread, it is important to ensure that these forms of healthcare are accessible to the users. One factor that is key to accessing eHealth is digital health literacy.This scoping review assesses available tools that can be used to evaluate digital health literacy.A systematic literature search was made in MEDLINE, CINAHL, APA PsychInfo, Ageline, AMED, and APA PsychArticles to present the tools currently in use to assess digital health literacy. A qualitative synthesis of the evidence was carried out using a data charting form created for this review. Extracted data included details of the population of investigation and digital health literacy tool used. A report was produced following PRISMA-ScR guidelines.In total, 53 papers with adult participants and 3 with adolescent participants (aged between 12 and 19 years) were included in the scoping review. 5 questionnaires were identified that measured digital health literacy or attitudes towards the internet, of which the eHealth Literacy Scale (eHEALS) was the most commonly used questionnaire for both adults and children. Two children’s questionnaires were often accompanied by a second task to verify the accuracy of the responses to the eHEALS questions.eHEALS is the most commonly used method to assess digital health literacy and assess whether an individual is able to engage actively with eHealthcare or virtual resources. However, care needs to be taken to ensure that its administration does not exclude digitally disadvantaged groups from completing it. Future research would benefit from assessing whether digital health literacy tools are appropriate for use in clinical settings, working to ensure that any scales developed in this area are practical and can be used to support the allocation of resources to ensure that people are able to access healthcare equitably. Access to care; Health literacy; Health technology/technology assessment; Information technology’ Social deprivation. RecentlDigital literacy is an essential skill that people require to engage with digital or online materials, it describes the ability to use the internet and other digital platforms and to find, understand, and evaluate the presented information . DigitalThis scoping review builds on existing research  to inves2Literature searches were carried out in MEDLINE, CINAHL, APA PsychInfo, Ageline, AMED, and APA PsychArticles using EBSCO. The most recent search occurred on the 25/02/2021, no review protocol exists although the review followed the methodological framework described by Arksey and O’Malley  and the The following search strategy was constructed to encompass techniques used to measure digital health literacy in healthcare: “(inclusion or divide or literacy or exclusion) AND  AND ”. The search strategy was applied to all fields, title, abstract, and full text. Papers identified in this search were filtered using the database search system to include papers from academic journals and remove duplicates. Papers not written in English were also filtered out of the search due to the associated cost and time of translation. A two stage screening process was conducted by two researchers. After reading the title and abstracts, one reviewer excluded articles which were not relevant to the review. Papers pertinent to the review question were separated into papers which included adult participants and those which investigated children and young people and these were sought for retrieval. Retrieved reports were read in full by two researchers to assess relevance for the study and to determine the methods used to investigate digital health literacy, with particular interest in the means of eliciting information. All eligible papers were included in the review (see Appendix 1 for the full list of included articles). Any key references identified in included papers' reference lists, for example where the paper referenced a separate questionnaire, were also searched for and included in this review.A qualitative synthesis of the evidence was carried out using a data charting form created for this review. The authors recorded details of the publications included i.e. authors, year and location of the study before focusing on the aims of the study, the participant population and data collection method used to elicit information regarding participants' digital medical literacy. The questions used to collect information were recorded where possible. This data charting formed the basis of the analysis and was used to synthesise the results, no formal appraisal of evidence was required.2.1Patients and the public were not involved in any way in this project.3The database search identified 2714 papers of which 2595 were excluded following the process above, see In total, 53 papers with adult participants and 3 with adolescent participants (aged between 12 and 19 years) were included in the scoping review and were analysed to produce a narrative overview of the most used methods to assess digital health literacy.3.1A wide range of techniques were used to elicit information about digital health literacy. Most studies used surveys , 48, 49 Five questionnaires were identified that measured digital health literacy: DHLI  , see 3.3Each of the measures was checked to see if it contained any threshold criteria which could be used to assess participants' eHealth literacy. All measures were developed as self-completed questionnaires, and none included specific assessments or tests of knowledge or skills. None of the measures included a threshold to determine an individual’s digital health literacy. Of the five, the eHLS was the only measure which resulted in an average score and discussed that score in relation to a ‘lower’ and ‘higher’ eHealth literacy scale. However, within the study the measure was not used in a clinical sense, and there was no threshold included which was used to determine whether an individual had a particular level of eHealth literacy. This study could not access the original measure paper and so is unable to state whether the scale was originally developed or used in a clinical setting or whether it has a defining threshold for eHealth literacy.Of the scales identified in this scoping review, the eHealth Literacy Scale (eHEALS)  was the 3.4Surveys were used to elicit information in all three papers investigating young populations (12–19 years). The eHEALS questionnaire was used in all three studies to assess digital health literacy, translated as appropriate , 72. Two4This scoping review presents an overview of the range of methods that have been used to investigate digital health literacy. Questionnaires were the most common method used to elicit information, with the eHEALS being the most commonly used questionnaire overall, translated as appropriate, and sometimes combined with other questions or methods as part of a broader investigation. The papers included in this review which investigated children and adolescents all used eHEALS to measure digital literacy, although secondary elements were often incorporated into data collection to gain a broader understanding of participants' health literacy.As the NHS increases use of eHealth and digital healthcare resources, it is essential that care is taken to ensure target audiences can adequately access these facilities. The existing literature suggests that there are a wide range of factors which can act as barriers to populations accessing digital health , in partThe eHEALS questionnaire does not, however, provide a definitive assessment or score of digital health literacy which could be used to identify a population’s ability to engage with health resources in the digital world. Furthermore, as a self-reported measure its assessment qualities are limited by trusting the respondent to make an accurate assessment of their own abilities without any objective testing to confirm their judgement. It would therefore be inappropriate to use this as a means to accurately/objectively assess digital health literacy as a measure or standard of ability needed to engage with resources. This includes engagement without any accompaniment of further data collection features similar to those engaged by the adolescent studies described above , 73. FutFurthermore, though questionnaires are an effective means of eliciting information, care must be taken to ensure that the questionnaire and associated elements of research are equitably accessible and do not restrict participation. Administering the questionnaire using only digital means, for example, will exclude populations who lack either the access, skills or infrastructure to engage with the process - likely to also be those people who cannot engage with digital healthcare resources. Similarly, willingness to engage with the questionnaire will also impact on use and should be considered when developing new scales. Patient and clinician questionnaire fatigue should be considered when developing data elicitation methods, aiming to collect the maximum amount of information in the fewest number of questions. Likewise, any tools or questionnaires should be regularly revisited to ensure that they remain relevant and reflect updates to technology and digital services in what is a rapidly developing field.With these considerations in mind, more accessible and adapted approaches to data collection may be necessary for gathering data, considering ease and speed of data collection for healthcare professionals, and accessibility for groups who may not be able to easily access the questionnaire, e.g. those with low literacy or cognitive impairments. Although some of the studies in this review attempted to mitigate these problems by the provision of paper copies of the questionnaire or through phone administration, this still does not make the research accessible to all populations and so risks misidentifying or overlooking existing divides in society.4.1It is possible that this review may not have fully captured the range of methods used to investigate digital health literacy. Other studies may have used questionnaires, or similar, to investigate digital literacy but not incorporated the terms we used in our search strategy, or not investigated digital health literacy as a primary outcome measure. In these cases, the papers may not have appeared in our search findings and so will not have been included in the review. Since the screening process did not involve a second reviewer, the selection of the papers was based on a single perspective, and this may also have influenced the papers included in the review. While we acknowledge the limitations associated with this search strategy, given that our results were so conclusive, we feel that the impact of the exclusion of articles is minimal within this paper.4.2As health services increasingly incorporate the use of technology or digital based communications, it is essential that these modes of communication are considered as part of a wider appreciation of barriers to access digital healthcare. This review presented the range of surveys currently used to assess digital health literacy and which could be used to identify digital divides which may influence public access to healthcare. Out of the identified measures, the eHEALS questionnaire is the most commonly used, though it is limited in what it can assess. Future research would benefit from considering objective methods or ability thresholds to assess individuals' digital health literacy, or other factors which might influence public willingness/ability to engage with digital health services and resources. Identifying people who may struggle to access services makes it easier to better identify their healthcare needs and to guide resource allocation for further support to ensure that they are able to access health resources equitably. Since equity is fundamental in health care and inequity may be imparted by not addressing variation in digital ability, digital capital, digital literacy and more specifically, digital health literacy, it is critical to consider assessment tools, their ease of deployment and the utilisation of their outputs in practice as we further integrate digital health care delivery.All authors listed have significantly contributed to the development and the writing of this article.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.No data was used for the research described in the article.The authors declare the following conflict of interests:Allergan, Biometrics Ltd., Ipsen, and Merz outside of the submitted work.Professor Pandyan reports personal fees, unrestricted educational support, and non-financial support from The other authors declare no competing interests.https://doi.org/10.1016/j.heliyon.2022.e10380.Supplementary content related to this article has been published online at