ACVIMAmerican College of Veterinary Internal MedicineAESACVIM‐Endorsed StatementBoRBoard of RegentsCOIconflict of interestERCEducation and Research CommitteeGRADEGrading of Recommendations, Assessment, Development, and EvaluationPRISMAPreferred Reporting Items for Systematic Reviews and Meta‐AnalysesThe American College of Veterinary Internal Medicine (ACVIM) has commissioned groups of experts to produce “Consensus Statements” since 2000 to provide veterinarians with information about topics important to ACVIM Diplomates and the veterinary profession. The ACVIM Consensus Statements have been relatively succinct statements intended to guide decision‐making about diagnosis, management or treatment of diseases of animals. During the past 20 years, Consensus Statements have evolved and several versions of guidelines have been developed by the ACVIM Board of Regents (BoR) and staff to facilitate selection of the topics, identify panel members, and determine logistics related to format and dissemination of the statements. The general purpose of these guidelines has been to clarify the responsibilities of the Chair and members of the panel, define the length of the statement, set timelines, and establish a financial agreement with panelists. Little attempt has been made to define how ACVIM Consensus Statements are prepared and the manner in which they consider the relevant literature and evaluate and report on evidence.The medical and veterinary communities increasingly rely on evidence‐based statements on a particular topic for guidance and counsel on decisions relating to management of diseases.The variety of formats for these evidence‐based statements reflects that the underlying reason for commissioning a statement dictates its format. One size does not fit all, and such is the case with ACVIM Consensus Statements as reflected by the variety of formats found in the 45 Consensus Statements published through the end of 2020. Most  of these Consensus Statements are narrative reviews, although recently some statements have followed GRADE, Delphi or similar methodologies, likely reflecting increased recognition that ACVIM Consensus Statements should be developed using explicit and transparent criteria and methodologies.Of the 45 ACVIM Consensus Statements published between 2000 and 2020, only 13/45 (29%) describe the methodology used to develop the statement, 11 (24%) define particular questions to be addressed in the statement, 9 (20%) utilize descriptions of levels of evidence, and 4 (9%) address a limited number of questions  yet 20 (44%) provide specific recommendations. Clearly, guidelines in effect to date have not resulted in ACVIM Consensus Statements consistently conforming to contemporary standards for such expert statements.The ACVIM Consensus Statements make valuable contributions to the veterinary literature, providing practicing specialists and nonspecialists with recommendations developed by experts in the field and are consistently the most widely read of all articles published in the Journal of Veterinary Internal Medicine (based on downloads and citations). The ACVIM Consensus Statements are increasingly recognized as being an important source of expert advice and, as such, reflect well on the College. However, quality standards for such statements are increasing, and we believe that it is time that the College consider developing more uniform and rigorous practices and policies for creation of these statements. Doing so will ensure that readers of such expert statements are confident of the quality of the statement and that the statement reflects well on the ACVIM and the authors.1The ACVIM supports the production of materials intended to assist clinicians and others in assessing the best available or optimal approach to providing veterinary care of animals or in understanding aspects of animal disease. These have been referred to as ACVIM Consensus Statements.One of the roles of the ACVIM is to identify appropriate topics and to ensure that these Consensus Statements are uniformly reliable and of high quality. To achieve this purpose, the ACVIM must ensure that topics are timely and relevant, panels are appropriately comprised of experts who are free of conflicts of interest, methodology is rigorous and transparent, and that there is a process for review of the draft statement.2We proposed, and the Board of Regents accepted, that subsequent expert statements endorsed by the ACVIM be collectively referred to as AESs and that they be developed using specific methodologies. The roles of the Board of Regents and the Education and Research Committee may be modified from that proposed below to align with changes in the functions of the Board and Board officers.Consensus statements (as more narrowly defined below).Evidence‐based practice guidelines.Systematic reviews.The term “Consensus Statement” previously covered all such expert statements, but in the current terminology “consensus statement” has a much narrower definition. We propose that AES follow one of three formats:Narrative reviews, scoping reviews, and position papers are not considered suitable forms of AES. A narrative review provides a summary of current and relevant literature, but with few or limited comments on the quality of evidence and no formal recommendations for action. Importantly, they do not use PRISMA methodology.The appropriate format for an AES will vary depending on the topic, the available published evidence, and the intent of the statement. The AES can be developed using one of three approved methodologies. The methodology chosen for a particular AES will be decided as part of the process for selecting a topic, convening a panel, and developing specific questions.Have a defined, focused scope and address a topic by considering a series of unambiguous, succinct, and precise questions.Use methodology appropriate for the topic and tailored to meet the requirements of the particular topic and questions.Clearly describe the methodology, which will be different for each of the three types of statements.Be well‐written, concise, precise reports that conform to the Journal of Veterinary Internal Medicine format and editorial guidelines.Regardless of the format, the AES should:33.1Consensus statements are always developed using the Delphi method and reflect the collective opinions of a group of content experts. The opinions of the experts will be based on their individual expertise, experience, and knowledge of the literature. Consensus is tested and demonstrated using prescribed methodology to identify areas of agreement and disagreement within the group of experts.Consensus statements are applicable to situations where evidence is limited or lacking, but where there is the opportunity to reduce uncertainty and improve quality of care.A consensus statement is applicable to situations where the evidence base is of insufficient quantity, quality, or is too varied for development of practice guidelines.A topic that is not amenable to consideration using an evidence‐based practice guideline methodology or systematic review.Development using the Delphi methodology of iterative, systematic consideration and voting, not necessarily involving face‐to‐face meetings.A core process that considers a series of statements, established a priori, upon which consensus is or is not achieved, as defined by previously agreed criteria for consensus.Consensus statements are characterized by:An example of development of clinical consensus statements is the process used by otolaryngologists in human medicine.Consensus statements should not be based on a general statement of a topic  but should be more narrowly focused. In this example, a more narrowly defined topic would be “Treatment of asthma in cats,” which addresses the specific statements: (1) inhaled corticosteroids are indicated; (2) betamethasone is the optimal inhaled corticosteroid; (3) oral corticosteroids are less effective than inhaled corticosteroids; and (4) beta‐adrenergic bronchodilators are indicated. When considering the topic and its breadth, the available length of the final document should be considered. Statements should be concise and precise. Topics should be defined narrowly enough so as to be addressed within the limitations on length of the statement.3.2Evidence‐based practice guidelines (“guidelines”) guide provision of current best practice care to animals and are ideally based on a rigorous, methodical, evidenced‐based review of the relevant literature. Guidelines have become increasingly important and useful to practicing clinicians given the increasing availability of novel or innovative treatments, interventions, or diagnostic methodologies and large quantity of scientific literature.https://gradepro.org/product/#about; Table Guidelines should have a consistent and transparent method of development, be of uniformly high quality, and be free of bias or conflict of interest by the developers of the guidelines. High quality guidelines recommend a course of action based on a comprehensive and systematic review, grading of the evidence, and explicit comparison of the benefits and harms of a given test or treatment, such as achieved by the GRADE  process.An important component of a Guideline is the Summary of Findings table. A Summary of Findings table presents the main findings of a review in a transparent and simple tabular format. In particular, the table provides key information concerning the quality of evidence, the magnitude of effect of the interventions examined, and the sum of available data on the main outcomes.3.3Systematic reviews are important to veterinarians because they provide an objective assessment of existing data to assist with decisions about clinical practice, can provide rationale and justification for research, and are used as the basis for evidence‐based practice guidelines. The usefulness of a systematic review depends on the methodology and the clarity of reporting.A systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review. Statistical methods  may or may not be used to analyze and summarize the results of the included studies. The methodology must follow that of PRISMA or Cochrane systematic reviews.The difference between evidence‐based practice guidelines and systematic reviews relates more to the topic being reviewed and the scope of the review. Guidelines address an area of clinical practice and may have a large number of questions (>5) or statements to evaluate and collate in Summary of Findings tables. Guidelines provide explicit recommendations on clinical practice. Systematic reviews may address topics that are not directly related to clinical practice, for which there are a small number of questions (<5), or both. Systematic reviews might not provide explicit recommendations. The difference between the two approaches is not always clear and the methodologies have much in common.4Ensuring that the panel adheres to established methodology.Keeping the development group focused on the scope and purpose of the AES.Assisting the Chair on all conference calls to ensure active participation of all group members and to prevent “group think” and other biases.Reviewing and editing survey questions.Limiting the results to statements of consensus or lack of consensus (for the Delphi method).Assisting with writing and editing the manuscript.Approving the final version of the manuscript for journal submission.Ensuring appropriate opportunities for disclosure of conflicts of interest and referral of management of COI as needed.Assisting with ensuring that consensus or lack of consensus is managed appropriately.We recommend including a methodologist who advises and guides the development to ensure appropriate rigor and consistency among these statements. This individual should be appropriately experienced in these consensus/summarization methodologies, but would not necessarily be a content expert. Primary responsibilities of the methodologist include the following:5Historically, the topic was chosen by the At‐Large BoR members after consulting with colleagues and solicitation of ideas from ACVIM Diplomates. Our opinion, after reviewing all of the ACVIM Consensus Statements published to date, is that the topics chosen have been timely and well‐balanced with respect to topical areas that are important to the broad interests of ACVIM Diplomates. Ideally methods to receive proposals for topics from the ACVIM should continue to be developed.Oversight of the AES program will now be provided by the Education and Research Committee (ERC) of the ACVIM. We recommend that the ERC members, in consultation with the ACVIM BoR, develop a short list of proposed topics that then is posted on the ACVIM website, with the membership being notified and asked to respond within a specified period to rank and provide comments about the proposed topics, or make suggestions for additional topics.The Delphi method is most useful for topics about which there is a limited amount of objective scientific evidence, or contentious topics about which there may be varied opinions but insufficient evidence to support development of a guideline.The GRADE approach is best for developing evidence‐based clinical practice guidelines for conditions with adequate amounts of objective scientific evidence.Systematic reviews are most appropriate for topics where there is a substantial amount of objective research regarding a limited number of questions.The choice of topic will dictate the type of process used for AES development:The process for developing an AES would be to agree on the general topic and then for the ERC to seek advice from the President of the relevant specialty and the Chair of the panel on the most suitable format . The ERC and the relevant specialty President, guided by the methodologist, will be responsible for final approval of the AES topic and format.6The AES should be developed by a panel comprised of individuals who are widely recognized as having expertise on the topic. Ideally, most panel members will have published basic research, clinical studies, or both on the topic or in closely related areas.The process for identifying and selecting panel members should be carefully considered to ensure that selection is impartial, all potentially interested and qualified people have been identified and considered, potential conflicts of interest have been identified and effectively managed, the process for identifying panel members is accepted and actively supported by the ACVIM membership, and the final panel composition is approved by the ACVIM BoR, which may delegate this approval to the ERC. The process also likely will differ depending on the type of statement that is being developed Table .6.1Panels for all types of AES will have a Chair who will be assigned specific responsibilities documented in a formal role description. The panel Chair should be an ACVIM Diplomate unless there are strong reasons to select a non‐ACVIM‐Diplomate for this role. The Chair and, if needed, Assistant Chair, of each panel will be selected after the topic of the statement has been finalized, and will be identified by consultation of the ERC with the relevant specialty President . The ERC may seek additional advice from content experts and may call for nominations for the role(s).6.2The process for appointing panel members differs for each type of expert statement. Typically, recommendations for membership are developed by the panel Chair in consultation with the ERC and President of the relevant specialty, with the assistance of the methodologist. The final composition of each panel is approved by the ACVIM BoR, which may delegate this approval to the ERC. At least half of the expert panel should be ACVIM Diplomates.6.3For the Delphi method, the panel Chair, Assistant Chair, President of the relevant specialty and ERC will select 2‐3 panel members who will serve as core organizers and authors of the consensus statement. These panel members, with the support of a methodologist, then will identify the additional 11‐25 participants who will provide expert opinions that are the basis for content for the consensus statement. The methodologist should have expertise in the Delphi method and ensure that the correct approach and format are followed. The methodologist also will participate in writing the final document and ensure that submission deadlines are met. After a call for nominations (including self‐nomination), participants would be chosen from interested Diplomates who would need to provide evidence of their qualifications, including published research and clinical experience. Diplomates also could nominate qualified persons who are not members of the ACVIM .6.4The panel Chair, Assistant Chair, President of the relevant specialty and ERC will select 4‐6 expert panelists who will work remotely to develop the guidelines, with the support of a methodologist. The methodologist should have expertise in the GRADE method and help ensure that the correct approach and format are followed. The methodologist also can participate in writing the final document and ensure that submission deadlines are met. After a call for nominations (including self‐nomination), participants would be chosen from interested Diplomates who would need to provide evidence of their qualifications . Diplomates also could nominate qualified persons who are not members of the ACVIM .6.5When using PRISMA guidelines or the Cochrane methodology to conduct a systematic review, the ERC and President of the relevant specialty will select a content expert as panel Chair who then would recommend 2‐3 other content experts familiar with the development of meta‐analyses and systematic reviews to develop the statement. This approach also would benefit from the support of a methodologist familiar with meta‐analyses and systematic reviews.7Regardless of the method used to identify the panel Chair and members, the Chair should drive the process, encourage equal participation by all panel members, coordinate the roles of the panel members, ensure diversity of opinion, drive the writing process to meet submission deadlines, format and editorial standards, and manage any identified conflicts of interest that become apparent .8Where applicable, the definition of “consensus” must be based on criteria specified before the panel convenes to review evidence or prepare the content of their report. When a consensus statement is developed using the Delphi method, the planned number of rounds/iterations as well as criteria for stopping discussion should be specified before development of the consensus statement, and consensus will be defined as at least 75% agreement among authors.9All AES will be made available to ACVIM Diplomates for review and comment before finalizing and publishing. The draft documents will be posted on the ACVIM website, available only to Diplomates, for online provision of comment and feedback. The document will be available for no less than 30 days and its availability will be announced to all ACVIM Diplomates by email. However, formal peer review of consensus statements or practice guidelines will not be conducted. At the discretion of the panel Chair and the JVIM Co‐Editors‐In‐Chief, it may be appropriate and desirable to obtain peer review for systematic reviews.10Results of a 2020 survey of ACVIM Diplomates regarding Consensus Statements shows that the ACVIM membership is keenly aware of the potential for conflict of interest (COI) to adversely affect the outcome and content of AES. It is critically important that such conflicts be identified and managed, and the Chair of the panel and the ERC, with support from ACVIM Staff, should be charged with this responsibility.Simple disclosure of a potential COI does not represent management of that COI,A COI is a set of conditions in which professional judgment concerning a primary interest  could be unduly influenced by a secondary interest .Important concepts in managing COI are identifying the potential COI (disclosure or discovery) and managing the COI.10.1To be managed, a COI must be identified. This can be done by either the individual (self‐disclosure) or by a third party (discovery). Although considered by some to be critically important to managing COI, there is limited evidence regarding the effect of COI disclosure. Research suggests that disclosure can have “perverse effects” or, at least, is not the panacea it is often perceived to be. These perverse effects include unwarranted immunity of the individual declaring the COI from criticism or censure for their role in developing an AES. Disclosure could have the unintended result of enabling or permitting a COI without preventing the effect of the COI.10.2Those with a COI are expected to recuse themselves from  decisions where such a conflict exists. It may be sufficient to recuse an individual regarding discussions and decisions of a specific topic, or it may be more appropriate for an affected party to be fully excused from participating in the AES. The obligation to recuse depends on: 1) the potentially conflicted individual identifying  and disclosing the potential COI, and 2) the individual recusing themselves . It could be appropriate for a neutral adjudicator to assess the potential COI and to decide on whether to retain or remove the individual in question.10.3Optimally, AES panels would only include members who are free of COIs relevant to the topic of the statement. However, this will not always be feasible or possible, and processes must be in place to identify and manage COI. Transparency is key, and privacy concerns can be addressed by having the process widely acknowledged with details of the specific COI and management being private until publication of the statement, when COIs and management should be disclosed.To be considered for membership on an AES panel, nominees are required to disclose all relationships that could affect or be perceived to affect the AES (and those of immediate family members) for the 12‐month period before the formation of the panel and any relationships that are entered into during development of the statement.Potential COIs that should be declared include all relationships with commercial, noncommercial, institutional, and patient or public organizations. These include employment, consultancy, interests in start‐up companies and those in which stock is not publicly traded, ownership interests  in publicly‐traded companies , research funding directly paid to the individual, research funding paid to an employer, organization or other research institution with whom the individual is involved, serving as a principal investigator, honoraria, royalties, paid or unpaid expert testimony, speaking engagements, speaker bureaus, and other relevant relationships. Leadership positions and memberships of other entities (paid and unpaid) including nonprofit or for‐profit advisory boards and committees must also be disclosed.It is critical that the panel Chair (and Co‐Chair or Assistant Chair) is free from COIs or potential COIs because they are responsible for managing potential COIs for the entire panel. For consensus statements using a Delphi process, it is more important for the organizing panel members to be free from COIs than for the other expert participants.The Chair and Assistant Chair of the panel must be free of any COI or other biases that could undermine the integrity or credibility of the work.A majority (>50%) of the panel members and participants in Delphi processes must be free of relevant COI.Panel Chairs and panel members: The ERC, the ACVIM Chief Executive Officer and the ACVIM President will review all COI information and determine whether any relationship represents a potentially relevant COI. The final recommendations on management of the COI are provided to the ACVIM BoR for information, endorsement and approval.Panel members with relevant potential COIs are required to declare the situation, and the ERC, Chief Executive Officer and President must determine whether the relationship represents a relevant COI and whether or not and how that COI should be managed. Management may include recusal from participation in all or part of the AES development process, including participation in relevant discussions, votes, and drafting recommendations.Panel members are prohibited from adding new relationships that create COIs throughout the AES development process, until publication. If a new relationship is added, the ERC, Chief Executive Officer and ACVIM President must determine whether the relationship represents a relevant COI and whether or not and how that COI should be managed.Review of COI information is conducted as follows:The Chair of the ERC, with the assistance of the methodologist who is managing the AES, should interview the panel Chair and all proposed participants before initiating panel activities and ask the potential participants to disclose relationships that have the potential to create COIs.If a panel member is aware that another participant might have a COI and has not declared it for some reason, they are obliged to bring this concern to the panel Chair's attention.All potential COIs should be reviewed by the ERC, Chief Executive Officer and ACVIM President and any that require a management plan should be discussed with the affected participant.Disclosure and Review:Affected participants may be asked to recuse themselves from activities related to development of the AES for any part or all of the topics. Recused participants are prohibited from participating in developing or drafting guidelines sections that are directly related to their COI.Recused participants are prohibited from determining the strength and direction of a recommendation directly related to their COI.Recused participants are prohibited from voting on matters directly related to their COI.Recusal:Affected participants may alternatively choose to divest themselves of direct financial investments with entities that may have a potential financial interest in the contents of the guidelines or to otherwise alter or end relationships that are of a nonfinancial nature.Panel members must also refrain from participating in the marketing activities or advisory boards of such entities.Divestment:The ACVIM will report details of all COIs that are identified as such by the ERC, Chief Executive Officer and ACVIM President in a detailed table that is included in the draft document reviewed by ACVIM members and in published guidelines.More detailed COI documentation and management plans will be made available as needed in the form of published supplemental materials (to be available online).Transparency:If a relevant COI exists, it will be managed as follows:Processes for identification and management of COIs relative to the development of AES are summarized as follows:This editorial was prepared by the authors and was not peer reviewed. Kenneth Hinchcliff and Stephen DiBartola are Co‐Editors‐in‐Chief of the JVIM. None of the other authors declares a conflict of interest.


Vaccinium oxycoccos L.) and play important roles in plant growth and disease control, especially in cranberry yields. This article presents the results of a study which was aimed to investigate the diversity of fungi found on different clones and cultivars of the European cranberry grown in Lithuania, causing twigs, leaf diseases and fruit rots. In this study seventeen clones and five cultivars of V. oxycoccos were selected for investigation. Fungi were isolated via the incubation of twigs, leaves and fruit on a PDA medium and identified according to their cultural and morphological characteristics. Microscopic fungi belonging to 14 genera were isolated from cranberry leaves and twigs, with Physalospora vaccinii, Fusarium spp., Mycosphaerella nigromaculans and Monilinia oxycocci being the most frequently isolated fungi. ‘Vaiva’ and ‘Žuvinta’ cultivars were the most susceptible to pathogenic fungi during the growing season. Among the clones, 95–A–07 was the most susceptible to Phys. vaccinii, 95–A–08 to M. nigromaculans, 99–Ž–05 to Fusarium spp. and 95–A–03 to M. oxycocci. Microscopic fungi belonging to 12 genera were isolated from cranberry berries. The most prevalent pathogenic fungi M. oxycocci were isolated from the berries of the cultivars ‘Vaiva’ and ‘Žuvinta’ and clones 95–A–03 and 96–K–05.Fungi are associated with the European cranberry ( Vaccinium oxycoccos L., syn. Oxycoccos palustris Pers.) produces berries, which are an excellent source of bioactive, especially polyphenolic, compounds . Therefore, they are very beneficial for consumers’ health, and the consumption of these fruits and their products is widely recommended [The European cranberry  Purs.) are known for their exceptional economical characteristics. The European cranberry is less economically valuable in comparison with the American cranberry; however, new productive cultivars bred in Estonia and Lithuania have economic potential, especially taken into account that the consumption of these valuable berries is a long-lasting tradition [The geographical distribution of European cranberry is wide.  America . Europea America . Individ America . The culradition .Vaccinium species play an important role in plants’ growth and can have a negative impact on the quality of yield [V. macrocarpon) has been studied extensively, but there are only a few studies focused on the European cranberry (V. oxycoccos) [Phomopsis vaccinii, the most harmful pathogen of V. macrocarpon were identified for the first time in 2002 [Fungi inhabiting the of yield . Cranberof yield . Fungal of yield . The mycycoccos) . The divycoccos) . In Lith in 2002 . HoweverV. oxycoccos, the objectives of this study were to detect the causal agents, which could cause V. oxycoccos diseases in Lithuania. This could be one of the strategies to control diseases caused by various pathogens. The aim of this study was to describe the diversity of fungi of V. oxycoccos clones and cultivars growing in Lithuania.To promote the breeding and cultivation of cranberries, it is necessary to investigate the characteristics of cranberries that are important for horticulture. It is important to choose natural clones of cranberries which have the highest productivity and disease resistance. Mycological studies of the European cranberry will contribute to the justification of the prospects for the cultivation of this species and to the clarification of the diversity of pathogenic fungi on different clones and cultivars. To gain better knowledge of the pathogenic fungi associated with n = 68) from 17 European cranberry clones and yielded 297 isolates. A total of 150 fungal isolates were obtained from 5 cranberry cultivars with 20 collected samples (n = 20). The total amount of fungal isolates of cranberry clones and cultivars is presented in In total, 447 fungal isolates were obtained from cranberry twigs and leaves. These isolates represented 14 different fungal genera . Fungi gPhys. vaccinii, Fusarium spp., M. nigromaculans and M. oxycocci were the most frequently occurring fungi isolated from cranberry twigs and leaves. The number of isolates of Alternaria spp. and B. cinerea varied from 4% to 8%. Other fungi varied from 0.7% to 4% in cranberry twigs and leaves. Phys. vaccinii , where relative abundance was 25.3% and 34.7%, respectively  was detected from 27.3% of the examined plants . The higPhys. vaccinii was detected in 26.8% of cranberry plants , which accounted for 30% of the plants with the highest occurrence of fungi. Phys. vaccinii was isolated in the plants of three cultivars, and the highest occurrence (10%) was found in the cultivar ‘Vaiva’. The occurrence of these fungi in ‘Vita’ and ‘Amalva’ cultivars was 8.8%. However, no significant differences were established among individual clones and cultivars in relation to the occurrence of Phys. vaccinii. y plants a. The reFusarium spp. fungi were identified in 20.5% of the tested plants , 95–A–08 and 96–Ž–13 to M. nigromaculans  and 99–Ž–05 to Fusarium spp. (25%).The clones and cultivars more frequently infected by pathogens were identified in this study. The highest level of Phys. vaccinii (8.8%) and M. nigromaculans (17.5%) compared to other cultivars. The sensitivity of the cultivar ‘Vaiva’ to Phys. vaccinii (10%) and M. oxycocci (26.3%) was also evident in this study. Phys. vaccinii was prevalent in 8.8% of the plants of the cultivar ‘Vita’, whereas Fusarium was found in 10% of the plants. M. oxycocci and Fusarium were the most abundant in the leaves and twigs of cultivar ‘Žuvinta’, with, respectively, 32.5% and 10% occurence. The lowest number of pathogens was determined in cranberries of the cultivar ‘Reda’. Only a 10% occurrence of Fusarium spp. was determined in the ‘Reda’ cultivar.The cultivar ‘Amalva’ was one of the most sensitive cultivars to fungal pathogens. Leaves and other parts of this cultivar had higher occurrence of A total of 468 isolates from 12 genera were isolated from 22 samples of cranberry berries . It was M. oxycocci , and the relative abundance was 22.3% for clones and 22.8% for cultivars , and the relative abundance was 2.3% for clones 1.8% for cultivars.The most common species from clones and cultivars was ultivars . The speThe highest occurrence of fungi was isolated from the berries of cultivars ‘Vita’ (20%), ‘Amalva’, ‘Žuvinta’ (17.5% each) and ‘Vaiva’ (13.8%) . Among tM. oxycocci occurred in 22.4% of all tested berries. It was found in the berries of six clones and three cultivars  of M. oxycocci was isolated in the berries of clone 99–Ž–11, but during the study, these fungi were not common on the plants; only 1.2% occurrence was determined. In the berries of clones 95–A–03 and 97–J–04, the occurrence of M. oxycocci was not high, reaching, 10% and 8.8%; however, during the study, the fungus was isolated the most abundantly in the plants of these clones, reaching 32.5% and 27.5%. The positive  correlation was found between M. oxycocci on twigs and leaves of cranberry and rotten cranberry berries.In this study, a different occurrence of V. oxycoccos twigs and leaves was Phys. vaccinii (127 isolates), where the relative abundance was 28.4%, and M. oxycocci (105 isolates) on berries, where the relative abundance was 22.4% , with a relative abundance of 2.2%. The species with the lowest numbers of isolates on twigs and leaves was Phys. vaccinii, showing a relative abundance of 28.4%.The species richness on cranberry twigs and leaves was higher than on berries . The Shar2 = 0.66, p < 0.01) between the total count of pathogenic fungi on twigs and leaves and the total count of pathogenic fungi of cranberry berries was determined. The positive correlation  between the total count of pathogenic fungi from clones on twigs and leaves and the total count of pathogenic fungi of cranberry berries from clones was determined. The positive correlation  [M. oxycocci has been found in American cranberries only in organic farms, indicating that fungicides have a strong and persistent effect on the fungus population. Even though d Italy) . Under Ld Italy) . Pathoged Italy) , M. oxycM. nigromaculans is common in all cranberry sites and often associated with red leaf spots and the blackening of stems [V. oxycoccos is recorded as an intermediate plant and V. macrocarpon as a host plant [of stems . The funst plant . Phys. vaccini was found on cranberries in our study. Phys. vaccini causes serious diseases of cranberries, evident in upright dieback and blotch rot [Phys. vaccini is very common in American cranberries, damaging berries not only during the growing season but also during storage, causing blotch rot. Phys. vaccini can live as an endophyte and as a nectrotroph [Phys. vaccini was frequently detected in European cranberries. Similar results were obtained in American cranberries in Latvia [otch rot . The funtrotroph . In our n Latvia . Tadych n Latvia  suggest n Latvia  associatn Latvia  associatFusarium spp. fungi cause more damage in old growing areas [Cladosporium spp., Alternaria spp. and Penicillium spp. were isolated from cranberry twigs and leaves, with pathological relationships of minor importance on cranberry leaves; however, relatively early in the growing season, the spread of Alternaria spp. and Penicillium spp. can cause fruit spoilage during storage [Alternaria and Fusarium can cause fruit, leaf, stem or root diseases in cranberry, not only directly but also as secondary pathogens [Alternaria spp. and Cladosporium spp. were mostly found on the surface of the cranberry twigs. Colletotrichum spp. was found to be widespread in large cranberry sites in Poland and America [B. cinerea caused upright dieback, blossom and ovaries blight, and yellow rot in Latvia [ng areas . Cladosp storage ,29. Alteathogens . In our  America ,18. Thes America . Less con Latvia . M. oxycocci, Cladosporium spp., Alternaria spp., Penicillium spp., Colletotrichum spp. and Phys. vaccinii found in rotten berries indicate that the berries are infected during the growing season. Penicillium spp. causing damage to stored products were also isolated during the growing season. Michalecka et al. [Godronia cassandrae, Colletotrichum fructivorum, Allantomopsis cytisporea and Coleophoma empetri. Oudemans et al. [Coleophoma empetri, Colletotrichum empetri, M. oxycocci and Phys. vaccinii.The productivity of the European cranberry in its natural habitat depends on a variety of factors, including ecological factors . When asa et al.  suggest a et al. , four sps et al.  found CoM. oxycocci was one of the most frequently isolated pathogens in cranberry berries. The fungal infection was the most abundant in the berries of the cultivars ‘Žuvinta’ and ‘Vaiva’, and M. oxycocci was also predominant in the twigs and leaves of these cultivars. Oudemans et al. [In our study, s et al.  stated tPhys. vaccinii is rarely found, but according to Conti et al. [Phys. vaccinii can also be isolated from healthy berries (10–30%), indicating that fungal infection does not always cause disease.In small cranberries, i et al. , it was i et al.  reportedi et al. , Phys. vColletotrichum spp. have been rarely found on plants studied but are an important pathogen of cranberries that can cause the rotting of both ripening and stored fruit [acutatum is mentioned as one of the most common pathogens on ripe berries in pre-harvest studies by Conti et al. [ed fruit . C. acuti et al. .Cladosporium or Alternaria, are not significant causal agents of fruit rot [Alternaria spp. were abundantly isolated from the leaves and twigs of the plants, and A. alternata was also abundantly found in the berries. Studies have shown that A. alternata can dominate on plants and berries in the lethal phase until harvest [Other fungi isolated from the aerial parts of cranberries, such as ruit rot . These fruit rot  as commo harvest .In this research, it became clear that cranberry berries ripening during mid-ripening season (from 11 to 20 September) were more abundantly infected by fungi than those ripening later (from 22 to 30 September). Fungal occurrence is likely determined by genetic interactions of fungi with cranberry during both primary and secondary infections stages, temporal overlap of conidia production and bloom and environmental influences such as temperature and moisture . The study revealed that fungi predominated in the cultivars ‘Vaiva’ and ‘Žuvinta’ and clones , causing twig and leaf diseases and berry rot (clones 95–A–03 and 96–K–05). The differences in susceptibility of the cultivars are difficult to assess and they may be related to the particularities of the pathogen’s spread and dependence on environmental conditions. Different fungal species predominate at different locations, and the frequencies can vary greatly over years . CicalesColeophoma empetri, Colletotrichum gloeosporioides, Phyll. vaccinii and Phys. vaccinii). To reduce plant disease, it may be a viable strategy to select crop plants that maintain higher levels of organic acids or other potential virulence suppressors through plant development. Many bioactive compounds of cranberry can function as constitutive or inducible barriers against microbial pathogens, and bioactive compound composition can change in response to microbial attack ,38. TadyV. oxycoccos were collected in 2021 in the field collection of Vytautas Magnus University Botanical Garden, which represents the unique collections of genetic resources of European cranberry in Central Lithuania. V. oxycoccos clones were collected between 1998–1999 from Čepkeliai, Kamanos and Žuvintas reserves. Afterward, the clones were multiplied and planted in the outdoor collection of Vytautas Magnus University Kaunas Botanical Garden. Cranberries have been cultivated under uniform ecological conditions in acid peat beds, pH 3.5–5.0. Seventeen clones and five cultivars of V. oxycoccos were selected for investigation . The sample consisted of 10 pieces (approximately 5 cm long) of twigs with leaves. The samples were stored at +4 °C for 1 to 4 days until further examination. In total, 88 samples of cranberry twigs with leaves were analyzed. They were collected in the period from the last week of May to the third week of June and when the berries were ripe, before harvesting in the third week of September. Four samples of cranberry twigs with leaves were randomly taken from each sampling plot (1 mSamples of berries were collected before the harvest (in the third to fourth weeks of September). Approximately 50 g of berry samples were collected from a single genotype in each sampling plot. Rotten berries  pieces with a sterile scalpel. Twigs and leaves were washed in distilled water, placed for 1 min in 2% sodium hypochlorite (NaOCl) solution, then washed again in sterile distilled water 3 times (3 min each time). The surface-disinfected pieces were dried completely and cultured on a PDA medium in Petri dishes and incubated at 25 °C under photoperiod 12/12 h (light/dark) conditions for 14–21 days. −1) to inhibit bacterial growth. For each berry, one half was placed with its cut surface down onto a PDA medium. Each 90-mm Petri dish contained three berry halves. Berries were incubated at 25 °C, in the dark, for 10–14 days. The surfaces of berries have been disinfected by brief immersion in 95% ethanol followed by 5 min in 0.5% NaOCl. After briefly rinsing berries in sterile distilled water three times, calyces were removed. Ten pieces of randomly selected  berries of each clone and cultivar were cut longitudinally and placed onto Potato-Dextrose agar  amended with streptomycin sulfate  and PDA mediums and incubated at 25 °C for 10–14 days or 15–30 days for slowly growing species. Fungal identification was based on cultural  and morphological characteristics . Slower growing fungi and fungi which did not produce spores were transferred to new plates. The fungal strains which failed to sporulate following incubation (for 30 days) were considered ion keys ,40,41,42The frequency of occurrence (FO) of a fungal species was determined as the percentage of samples in which the species was found compared to the total number of samples used in the study. y = log(x + 1) prior to statistical evaluation. The differences between averages of clones and cultivars, marked by different letters, are significant at a 95% probability level (p < 0.05). Significant interaction between individual values obtained using the Pearson correlation coefficient.The statistical analysis of the study data was performed using the software One-way ANOVA from the statistical analysis package STATISTICA version 10. Duncan’s criterion and the LSD test were used to assess the significance of the differences between clones and cultivars . The resThe data were analyzed for the relative abundance and similarity index , speciesThis study evaluated the diversity of microscopic fungi in 17 clones and 5 cultivars of European cranberry plants. Microscopic fungi belonging to 14 genera were isolated from cranberry leaves and twigs, and 12 genera were isolated from berries.Phys. vaccinii, Fusarium spp., M. nigromaculans and M. oxycocci were the dominant pathogenic fungi on cranberry twigs and leaves. Phys. vaccinii was the most abundantly isolated in cultivar ‘Vaiva’; Fusarium spp. in cultivars ‘Reda’, ‘Vita’ and ‘Žuvinta’; M. nigromaculans in cultivar ‘Amalva’ and M. oxycocci in cultivars ‘Žuvinta’ and ‘Vaiva’. Among the clones, Phys. vaccinii was the most abundant in clone 95–A–07, Fusarium spp. in clone 99–Ž–05, M. nigromaculans in clone 95–A–08 and M. oxycocci in clones 96–Ž–13 and 95–A–03.The results showed that M. oxycocci was the most abundant in rot-damaged berries. ‘Vaiva’ and ‘Žuvinta’ cultivars berries were established with the highest M. oxycocci occurrence. Among the clones, the highest occurrence of M. oxycocci was established on the 95–A–03 and 96–K–05 clone berries.The species richness on cranberry twigs and leaves was higher than on berries. The species diversity on cranberry twigs, leaves and berries was low. The structure of fungal communities on twigs, leaves and berries was stable.


Cranberry supplements are commonly used to prevent urinary tract infections (UTIs). However, their usefulness is uncertain in pregnant women. We aimed to comprehensively summarize the current knowledge on cranberry supplements' efficacy and acceptability during pregnancy in addition to the outcomes measurement methods and studies' feasibility. To achieve it, we searched PubMed, PMC, and Europe PMC databases plus screened citations followed by critical appraisal of included eligible English-written primary studies that (1) focused on pregnant women supplemented with any cranberry supplements; (2) provided data on cranberry supplements' efficacy, acceptability, outcomes measurement methods, and studies' feasibility; (3) included human subjects; and (4) published worldwide. Two randomized clinical trials (RCTs) and one nested cohort study, including 1156 pregnant women in total, contributed to our analysis. A tendency toward UTI reduction was demonstrated, although the results' validity was impacted by significant juice-induced gastrointestinal intolerance . Changing the form of supplementation from cranberry juice to capsules reduced the issue, causing side effects in one of 49 subjects (2%). Nevertheless, both RCTs still experienced significant recruitment and retention problems, which were at 33% and 59% on average, respectively. Newly acquired safety data on 919 more subjects suggests no increased risks of all malformations, vaginal bleeding, and neonatal complications. Investigating cranberry capsules' efficacy as a non-antibacterial option for UTI prevention in pregnant women has become a feasible and important direction with the current advancement in understanding cranberry supplements' actions, recommended doses plus regimens, and their safety in the population. We reviewed the challenges and discovered knowledge gaps and the implementation strategies for future studies. Urinary tract infections (UTIs) are a frequent complication with an overall prevalence of 8% during pregnancy ,2. TheseAccording to the recently published Clinical Consensus document on the management of UTIs during pregnancy by the American College of Obstetricians and Gynecologists, (1) all women should be screened once for ASB early in pregnancy; (2) any UTIs should be treated with a five to seven days course of targeted antibiotics; and (3) postcoital or continuous suppressive antibiotic treatment can be considered in women with recurrent UTIs, defined as the occurrence of at least two UTIs during pregnancy . HoweverEscherichia coli, which are responsible for the pathogenesis of cystitis and pyelonephritis, respectively [E. coli causes 82.5% of pyelonephritis in pregnant women [ E. coli [Cranberries are a popular food product thought to be effective in the prevention of UTI due to their phenolic compounds and A-type proanthocyanidins' (PACs) ability to hinder the adhesion of the uropathogenic bacteria -15. It iectively -18. Thisnt women . Besides E. coli -22.E. coli, they also showed antibacterial activity against other most common uropathogens, such as Enterococcus faecalis, Staphylococcus species, and even Pseudomonas aeruginosa [In addition to cranberry metabolites' activity against ruginosa -25. Besiruginosa -30.Recently, the Cochrane Group released a fifth update of the review on the efficacy of cranberry use in UTI prevention . They coConsidering the described benefits of cranberries, minimal knowledge of non-antibacterial prevention during pregnancy, and lately established differences in cranberry supplements' efficacy to prevent UTIs in non-pregnant and pregnant populations, we aimed to review the full spectrum of primary clinical studies of cranberry supplements in preventing UTI during pregnancy to (1) analyze its efficacy, acceptability, outcomes measurement methods, and studies' feasibility and (2) determine the challenges and ways these issues can be addressed in future studies.MethodsThe current review followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) .Eligibility CriteriaThis study focused on the inclusion of clinical trials and observational studies in which pregnant women were supplemented with nutritional cranberry supplements. We did not restrict a comparison group in any way. For the outcomes, we choose efficacy (estimates of UTI prevention ability), tolerance , studies' feasibility , and studies' methodology (types of studies and data collection methods). We focused on retrievable English-written primary studies that were published worldwide and excluded non-primary studies after the completion of the snowballing process for additional potentially relevant articles. We did not screen databases for unpublished articles.Search StrategyA systematic search was performed in Pubmed, PubMed Central (PMC), and Europe PMC databases to retrieve publications from the date of their uploading to the databases until August 2, 2023. The search strategy for each database is detailed in Appendices Table .Studies Selection and Data ExtractionThe screening process was independently hand-performed by three authors , and another author (AAM) settled disagreements. After removing duplicates and non-English-written articles, the studies' eligibility was first screened by title and abstracts, and then all full-text studies that satisfied the study criteria were selected. We also reviewed the record's reference lists. The entire process is shown in Figure After retrieving eligible studies, three reviewers  independently critically appraised the studies' methodology and categorized the risk of bias for each study according to the Joanna Briggs Institute (JBI) critical appraisal tools, as follows: ≤49% ("high"), 50-69% ("moderate"), and >70% ("low") -36. The We did not prepare the protocol or register the review due to the preplanned short timeline for the review completion. The data was extracted to the Excel  file by three independent reviewers , including author, year, country, type of study, studies' design, sample size, entry criteria, treatment arms, products, single dose of active intervention, duration of treatment, and previously mentioned outcomes. The results are provided in Tables Data SynthesisWe pooled continuous variables by sum dividing by the total to obtain average data. The characteristics and results were grouped according to the categorized data and displayed in tables.ResultsStudies Selection and Critical AppraisalOur search resulted in 157 publications. After removing duplicates (n=35) and non-English written records (n=9), we screened 113 titles and abstracts for relevance, ending with 16 full-text articles after a successful retrieval step. We identified 13 reports as ineligible due to the wrong publication type, wrong population, wrong intervention, and wrong outcomes of interest -50.The final three selected studies underwent a critical appraisal process, scoring "low" and "moderate" risk of bias -53. The Studies CharacteristicsThis review included two pilot randomized controlled trials (RCTs) and one observational study -53. The The total number of pregnant women who ingested cranberry supplements in all studies was 1156. Both RCTs targeted 237 relatively healthy pregnant women who underwent early screening for ASB, evaluating mainly compliance with supplementation by cranberry juice and capsules ,53. Of tIntervention and Exposure CharacteristicsThe first placebo-controlled RCT compared three arms and evaluated the Vaccinium macrocarpon (Aiton)  juice efficacy, given three  and one  times daily from the early term of gestation until delivery. However, the trial faced significant compliance and tolerability issues, requiring a dose reduction. As a result, the actual "dosing did not differ between groups" . In the Recruitment and Retention RatesPooled recruitment and retention rate calculations are shown in Table Efficacy, Side Effects, and SafetyOne trial reported the efficacy in terms of ASB and any UTI prevention estimates, showing a tendency toward incidence reduction . Two stuDiscussionThis is the first systematic review that comprehensively analyzes the determinants of intervention implementation strategies of supplementation with cranberry supplements during pregnancy.Recruitment Capability and Sample CharacteristicsHistorically, the recruitment of pregnant women is a particular challenge. Both included RCTs did not escape from being able to enroll only 33% of 724 eligible women , which was notably low compared to the expected overall interest at an 86% rate of pregnant women to participate in trials investigating "healthy eating" interventions . The autData Collection and Outcome MeasuresEnsuring medication adherence and selecting suitable outcome measurements are necessary to achieve adequate power and obtain valid results. As shown, "sloppy" compliance of 60-89% contributed by 30-70% may lead to efficacy result miscalculation . HoweverIn choosing the compliance assessment tool, it is known that there is no ideal and simultaneously accurate and inexpensive measurement method. Analyzed studies relied on subjective  and objective (capsule counts) approaches, which are simple and suitable although less accurate, carrying the risk of compliance overestimation ,53,57,58To evaluate the efficacy of cranberry juice, Wing et al. (2015) tested participants with a urinary dipstick, a routine test used during monthly antenatal visits . AlthougAcceptability and SuitabilityPrevious studies revealed that cranberry supplements' most bothersome side effect is gastrointestinal distress, which seems worse when using juice and becomes unacceptable with increasing juice daily amounts - 23% of pregnant women left the study . As expeSince the last enrolled participant in the RCT performed by Wing et al. (2015), a new nested cohort within the prospective cohort study remarkably extended the current knowledge on the safety of cranberry supplements usage by 919 pregnant women ,53. Of nIntervention and Participant ResponsesEarlier, we mentioned the estimated overall cranberry supplement efficacy in UTI reduction of 30% . Though To our knowledge, no studies have explored the effective dosage regimen of cranberry supplements in pregnant women. In nonpregnant women with normal kidney function, Howell et al. (2010) established dose- and time-dependent efficacy of 36 and 72 mg of PACs daily dosages, stating that 36 mg taken twice daily is more beneficial because (1) single 72 mg of PACs administration preserves significantly lower adhesion index after 24 hours, and (2) splitting the dose in two may provide better protective coverage as the PACs activity's peak occurs in six hours post-ingestion after any of the dosages . ReviewiIn electing suitable outcome measures, we think it is essential to consider the population of interest and the follow-up period's duration, as cranberry metabolites impact bacterial virulence factors but do not kill them . For insStrengths and LimitationsThe study endows the strengths of a systematic review that answered a narrow research question on the cranberry supplements' efficacy, acceptability, outcomes measurement methods, and the studies' feasibility parameters during pregnancy. In light of the Cochrane review published a few months ago, our search strategy was comprehensive and, as a result, indirectly covered the availability of non-English-written literature on the topic . BesidesWe explored the current knowledge of supplementation with cranberry supplements to prevent UTIs during pregnancy. Overall, the results showed this is a promising but under-investigated direction, likely due to feasibility issues and an extended follow-up period. Among the obstacles, we identified a low average recruitment rate of 33% and a substantial average dropout rate of 41% (resulting in unacceptable missing data levels to obtain reliable estimation of their prophylactic effect in pregnant women). Newly generated knowledge on a better understanding of the cranberry's mechanism of action and effective regimens has become sufficient to overcome the theoretical connection between selected populations and outcomes. In addition, accumulated data on cranberry supplements' malformation risks makes the investigation more feasible and ethical, although it demands measured dose-dependent confirmation as a secondary outcome.In general, considerable evidence supports the connection between cranberry supplement consumption and its ability to prevent UTI recurrence. Nonetheless, this field of knowledge exploration acquired some chaotic features in terms of urine culture threshold differences in defining clinical UTI, unstandardized products based on reliably measured amounts of PACs inside them, unexplained choice of the regimens, and theoretical misalignment between the purposes and selected measured outcomes, overwhelming databases with conflicting results. Thus, based on our example, we call other researchers to organize the area contingent on populations, standardized cranberry supplements' dosages, and measured outcomes of interest. In addition, performing a systematic review or meta-analysis on risk factors for UTI recurrence is valuable for identifying confounders that need to be controlled. As for pregnant women, focusing on motivated populations, selection of cranberry supplements in the form of capsules, supplementing women with at least 72 mg of PACs daily, and estimation of the prophylactic effect by detecting the difference in the incidence density of UTI events between groups, along with the introduction of the discussed intervention implementation strategies, might finalize in the first high-quality clinical trial to answer the research question on cranberry supplements' efficacy in pregnant women and, in the case of success, spread up future investigations . Besides, an update on the prevalence of UTI and associated pregnancy complications is desirable.


Calcaneal apophysitis is a common condition in childhood. Parents often seek online information for children’s’ health care concerns prior to seeking care. Therefore, we aimed to evaluate the credibility, readability, and accuracy of calcaneal apophysitis advertising on popular websites in three countries.We used content analysis of publicly accessible data. This involved identifying the top 50 websites in each country from their hit rates. We used elements of validated tools to audit and determine frequencies relevant to credibility (e.g. publisher), readability (e.g. literacy score) and accuracy . Data were analysed quantitatively and reported against each element.n = 118, 79%). The mean (SD) SMOG (readability) score was 9.3 (4.5). The majority of websites  provided at least one treatment recommendation, and less than 10% (n = 11) of websites advertised treatments fully aligned with evidence. Use of treatment modalities without evidence and with high risk to children were also found including surgery, extracorporeal shock wave therapy and laser.Websites were predominantly hosted by private health services (Calcaneal apophysitis online advertising is mostly curated by clinicians. Clinicians should consider revising online advertising to increase understandability and accuracy to reduce health care wastage, risk, and low value care.The online version contains supplementary material available at 10.1186/s13047-023-00637-9. Parents commonly use online information to determine when, and who to see for their children’s health conditions . HoweverHowever, online condition-specific information and treatment advertising is not always consistent with evidence-based practice . InaccurAt present, calcaneal apophysitis is commonly considered benign and self-resolving in most children . This meThe study design included content analysis of publicly available information provided about children’s heel pain consistent with calcaneal apophysitis. This design is a systematic method of coding text in order to categorise similar words and sentences .We were initially supported in the development of search terms by five non-health professional parents. We asked these parents to describe the terminology they would use when searching for health care advice if their child had heel pain. Parents preferred online search terms were “child heel pain” or “my child has heel pain”.Next, we used scraping software (Thruuu by app.samuelschmitt.com) in September 2021. We used this software to extract the top 300 location specific websites (top 100 in each region of interest) through their organic ranking by Google search engine results page analysis. This software program uses specific keywords entered by the user to identify websites with the search terms and extracts both the webpage URL from Google and key information from that website. This method of data acquisition and software program was chosen to eliminate influence of website choice through any saved settings, location blockers or “cookies” on authors computers. This method of data acquisition was also chosen to minimise the impact the influence of paid advertising where possible, on the ranking of the website. We used the terms “child” “heel” “pain” as three separate words in the scraping program in addition to limit country of origin to USA, UK and Australia. It was pre-determined to exclude websites only describing children’s heel pain presentations inconsistent with calcaneal apophysitis , and exclusion occured during manual data extraction by research team. Where a site was excluded based on its content, we moved to the next ranked site on the extraction list until we had 50 sites extracted for each country.Next, the data were extracted by the scraping program in the form of an excel spreadsheet. This extracted data included the website link and organic ranking. The scraping program provided additional information such as number of images and word count. All other website information was manually extracted by the author team in a purpose-built spreadsheet to minimise the influence of any online advertising that would potentially change the webpage content in the scraping program’s extraction.The first 50 websites provided from the Thruuu extraction of each geographical search were manually checked by all authors for location matching. Where one was outside the location, an additional was included until we had a final 150 websites (50 from each geographic location) to audit. All additional data were extracted by one author and checked by a second author . As two authors  are practicing health professionals in the UK and Australia, JJW and CMW did not audit or secondary check websites arising from the country they worked in to minimise bias.https://www.webfx.com/tools/read-able/). The SMOG score is calculated by the number of words containing three or more syllables within three passages of ten sentences or more [We extracted information into three domains: credibility, readability, and accuracy of online advertising information. Our created purpose-built spreadsheet used elements from the DISCERN tool  and JAMA or more . The out or more . In thisData extracted was described in frequencies, means and standard deviations (SD). There are no consensus-based methods for the diagnosis of calcaneal apophysitis. Research commonly advocates and supports clinicians to diagnose calcaneal apophysitis based on its signs and symptoms through history taking, pain on palpation consistent with location of apophysis at the heel, and in the absence of any other localised inflammation or joint pain as a potential indicator of systemic inflammation , 16. Webth of September, 2021 [n = 4) and podiatrists (n = 3) all having greater than 10 years extensive clinical and research experience relating to lower limb apophyseal conditions. We considered evidence supporting use, to be treatments studied in randomised control trials or quasi-randomised control trials [Once we extracted the treatment elements, we aligned them with treatment groupings as described below. The treatment elements were extracted from the most recently published systematic review  and rander, 2021 . We thenThose treatment groupings with evidence support through randomised control trials supporting use for this condition: load reduction strategies  exerciseThose treatment grouping without evidence supporting use for this condition identified by authors through the systematic review and subsequent clinical trials: pharmaceutical interventions, stretching, manual therapy , other mechanical or electrotherapy treatment modalities such as extracorporeal shock wave therapy or laser, surgery, weight managementTherefore, the extracted treatments groups were:The accuracy of diagnostic methods and treatments were coded as i) All advertised recommendations supported by evidence, ii) More advertised elements supported by evidence than not, iii) Equal number of advertised elements supported and not supported by evidence iv) More advertised elements without support of evidence than those with v) All advertised elements inconsistent with evidence. This grouping approach has been broadly employed in another study investigating advertising online treatment recommendations .n = 118, 79%). Table n = 31, 21% of the 150 websites), with Australia having the least number of public health entities appearing in the top-rated sources . The “other” category contained a UK newspaper article written by a journalist. Half of the 150 websites (n = 75) provided a publication date, and of these, 38% of the 150 websites (n = 57) were published within the last five years.The full list of 150 domains are provided in Additional file n = 60, 58% of 101 single author websites), followed by medical health professionals  and physiotherapists . The distribution of professions providing information differed across countries.There were 101 of the 150 websites produced by a single profession author or group practice of the same profession. The podiatry profession made up the majority of authorship . Sever’s disease was only mentioned first  in the information, particularly in the UK (93.6%) compared to the other countries. There were eight websites that did not mention either Sever’s disease or calcaneal apophysitis, only discussing children having heel pain. Despite this, the information provided was consistent with calcaneal apophysitis and therefore remained within the analysis.Table n = 77, 51% of 150 websites), while others described locations of plantar heel or above the heel. Some websites described theories commonly accepted as being contributing factors to the development of calcaneal apophysitis. These were compression forces from ground impact, traction from the Achilles tendon and increased activity . Just under half (45%) described the condition as benign or self-limiting in nature; this description was less frequent in USA websites (38%).Approximately half of the websites described the correct anatomical location being the posterior heel  did not provide any information about how calcaneal apophysitis was diagnosed, yet the majority provided at least one treatment recommendation . There were 11 (7%) websites with all treatment recommendations having support of evidence  diagnostic imaging and treatment modalities or initiation of self-care strategies with the accuracy and quality of online health advertising information . This hiCalcaneal apophysitis online advertising is mostly provided by clinicians and there are diagnostic and treatment modalities advertised that are not supported by evidence. More concerning was the number of low-value (high cost without high benefit), or inappropriate treatments being advertised that may place the child at unnecessary or unsubstantiated pain or infection. These treatments included laser therapy, extracorporeal shock wave therapy or Achilles tendon lengthening surgery. Clinicians should consider revising any online information to increase understandability and incorporating evidence-based treatments. These finding have practical application. That is, health professionals have an ethical responsibility to provide accurate and evidence-based online advertising, providing reassurance calcaneal apophysitis is a benign condition, when to seek care, and treatments that have evidence supporting their use. This research highlights the opportunities for health professionals to align diagnostic and treatment recommendations for calcaneal apophysitis with high value care. Health professionals also should regularly review their information to ensure it aligns with current evidence or point consumers to contemporary and regularly reviewed information.Additional file 1: Appendix A. Data extraction template.Additional file 2: Appendix 2. Randomised list of audited websites and their country of origin.Additional file 3: Appendix 3. Coding legend and coding corresponding to 150 websites for diagnosis and treatment elements where grey shading are elements without evidence supporting their use.Additional file 4: Appendix 4. 150 websites coded against elements with and without evidence.


The coronavirus 2019 (COVID-19) pandemic allowed for exceptional decision-making power to be placed in the hands of public health departments. Data and information were widely disseminated in the media and on websites. While the improvement of pandemic management is still a learning curve, the ecosystem perspective – that is, the interconnection of academic health research systems and decision-making spaces – has received little attention. In this commentary, we look at the mechanisms in place, or not, in Canada for ensuring decision-making spheres can “speak” to academic research systems. We look at the thick walls that are still in place between health research systems and decision-making spaces. More precisely, we discuss three organizational flaws that we identified in the evidence-informed decision-making ecosystem of Québec and, more broadly, Canada. We introduce some inspiring measures that other countries have implemented to better link evidence and public health decision-making during health crises. The observed flaws and options are related to the vitality of early information sharing relays, the cross-sectional capacity to issue opinions, and the collection and integration of hard and soft data. Ecosystems are organized systems of connected actors who work collectively. During the pandemic, the health emergency allowed for exceptional decision-making power, with the support of health data and information, to be placed in the hands of public health departments. One key to advancing a crisis management agenda is ensuring the efficiency of the evidence-informed decision-making ecosystem, that is, the combination of academic health research systems and decision-making spaces. This perspective on ecosystems as a means to optimize decision-making has received little attention from research funders, academic institutions, researchers and the public .Much is known about strategies that foster connections between scientists and the decision-maker communities. Push, pull, link and exchange  strategiIn an emergency situation, the novelty of the event may lead to decisions being made on the basis of extrapolated data or historical information, as opposed to decisions being made on the basis of new knowledge. However, such data and information may not be particularly well suited to the emergency in question. Since the literature on the use of scientific data in political decision-making during health emergencies remained very poor before the coronavirus disease 2019 (COVID-19) pandemic , it is uSince COVID-19, several jurisdictions embraced the topic of bringing relevant knowledge to decision spaces. The WHO developed a framework with macroscopic criteria for routine use of evidence in such spaces . The latHere, we examine issues related to the national ecosystem of evidence-informed decision-making. “Research evidence” is understood here as data and information that adopt a scientific methodology. It encompasses, among other things, data analytics, evaluations, behavioural/implementation research, qualitative research, synthesis and technology assessment/cost effectiveness. “Decisions” refer to decisions made by government policy-makers. “Evidence/decision ecosystem” refers to the ecosystem of research evidence/government policy-making.To the best of our knowledge, systems thinking at the level of an evidence/decision ecosystem is just emerging , 16. TwoOur examination of evidence ecosystems focuses on the steps that should be followed to produce, translate and then linearly use evidence. However, decision-making, at its core, is also political and organic. Deficient links in the ecosystem may hamper its effectiveness and lead to harmful consequences, such as mortality, morbidity, negative impacts on social inequalities and additional costs.Developments related to the evidence/decision ecosystem take evidence as a core concept, hence their name “evidence ecosystem”. Recommendations to build stronger evidence ecosystems cover the relevancy and quality of evidence, clarifying the information needs of decision-makers, and developing units and resources to support evidence and implement evidence into decision-making. In our view, this conception is still too linear, despite the openness to feedback from decision-makers. Much smaller consideration, if any, is given to institutionalized mechanisms that not only push research systems  into decision-making spaces , but push decision-making spaces into research systems. The processual approach at the nexus is what is of interest here – the in-between evidence and decision, so to speak.This commentary takes a managerial and organizational view of the pandemic. We argue that beyond COVID-19 initiatives such as the production of policy briefs, the sustainability of such collective efforts to bring evidence into decision-making in times of crisis relies upon strong processes located at the nexus between decision-making spaces and  research systems. This paper looks at the thick walls that are still in place between health research systems and decision-making spaces. More precisely, we discuss three organizational flaws that we identified in the evidence-informed decision-making ecosystem in Québec and, more broadly, in Canada. We introduce some inspiring measures that other countries have implemented to better link evidence and public health decision-making during health crises. The observed flaws and options are related to the vitality of early information sharing relays, the cross-sectional capacity to issue opinions, and the collection and integration of hard and soft data.In short, this commentary focuses on the structure – others would say institutionalization  – of theJurisdictions responsible for public health are expected to anticipate crises. Starting in the late 2000s, international experts warned that various signals indicated that the emergence of new pandemic strains was very likely, making it possible to grasp the possibility that a pandemic could occur , 25. To The Global Public Health Information Network (GPHIN) was created by the Public Health Agency of Canada in collaboration with the WHO in the late 1990s to be a primary source for the detection and early warning of contagious diseases for agencies in several countries. However, in 2019, the GPHIN failed to detect clues about the emergence of COVID-19 . OverallAt the provincial level, there has been a plan in place to fight an influenza pandemic since 2006: the Québec Pandemic Influenza Plan – Health Mission . HoweverIn short, pandemic response plans in Canada and Québec had not ever been rigorously evaluated or updated before the start of the COVID-19 pandemic , 29, 30,Globally, various mechanisms for the early detection of epidemics make it possible to anticipate health crises. Early detection tools for health events target infectious diseases that pose a high level of risk to humans before these health emergencies become epidemics, including the Epidemic Intelligence from Open Sources, headed by the WHO and the European Commission (EC). Real-time visualization of emerging infectious threats to public health is facilitated by tools such as HealthMap in the United States and the EC’s Medical Information System (MediSys). Many tools translate evidence into a format suitable for decision-makers: Eurosurveillance provides the European public health community with an open-access platform for exchanging relevant monitoring results, the Knowledge for Policy (K4P) interface is operated by the EC, there are knowledge services and knowledge brokers for policy-makers, and the What Works Network brings together nine specialized research centres in the United Kingdom, and more.Despite all these tools in different parts of the world, early action supported by detection tools still needs to be strengthened. The tools may be completely or little known to some decision-makers, and they are unnecessary and expensive if not used. There seems to be a lack of vitality in the devices used for capturing events and information needed by decision-makers. Thus, in the United States, the first person to be notified of the start of the crisis, in December 2019, was Dr. Marjorie Pollack, deputy editor of ProMed, a website run by the International Society for Infectious Diseases that advises healthcare professionals globally on emerging diseases. She was notified by one of her contacts, who lived in Taiwan and was active on Chinese social networks (Weibo). Dr. Pollack informed network members on 30 December 2019 . Dr. PolOn the one hand, there are many systems for monitoring and producing support material for decision-makers. On the other hand, there is a need to ensure health security. These two areas seem to have connected only with difficulty and in slow motion at the start of the pandemic. This highlights a key missing element: the vitality of the relays between decision-making spaces and evidence systems during times of crisis.The importance of the vitality of the evidence/policy ecosystem is presented in relation to the problem identification stage of the policy cycle. It would be possible to extend this reflection on ecosystem vitality to each relevant stage of the policy cycle with questions such as “Once a problem was identified, what mechanisms ensured the efficiency of best-available systematic reviews about pandemic management across decision-making bodies?”, “Once reliable evidence emerged as being in opposition to earlier decision-making, what mechanisms ensured the adjustment of decisions?” or “If a decision rippled into adverse health consequences, what mechanisms enabled researchers to pivot to emerging issues?”, and so on.The existence of event-based surveillance systems has not kept decision-makers from being confronted with a lack of clear, unambiguous and readily available evidence to characterize risks and make effective decisions  when neeIndeed, public health policy-makers usually resort to a wide range of contextualized local data and information sources , 32, sucIn autumn 2020, Québec’s public health body  and the WHO recommended half-day school attendance for fourth- and fifth-year high school students in areas where the cumulative number of confirmed COVID-19 cases was very high. The Québec government rejected this recommendation because it did not consider data specific to the context of intervention, namely, the pre-existing shortage of teachers and classrooms. Later, another contextual solution was designed based on administrative data from sources, including the educational and employment sectors. The chosen approach was alternate-day school attendance, with students being in class one day and having distance education from home the next day. Many agree that, beyond interventions based on universal public health approaches and international data, there is a need to make decisions rooted in the context and heterogeneity of living environments .In times of crisis, data from specific health disciplines combine more or less harmoniously with data from the social sciences. It would have been helpful to draw on and integrate findings from a variety of fields when analysing the pandemic’s impact on seniors’ residences and how to manage it, including epidemiological data for people over age 65 years, organizational science for creating mobile teams, gerontology for optimizing modalities of care and social work for adapting living environments in residential centres. Regarding the pandemic in Québec, there was a wide effort to bring best evidence to front line workers  but goveAt the federal level, information is fed ministry by ministry, but no opinion forum provided an overview, so information remained fragmented before the COVID-19 pandemic hit. There have been several initiatives in Canada aimed at pulling together best-available evidence, including the COVID-19 Evidence Network to Support Decision-making (COVID-END), reviews of best-available evidence and scans of emerging issues, policy briefings from the Royal Academy of Sciences and the Canadian Network of COVID-19 Clinical Trials Networks. Of particular interest is knowing how to translate the efficacy of these platforms into an evidence/policy ecosystem that is sustainable, that is, capable of managing the next pandemic.Some authors suggest reassessing those situations that, during health crises, favour the selection of evidence from biomedical research over other disciplines, such as social and political sciences . Indeed,Creating a dialogue between evidence and decision-making relies at least in part on mechanisms such as summary lists or teams of hard- and soft-evidence experts, the general principle being to the exposure to heterogeneity in disciplinary profiles.Highly recognized structures promote the linkage between evidence and decision-making. One example of this is the guiding principle "evidence comes first" in the Action Plan to Strengthen the Use of Evidence, Information and Research for Policy-Making in the WHO European Region . HoweverAt the federal level, the institutionalization of this permeability can take the form of mechanisms such as ministerial scientific advisers. In 2019, Canada’s Chief Science Advisor established ministerial science advisors, who work closely with senior officials in federal departments but do not participate in their day-to-day activities. They provide objective feedback to senior managers and decision-makers after evaluating various sources of information, and facilitate the integration of evidence into decision-making processes . These aResources dedicated to the ecosystem of evidence-informed decisions are nonexistent or invisible in Québec. Starting in the late 1990s, a broad movement towards outsourcing ministerial research functions significantly weakened the research and evaluation capacities of the Ministry of Health and Social Services (MSSS). Since the state of research departments in Québec’s research institutes and centres and in the MSSS have not been assessed since then, it is difficult to know the nature of their practices.However, a number of initiatives have had a favourable influence on the links between evidence and decision-making in Québec, including the creation of the advisory position of Chief Scientist of Québec in 2011, a concerted action programme between the ministries and research, and the arrival of advisory bodies such as the National Institute for Excellence in Health and Social Services (created in 2011) and the INSPQ (created in 1998).Caution must be exercised with respect to the proximity of such agencies to the executive branch and possible biased forecasts about government preferences . MoreoveSuch capabilities, when created in organizations, can fulfill several tasks. This is the case for chief data officers in the public and private sector, whose role is to support the reaching of objectives through evidence . They coThe relationship between research evidence systems and decision-making spaces in the context of a health crisis has been little studied. It deserves greater attention, notably to ensure that scientific data and information in these contexts allows for rapid and effective crisis management . To dateNote that decision-makers include government policy-makers, organizational leaders and citizens and professionals, and since best-available evidence based on scientific method is numerous , it can Our first observation is that the existence of anticipatory tools, such as risk management plans or event detection systems, does not guarantee their timely mobilization. Knowledge of these anticipatory tools, an understanding of them and using them appropriately require unique know-how and expertise by individuals wanting to harness these tools. In the absence of mechanisms and actors to ensure their vitality, evidence might risk being useless, while also creating a false sense of security. We therefore note that the emphasis must be on institutionalizing the vitality of the evidence/decision ecosystem at relevant stages in the policy cycle.Our second observation is that the diversity of research evidence available to government policy-makers in times of pandemic adds to the high level of uncertainty about the situation and its evolution. Thus, resources and mechanisms should make it possible to integrate research evidence from various disciplines, hard and soft, to give them meaning for decision-makers and answers to the variety of situations they face. One of the underlying issues is the selection of sources and methods for data and information integration. Care must be taken that the government does not make these choices based on political and strategic parameters, that contradictory data and information is countered by subsidizing the media and their fact checkers, and that sources that share the decision-maker’s own predispositions are not overly influential . One path to consider is centralizing human resources with cross-sectoral skills to handle both the political and scientific points of view, for example by appointing an independent advisor to parliament. The success of the evidence/decision ecosystem lies in the independence of such structures. Research evidence might be produced without conflicts of interest and decisions might be taken from government policy-makers without any link to particular lobbies, but if the nexus that connects them both is not free from conflicts of interest, the entire ecosystem will lack independence.Our objective in this commentary is not to provide a complete picture of each institution, mechanism and tool involved in the linking of the government policy-making and research evidence arenas. From a pragmatic point of view, at the time of writing (mid-2022), the health and social services network staff is still managing the pandemic and does not have time to answer uncomfortable questions in any detailed way. No one from the provincial or federal ministry of health would speak at length about the effectiveness of the internal mechanisms put in place and mobilized during the pandemic. For some, this was because they were not allowed to spend time on any form of research study.Finally, given that we do not present any ecosystems as such, our inventory cannot be exhaustive. It was not a question of validating whether the situation in Québec or Canada corresponds to some pre-established framework that should be followed on a normative basis. This article complements the lessons learned from pandemic management in studies that examine the issues of care management and service delivery operations, along with their management and governance , 45.This article makes several contributions to COVID-19 pandemic management and understanding evidence/decision ecosystems. It also opens up several avenues for reflection. This commentary brings a complementary perspective to the macroscopic-level WHO checklist for evidence-informed policy-making. We comment on dynamics that apply to middle-level management. Hanney et al.  present Several elements are known to play a role in using research evidence in decision-making processes; a primary one is the lack of clear, unambiguous and rapidly available data and information on the characterization of risks and the effectiveness of intervention measures , 10. OurIt is widely accepted that risk prevention and anticipation are essential phases in managing a pandemic , 10. We The Knowledge Management for Policy (KPM) initiative, introduced by the European Commission’s Joint Research Centre, identifies eight attributes to maximize the value and impact of research when shaping evidence-based policies: synthesize research, manage communities of experts, understand policy and science, ensure effective people-to-people skills, engage with citizens and stakeholders, communicate scientific knowledge, monitor and evaluate, and advise policy-makers . These aFinally, the interest in managing pandemics based on research evidence is part of a tradition dating back several decades in which the objective is to identify the best methods for transferring evidence to the field of decision-making, as underscored in 2021 in the WHO report, Rapid Response: Knowledge Translation Mechanisms to Translate Evidence into Public Health Policy in Emergencies. Our article draws on another perspective: not that of seeing two entities separately, but that of thinking of a third link, where both entities influence each other in a bi-directional manner. We started to explore the connections that unite (or not) these two spaces, and we suggest further studies on ecosystem governance, that is, the bringing together evidence production space and the decision-making space.Further research on organizational and managerial good practices and flaws in the evidence/policy ecosystem are needed. For example: Which mechanisms allow for a sustainable and independent nexus between evidence and policy? Which mechanisms are independent from the rotation of human resources in the production of evidence and in the uptake by decision-makers? Do the mechanisms currently in place cover key junctures in the policy cycle and agenda?