The COVID-19 pandemic required policy makers to make urgent decisions to limit the spread of the disease. International and regional health bodies and research institutions have a role in supporting decision makers and health actors in providing accurate and timely research evidence and guidance in decision making and practice. In ECOWAS region, the West African Health Organisation (WAHO) has experience in promoting evidence use decision making and practice as part of its role as Health Policy and Research Organisation. Promoting the use of evidence to influence policy and practice is possible through various approaches including training, the development of guides and policy briefs, the synthesis and sharing of evidence, and the organisation of meetings to share experiences. In the context of the COVID-19 pandemic, WAHO has deployed several approaches to bring the use of evidence to decision-makers and stakeholders to influence policy and practice. To improve practices, WAHO has organized regional training workshops on laboratory diagnostic, surveillance and simulation exercises of outbreak response for key actors, as well as webinars on different aspects of COVID-19 pandemic surveillance, coordination and management. In addition, a synthesis of the most recent evidence and epidemiologic models were developed to enlighten decision makers in selecting and implementation response interventions. COVID-19, a disease discovered in China in December 2019, was declared a public health emergency of international concern in January 2020 and a pandemic in March 2020 [et al. with the functions of promoting governance, financing, institutional and individual capacity building, dissemination and use of evidence and promotion of regional collaboration [The first objective of WAHO in his protocol of creation is to promote research on the main endemic diseases in the sub-region and to undertake activities aimed at the control and eradication of these diseases. This objective shows the importance of promoting of the research and use of evidence in WAHO's mission. To be successful in this area, WAHO worked to develop national health research systems by working according the framework of Pang boration . In the boration . In thisboration . This anboration , the estboration , and theboration . The comboration .Promoting the use of evidence to influence policy and practice is possible through various approaches including training, the development of guides and policy briefs, the synthesis and sharing of evidence, and the organisation of meetings to share experiences . In the Capacity building for evidence-based practices: the knowledge of health actors and the public on the evolution of the epidemic in the sub-region is regularly updated. Indeed, WAHO has developed a dynamic platform for daily updates on epidemiological information on the fifteen ECOWAS countries [ountries . In addiInfluence of policies and other measures by evidence: first, WAHO has produced evidence synthesis made available to the Ministers of Health in certain areas including the use of chloroquine, hydroxychloroquine and azythromycin in the management of patients with COVID-19. It has also shared information on the state of research in the field of drugs and vaccines at technical meeting of the Ministers of Health on the follow-up of the recommendations of the ECOWAS Heads of State. Second, to help maintain essential healthcare services during the epidemic, WAHO with partners including WHO Afro, JPhiego, IntraHealth conducted a situation analysis with programme managers to identify challenges and potential solutions to improve essential health services during the COVID-19 pandemic. A webinar organised following the survey to present the findings and guides needed to support the maintenance of maternal and child health services. Thirdly, WAHO has developed epidemiological models to help improve the response by monitoring the evolution of reproductive rate and estimating the needs in terms of testing kits, protection and care materials. This information has helped WAHO management to tailor its support to the actual needs of countries. These models were presented to countries national coordination institute, and made available on a dynamic electronic platform. Fourthly it organized weekly regional online regional meetings with all countries to share innovative practical experiences in responding to each other's needs. Finally, WAHO support some regional institutions in developing and testing the performance of rapid diagnostic test to facilitate their adoption by the countries in their testing strategies.Future directions: WAHO is currently planning the establishment of communities of practice that will include decision-makers, researchers, practitioners and partners to continue the exchange between stakeholders for the use of best evidence in strategic and programmatic decision-making. Furthermore, WAHO is developing risk awareness, information, and education and communication tools to help improve risk communication to improve the health literacy of populations. It will also organize the Good Practice Forum in 2021, which will promote the innovations and best practices identified during the current pandemic response. Finally, it is planned to set up a network of champions in countries for advocacy, training of knowledge brokers and various actors who will contribute to the identification, dissemination and support for the use of evidence.This commentary highlights the facilitation role that a regional health institution can play in empowering country actors and promoting evidence to influence decisions and response practices. This role of facilitating the use of evidence will be maintained as a key activity of the ECOWAS Regional Centre for Disease Surveillance and Control, the ECOWAS regional framework to support countries in epidemic preparedness and response.


Education and training over the life course or lifelong learning has become critical in the fast-changing U.S. society. Foundation skills , motivation, curiosity, as well as access to learning opportunities are essential to promote lifelong learning. Despite the importance of these promoting factors, empirical research focusing on complex relationships between literacy skills, immigration and motivation to learn (MtL) among middle-aged and older adults is scarce. The objective of this study is to examine how literacy skills and immigration (vs. U.S. born) are associated with MtL among middle-aged and older adults in the U.S. Nationally representative data  of adults aged 45 years and older were obtained from the 2012/2014 Program for International Assessment of Adult Competencies (PIAAC). Structural equation models were constructed to examine the formerly tested and validated latent MtL construct based on four 5-point Likert-type scale items among the sub-population of interest. Results showed that higher literacy skills  was associated with greater MtL. Additionally, immigrants were less likely  to have greater MtL than those who are non-immigrants (i.e. U.S. born). Higher literacy skills may indicate positive experiences in previous adult education and training and greater readiness for further learning. Findings from this study provide new empirical evidence of lifelong learning determinants. Educators and researchers should be aware of limited literacy and being an immigrant as potential barriers to knowledge-seeking in later life.


Image-guided musculoskeletal interventional procedures around the hip are widely used in daily clinical practice. The need for clarity concerning the actual added value of imaging guidance and types of medications to be offered led the Ultrasound and the Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) to promote, with the support of its Research Committee, a collaborative project to review the published literature on image-guided musculoskeletal interventional procedures in the lower limb in order to derive a list of clinical indications.In this article, we report the results of a Delphi-based consensus of 53 experts who reviewed the published literature for evidence on image-guided interventional procedures offered in the joint and soft tissues around the hip in order of their clinical indications.Ten statements concerning image-guided treatment procedures around the hip have been collected by the panel of ESSR experts.This work highlighted that there is still low evidence in the existing literature on some of these interventional procedures. Further large prospective randomized trials are essential to better confirm the benefits and objectively clarify the role of imaging to guide musculoskeletal interventional procedures around the hip.• Expert consensus produced a list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the hip.• The highest level of evidence was only reached for one statement.• Strong consensus was obtained for all statements.The online version contains supplementary material available at 10.1007/s00330-021-07997-5. Musculoskeletal interventional procedures in the lower limb are very common. Joint, tendon, and bursal injections are routinely performed by different physicians, including radiologists, orthopedists, and physiotherapists. However, radiologists have an arrow in the quiver, namely the possibility to use imaging to guide interventional procedures –5. In thFurthermore, another controversial issue concerns the actual role of hyaluronic acid and regenerative medications like platelet-rich plasma (PRP) to treat musculoskeletal conditions around the hip , 11. TheIn 2019, the need of clarity on this topic led the Ultrasound and the Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) to promote, with the support of its Research Committee, a collaborative project to review the published literature on image-guided musculoskeletal interventional procedures in the lower limb and to derive a list of consensus-based clinical indications, as already done for interventional procedures in the upper limb –14. In tInstitutional Review Board approval was not required as no patients were involved. This article was conceived as part of a collaborative project aimed to the review of image-guided musculoskeletal interventional procedures in the lower limb and to derive a list of consensus-based clinical indications. In this article, we have reported the results concerning tendon, joint, and bursal procedures around the hip. Similar to previous ESSR consensus papers –16, a liUltrasound- and fluoroscopy-guided iliopsoas peri-tendinous/bursal injections with local anesthetic and corticosteroids are both safe and feasible and provide good pain relief in symptomatic patients with iliopsoas tendinopathy. This procedure may also be used to exclude the iliopsoas tendon as a cause of hip or groin pain in both arthroplasty and non-arthroplasty patients.Level of evidence: 3n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, Iliopsoas bursa injection under ultrasound  and fluoA single ultrasound- or fluoroscopy-guided corticosteroid and local anesthetic injection into the symphyseal cleft and/or site of abnormality detected by magnetic resonance imaging (MRI) at the rectus abdominis or adductor longus insertion may result in clinical improvement in athletes with pubalgia.Level of evidence: 4n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, A single ultrasound-guided corticosteroid-anesthetic injection into the area of degeneration or fraying of the rectus abdominis and/or adductor longus led to clinical improvement in 12 patients with pubalgia, with all of them having returned to their preinjury activity level . FluorosUltrasound-guided needling and autologous blood product injection are both safe and feasible and may improve the clinical symptoms in hamstring tendinopathy.Level of evidence: 3n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, Percutaneous ultrasound-guided dry needling of tendons around the hip and pelvis, including hamstring tendons, may be a safe and effective treatment for tendinopathy and partial tears. In a single retrospective study , improveImage- and palpation-guided corticosteroid-anesthetic injections are both feasible, safe, and effective to treat greater trochanteric pain syndrome (GTPS) providing clinical improvement up to 3–6 months. Ultrasound-guided injections seem to be more effective, compared to palpation-guided injections, when performed into the greater trochanteric bursa.Level of evidence: 2n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, Injection therapies for trochanteric bursitis with palpation guidance or image guidance are both safe and effective for relieving GTPS, resulting in a significant reduction in pain up to three months . UltrasoUltrasound-guided corticosteroid injection, needling, and PRP injection for GTPS are all valuable measures to reduce pain and no clear evidence exists to define one treatment as superior to the others. PRP may have more long-lasting clinical improvement than corticosteroid injections, although high-quality evidence is still missing.Level of evidence: 2n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, Ultrasound-guided tendon dry needling and PRP injections are valuable and relatively safe treatment strategies in patients with GTPS refractory to conservative measures. Both methods showed similar outcomes at 1 and 2 weeks and at 3 months post treatment in a single blind prospective study . AccordiUltrasound-guided ischiogluteal bursa injections are technically feasible in cadavers but no clinical data is available.Level of evidence: 4n = 52; disagree, n = 1; abstain, n = 0. Agreement = 98%Agree, The ischiogluteal bursa is located posterior and inferior to the ischial tuberosity and deep to the inferior portion of the gluteus maximus muscle. Ischiogluteal bursitis can present as an acute or chronic condition. The etiology includes direct trauma to the ischial tuberosity, abnormal friction between the ischial tuberosity, hamstring origin, and overlying gluteus maximus, and underlying hamstring tendinopathy . IschiogImage-guided intra-articular hip injections are well-tolerated and safe procedures, which are more accurate and effective than palpation-guided injections.Level of evidence: 1n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, Several studies reported that image-guided intra-articular hip injections improve the accuracy of intra-articular placement –55. A syPositive response to image-guided diagnostic intra-articular injections with anesthetics can help confirm the intra-articular origin of hip pain.Level of evidence: 3n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, When the pain generator site is unconfirmed, diagnostic injections may be used to diagnose a variety of underlying intra-articular hip pathologies , 61. IntImage-guided corticosteroid hip injection is effective in providing short-term pain relief and can transiently improve function in patients with osteoarthritis.Level of evidence: 2n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, Hip intra-articular corticosteroid injection may be effective in delivering short-term, but clinically significant, pain reduction in patients with hip osteoarthritis, and may also lead to transient improvement in function. The treatment effect appears to be of rapid onset with a large group of responders reported at 1-week post-injection. The magnitude of pain reduction and functional improvement decreases thereafter, although two trials reported clinically significant differences in both pain and function at 8 weeks post-injection , 66, 67.Ultrasound-guided intra-articular hip injection of hyaluronic acid is not different for pain and function improvement from placebo, corticosteroid (at 1 and 6 months), and PRP (at 6 and 12 months) in patients with hip osteoarthritis. No different outcomes have been observed by using different hyaluronic acid formulations.Level of evidence: 2n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, Ultrasound-guided intra-articular hip injection of hyaluronic acid does not significantly reduce pain or improve function when compared to placebo in short-term follow-up , with miPrevious studies also demonstrated the superiority of methylprednisolone over hyaluronic acid injection at 1 month (for pain and disability) and no difference at 6 months . HyaluroFollowing a Delphi-based consensus, 10 statements regarding image-guided musculoskeletal interventional procedures on joints, tendons, and bursae around the hip were provided by a panel of 53 experts from the Ultrasound and Interventional Subcommittees of the ESSR. According to the results of this consensus, the evidence for procedures performed in the hip joint and trochanteric region is sparse. Specifically, statement #7 concerning the safety and higher accuracy and effectiveness of image-guided intra-articular hip injections than palpation-guided injections is the only one reaching the highest level of evidence, thus establishing the added value of imaging to guide hip injections. Interestingly, prospective randomized trials have proven the efficacy of image-guided corticosteroid hip injection to obtain short-term pain relief, with similar outcomes of ultrasound-guided intra-articular injection of hyaluronic acid with that of corticosteroid and PRP in hip osteoarthritis, allowing reaching level of evidence 2 in statements #9 and #10. Even procedures aimed to treat GTPS have reached level of evidence 2, with similar outcomes obtained using image- and palpation-guided corticosteroid-anesthetic injections, as well as with ultrasound-guided corticosteroid injection, needling, and PRP injection. On the other hand, the evidence for the remaining procedures on iliopsoas, pubic symphysis, hamstring tendons, and ischiogluteal bursa is still low. Indeed, no randomized clinical trials or well-designed prospective longitudinal trials have been published on these interventions. Notably, a strong consensus has been achieved in 100% of statements provided by the experts, with all of them having agreed on the clinical indications of these procedures, except for one disagreement concerning statement #6.In conclusion, 10 statements concerning image-guided treatment procedures around the hip have been collected by a panel of experts from the ESSR. There remains low evidence in the existing literature on some of these interventional procedures. Further large prospective randomized trials are therefore essential to further clarify and consolidate the additional role of imaging to guiding musculoskeletal interventional procedures around the hip.ESM 1(DOCX 21 kb)


People with an intellectual disability are a vulnerable group during COVID-19 due to multi-morbidity, frailty, underlying conditions/health problems, social circumstances and limitations in understanding. This places them at greater risk of more severe outcomes from COVID-19.To chart the evidence of the effects of the COVID-19 pandemic on people with intellectual disability and their carers reported in the research.A scoping review method was used to review literature published across eight databases in 2020 and included manual searches of reference lists of included articles.Sixteen studies were selected for inclusion. The findings highlight that professionals, people with intellectual disability and their carers were keen to comply with pandemic related public health guidance. However, implementing infection prevention and control measures in certain contexts for people with intellectual disability was challenging. Thereby a rights-based, person-centred approach to care is essential and professionals need to extend their understanding and practice of collaborative working to include people with intellectual disability and their family/carers. The findings highlight that compliance with public health guidance and infection control measures can be difficult for people with intellectual disability to implement.There is limited good quality robust research on COVID-19 and people with intellectual disability and/or their carers experiences. A pandemic is a worldwide epidemic in which a disease spreads easily and rapidly  and whilPeople with multi-morbidity, frailty and underlying conditions are at increased risk of COVID-19 . Public Public health actions to avoid transmission can increase the risk of loneliness and social isolation, which are well-recognized risk factors for physical and mental illness . AttainiA scoping review was selected as it allows for the evidence on a topic to be mapped, an examination of practice, policy and research, and the identification of gaps in evidence and policy . ScopingTo meet the aim of this review, the authors addressed the following questions: (a) What effects of the COVID-19 pandemic on people with intellectual disabilities and their carers are reported? (b) What responses have been directed towards people with intellectual disability and their carers? and (c) What recommendations have been made regarding people with intellectual disability and their carers?To identify a breadth of literature a wide ranging set of keywords for search terms searching were adopted. Processes for searching integrated subject headings and Boolean operators were also used to expand and merge searches. Searches were completed using the Title OR Abstract and Keyword options, with individual searching of each search string and subsequent combination of all strings . InclusiElectronic database searches yielded 268 papers which were exported to Endnote and duplicates removed leaving 129 papers remaining. Following screening of title and abstracts guided by the inclusion and exclusion criteria 99 papers were excluded. 30 papers went forward to full text review and were assessed and agreed by the authors with 14 excluded and 16 included in the review. This review was limited to peer review research papers in 2020 in order to scope the evidence of the effects, responses and recommendations regarding COVID-19 and people with intellectual disability and their carers. All studies that met the inclusion criteria were included in this review as the authors wanted to capture all studies on COVID-19 within the intellectual disability population published in 2020. Furthermore, as critical appraisal and risk of bias are a choice in scoping reviews  PreferreThis scoping review aims to map the existing literature in terms of volume, nature, characteristics, and sources of evidence . Plottinn = 5, Netherlands n = 4, United Kingdom n = 3, Ireland n = 1, Italy n = 1, China n = 1, France n = 1). The findings of the review are identified under the key questions identified in step one of the review process.The final stage summarizes and communicates the findings. This scoping review generated 16 papers across seven countries . Population-based registries have an important role in determining the prevalence, aetiology, distribution, frequency and severity of a particular condition/disability in a national or international region. However, there is little if any population-based data on people with intellectual disability and there needs to be an identification of people with intellectual disability in a systematic manner. Without the capacity to identify people with intellectual disability in emergency management surveillance systems, they may be overlooked when interventions are planned and evaluated. While this review highlights that infection control measures in healthcare facilities have managed the pandemic well there is little known about infection control knowledge, attitudes, and practices among staff . This isThis review highlights the psychological and social consequences of the pandemic for people with intellectual disability who have stopped participating in their communities and have had their routines interrupted during lockdown/restrictions for a prolonged period ,60,61 anThis review highlights the essential and important role families play in the support, health and well-being of individuals with intellectual disability . With puAs the focus of this review was to map the evidence, no evaluation of the quality of evidence/quality appraisal were performed and this paper only provides an explanatory account of available information. This review only included papers published in English and this may have resulted in the exclusion of relevant papers. In addition, the review only covers the year 2020 and we acknowledge that the evidence regarding COVID-19 grows daily. However, within the review, the authors engaged with relevant papers post 2020 for inclusion within the discussion. Furthermore, this review has to be considered within the limitations identified within the studies that met this paper’s inclusion criteria mainly the fact that (1) most data collection took place very early in the pandemic and further data is required to identify the long-term impact of Covid-19, (2) samples were small in size and not representative of the full nature of the intellectual disability population, (3) data collection utilised self-reporting measures and were administered mainly online where there may be limited issues with access, connectivity and literacy and (4) the data collection tools used were not validated, inferential analysis was not conducted and no pre-COVID-19 measures were available to compare against. These factors all affect the reliability, validity and generalizable of the studies in this review and further analysis as to whether these aspects are addressed in 2021 studies is warranted.This review highlights that the peer-reviewed press is dominated by professional opinion pieces, editorials and letters to the editors presenting various personal as well as professional polemics, some of which are supported with reference to the literature, as well as anecdotal evidence. However, there is limited research about pandemics/epidemics and people with intellectual disability. Rarely is space provided for population studies or the rich perspectives of the experiences of the person with an intellectual disability. In saying that, the research that does exist clearly highlights that core to the management of pandemics and epidemics are 1. A rights-based, person-centred approach to care is essential as professional and organisational approaches, as well as ubiquitous strategies often fail or fall short; 2. Professionals need to extend their understanding and practice of collaborative working to include people with an intellectual disability and their family/cares, not just begin to include other professional colleagues; 3. High levels of concordance with public health guidance and 4. Rigorous implementation of quality infection control measures are essential prerequisites.


In paediatric wards, children are often reluctant to receive medication from nurses and eventually it is given by the parents. It is a common practice for nurses to hand the medication to mothers to give to their children, However, it is an ‘informal’ practice and lacks evidence-based guidelines.To develop a contextualised and adapted evidence-based guideline to support nurses to partner with mothers/carers so that they can safely give oral medication to their hospitalised child under the supervision of a competent nurse.Existing relevant guidelines were identified through searches of bibliographic databases and websites. The AGREE II: Appraisal of Guidelines for Research and Evaluation II instrument was used to appraise the quality of the identified sources. The process of guideline adaptation recommended by the South African Guidelines Excellence project was followed, and a list of adapted recommendations was developed, aligned with the legislative and regulatory frameworks for nursing in South Africa. Accessible end user documentation was developed.Six sources were screened and three sources were found to be eligible and were subjected to full appraisal. Two guidelines and one policy document were identified as suitable for adaptation. Expert consultation confirmed that the resulting adapted guideline was sound, easy to understand, and well presented for the target audience.This process successfully led to the development of a modified evidence-based practice guideline to enable nurses to partner with mothers/caregivers in safely giving oral medication to their hospitalised child in lower-resourced African settings. Medication errors are one of the most frequent causes of adverse events in the hospital setting and children are believed to be at a higher risk of harm from such errors  who is admitted with the child  and mothers or caregivers partnering together, to safely give oral medication to their hospitalised child in lower-resourced paediatric wards in South Africa.A Population–Concept–Context (P-C-C) approach was used to define the focus for the guideline, as follows:Population: Children in hospital and their mothers who are involved in their care.Concepts: The involvement of mothers in the administration of oral medication to their children.Context: Paediatric wards in a lower resourced health facility in Southern Africa.In the following sections, a detailed description of the methods used at each of the six stages outlined above see  is proviDeveloping new evidence-based practice guidelines can be time-consuming and expensive, and this can be even more difficult in a low resourced country settings. A more efficient approach could be to adopt, adapt or contextualise recommendations from existing evidence-based guidelines and tailor them to the local context , as well as grey literature searches were conducted using keywords to identify the existing guidelines relating to the topic of concern, with a focus on identifying sources relevant to the P-C-C approach described above.The language selected was English; publication types included journal articles, systematic reviews, guidelines and electronic books. We did not specify a date range as we anticipated that eligible sources would be few and our aim was to be as comprehensive as possible.The AGREE II: Appraisal of Guidelines for Research and Evaluation II instrument was used to appraise the quality of the identified sources  nurses and postgraduate students with recent training in the appraisal method. Identified guidelines were appraised individually and the scores were handed back to the project leaders for compilation and resolution of any disparities of more than three. The individual raw scores were summarised, total scores were calculated and then presented in the form of a table.As recommended by Dizon et al. , the proRecommendations of the each included guideline, together with the associated evidence or rationale as stated in the original guideline, were tabulated. The purpose of this was to ensure that any modifications made later would be informed by the relevant evidence base and would preserve the rigour of development of the original source.The recommendations were assessed using prompts, which were adapted from the United Kingdom National Institute for Clinical Evidence (NICE) baseline assessment tool NICE . This prExpert input is essential in determining relevance and applicability of research evidence to local contexts  to V (least robust), and the grade of recommendation from A  to E  using the approach described by Xynos et al. .An additional scoring system was developed to support recommendations that related to the legislative and regulatory frameworks that govern nursing practices in South Africa and which could be regarded as mandatory recommendations. These recommendations were indicated as a legal requirement (LR) or regulatory requirement (RR).We wanted to ensure that the key messages of our guideline would be accessible to nurses. A flowchart is a ‘process map’ with easy to understand diagrams of step-by-step instructions to assist in understanding an existing process or develop ideas about how to improve it  (UK) Foundation Trust. . ClinicaGuideline 2 (policy statement): ‘Aberdeenshire Council . SupportGuideline 3: ‘NICE guideline [NG5] Published date: . MedicinThe individual raw scores were summarised and total scores were calculated as shown in Levels of evidence for the relevant recommendations in the existing guidelines were scored between II  with a suspicion of bias, or meta-analysis of such trials with demonstrated heterogeneity) and V .As a result of this exercise, informed by the available evidence about medication errors in African settings, we decided that the priority areas for our guideline to focus on should be:Supporting nurses to partner with mothers to give medication to their child, working within a well-defined professional and ethico-legal frameworkActions to prevent the most common and the most serious types of reported medication errors: omissions without valid reason and failure to record and wrong route of administration.A total of 40 recommendations relevant to the topic were identified from the included sources. After consideration of priorities, risks and relevance to the proposed setting, none of the recommendations were identified as suitable to include without modification. A total of 21 recommendations were excluded for stated reasons including lack of applicability to the settings. A total of 19 recommendations were identified as suitable to include with modification. This remaining set of 19 recommendations contained closely similar material and the list was edited and further reduced to a final list of 12 adapted and contextualised recommendations, which were categorised into four themes  aligned with the nursing process (with the help of expert consultation). These are presented in For the final list of 12 recommendations, the levels for the grades of evidence scored between II and V and strength of recommendations were graded between B and C, which was the same as before modification. Recommendations graded C were additionally supported by feedback from the clinical experts consulted, with the low grading thought to reflect a lack of impact studies rather than a likelihood of ineffectiveness.Expert consultation confirmed that the resulting adapted guideline was sound, easy to understand and well-presented for the target audience.A flowchart  was deveIt has been acknowledged that current practice in many wards is for nurses to hand medication to mothers to give to their children, but this is usually an ‘informal’ practice and lacks evidence-based guidelines. We found that this issue is amenable to improvement through evidence-based guidance (Williams et al. We found limited evidence regarding interventions that are effective in preventing medication errors in the paediatric population (Maaskant et al. We identified two main categories of problem as the focus for our contextualised guideline. Firstly, we prioritised the need for the guideline to support nursing practice by aligning with a well-defined professional and ethico-legal framework. Nurses working without explicit policies concerning partnering with mothers find that practice varies between wards and sisters in charge, leaving nurses unsure of what is an acceptable practice and how to fulfil their professional responsibilities (Phiri et al. Secondly, the area that we prioritised was to focus on nursing actions to prevent the most common and the most serious reported types of medication errors (Maaskant et al. Involvement of mothers in the care of the child forges relationships between the mother and the nurse, and encourages the family of the child to have a sense of trust in the nurses working closely with the child and the mother (Salmani, Abbaszadeh & Rassouli The focus of our guideline is on supporting nurses to partner with mothers to give medication. We have assumed that registered professional nurses will be competent to fulfil this role. Additional work to support nurses in maintaining and updating their knowledge in respect of medicines management would be valuable.Although we ensured that all recommendations were supported by evidence-based rationale statements, we were limited by the availability of evidence. It was beyond the scope of our study to undertake a systematic review for every recommendation. Instead we have transparently presented the results from limited but focused literature searches. We recommend further research to build the evidence base on this topic, particularly looking at the outcomes of interventions.Prior to implementing this guideline, the nurse with overall responsibility for medicines management on the ward should agree to a list of medications with the head pharmacist, the head clinician and the nursing unit manager on which medications can and cannot be handed to mothers for administration to their children. The overall responsibility for administration of oral medication in the ward belongs to the nurse. The nurse will have continuing responsibility for recognising and acting upon changes in a patient’s condition, regardless of the mother/carer’s participation in the process (Guy’s and St. Thomas’- NHS Foundation Trust This process successfully led to the development of a modified evidence-based practice guideline to enable nurses to partner with mothers or carers in safely giving oral medication to their hospitalised child in South African settings. The guideline can be used by nurses to review and improve the care offered to children, with the aim of contributing to a safer care through reduced medication errors.


This triangulation of two distinct sources of evidence provides guidance on how BCTs may affect the mechanisms that change behavior and is available as a resource for behavior change intervention designers, researchers and theorists, supporting intervention design, research synthesis, and collaborative research.Researchers, practitioners, and policymakers develop interventions to change behavior based on their understanding of how behavior change techniques (BCTs) impact the determinants of behavior. A transparent, systematic, and accessible method of linking BCTs with the processes through which they change behavior  would advance the understanding of intervention effects and improve theory and intervention development. The purpose of this study is to triangulate evidence for hypothesized BCT–MoA links obtained in two previous studies and present the results in an interactive, online tool. Two previous studies generated evidence on links between 56 BCTs and 26 MoAs based on their frequency in literature synthesis and on expert consensus. Concordance between the findings of the two studies was examined using multilevel modeling. Uncertainties and differences between the two studies were reconciled by 16 behavior change experts using consensus development methods. The resulting evidence was used to generate an online tool. The two studies showed concordance for 25 of the 26 MoAs and agreement for 37 links and for 460 “nonlinks.” A further 55 links were resolved by consensus . Full data on 1,456 possible links was incorporated into the online interactive Theory and Technique Tool ( Practice: Behavior change intervention designers can use the Theory and Technique Tool (TATT) to select behavior change techniques (BCTs) for inclusion based on expert evidence.Policy: Policymakers involved in behavior change can use the TATT to access resources, request advice, and identify BCTs relevant to the changes they plan to implement.Research: Future research can use the TATT to identify links between BCTs and theoretical constructs, download and upload evidence, and engage in discussion and collaborations.Behavior change interventions are the basis for addressing many current global health challenges. Theoretical progress in behavioral science has identified key determinants of behavior and proposes that behavior change is elicited by interventions that alter these causal factors. These factors serve as the “mechanisms of action” (MoAs) mediating the effect of interventions on behavior change. In developing an intervention to change behavior, the researcher or practitioner typically has an explicit or implicit theory about the MoAs affecting the behavior and then seeks to incorporate techniques within their intervention that will engage these mechanisms and thereby the target behavior. There have been advances in the transparency and reporting of intervention methods, particularly in the specification of behavior change techniques (BCTs), the active ingredients of an intervention with the potential to change behavior, in the 93-item BCT Taxonomy (BCTTv1) . DespiteEvidence clarifying which BCTs might influence which MoAs is likely to prove useful in the field of behavioral medicine by suggesting the techniques to use in changing health-related behaviors. For example, a practitioner wishing to reduce dentists’ prescribing of antibiotic medications may seek very different intervention techniques if they have evidence that the dentists have the intention to reduce their prescribing compared with the situation where they lack the intention: in the latter case, the proposed MoA would be “intention,” and techniques would be selected that are thought to increase intention, whereas, in the former case, the MoA might be “memory,” “reinforcement,” or “social influences,” and the practitioner would select quite different techniques.Several approaches to intervention development identify the need for guidance on links between BCTs and MoAs. In Intervention Mapping, a key step following identification of determinants is that the choice of behavior change methods to address these determinants and proposed links are provided . DiscussTriangulation of the findings of these two previous studies is necessary for two reasons. First, it is possible that the two studies provide conflicting or diverging evidence, resulting in ambiguous guidance for those wishing to implement the findings in designing interventions. By triangulating the findings, it is possible to identify the links supported in both studies, giving the user more confidence in applying the resulting evidence. Second, scientifically, triangulation of studies using different methods to tackle the same question gives greater confidence that the results obtained are not simply due to repetition of biases and limitations in design, methods, or analyses . The litOur approach was comprised of two steps. First, concordance between the findings of the two studies was investigated statistically to assess agreement and, then, to identify links described consistently by both methods. Second, inconclusive links from the concordance study were examined in a reconciliation study in which a new group of experts, referred to as “reconciliation experts,” were provided with the evidence from the two previous studies and asked to reconcile them. As suggested by Archibald , it was Since the results are intended as a resource for intervention development, evaluation, and synthesis, all findings were made accessible in an online tool that allows users to search for evidence of linkage , share additional information about the links, and propose collaborative research into underinvestigated links.The tables of BCT–MoA links produced by the two previous studies were compared in order to (a) estimate agreement between the findings of the two studies overall and for each MoA, (b) identify BCT–MoA links where there was agreement, that is, links that exceeded preset criteria in both the literature synthesis and expert consensus studies as either linked  or not linked , and c) identify links with inconclusive results from the two studies for further investigation in the reconciliation study.not exist, whereas, in the literature study, it was only possible for a link to be absent from the 277 papers investigated. Thus, evidence of absent links in the latter study was ambiguous: a link might be absent because it could indicate the link is impossible or improbable or because it simply was not used in the 277 interventions.Both the literature and consensus studies considered the same 26 MoAs. However, while the consensus study focused on linkages with a subset of 61 BCTs, the literature study had the potential to consider linkages with any of the 93 BCTs in BCTTv1. Also, the consensus study allowed experts to say explicitly that a potential BCT–MoA link definitely did Full details of the methods used in the two previous studies are provided in  and 9]..9]. Hereand (b) the 12 most frequently occurring MoAs  identified in a systematic review of 83 behavior change theories [Peer-reviewed published behavior change intervention reports were identified using electronic searches, requests to experts, and citations of papers, which included some coding of either BCTs or theory. They were included if (a) they provided the description and/or evaluation of a behavior change intervention and (b) a BCT (not necessarily labeled as such by the authors) was explicitly linked to one or more MoA(s). BCTs in the reports were coded using BCTTv1 ,13 and (theories .= 13.80). For each possible link, a one-tailed exact binomial test was conducted comparing the observed to the expected frequency of occurrence for each link, computing an expected value as the frequency that might be observed if BCTs were randomly linked to MoAs , allowing readers to examine the relative frequency of links in more detail. Eighty-seven BCT–MoA combinations met the criterion for a link.A total of 2,636 BCT–MoA links were made by authors, including 70 BCTs and 25 MoAs, identified from 277 articles  in a set of 40 systematically identified and coded intervention descriptions covering a range of different behaviors [Sixty-one BCTs and 26 MoAs were included in the study based on the following criteria: (a) BCTs had to be commonly used within the intervention literature; therefore, we selected only those BCTs identified more than twice  MoAExperts individually rated each link in an online task, then participated in an online, asynchronous discussion of the ratings of their group, and finally completed a final set of individual ratings using responses: “Definitely Yes,” “Definitely No,” “Uncertain,” or “Possibly.” These final ratings provide the data for the concordance study. Two scores are used for each of the 1,586 links: Proportion of YES = the proportion of experts answering “Definitely Yes”; and Proportion of NO = the proportion of experts answering “Definitely No.” Scores ranged from 0 to 1 and higher scores indicate a higher proportion of agreeing on links or “nonlinks” (answers of “Uncertain” or “Possibly” were excluded.)Because the two studies shared 56 BCTs and all 26 MoAs, the concordance in the probability of a link could be assessed for 1,456 (56 BCTs × 26 MoAs) possible links. Concordance was examined using two approaches: (a) multilevel modeling (MLM) and (b) comparison of the matrices of BCT–MoA links.p value, p+, in the literature synthesis. The decision to treat expert consensus as the independent and literature synthesis as the dependent variables for the MLM was based on (a) the better distribution of data for the consensus study as there were fewer tied results and (b) the literature synthesis preceded the consensus task.The dependent variable was the proportion of experts either asserting that there was a link (definitely “yes”) for a given BCT/MoA combination or, separately in a second model, that there was no link (definitely “no”). The predictor was the relative frequency of each link as indicated by the exact In a two-level analysis using MLwiN 3.01, BCTs were nested within MoAs. The intercept was allowed to vary randomly at both levels; the probability of a link from the literature synthesis varied at the MoA level. These analyses can show if there is a relationship between the links established by the literature synthesis and the expert consensus across all MoAs and if that relationship varies by MoA.p+ value of 1. For example, BCT 2.6 “Biofeedback” was linked in the literature study to MoA “Skills” but not to MoA “Knowledge”  and theLink: evidence of link across both studies , (b) No Link: no evidence of link in literature synthesis, evidence of “no link” in expert consensus , (c) No evidence: no evidence of link in literature synthesis and no strong evidence in expert consensus , (d) Inconclusive: evidence of link in literature synthesis but evidence of “no link” in expert consensus or no evidence of link in literature synthesis but evidence of link in expert consensus or some below-criterion level of evidence in either the literature (.05 < p+ <.10) and/or expert consensus . The first three of these categories were categorized as “concordance” between the two studies . Links from the fourth, inconclusive, category were brought forward to be considered by the reconciliation experts.We compared the findings of the two studies and classified the links into one of the following categories: (a) The flowchart in p+ values from the literature synthesis study plotted against the proportion of “definitely YES” responses in the expert consensus study; each line represents one MoA. Lower p+ values, indicating links with greater relative frequency, are associated with a higher proportion of “YES” responses.The regression lines and scatterplots show the proportion of experts asserting a link in the expert consensus study against the probability of a link in the literature synthesis study for each BCT linked to each MoA. The negative slope indicates concordant relationships between the two studies with the steepness of the slope indicating the strength of the relationship.In order to illustrate the observed relation between the findings in the two studies, p+ value in the literature and a high proportion of experts responding “YES”), whereas “no link” was found in both studies for instruction on how to perform the behavior (BCT 4.1). In addition to scientific evidence of triangulation, the results can provide recommendations to users who are trying to decide which BCT to use to engage a particular MoA. Thus, a user who hopes to change behavior via the MoA of Reinforcement might choose to use BCT 10.3 or 10.4 but avoid BCT 4.1. Detailed scatterplots for each of the 25 MoAs (not for “norms” as this was not found in the literature study), showing which BCTs are linked to which MoAs in the two studies, can be accessed in In the Reinforcement example, a strong link is found across both studies for nonspecific reward (BCT 10.3) and social reward  are included or removed. Both sets of results are presented in p+ values of 1 removed but both sets of results are presented in Further details about the multilevel models are reported in Links exceeding preset criteria for both studies were examined: 37 BCT–MoA “links” reached the criterion for a link in both the literature synthesis and expert consensus studies, covering 28 BCTs and 18 MoAs see .For 460 links (61 BCTs and 22 MoAs), there was also concordant evidence of “no link”; that is, absence of evidence in the literature and agreement between the experts that these BCTs do not act on those MoAs see . Thus, tN = 179) were brought to the reconciliation study: evidence of a link in literature synthesis but “definitely no” link in expert consensus (n = 3); evidence of a link in literature synthesis and below-criterion level of evidence or link not included in expert consensus (n = 45); no evidence of a link in literature synthesis but “definitely” a link in expert consensus (n = 53); below-criterion level of evidence in either the literature synthesis (.05 ≤ p+ ≤.1) or the expert consensus study  for 904 (56.9%) “absence of evidence” links.There was insufficient evidence in both studies , USA (n = 1), Canada (n = 2), Australia (n = 1), and Russia (n = 1).Sixteen experts who design, evaluate, and/or synthesize evidence about theory-based behavior change interventions were selected from the database of experts for the original expert consensus exercise (and who were not participants in the previous expert consensus study). Additional experts were selected based on the recommendations of the project’s international advisory board. Experts were invited to participate based on a self-assessment questionnaire on their objective experience of publishing papers and conducting systematic reviews to assure expertise and a breadth of background (see ). ParticOne hundred seventy-nine inconclusive links were identified in the concordance study.Expert consensus methodology was used to examine the 179 BCT–MoA links that were identified as inconclusive based on the comparison of the two prior studies. The task consisted of three rounds.Prior to the initial round, experts were emailed detailed guidelines for the study, including the sources of the data to be presented see . In the During Round 2, experts took part in an online, anonymous, asynchronous discussion hosted via Loomio, a digital discussion platform, which they could access over a 2 week period. The purpose of this round was to facilitate discussions between experts on the 25 links for which there remained high uncertainty and/or disagreement. Experts were advised to focus the discussion on links for which they remained uncertain or where their views differed from those of other experts. A moderator from the research team periodically summarized the discussion and raised issues for further discussion.During Round 3, experts had access to their personalized statistical summaries from the Round 1 ratings, the original information comparing the two sources of evidence, and were provided with transcripts of the Round 2 discussions. The detailed information from the previous rounds allowed experts to reevaluate their original ratings for each link in light of the thoughts and ratings of the other experts. As in Round 1, the potential links were presented in random order and experts judged whether each BCT–MoA pair was linked by rating “definitely yes,” “definitely no,” or “uncertain/don’t know.” A link was judged to be resolved as a link if 80% or more of the reconciliation experts rated it “definitely yes” or as a “no link” if 80% or more rated it “definitely no.” The data from all studies were made available for each of the 1,456 BCT–MoA links in an interactive format.The 179 links brought forward to be considered by the reconciliation experts were those for which there was inconclusive evidence across the literature synthesis and expert consensus studies. Reconciliation experts reached the criterion for agreement for 60/179 (33.52%) BCT–MoA links: For five possible links, experts agreed there was “no link,” that is, ≥80% rated it “definitely no” link see  and, forp+ ≤.1 in literature synthesis and 70%–79% of experts answered “definitely yes”). Seven of the 60 identified links were for BCTs that had not been identified in the literature study and three links were for BCTs found in the literature synthesis but not in the expert consensus study. In sum, the results provide evidence for 92 hypothesized links, 465 nonlinks, and more evidence needed for the remaining 899 links investigated.Thus, across all stages (concordance and reconciliation), 92 BCT–MoA links were identified, covering 51 of 61 BCTs and 22 of 26 MoAs. The total of 92 links identified resulted from 37 links identified through concordance and 55 links identified through the reconciliation study. In the reconciliation study, 14 of the 60 resolved links confirmed the literature synthesis finding, 42 confirmed the previous expert consensus finding, and 4 links were based on the marginal evidence provided by both studies . A screen shot of the home page is shown in The online tool can be accessed at (n = 100) on 37 links; this was extended to 92 based on the reconciliation study involving a further 16 experts. Hence, this triangulation study provides the first systematic evidence of (a) 92 hypothesized BCT–MoA links that could be targeted or evaluated in interventions, (b) 465 links that this evidence suggests do not exist, and (c) more research being needed to resolve the status of the remaining links. Due to an error, data are lacking for the 11 omitted links and data from the 6 incorrectly included were removed from further analyses. Since data are provided separately for each potential link, these errors have no additional implications for other links.The purpose of these studies was to examine evidence regarding hypothesized links between BCTs and MoAs and to present the information in an online interactive tool that might be helpful in intervention design, evaluation, and evidence synthesis, identifying priorities for future research, and advancing research and collaborations. Triangulation of the results of the previous literature and consensus studies showed that, overall, the results produced by these two methods of investigating BCT–MoA links converged. This was true both for positive links (“YES” responses) and for nonlinks (“NO” responses) and for each MoA . Examination of each possible BCT–MoA link revealed concordance between the literature study (277 interventions) and expert consensus (subjective norms as an MoA while norms are seen as moderating variables.The reconciliation study was successful in resolving over a third (60/179) of the inconclusive results of the previous two studies. The reconciliation experts were more likely to agree with the previous expert consensus exercise than with links identified in the literature, perhaps, in part due to the similarity of the methods. However, the reconciliation experts had much more information available than the experts in the consensus study, and comments made by experts during the discussion round made it clear that the experts were indeed using the evidence from both previous studies in addition to their own judgment and the judgments of other reconciliation experts. Where there were differences between the literature synthesis and expert consensus, the reconciliation experts discussed possible explanations, including poor methodology in some and the recent specification of BCTs and MoAs, which would not have been available to earlier literature. Nevertheless, the judgments of the reconciliation experts are more likely to be in accord with the previous judges for several reasons. First, the literature synthesis study is restricted to what has actually been done, whereas the judgments, of both groups of experts, address what is theoretically possible. Second, the expert opinion in both the original consensus study and the current reconciliation study reflects current evidence, whereas published studies synthesized in the literature synthesis study were based on the history of evidence available to authors at the time of planning and development of the interventions. https://theoryandtechniquetool.humanbehaviourchange.org/) allows the user to examine results for each of the three studies for each possible BCT–MoA link. Users can also post comments, upload information about links , and suggest the possibility of collaborative research for underinvestigated links.The results have been integrated into an online TATT that allows the user to explore evidence for each possible link, presenting data from the literature, consensus, and reconciliation studies. The online tool . While this example is immediately obvious, the detailed evidence for each MoA available via the online tool enables the intervention designer to move beyond the specific example illustrated in The substantial number of links shared by the two studies provides a resource reflecting both current expertise and practice in published interventions for selecting BCTs that might be used to change theoretical constructs that are hypothesized to mediate effects on behavior. BCTs have been identified for each MoA and, since the MoAs investigated address the main theoretical domains and commonly theorized constructs, the links identified offer a range of potential BCTs that might be applicable within a wide range of theoretical frameworks. These links may also prove helpful in suggesting alternative theoretical explanations of the effects of BCTs on behavior in intervention studies, especially those conducted without an explicit theoretical base or where the proposed theoretical basis cannot account for the findings. Further, the links may also assist the synthesis and interpretation of evidence across intervention studies, which had varying theoretical bases as illustrated by Gardner et al.’s examination of theoretically diverse interventions using audit and feedback to change behavior. In their method, “…behavior change intervention is deconstructed into component techniques, which are then mapped onto the most relevant behavior change theory or theories…” . Nevertheless, there continues to be a large number of links where our results are inconclusive. To some extent, this reflects the recency of this field of research but also the lack of an integrating framework that enables areas requiring more evidence to be identified. The online TATT may assist in integrating evidence. However, in some cases, inconclusive results can occur when a BCT may act through several MoAs and so the links found in the literature study for any particular MoA might fail to meet our preset criterion. If so, then these BCTs would be particularly useful as they might activate several MoAs simultaneously. They can be identified in the online tool as being near criterion level for the literature study on several MoAs or linked by experts to several MoAs. For example, BCT 1.1 “goal setting (behaviour)” is strongly linked by experts to MoAs “Intentions,” “Goals,” and “Motivation.” There may also be instances where BCTs are most effective in combination with others. BCTs working via many MoAs may be particularly valuable as they may be tapping more general underlying mechanisms. As a result, these BCTs might be particularly useful in practice.The findings also indicate agreement about BCTs that are The majority of experts recruited to the reconciliation study were from the UK, reflecting the origin and continuing interest in research on BCTs in that country. It is possible that different results might have been obtained with experts from other countries, although there are no a priori reasons to expect their responses to differ. A further limitation is that this study could only investigate links with the 56 BCTs shared by the two previous studies.hypothesized BCT–MoA links and it has not been empirically demonstrated that the BCT works via the MoA; further work is needed to ascertain whether the specified technique is able to activate the hypothesized mechanism and, then, in turn, elicit change in behavior. Moreover, although there is concordance between the findings obtained by the two different approaches, they are not completely independent. On the one hand, the experts in the consensus study are likely to have influenced the content of behavior change interventions by having published in the field and, on the other hand, their judgments about links likely to be effective may have derived in part from their knowledge of the literature. The finding of concordance between the results of the two methods provides confirmation of the knowledge base in this field as represented both by a systematic search of relevant literature and by the informed opinions of those working in the field and, therefore, goes beyond the value of either method alone. In addition, by identifying and reconciling discrepant findings, the results go beyond simple confirmation of the quantitative findings [It is important to keep in mind that these are findings .Links may also have been shared by the two methods as both are informed by dominant behavior change theories . For exaThe concordant links may prove particularly useful in developing theory-based interventions. Intervention developers have been criticized for the limited connections between the proposed theoretical basis for their intervention and its actual implementation ,27, and Theoretical constructs are hypothesized to influence behavior in tandem with other theoretical constructs within each theory, a process included within Intervention Mapping as the “parameters” within which one might expect a behavior change method to have an effect . In the The triangulation of the literature synthesis and expert consensus studies has resulted in a replicable set of hypothesized links between BCTs and MoAs, as well as a set of hypothesized nonlinks of BCTs that are unlikely to influence a particular MoA. This has resulted in an online resource (see the interactive online TATT), which can be used to guide intervention development and the theoretical interpretation of results of behavior change interventions. Additionally, this study revealed key areas where experts disagree on potential BCT–MoA links, offering ample opportunity for further research to strengthen the TATT. Hence, we hope this work will provide the basis for more systematic, coordinated research studies to examine and strengthen the evidence base underlying behavior change interventions.ibaa050_suppl_Supplementary-File-1Click here for additional data file.ibaa050_suppl_Supplementary-File-2Click here for additional data file.ibaa050_suppl_Supplementary-File-3Click here for additional data file.ibaa050_suppl_Supplementary-File-4Click here for additional data file.


Wandering spleen is a rare clinical entity with a less than 0.2% reporting incidence rate. In this case, the spleen is present abnormally in the abdominal or pelvic cavity instead of its normal anatomical location. The aetiology is either congenital or acquired. The condition is caused by the absence or maldevelopment of the spleen's suspensory ligaments, which holds the spleen static in the left hypochondrium.A 27-year-old female patient presented to the emergency department with complaints of abdominal pain, fever, nausea, vomiting, and constipation for three days. A palpable movable mass was found during the physical examination, and torsion of the wandering spleen’s pedicle was confirmed by CT scan. Open splenectomy was performed, and the patient was recovered uneventfully.Even though ectopic spleen is a rare disease, clinicians should be aware of its incidence. Early diagnosis in the case of an acute abdomen is vital for the preservation of the spleen. Patients presented with acute abdomen and absence of splenic shadow under left hemidiaphragm should be suspected, and further radiological investigation will confirm the diagnosis. Surgery is the gold standard for wandering spleen with either splenopexy or splenectomy, depending on the spleen's condition during surgery. The disease does not have any genetic background but can either be congenital or acquired . The aetIt can be diagnosed easily and can be sometimes challenging too, especially in children, due to ambiguous presentation. Because the symptoms are very nonspecific radiological investigations are of great help. Plain x-ray, doppler ultrasonography, computerized tomography(CT), magnetic resonance imaging(MRI), scintigraphy, and splenic angiogram are very helpful in diagnosis –7. TimelHere we present a 27-year-old female patient referred to the emergency room of Amiri Medical Complex, Kabul, Afghanistan, from a rural area of the country.A 27-year-old, multiparous, female, poor patient with a history of umbilical herniorrhaphy eight years ago, and otherwise healthy, presented to our emergency department with acute onset abdominal pain, nausea, vomiting, constipation, on and off fever, and urinary retention from last three days. The pain was relieving with analgesics but exaggerated with physical activity. She said, she experienced the same episode of pain two years ago but was diagnosed as gastritis on endoscopy, for which she was treated. The sonologist at that time suggested her to seek a surgeon's opinion, but she ignored it. She had no previous records with her at the time of admission. Drug and family history was unremarkable.2 97%. On physical examination, the abdomen was mildly distended with a midline surgical scar and hypoactive bowel sounds on auscultation. A mobile palpable mass with a smooth surface in the right lower abdomen extending into the pelvis was observed, which was painful on movement. No signs of peritonitis were observed. Blood investigation results were TLC 11,000/mm3 , neutrophil 83% , Hb 12.8 g/dl , INR 1.18, blood group A + , anti HCV Ab + , HbsAg, and HIV were negative.The vital signs were BP 110/70 mmHg, RR 22/m, PR 70 b/m, Temp 37.5 °C, and SpOUltrasound result was not diagnostically significant, so an abdominal CT scan with and without contrast was advised, which showed an empty splenic fossa and mildly enlarged ectopic spleen measuring 15.5 cm in length, present in the right lower abdomen extending into pelvis resting on the bladder fundus. No enhancement of the spleen was noted after iv contrast. The bright capsule of the spleen was observed, indicating collateral flow (rim sign). Regional ileus of the small and large bowel was also seen, as shown in Fig. 0 twisted pedicle was found, as shown in Figs. Laparoscopic surgery was not feasible because of lack of technology and expertise, so laparotomy was performed, and mildly enlarged congested and ischemic spleen with 180The patient recovered well without any complication and was discharged on 3rd post-operative day. She was followed up for a month without any complaints.o [Wandering spleen, which is also called floating spleen, ectopic spleen, ptotic spleen, or splenoptosis, can wander anywhere in the abdominal or pelvic cavity attached only by its vascular pedicle with no attachment to the surrounding structures. The long pedicle makes it liable to torsion on itself and can cause complications. The degree of torsion, according to literature, ranges from 90° to 2160o . The cauo .The concept of wandering spleen was first described by Van Horne in 1667 . One of The presentation is very nonspecific. Asymptomatic cases may be left undiagnosed or diagnosed incidentally. Symptomatic patients may have different clinical signs and symptoms as reported in the literature, e.g. acute, intermittent, or chronic pain because of torsion and detorsion of the splenic pedicle, vomiting, abdominal distention, constipation, palpable, movable mass in the abdomen or pelvic same like in our case or other signs and symptoms of an acute abdomen may present –4, 13–15All the signs and symptoms presented in our patient were not different from the literature. While we were investigating the cause of abdominal pain and found the palpable, smooth surface, mobile mass on physical examination, it was considered the definitive cause for abdominal pain. Keeping her age and gender in mind, the first impression was the torsion of ovarian cyst. But after an ultrasound showed a complex mass in the right lower abdomen and absence of splenic shadow from splenic fossa on x-ray, the diagnosis of wandering spleen was more likely, which was finally diagnosed on CT scan and confirmed during operation. The acute pain was because of torsion of the splenic pedicle leading to ischemia of the spleen. Abdominal distention, nausea, vomiting, and constipation with hypoactive bowel sounds on auscultation were possibly because of paralytic ileus. The patient was not having the signs of peritonitis because the spleen was not infarcted and ruptured. But peritonitis can occur as a complication of torsion. Almost all the symptoms of our case were in compliance with the literature and have already been explained above.The diagnosis can be made by doing a proper physical examination, ultrasonography, CT scan, MRI, scintigraphy, and angiography, etc. The absence of the spleen from its normal anatomical position and the presence of soft tissue splenic shape mass in the abdomen or pelvis on a CT scan is suggestive of a wandering spleen. In addition, a "whirl sign" with no or partial enhancement of the splenic shape mass on iv contrast-enhanced CT scan in the patient presented with the acute abdomen is strongly suggestive for pedicle torsion of the wandering spleen, as also seen in our case . BecauseTimely diagnosis and interventions are vital for spleen salvage and avoiding life-threatening complications. Thrombocytopenia is another rare complication usually related to torsion of elongated splenic pedicle .The gold standard treatment for wandering spleen is surgery. Conservative management of asymptomatic wandering spleen is associated with a 65% complication rate . The twoWhen the spleen is enlarged, infarcted, ruptured, or there are signs of hypersplenism, the choice of treatment is splenectomy, where the spleen should be totally removed either laparoscopically or through laparotomy –4.Wandering spleen is a comparatively rare clinical entity, which can present with various signs and symptoms. Emergency room physicians and surgeons should be aware of this entity, especially when the patient presents with the acute abdomen. The absence of the spleen from its normal anatomical location and the presence of soft tissue splenic shape mass anywhere else in the abdomen or pelvis is the likely diagnosis of a wandering spleen. Whirl sign and partial or no enhancement of splenic shape mass on contrast-enhanced CT scan is the likely diagnosis for pedicle torsion of the ectopic spleen in patients presenting with acute abdomen. Timely diagnosis and interventions are crucial for spleen preservation and avoiding life-threatening complications. Surgery for splenopexy or splenectomy is the treatment of choice depending on the condition of the spleen.


These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist with clinical decisions about management of ccSVD, specifically white matter hyperintensities and lacunes, to prevent adverse clinical outcomes. The guidelines were developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We prioritised the clinical outcomes of stroke, cognitive decline or dementia, dependency, death, mobility and mood disorders, and interventions of blood pressure lowering, antiplatelet drugs, lipid lowering, lifestyle modifications, glucose lowering and conventional treatments for dementia. We systematically reviewed the literature, assessed the evidence, formulated evidence-based recommendations where feasible, and expert consensus statements. We found little direct evidence, mostly of low quality. We recommend patients with ccSVD and hypertension to have their blood pressure well controlled; lower blood pressure targets may reduce ccSVD progression. We do not recommend antiplatelet drugs such as aspirin in ccSVD. We found little evidence on lipid lowering in ccSVD. Smoking cessation is a health priority. We recommend regular exercise which may benefit cognition, and a healthy diet, good sleep habits, avoiding obesity and stress for general health reasons. In ccSVD, we found no evidence for glucose control in the absence of diabetes or for conventional Alzheimer dementia treatments. Randomised controlled trials with clinical endpoints are a priority for ccSVD.


With population ageing worldwide, dementia poses one of the greatest global challenges for health and social care in the 21st century. In 2019, around 55 million people were affected by dementia, with the majority living in low- and middle-income countries. Dementia leads to increased costs for governments, communities, families and individuals. Dementia is overwhelming for the family and caregivers of the person with dementia, who are the cornerstone of care and support systems throughout the world. To assist countries in addressing the global burden of dementia, the World Health Organisation (WHO) developed the Global Action Plan on the Public Health Response to Dementia 2017–2025. It proposes actions to be taken by governments, civil society, and other global and regional partners across seven action areas, one of which is dementia risk reduction. This paper is based on WHO Guidelines on risk reduction of cognitive decline and dementia and presents recommendations on evidence-based, multisectoral interventions for reducing dementia risks, considerations for their implementation and policy actions. These global evidence-informed recommendations were developed by WHO, following a rigorous guideline development methodology and involved a panel of academicians and clinicians with multidisciplinary expertise and representing geographical diversity. The recommendations are considered under three broad headings: lifestyle and behaviour interventions, interventions for physical health conditions and specific interventions. By supporting health and social care professionals, particularly by improving their capacity to provide gender and culturally appropriate interventions to the general population, the risk of developing dementia can be potentially reduced, or its progression delayed. With population ageing worldwide, dementia poses one of the greatest global challenges for health and social care in the 21st century. In 2019, around 55 million people were affected by dementia, with the majority living in low- and middle-income countries (LMIC). The total number of people with dementia is projected to reach 78 million in 2030 and 139 million in 2050 . This number is expected to more than double by 2030, reaching US$2.8 trillion  developed the Global Action Plan on the Public Health Response to Dementia 2017–2025, endorsed by the World Health Assembly in May 2017. It proposes actions to be taken by governments, civil society, and other global and regional partners across seven action areas, one of which is dementia risk reduction. This paper is based on the first WHO Guidelines on risk reduction of cognitive decline and dementia  methodology , 9. To sThe resulting WHO recommendations targeting nine (of the 12 reviewed) modifiable risk factors are based on evidence from 51 good-quality systematic reviews, including those of observational studies, published in the last 2 years and expanded by up to 5 years, when necessary. Further considerations taken into account included: the balance of benefits and harms of each intervention; values and preferences of the end-user involved; costs and resource use; acceptability of the intervention to health care providers; feasibility of implementation; and impact on equity and human rights. In addition to these systematic reviews, other related guidelines were considered in the development of the recommendations. Some of these are detailed in Box 1http://www.who.int/mental_health/mhgap/mhGAP_intervention_guide_02/en/mhGAP Intervention guide for mental, neurological and substance use disorders in non-specialist health settings – version 2.0. Geneva: WHO; 2016. 173 p. Available from: http://apps.who.int/iris/bitstream/10665/76173/1/9789241548397_eng.pdfPrevention and control of non-communicable diseases: guidelines for primary health care in low-resource settings. Geneva: WHO; 2012. 72 p. Available from: https://www.who.int/publications/i/item/who-package-of-essential-noncommunicable-(pen)-disease-interventions-for-primary-health-carePackage of essential non-communicable (PEN) disease interventions for primary health care in low-resource settings. Geneva: WHO; 2010. 85 p. Available from: http://www.who.int/dietphysicalactivity/publications/9789241599979/en/Global recommendations on physical activity for health. Geneva: WHO; 2010. 60 p. Available from: https://www.who.int/publications/i/item/9789241550109Guidelines on Integrated care for older people (ICOPE). Geneva: WHO; 2017. 60 p. Available from: https://www.who.int/publications/i/item/hearts-technical-package .HEARTS Technical package for cardiovascular disease management in primary health care: evidence-based treatment protocols (2018). https://www.who.int/ageing/publications/Global_age_friendly_cities_Guide_English.pdfGlobal age-friendly cities: a guide. Geneva: WHO; 2007. 82 p. Available from: http://www.who.int/en/news-room/fact-sheets/detail/healthy-diet .Recommendations on healthy diet (2019). https://www.who.int/publications/i/item/strengthening-health-systems-for-treating-tobacco-dependence-in-primary-careStrengthening health systems for treating tobacco dependence in primary care. Geneva: WHO; 2013. 78 p. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf?ua=1Framework on integrated people-centred health services. Geneva: WHO; 2016. 12 p. Available from: Taking into account these considerations, recommendations were classified by their strength . Strong recommendations were issued when the multidisciplinary panel had clear confidence that the desirable effects of the intervention outweighed any undesirable effects. In case the panel was uncertain about the balance between the desirable and undesirable effects, a conditional recommendation was issued. Strong recommendations imply that most individuals would want the intervention and should receive it, while conditional recommendations imply that different choices may be appropriate for individual patients, and they may require assistance at arriving at management decisions. In some instances, even when the quality of evidence was low or very low, it was agreed that if the recommendation would be of general benefit, and this was seen to outweigh the harms, it may still be rated as strong.https://www.who.int/publications/i/item/risk-reduction-of-cognitive-decline-and-dementia).The full evidence profiles underpinning the recommendations are available at the WHO website , for which there is inadequate guidance offered as to their worth or effectiveness.The recommendations are considered under three broad headings: lifestyle and behaviour interventions, interventions for physical health conditions and specific interventions .Many of the interventions included in these guidelines are strongly related to managing risk factors for cardiovascular disease and diabetes. Therefore, the implementation of these recommendations should be combined, whenever possible, with the ongoing prevention programmes to reduce the risk of these conditions in the relevant target populations. For example, non-communicable disease prevention programmes need to include dementia as an integral part of action at global and national levels. Such an approach is particularly interesting as it provides opportunities to develop public health policies that will work in synergy and a single designed intervention has the capacity of impacting risk reduction efforts of more than one disease. Countries should include the recommendations in training and education programmes of healthcare providers, so that these interventions can be provided to all adults in primary health care. An important initiative aimed at leveraging mobile technologies to provide health information to those at risk of developing dementia is WHO's mDementia programme and its mDementia handbook . The hanBox 2Link dementia risk reduction to existing non-communicable disease policies and programmesIntegrate reducing the risk of cognitive decline and dementia into community services and social protection policies especially among older persons.Train the health workforce in early detection of cognitive decline and in providing interventions to reduce dementia riskConduct campaigns  to educate and empower the general public about modifiable dementia risk factors and how these can be mitigatedIntegrate surveillance of cognitive decline and dementia in national demographic and health surveys to inform policy on prevention and treatmentUse digital technologies and innovation to combat risksInvest in research to build the evidence base for risk reduction interventions and address research gapsStrengthen monitoring efforts to measure implementation of risk reduction strategies and their impactStrengthen collaboration between civil society, government, private sectors and institutions to achieve an impactful implementation of integrated risk reduction strategiesThe optimal preventive effect may be obtained by addressing several risk factors at the same time. Collaboration among different stakeholders and multidisciplinary approaches will also be needed. Local adaptation is necessary to ensure that the guidelines are appropriate for the local conditions that affect the care of people with cognitive decline and dementia in health facilities and the community.As countries consider how to implement these guidelines, the budgetary and human resource requirements, and other health systems implications should be analysed to identify what inputs and systems are currently available and what areas require additional investment. These may include training of health workers, supply of medicines and adaptations of health information systems to collect data on service utilisation.While these guidelines used transparent and robust methodologies for evidence synthesis and the development of recommendations according to the WHO Handbook for Guideline Development, the limitations of the guidelines chiefly result from the inadequate evidence available for some of the research questions.Though the prevalence of dementia is increasing in LMIC, most of the studies were conducted in high-income countries. Much of the evidence came from well-resourced settings, which could potentially impact on generalizability. The relatively short follow-up of most intervention trials limits our ability to judge the potential impact of the intervention on the development of cognitive decline and dementia, both of which have long prodromal periods. Additionally, most studies failed to distinguish between mid-life vs. late life risk factors. For example, the majority of the evidence relating to blood pressure-lowering is drawn from late life samples. However, the epidemiological evidence suggests that the association between high blood pressure and increased risk of cognitive decline or dementia is strongest for high blood pressure experienced in mid-life  . Few stuFew data were available for interventions targeting some of the modifiable risk factors and reporting outcomes related to dementia or cognitive decline. Therefore, although social isolation, depression and hearing loss were included in the initial scoping, no recommendation could be made relating to these risk factors. However, new evidence is emerging for interventions targeting these risk factors and will be considered when the guidelines are updated.In instances where the evidence was limited, we took advantage of the GRADE methodology , 16, whiThese limitations, together with the critical analysis of the evidence collected, which is presented in the current issue in a separate paper , emphasiMajor research questions that need to be addressed as a priority are listed in Box 3Explore single and multi-domain approaches addressing multiple risk factors for primary and secondary prevention of dementias based on evidence on risk/protective factors and the relationship with other chronic diseasesUnderstand the influence and interactions of non-modifiable  and modifiable  risk and protective factors for dementia in population-based samplesDetermine the feasibility, optimal mode of administration, and effectiveness of interventions to address risk factors for dementia, including identifying and managing barriers to, and facilitators of, implementing evidence-based guidance and policy recommendationsStudy the effectiveness of eHealth applications targeting risk reduction and behaviour change messagingIn this article we propose evidence-based recommendations to reduce the risk of cognitive decline and dementia and will facilitate the implementation of WHO's Global Action Plan on the Public Health Response to Dementia 2017–2025, specifically to achieve the global target for dementia risk reduction.The recommendations are designed to inform policymakers, healthcare providers, as well as other stakeholders. Given that the risk factors identified by the studies and recommendations proposed in the guidelines are shared among other diseases, especially with cardiovascular diseases and diabetes, it is of particular importance to identify how to strategically develop interventions and/or integrate such recommendations in a manner that will maximise the impact and increase their cost efficiency.New evidence in these areas are regularly monitored by WHO, in consultation with international experts and academic partners. These guidelines will be reviewed in around 5 years, unless an earlier review and update is warranted by breakthrough research. We also expect revisions to include relevant new questions or areas currently not covered by these guidelines.We intend that the publication of the WHO guidelines, and the evidence-base that underpins them, will stimulate interest in the global scientific, policy and practitioner communities and thereby contribute to increase research capacity and strengthen evidence from countries/regions where needed. Though comprehensive and quality evidence has been gathered in the last decade on risk factors for dementia and cognitive decline, efforts should be targeted at improving the representation of LMICs. To achieve that, global prioritisation and coordination are necessary to ensure that ongoing dementia research covers critical areas within dementia risk reduction in ways that harmonise investigative approaches and reduce redundancies. Moreover, research efforts must be rooted in equity, diversity, and inclusiveness, be person-centred and family inclusive. This also necessitates building greater research capacity in all income settings and coordinated actions at the global level with all stakeholders.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.TD and NC contribute to overall coordination of the guideline development. NC wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.KA is funded by NHMRC Fellowship 1102694. RP and LZ are funded by the NHMRC Dementia Centre for Research Collaboration. LZ is also funded by NHMRC Grant 1100579. MK is funded by Academy of Finland [Grants Nos. 317465 and 335524], the European Union Joint Programme – Neurodegenerative Disease (JPND) project EURO-FINGERS [Academy of Finland Grant No. 334804], Stiftelsen Stockholms Sjukhem, Center for Innovative Medicine (CIMED) at Karolinska Institutet, Knut and Alice Wallenberg Foundation, the Swedish Research Council for Health, Working Life and Welfare, Region Stockholm grants , and Konung Gustaf V:s och Drottning Victorias Frimurarstiftelse. AB and MB are funded by the European Research Council (ERC) [Grant No. 804371]. AB and RS are funded by the Finnish Cultural Foundatio. AB is also funded by the Academy of Finland [Grants Nos. 287490 and 319318] and Alzheimerfonden.The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.