Staphylococcus aureus has evolved mechanisms to evade immune responses that contribute to its persistence in PMNs, and acquired resistance to several antimicrobials. Additionally, methicillin-resistant S. aureus (MRSA) is one of the most common causes of acute bacterial skin and skin-structure infections (ABSSSIs). Dalbavancin (DBV), a lipoglycopeptide, is indicated for the treatment of ABSSSIs, and has a broad spectrum of action against most microorganisms. Here, we sought to determine the effect of DBV on the neutrophil killing of MRSA and its potential immunomodulating activity. Our results revealed that DBV boosts MRSA killing by acting on both bacteria and PMNs. DBV pre-treatment of PMNs did not change the respiratory burst or degranulation, while an increased trend in neutrophil extracellular traps-associated elastase and in the production of TNFα and CXCL8 was revealed. In parallel, DBV caused a delay in the apoptosis of MRSA-infected neutrophils. In conclusion, we demonstrated a cooperative effect between the antimicrobial properties of PMNs and DBV, thus owing to their immunomodulatory activity. In the choice of the treatment management of serious S. aureus infections, DBV should be considered as an outstanding option since it reinforces PMNs pathogen clearance capability by exerting its effect directly, not only on MRSA but also on neutrophils.Polymorphonuclear leukocytes (PMNs) are the most important cell type involved in the early nonspecific host response to bacterial pathogens.  Dalbavancin (DBV), a lipoglycopeptide derived from a teicoplanin-like natural antibiotic, interferes with the biosynthesis of the bacterial cell wall by binding to the terminal d-alanyl-d-alanine residues of peptidoglycan precursors with consequent inhibition of both transpeptidase and transglycosylase activities ,2,3. In Streptococcus pyogenes and Staphylococcus aureus, mainly the methicillin-resistant S. aureus (MRSA) strains [The most common pathogens involved in ABSSSIs are Gram-positive bacteria,  strains ,8,9. The strains ,8,10,11.Polymorphonuclear leukocytes (PMNs) are the most prominent cell type involved in the early, non-specific host response to invading microorganisms ,13,14,15S. aureus survival and persistence within PMNs greatly contribute to the pathogenesis and progression of staphylococcal infection [S. aureus has evolved several strategies to interfere with PMN functions essential for bacterial clearance. Specifically, S. aureus has been shown to inhibit neutrophil recruitment, phagocytosis and bacterial killing mediated by reactive oxygen species (ROS), antimicrobial peptides and neutrophil extracellular traps (NETs) production [S. aureus infections. In recent years, more studies have been focused on the influence of antibiotics on the function of host immune cells such as monocytes/macrophages and neutrophils [S. aureus and neutrophils are present in literature [Unfortunately, nfection ,21. S. aoduction ,17,22. Moduction ,24. Resttrophils ,26. For trophils ,28. In ftrophils . Howeverterature .To date, there have been no studies regarding the potential immunomodulating activity of DBV. Firstly, the aim of the present research was to investigate the DBV–MRSA–PMN interactions, and intracellular killing of MRSA was determined in the presence of DBV at different concentrations. Going forward, to distinguish between any separate effects of DBV on MRSA and/or PMNs, we investigated the susceptibility to the killing of DBV pre-treated MRSA and the functional activities of PMN pre-treated with DBV, including MRSA killing activity, viability, ROS production, degranulation, NETs and pro-inflammatory cytokine release.p < 0.05 or p < 0.001) enhanced the PMN killing capability, reaching values of ~50% (~SI = 1.50) within 90 min of incubation  and 0.5 µg/mL (2xMIC), on the intracellular killing activity of human PMNs towards MRSA at increasing timepoints , measured as survival index (SI) and as the corresponding killing percentage . In the cubation A, in comp < 0.001) improved to 41% (SI = 1.59), 50% (SI = 1.50) and 50% (SI = 1.50), after 30, 60 and 90 min of incubation. A comparable trend was revealed with 0.5 µg/mL DBV concentration.To differentiate between any separate effect of DBV on bacteria or PMNs, in vitro DBV pre-treatment experiments were also performed by exposing each of them to DBV for 60 min, before they were incubated together; thereafter, the intracellular killing activity was assessed. p < 0.001) saw a significant rise compared to controls reaching 59% (SI = 1.41) after 30 min, 56% (SI = 1.44) after 60 min, and 53% (SI = 1.47) after 90 min of incubations  and at the therapeutically achievable concentration of 25 µg/mL. After 4 h, cell viability was evaluated using the Annexin V FITC/Propidium iodide (PI) staining. As demonstrated in To verify if DBV can modulate ROS production by PMNs, we assessed the respiratory burst by flow cytometry, via DHR123 oxidation. Cells, pre-treated for 60 min with the antibiotic, were left unstimulated or stimulated with PMA or MRSA for 30 min. DBV does not modulate ROS production in resting neutrophils (data not shown). Whereas, the presence of DBV, both at MIC and plasmatic concentration, had a mild effect on ROS, following MRSA and PMA treatment .NETosis is an antimicrobial mechanism representing the release of NETs able to neutralize pathogens . The synTo understand if DBV might influence NETosis, cells were pre-treated with the drug, at MIC and plasmatic concentration, and then stimulated with PMA to induce NETs formation. An increasing trend in NET-associated elastase, although not significant, was observed in PMNs in the presence of DBV in both resting and activated cells A.In parallel, neutrophils were evaluated for degranulation, another important feature of PMN activity. Using flow cytometry analysis, the side scatter channel was used as an indicator of the granularity and internal structure of the cells. No difference in the presence of DBV was observed with respect to not stimulated and PMA-treated cells B.Finally, we evaluated the effect of the antibiotic on the release of the pro-inflammatory cytokines CXCL8 and TNFα by neutrophils. A significant increase in CXCL8 and TNFα was observed after PMA and MRSA stimulation. Cells pre-treated with DBV at the MIC value showed an increase in cytokines production, both in basal conditions and after stimuli activation. Cells pre-treated with DBV at the plasmatic dose released an amount of cytokines similar to those of not pre-treated cells A,B.milieu that is pivotal for an effective bacterial killing and degradation [Neutrophils represent the highest number of leukocytes in the human blood of healthy subjects, and they are considered the first line of immune protection after bacteria have penetrated into the epithelial barriers ,34. PMNsradation ,35,36,37radation ,35.S. aureus, a widespread Gram-positive bacterium, is a common commensal microorganism, but it can be responsible for a wide range of infections and inflicts a relevant burden on the healthcare system [S. aureus acquired the ability to escape neutrophil-mediated host defenses by altering neutrophil chemotaxis, phagocytosis and antibacterial activities [S. aureus survival inside PMNs facilitates the dissemination, causing infections distant from the initial site [S. aureus predisposition to develop antibiotic resistance and to escape the human immune effectors, mainly neutrophils, means a search is required for novel therapeutic regimens. In fact, diminished S. aureus susceptibility to glycopeptides, especially in MRSA strains, posed a challenge in antimicrobial availability [e system ,38,39,40tivities ,38,41. Fial site . The S. lability . In thislability ,4,42.The aim of the present research was to investigate whether dalbavancin could boost neutrophil antibacterial activities, by the in vitro evaluation of intra-MRSA killing activity, PMN viability, ROS production, degranulation and NETs and the pro-inflammatory cytokine release.Klebsiella pneumoniae, have an enhanced capacity to circumvent both phagocytosis and killing by human neutrophils [S. aureus killing by neutrophils [S. aureus with clindamycin or lincomycin causes an augmented susceptibility to phagocytosis and quicker PMN-induced killing [We observed that in the drug-free controls, human PMNs harvested from heathy subjects were partially unable to counteract staphylococcal growth, as demonstrated by decreasing killing values (from 33% to 12%) overtime. Notably, our results agree with works reporting that resistant microbial strains, such as MRSA and carbapenem-resistant trophils ,40,43,44trophils ; whereastrophils ,46. Here killing .S. aureus [S. aureus [Several studies discussed the challenge in discerning between the direct intracellular antibacterial effects of antibiotics that enter into PMNs and the effect of antibiotics on antimicrobial neutrophil functions against . aureus . Mandell. aureus . Similar. aureus , as for . aureus . Other r. aureus ,50,51,52As expected, when MRSA was pre-treated for 60 min with DBV, before the incubation with neutrophils, enhanced killing action was observed with killing percentages ranging from 41% to 50% at both MIC and 2xMIC DBV concentrations, if compared with untreated controls. These data agree well with those of Yamaoka T. (2007) and with our previous study ,54,55,56The most important data pertain to the experiments conducted by pre-treating PMNs with DBV at 0.25 µg/mL before pooling with MRSA: the obtained killing percentages were significantly higher, with respect to controls, reaching values of about 56%. These results indirectly demonstrated that DBV penetrates into the neutrophils and boosts their intra-MRSA killing capability.Notably, PMNs have a short lifespan and under homeostatic conditions undergo apoptosis to be removed by macrophages and avoid inflammation. Different works have evaluated the effect of antibiotics on neutrophil death. Healy D.P. et al. (2002) have demonstrated that clinical concentrations of eight different antibiotics, among which ceftazidime, gentamicin and ciprofloxacin were studied, had a modest but significant effect on the prolongation of survival . On the S. aureus-activated cells, the ROS production was less pronounced than in PMA-activated cells; however, DBV pre-treatment only modestly increased ROS generation. The role of ROS in S. aureus killing is debated and the bacterium can produce different virulence factors that inhibit ROS mediated killing [S. aureus virulence factor expression, which in turn may indirectly influence the activity of innate host defense peptides.Since ROS have been proposed to be correlated with bacterial killing, we explored ROS production in the DBV–neutrophils interaction. In  killing . Moreove killing . Since w killing . There h killing ,64. It istimulus often used to induce NETosis and degranulation in in vitro experiments [S. aureus, inducing NETs to eliminate the bacteria [S. aureus infection by inducing more entrapment and killing of the bacteria. These results are in line with ours, demonstrating a possible different effect on neutrophil functions, dependent on the antimicrobial mechanism of action. While NETs are important in innate immunity and resolution of infection, on the other end, an increase in NETs could represent a risk in stimulating autoimmune disorders. Therefore, an evaluation on the use of the antibiotics in some types of patients could be necessary to avoid detrimental consequences.NETosis is an alternative mechanism of bacterial killing that can be modulated by antibiotics . PMA is eriments . Here, weriments ,66; wherbacteria . Other cbacteria ,68; in pS. aureus and showed that the release of pro-inflammatory molecules was inhibited [Neutrophils represent a source of pro-inflammatory cytokines and chemokines, which can act in paracrine and autocrine ways to mediate the inflammatory process. CXCL8 acts to recruit immune cells to the site of infection and has an important role in neovascularization, while TNFα is important to induce acute inflammation and is implicated in neutrophil survival/apoptosis ,64. Thusnhibited . An immunhibited . The surnhibited . As we hA strain of MRSA clinically isolated, and frequently a cause of ABSSSIs , was pla6 cells/mL, and placed into sterile tubes containing RPMI 1640 added with 10% fetal calf serum (FCS). Before each experiment, the PMN viability, greater than 95%, was ascertained by trypan blue exclusion test [Healthy donors were subjected to collection of peripheral venous blood into lithium heparin tubes (15 UI LH/mL blood) and maintained for 30 min at room temperature in a ratio 1:1 with 2.5% dextran  prepared in buffered saline solution. The supernatant containing leukocyte-rich plasma was gently layered on Ficoll-Paque  and centrifuged twice . A 30 s hypotonic shock in sterile distilled water was performed to lyse erythrocytes and to obtain pure PMNs that were counted in a Bürker chamber , resuspended in phosphate buffered saline  to reach 10ion test ,55,56.The intracellular microbial killing exerted by PMNs against staphylococci (in a ratio of 10:1) in the presence of DBV (Sigma-Aldrich)—1xMIC, 0.25 µg/mL; 2xMIC, 0.5 µg/mL—was tested for 30, 60 and 90 min at 37 °C. Controls without DBV were also considered. The intraPMN killing values were measured, as punctually described in our previous works ,19 and eDBV-pre-treated PMN killing activity against MRSA and PMN killing activity against DBV-pre-treated MRSA were also tested. Briefly, PMNs or MRSA were independently incubated for 1 h with DBV (0.25 µg/mL or 0.5 µg/mL), and then bacteria or PMNs were added at 37 °C to permit phagocytosis for 30 min. The obtained PMN-bacterium mixtures were centrifuged  and washed with phosphate saline to remove the free extracellular bacteria. After that, the intraPMN killing was evaluated as above mentioned .At the end of the time killing, the culture supernatants of the pre-treated PMNs were stocked at −20 °C to determine the release of the pro-inflammatory cytokines (TNFα and CXCL8) analyzed by ELISA according to the manufacturer’s instructions  ,19.6 in 0.5 mL RPMI 10% FCS without antibiotics and pre-treated for 60 min with DBV at MIC and at 25 µg/mL, a dose within the therapeutically achievable plasma concentration (20–30 mg/L) [Purified PMNs were harvested in polypropylene tubes at a concentration of 1 × 1030 mg/L) ,71. The 6 in 0.5 mL RPMI 10% FCS without antibiotics were pre-treated in polypropylene tubes with different DBV concentrations (0.25 µg/mL and 25 µg/mL) for 60 min. Then, they were incubated with PMA (100nM), MRSA (10:1) or left untreated at 37 °C for 30 min with shaking. Subsequently, dihydrorhodamine 123 (DHR 123) solution (Sigma Aldrich), at a concentration of 30 μg/mL, was added to the stimulated and resting samples for 5 min. After centrifugation and two washes in PBS, the samples were resuspended in 1% paraformaldehyde to stabilize the cells and then analyzed by flow cytometry using BD FACSCanto™ II. A total of 10,000 events were collected for each sample and neutrophils were identified by their typical forward and sideward scatter characteristics [The ROS production was determined during the respiratory burst. Separated PMNs at 1 × 10eristics .6 PMNs were incubated with DBV (0.25 µg/mL or 25 µg/mL) for 60 min in 0.5 mL Hank’s Balanced Salt Solution  supplemented with 1% human serum albumin (Sigma Aldrich) and then treated with PMA (100 nM) for 30 min with shaking. The granularity degree of neutrophils was determined in the side scatter channel (SSC) after doublet discrimination and exclusion of dead cells using the LIVE/DEAD Fixable Violet stain (Thermo Fisher Scientific). Results are expressed as geometric mean fluorescence intensity (gMFI), which represents the cell density.Degranulation of separated PMNs was analyzed using BD FACSCanto™ II: 1 × 106) in 0.5 mL of RPMI base cell culture medium supplemented with calcium chloride (1 M) and 1% bovine serum albumin were incubated and pre-treated with 0.25 or 25 µg/mL of DBV for 60 min in a 24-well plate. Afterwards, the cells were stimulated with PMA (100 nM) for 4 h at 37 °C. After stimulation, neutrophils were washed to remove soluble neutrophil elastase that is not NET-associated. Next, 500 µL of nuclease (15 U/mL) was added to each well, incubated for 15 min at 37 °C and then inactivated by EDTA (500 mM). Supernatants were collected, centrifuged at 1200 rpm for 10 min and analyzed by NETosis Assay Kit as a release of neutrophil elastase , as indicated by the manufacturer’s instructions.Purified neutrophils (1 × 10The supernatants of PMNs pre-treated with DBV at MIC (0.25 µg/mL) or plasmatic concentrations (25 µg/mL) for 60 min and stimulated with PMA (100 nM) or MRSA (10:1) for 4 h, were collected to evaluate the cytokine release (CXCL8 and TNFα) by ELISA kit . The results are expressed as a percentage of release, with respect to untreated cells, considered as 100% .S. aureus still represents a key pathogen in determining severe human infections, and the increasing isolation of drug-resistant strains—mainly MRSA—in the clinical setting poses a challenge in the choice of treatment management. PMNs are typically underappreciated professional phagocytes, regarding the history and advancements of contemporary immunology, but they play a pivotal role in S. aureus clearance and in determining the fate of infection. Unfortunately, S. aureus is able to evade immune response by several escaping strategies, in particular by inhibition of neutrophil recruitment, phagocytosis and staphylococcal killing.S. aureus is not fully explainable by ROS and/or NET production, and suggests the involvement of oxidative independent mechanisms, or a DBV direct effect on the modulation of staphylococcal virulence factors.Therefore, we investigated the potential immune modulating properties of DBV on PMNs towards MRSA. Our results suggested that DBV acts in synergism with neutrophils by enhancing staphylococcal killing. The pre-treatment with DBV did not affect respiratory burst and degranulation, while at the MIC concentration, it upregulated the release of CXCL8 and TNFα, and increased NETosis. In addition, DBV at human plasmatic concentration determined a delay in PMN apoptosis in the presence of MRSA. The DBV action on the boosted neutrophils’ capability to kill resistant S. aureus infections, sustained also by multi-drug resistant strains. Actually, it performs a double effect by acting both on MRSA and PMNs, and by reinforcing their clearance capability after the uptake of the pathogen.Our observations highlighted that DBV should be considered as an outstanding therapeutic option for the management of serious


When the unexpected happens, such as a pandemic caused by a novel virus, governmental agencies, organizations, and experts in the field are rightly concerned that the paucity of available evidence may trigger unsubstantiated or erroneous recommendations. The harms of which can be exacerbated with today's massive spread of misinformation through unregulated social media or other trusted information sites, inevitably influencing frontline clinicians' and healthcare workers' behavior and practices. However, recommendations for clinical practices are essential for the prevention, detection, treatment, and management during a global crisis.In response to the COVID-19 pandemic, clinical and research experts, government agencies, and specialty societies immediately took action to provide guidance to their constituents on how to manage all aspect of the pandemic. Although well-intentioned, the rapid development and publication of consensus recommendations and expert opinions came at the expense of those affected by the pandemic. Lacking the rigor or foundation of evidence-based methods, these documents were at risk for selective reporting, unclear and ambiguous decision-making, and subjective interpretations of the limited evidence, sometimes driven by political views.During this period, many academic centers, societies, and organizations published trustworthy recommendations following gold standard methods; however, the challenge then becomes discerning between high-quality and potentially misinformed advice. During a period of such uncertainty, yet at the same time information overload, healthcare workers and the general population are forced to identify the best course of action with the lowest risk of undesirable consequences.In this edition of the Journal, Zhao et al. extensively reviewed COVID-19 guidelines published during the first year of the pandemic, in 2020. Out of hundreds of publications making recommendations, 92 clinical practice guidelines (CPGs) fulfilled minimal criteria for inclusion by presenting management recommendations for COVID-19. Using a rigorous systematic review methodology, the authors meticulously examined adherence to reporting standards (RIGHT statement) .The quality of CPG development ratings is expected to be somewhat lower initially in a pandemic when organizations try to rapidly develop recommendations. This is because certain elements may be less feasible in a short time frame, such as consumer or patient involvement or extensive public comment. The authors found this to be true with an initial overall rating percentage in the low 30s across assessment domains. While this rating reflected limitations to the aforementioned areas, it is of concern that even basic elements such as adequate financial conflict of interest (COI) management appeared to be lacking in more than three-quarters of examined CPGs. More than 70% of CPGs did not assess the quality of the underlying evidence nor did they provide a rating of the strength of the recommendation. For guidelines to be trustworthy, it is generally accepted that clinicians need to be informed about limitations of the evidence that may impact whether desired consequences actually outweigh any undesirable consequences. It is important to note the authors' finding that the quality of CPGs appeared to improve over time during 2020.Despite the IOM's criteria from 2011, less than 10% of the examined CPGs used a systematic review process to inform their recommendations . SelectiIt is likely that at least some of the guideline developers believed that because of the time pressure to develop guidance quickly, a traditional development process would have failed. However, resources to specifically support rapid reviews are available that can successfully guide development teams in the necessary steps to develop methodologically rigorous guidance documents in a time of crisis .Not surprisingly, factors associated with an increased quality score included an evidence-based development process, COI management, and using a rating system for the certainty in the evidence and strength of recommendations, such as GRADE framework. GRADE provides international recognition of desired methodological principles that have been carefully developed, transparently documented, and rigorously tested . It is aThe authors also showed that the timeliness of incorporating evolving evidence  was variable, and it appeared that some CPGs did not have the mechanism in place to provide timely updates to their guidance when the effectiveness for interventions had been established. The introduction of “living” reviews and guidelines published in a web-friendly format has largely solved the need for continuous updating in response to the availability of the rapidly changing evidence during a pandemic .https://covid19.recmap.org) exist to provide a continuously updated, interactive map of COVID-19 recommendations. COVID19.recmap.org organizes management recommendations by intervention and presents assessments of the rigor of development. These resources, coupled with studies assessing adherence to gold standard guideline development criteria, will reduce barriers to access for frontline clinicians, policy makers, and the public, as well as assist end-users in discerning high-quality recommendations to make well-informed decisions for health interventions. We hope that raising awareness and providing strategies for development and maintenance of trustworthy guidelines in situations of both limited and quickly evolving information will restore the public's confidence in health recommendations far beyond the reach of the pandemic.Furthermore, newly developed web resources (e.g. Yngve Falck-YtterRebecca L. Morgan


Altered long non-coding RNAs (LncRNAs) exert pivotal parts in pathogenic processes in glioma. Here, we uncovered a differentially expressed long intergenic non-coding RNA 1088 (LINC01088) in glioma and elucidated the molecular mechanism by which LINC01088 affected the malignant phenotypes of glioma cells. Functionally, LINC01088 silencing degraded cell proliferation, invasion in glioma, while LINC01088 overexpression elicited opposite results. Mechanistically, we verified LINC01088 physically interacted with small nuclear ribonucleoprotein polypeptide A (SNRPA) and regulated the expression of SNRPA at the transcription level. Phenotypic analysis ascertained that LINC01088 substantively aggravated glioma cell progression in an SNRPA-dependent manner, and SNRPA played a pivotal part in the tumor-promoting properties of LINC01088. Our findings revealed a novel mechanism by which LINC01088 exerted pro-oncogenic functions through binding with SNRPA and transcriptionally regulating SNRPA mRNA in glioma.  Glioma remains the prevalent primary intracranial tumor in the brain . CurrentDysregulated transcripts including LncRNAs can be the primary characteristic in cancers ,5. LncRNvia modulating microRNA-24-1-5p (miR-24-1-5p) 316). Excised tumor tissues were subjected to immunohistochemistry (IHC) staining as previously described [Hundred microliters of T98G cells . Analyses of association between LINC01088 or SNRPA and clinicopathological features of patients with glioma were performed using the Mann-Whitney U-test. Pearson’s correlation test was used to determine the correlation between LINC01088 and SNRPA. This study aimed to reveal the expression level, biological significance, and potential mechanism of LINC01088 in glioma. We demonstrated that LINC01088 was upregulated in glioma tissues and cell lines. Mechanistically, LINC01088 exerted the pro-oncogenic functions through binding with SNRPA and transcriptionally regulating SNRPA mRNA in glioma. Overall, this study verified the function and mechanism of the LINC01088/SNRPA regulatory axis in glioma.via the Gene Expression Profiling Interactive Analysis (GEPIA) website (http://gepia.cancer-pku.cn/index.html), we observed that the level of LINC01088 was tremendously elevated in glioblastoma multiforme (GBM) and brain lower-grade glioma (LGG) tissues in comparison to nontumor samples  were transfected into T98G and U251 cells . sh-LINCEmerging studies have reported that lncRNAs interact with DNA or RNA binding proteins (RBPs) and finally promote tumor progression. To unravel the molecular mechanism by LINC01088 in glioma, the catRAPID algorithm was utilized to seek the potential RBPs of LINC01088. Among those RBPs, SNRPA possesses the highest interaction strength with LINC01088 . With thTo elucidate the biological effect of LINC01088-SNRPA interactions and examine whether LINC01088 affects SNRPA expression, we transiently transfected a LINC01088-expression vector (oe-LINC01088) into U251 and T98G cells . We founSince SNRPA expression is regulated by LINC01088 in a transcriptional manner, we presumed SNRPA might be a critical element for LINC01088 in glioma progression. Coincidently, co-transfection of sh-SNRPA abated the LINC01088-upregulated SNRPA mRNA level and expression in U251 cells . Conversin vivo , and RBPs ,23. We iIn rescue assay, after SNRPA was knocked down in LINC01088 over-expression cells or SNRPA overexpression in LINC01088-downexpressing cells, the growth and invasion trends were reversed. As a result, LINC01088 effectively induces glioma cell growth and invasion in an SNRPA-dependent manner, and SNRPA mediated the pro-tumorigenic efficacy of LINC01088. Our study also shown the LINC01088 level is positively correlated with SNRPA level in glioma. Nuclear genes bind to the promoter regions of distinct target genes, upregulate gene expression, and promote cancer cells metastasis. In spite of a study that has confirmed nerve growth factor (NGF) gene acts as a functional downstream effector of SNRPA and is essential for SNRPA modulated gastric cancer cells growth . Whetherin vitro and in vivo. LINC01088 physically binds SNRPA and SNRPA is implicated in the tumor-promoting properties of LINC01088 in glioma.In sum, we uncovered an upregulated lncRNA, LINC01088 in glioma. LINC01088 deletion inhibits glioma progression both Click here for additional data file.


The precise location and role of all types of hydroxyls in zeolites are still enigmatic, and their control permits tailoring of novel properties increasing the efficiency of catalysts and adsorbents in industrial processes for cleaner energy. Often referred to as bridged hydroxyls [Si–O(H)–Al], they are formed when a proton is bound to one of the oxygens adjacent to an aluminum. This hydroxyl group is at the heart of the remarkable properties of zeolites in acid-catalyzed reactions, as these sites and the reactants are confined in a well-defined molecule-sized environment. Other hydroxyl groups called silanols [Si–O(H)] are also present in the zeolite structure and their role is still not fully understood. Both the BAS and silanols are considered as defects of zeolite framework structures yet they hold the key to transforming inert perfect pure-silica frameworks such as quartz into chemically active materials.The ideal crystalline framework of zeolites is perturbed by hydroxyl groups. In pure silica zeolites the framework is neutral, however, the introduction of AlBAS and silanols have been investigated for decades, during which time different characterization methods were employed in order to optimize the properties of zeolite-based catalysts, and will continue to intrigue researchers for years .Various direct and post-synthesis approaches have been developed either to create or heal BAS or silanol groups in zeolites. Synthetic control of the distribution of Al in high-silica zeolites is critical due to the enormous number of Al arrangements and their effect on the catalytic performance of zeolites . The disThe main techniques used to characterize hydroxyls in zeolites are X-ray diffraction and infrared (IR) and nuclear magnetic resonance (NMR) spectroscopy . TheoretSilanols present a different but equally important type of hydroxyl group because they can act as sites for further functionalization, i.e. introducing metals into the zeolite framework . Post-syThe properties of BAS are one of the major concerns when it comes to designing zeolitic catalysts . Regardi transitional states of reactive intermediates in the confined void; this is described as the solvation effect . At relaBesides acidic activity, hydroxyl groups play a key role in bifunctional catalysts by providing anchor points to disperse metals .The understanding of hydroxyls in acidic catalysts is continuously progressing; the constant evolution of synthesis and characterization methods will undoubtedly reveal more about the role of silanols in catalysis and allow tuning of new active sites. For example, Lewis Acidic sites possessing hydroxyl groups may arise from the formation of extra-framework Al species that canin situ and operando techniques. Considering the above statements, several additional questions need to be answered: how do silanols impact the local and extended environments of BAS? Is there a synergetic effect between silanols and neighboring BAS upon activity or hydrogen mobility?exist in different oxide and hydroxide forms . Still, 2 emissions.From this, we can clearly see that hydroxyls in zeolites demand further understanding. They belong to the ‘Zeolite Crystal Engineering’ toolbox for designing new materials for catalysis and adsorbents. Advances in the understanding of hydroxyls in zeolites will provide endless opportunities for discovering zeolites with original properties not previously known Fig. . In the


Evidence-based practice (EBP) means integrating the best available scientific evidence with clinical experience and patient values. Although perceived as important by many psychotherapists, there still seems to be reluctance to use empirically supported therapies in clinical practice. We aimed to assess the attitudes of psychotherapists in Austria toward EBP in psychotherapy as well as factors influencing the implementation of EBP. We conducted an online survey. To investigate attitudes toward EBP, we used two subscales  of a translated and validated short version of the Evidence-Based Practice Attitude Scale-36 (EBPAS-36). Participants provided perceived barriers and facilitators as answers to open-ended questions. We analyzed the responses mainly using descriptive statistics. Open answers were analyzed using a thematic analysis. In total, 238 psychotherapists completed our survey . Psychotherapists scored on average 2.62 (SD = 0.89) on the reversed EBPAS-36 subscale “Limitations,” indicating that the majority do not perceive EBP as limiting their practice as psychotherapists. They scored 1.43 (SD = 0.69) on the reversed EBPAS-36 subscale “Balance,” indicating that psychotherapists on average put a higher value on the art of psychotherapy than on evidence-based approaches. Organizational factors such as lack of time and access to research studies as well as negative attitudes toward research and a lack of skills and knowledge kept respondents from implementing EBP. Our study highlights that EBP is still not very popular within the psychotherapy community in Austria. The academization of psychotherapy training might change this in the future. This approach has been internationally widely implemented in the medical field medicine since its introduction in the 1990s. In other health professions such as psychotherapy, EBP is still quite a novel concept2. Although EBP has many benefits, and research has shown that implementing EBP can improve clinical outcomes in psychotherapy compared to usual care5, many psychotherapists remain skeptical whether it is useful in the field of psychotherapy2.Evidence-based practice (EBP) means integrating the best available scientific evidence with clinical experience and patients’ values or preferences7. However, many perceive such evidence as less influential than other sources of information, such as clinical experience or advice from colleagues8. Studies have also reported low use of empirically supported therapies in clinical practice14. Cook et al. summarize a range of potential barriers to implementing EBP in clinical practice. One major barrier was a negative attitude toward controlled research studies or evidence-based manuals, which are perceived as lacking applicability to real-world settings as well as providing limited flexibility to tailor therapies to individual patients15. Gaudiano et al. showed that, in particular, psychotherapists who tend to rely on their intuition and perceive psychotherapy as more of an art than a science refuse to implement an evidence-based approach in practice16. Other barriers were lack of time, lack of training, institutional constraints , or that an evidence-based approach was not in accordance with the therapeutic philosophy already in place15.Surveys have shown that, in general, most psychotherapists think that evidence from research studies is relevant to their practice17. Resistance was also more prominent in older practitioners who received their diplomas before EBP entered the field of psychotherapy than in younger ones18.Barriers to implementing EBP in psychotherapy varied with clinicians’ characteristics. Practitioners with more professional education had more favorable attitudes toward EBP than those with less education19, which can be summarized into four psychotherapeutic orientations: psychodynamic, humanistic, systemic, and behavioral. Although educational programs at some training institutions have integrated EBP into their curriculum within the last few years, many psychotherapeutic schools accredited in Austria still do not fulfill the criteria to be regarded as evidence based.Austria has a long tradition of psychotherapy going back to the 1920s and a wide range of established psychotherapeutic schools of thought. Psychotherapists can choose from 23 accredited psychotherapeutic schools in AustriaQuestion 1: What are the attitudes of Austrian psychotherapists toward EBP?Question 2: Do psychotherapists’ attitudes toward EBP vary by age, gender, psychotherapeutic orientation, years of experience, professional status (licensed or in training), setting, and patient group ?Question 3: How much time do psychotherapists spend informing themselves about the latest research in their specialty, and what information sources do they use?Question 4: What factors act as barriers when working according to EBP standards, and what could be facilitators?The aim of our study was therefore to assess the attitudes of psychotherapists in Austria toward EBP in psychotherapy. Specifically, we wanted to answer the following research questions:20. The current study was part of a larger study previously published by Humer et al. examining the provision of psychotherapy in Austria one year after the onset of the COVID-19 pandemic21. We received approval from the ethical review board of the University for Continuing Education Krems (EK GZ 23/2018–2021); the study was not registered elsewhere. The ethical review board of the University for Continuing Education Krems provided guidelines on study conduct as stated in Section IX § 2 of the Statutes of the University for Continuing Education Krems and we adhered to them. Throughout the manuscript, we adhere to the CHEcklist for Reporting Results of Internet Surveys (CHERRIS) guidelines for online surveys22.To answer our research questions, we conducted an online survey comprising 40 items in total using REDCap Psychotherapist is a licensed profession in Austria. Psychotherapy training is offered by institutions accredited by the Austrian Federal Ministry of Social Affairs, Health, Care and Consumer Protection. An institution can be accredited for one or multiple therapeutic approaches. Training is regulated by the Austrian psychotherapy law and comprises two parts: first 765 h of lessons in theory and 550 h of practical training, second 300 advanced lessons in theory and 1600 h of practical training. Persons who are at least 28 years old and who have completed the required training are allowed to work as psychotherapists in Austria. Most psychotherapist, in addition to their psychotherapy training have training in another professional field such as psychology, medicine, or social work. However, an additional profession is not a prerequisite. The Austrian Federal Association for Psychotherapy  supported recruitment for this study by sending their members an information e-mail. In addition, all licensed Austrian psychotherapists who are registered with the Austrian Federal Ministry of Social Affairs, Health, Care and Consumer Protection as psychotherapists and who had provided a valid e-mail address  were invited to participate in the survey.24. The “Limitations” subscale assessed whether EBP is perceived as useful in working with clients or as too narrowly focused or not individualized enough. The “Balance” subscale assessed whether psychotherapy is perceived as more of an art than a science, or whether it is both, and whether psychotherapists perceive their competence as a therapist as more important than a particular approach. We also asked psychotherapists about the proportion of time they spend informing themselves on the current evidence in their field. Finally, we asked three open-ended questions about the sources used for finding research evidence as well as the perceived barriers and facilitators that influence the individual implementation of EBP.Assessing the attitudes toward EBP was part of a larger study for which we developed a German-language questionnaire that comprised the following thematic areas: provision of psychotherapy in face-to-face contact, via telephone or internet, self-assessment bias, and attitudes toward EBP. First, we asked about age, gender, patient group treated , experience (licensed vs. in training), setting , and therapeutic orientation . Second, to investigate attitudes toward EBP, we used two subscales  of a translated and validated short version of the Evidence-Based Practice Attitude Scale-36 (EBPAS-36)Before starting the survey, two team members pretested its usability and technical functionality. We conducted the survey between February 16, 2021 and April 2, 2021 by sending out one general link. We included only completed surveys in our analysis to avoid multiple entries from the same person . The data collection was anonymous, and the data was stored in REDCap because this allowed us to store data on a local campus server and to be in compliance with European data protection legislation.23. Therefore, users of the scale reverse the ratings of the “Limitations” and “Balance” subscales to compute an overall score. Although we did not calculate an overall EBPAS-36 score, we reversed the ratings of the two subscales to make our results comparable with the results from other studies. To assess the mean proportion of time psychotherapists spend on informing themselves about the latest research in their specialty, we calculated the mean and SD. We presented the sources searched by psychotherapists as proportions. To explore differences in attitudes between gender, patient group , and professional status (licensed vs. in training), we used independent t-tests, with a significance level of p ≤ 0.05. To explore the mean differences in attitudes among multiple groups (psychotherapeutic orientation and setting), we calculated a one-factorial analysis of variance (ANOVA) after Kruskal–Wallis and corrected for multiple testing within this comparison using the Bonferroni correction. Due to the exploratory nature of the analysis, we did not correct for multiple comparisons across the different tests. We calculated Pearson coefficients to assess correlations between age as well as years of experience and the two EBPAS subscales “Limitations” and “Balance.” We completed all calculations in IBM SPSS Statistics Version 26 for Windows .We analyzed the responses mainly using descriptive statistics. For the outcome “evidence-based practice attitude,” we calculated the mean scores and standard deviations (SDs) of the “Limitations” and “Balance” subscales of the EBPAS-36. These subscales comprise three items; each can be rated from 0 to 4 points. A higher score on the “Limitations” and “Balances” subscales indicates a more negative attitude toward EBP. Considering all items in the EBPAS-36, most are worded in a way where a higher total score indicates a more positive attitude toward the adoption of EBP26. We assigned initial codes to the responses and combined similar codes into subthemes and overarching themes. One researcher performed the initial coding. Two researchers independently combined similar codes into subthemes and overarching themes. The interim results were discussed and revised with another researcher to corroborate the findings. We calculated the interrater reliability of the two researchers when grouping the codes into themes.Psychotherapists were asked to name one or more factors that hinder or facilitate their implementation of EBP. We analyzed the answers using an inductive thematic analysisWe received approval from the ethical review board of the University for Continuing Education Krems (EK GZ 23/2018–2021). Participants were informed about the aim of the study and were guaranteed that all given information will be presented in an anonymized way. Participation in the survey was voluntary, and we did not offer any incentives for completion. To access the survey, participants had to provide informed consent and agree to the data protection declaration (electronic informed consent).In total, there are more than 10,579 licensed psychotherapists in Austria (July 2021), and 238 completed our survey (17 were not yet licensed but in training under supervision). Their mean age was 51.0 years (SD = 9.9) and three-quarters were female. The majority (92.9%) were registered psychotherapists with a median of 11 years of experience (1–36 years); the other 7.1% were psychotherapists in training. Three-quarters worked in a single workplace, the others in two (24%) or even three in parallel (1%). Most psychotherapists worked in private practice (97.9%), 20.2% in an outpatient clinic setting, and 8.4% in an inpatient setting. Half of the participants worked exclusively with adults, and the other half with adults, children, and adolescents (see Table Psychotherapists scored on average 2.62 (SD = 0.89) on the reversed EBPAS-36 subscale “Limitations,” indicating that the majority do not perceive EBP as limiting their practice as psychotherapists. Nearly half of the respondents consider EBP as useful for clients with multiple problems. Two-thirds of psychotherapists think EBP allows for individualized treatment. More than half of the participants stated that EBP is not, or is only to a slight extent, too narrowly focused  on the reversed EBPAS-36 subscale “Balance,” indicating that psychotherapists on average put a higher value on the art of psychotherapy than on evidence-based approaches. Most respondents think their competence as a therapist is more important than a particular approach. However, nearly all agreed, from a moderate to (very) great extent, that therapy is both an art and a science  worked in private practice, and too few representatives worked solely in outpatient or inpatient clinics.On average, psychotherapists stated they spend 16.0%  of their working time informing themselves on the current evidence in their field. The majority of the 238 respondents sought information by exchange with colleagues (97%) followed by education (92%) and attendance of scientific congresses (70%). About 55% subscribe to German scientific journals, 42% read systematic reviews, 36% use guidelines and manuals, and 19% subscribe to international journals. Forty percent also use other sources of information such as theses, libraries, online databases , search engines , websites from professional associations, websites from colleagues, YouTube videos, and Wikipedia.Organizational factors such as lack of time and lack of access to research studies as well as negative attitudes toward research and a lack of skills and knowledge kept respondents from implementing EBP. The interrater reliability of the two coders was 88% (93/106 codings).We identified three major barriers. Organizational factors such as enough time, easy access to studies, and support from the team or organization helped psychotherapists implement EBP. Participants also named external input such as conferences or trainings as helpful. In addition, exchange with others, good packaging of the evidence, and the need to use evidence for work were considered facilitators of EBP. On an individual level, a positive attitude as well as knowledge and skills helped practitioners use an EBP approach. The interrater reliability of the two coders was 86% (190/222 codings). Table We identified seven major facilitators. 9. However, the belief that therapy is more of an art than a science and that overall competence is more important than science was more prominent in our sample than in other countries such as Germany, Norway, and the United States23. A potential explanation could be that in Austria psychotherapists do not need to complete an academic education. Learning how to plan, conduct, or use studies is underrepresented in their education. In addition, not all accredited psychotherapeutic orientations in Austria fulfill the criteria to be evidence-based, while in Germany, for example, only evidence-based psychotherapeutic orientations are accredited and eligible for reimbursement27.To the best of our knowledge, this is the first study assessing attitudes toward EBP, information-seeking behavior, and barriers and facilitators for implementing EBP in psychotherapy in Austria. Although psychotherapists mostly perceive EBP as an important aspect of psychotherapy, they think that their experience and competence is more important than following a specific evidence- or manual-based approach. These findings are in line with the results from other studies that indicate a reluctance to implement an evidence-based approach in clinical practice within the field of psychotherapy28. Additionally, it remains unclear whether all colleagues are experts in their field. It seems necessary to raise awareness within the psychotherapy community that expert opinion is not enough to implement EBP. Such opinions are subjective and have a high risk of being distorted by confirmation bias—the tendency to search and interpret information in a way in which it supports one’s own beliefs—and, therefore, are not sufficient to foster transparent EBP29.Respondents named colleagues as the major source of information, while guidelines and systematic reviews were used by about one-third of respondents. In EBP, expert opinions are, although important, considered to be the lowest level of evidence16. Most often, they named lack of time as a barrier. The second aspect might be aligned with the participants’ perceived lack of knowledge and skills and the lack of access to evidence (research results). Providing more trainings and integrating courses into psychotherapy curricula to build capacity in EBP as well as more support from academic institutions  could help overcome these barriers.Psychotherapists in Austria reported the same barriers to implementing EBP as international studies18. We could also identify this correlation with age in our sample. However, this could be due to a lack of training in EBP or due to a general lack of experience in searching for information online, not necessarily because of resistance to EBP.On an individual level, some psychotherapists had negative attitudes toward EBP. They stated they distrusted study results and did not see the applicability to their individual patients and, therefore, did not perceive evidence from studies as helpful to their work. Enabling psychotherapists to implement meta-skills such as finding trustworthy sources and critically appraising and interpreting study results could help overcome this distrust. In a study from 2006, the findings showed that resistance to EBP was more prominent in older practitioners who received their diplomas before EBP entered the field of psychotherapy than in younger onesBesides the more obvious facilitators such as more time, easier access to evidence, and better knowledge and skills, we also identified novel facilitators that should be considered in the field of psychotherapy. Participants mentioned that presenting evidence in a more user-friendly way, such as translating research results into lay language or combining them with practical examples, would help them use research results for their individual patient work. Instead of needing to search for evidence (pull approach), receiving evidence via newsletters or congresses (push approach) was also perceived as useful. Producers of evidence should consider this in their dissemination and knowledge translation activities. Further, if colleagues and employers support an EBP approach, this helped individual psychotherapists implement it.Assessing the attitudes toward EBP was part of a larger study. The complete survey aimed to answer multiple research questions and therefore consisted of 40 items. To make completing the survey feasible, we decided to focus on two subscales of the EBPAS-36 instead of using the entire tool. We chose the two subscales that seemed most important for the Austrian context and believe that the results give important insights into the attitudes toward EBP in Austria.30.Another limitation is the uncertainty about how representative our results are. Only a small proportion of eligible psychotherapists participated in the survey, and since we did not draw a random sample, the self-selection of participants might have influenced the sample. While the gender distribution is representative for Austria, the psychiatric orientation is not. In our sample psychotherapists with a humanistic orientation are overrepresented (50% vs. 38%) while those with psychodynamic (16% vs. 26%) is underrepresented31. In general, Austrian psychotherapists rated psychotherapeutic interventions such as psychodynamic, humanistic, systemic, cognitive, behavioral interventions as less typical for tele-psychotherapy than for face-to-face psychotherapy during the pandemic32. Moreover, differences between therapeutic orientations in behavioural-oriented interventions—which have the most evidence-base in the context of psychotherapy—have been shown to become less prominent in tele-psychotherapy as compared to face-to-face psychotherapy in Austria during the pandemic32. In addition, we cannot rule out that participants provided socially desirable answers , although we guaranteed full anonymity to all participants.The survey was conducted during the Corona virus pandemic, which might have had an influence on the perception of evidence-based practice as evidence-based medicine was a prominent topic during COVID-19. It should also be kept in mind that most Austrian psychotherapists changed the treatment format for the first time from face-to-face psychotherapy to tele-psychotherapy  due to COVID-19 related restrictions16. In particular, the identified barriers are in accordance with those reported in other studies, indicating that there are common issues across countries, which likely makes our findings of interest to many countries. The focus on Austria can also be a strength since it homogenizes the results and allows for comparisons between different countries.We focused on Austrian psychotherapists in our sample, compromising the generalizability of our findings to other countries. However, the findings are generally in line with the existing researchWe used open-ended questions to collect information about barriers and facilitators for the implementation of EBP. Other qualitative research techniques, such as interviews or focus groups, might have offered us even more in-depth insights; however, they would not have been feasible in such a large sample. Therefore, we are confident that our approach helped us identify the most important barriers and facilitators among Austrian psychotherapists, with the additional benefit that the results are more representative because they are based on a large sample.Our study highlights that EBP is still not very popular within the psychotherapy community in Austria. Soft skills such as experience, competence, and the personality of the psychotherapist are perceived as more relevant to successfully treating patients than following an evidence-based approach. The combination with other perceived barriers such as organizational constraints and lack of knowledge/training in EBP methods may currently still prevent the broad application of EBP in Austria. The academization of psychotherapy training might change this in the future.


Perianal fistulas in Crohn's disease (CD) are often recurring and challenging to treat. This systematic review aimed to evaluate the medical, surgical, and combination treatment options and provide an overview of their efficacy. We performed this systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Our group searched PubMed, Medline, PubMed Central, Google Scholar, and ScienceDirect for articles within the last ten years using different terms and criteria mentioned in detail in the search strategy and eligibility criteria sections. Initially, 739 records were retrieved, out of which we excluded 731 records for various reasons, such as irrelevant titles and abstracts and low scores on quality assessment tools. The evidence for combination  therapy is superior to that for medical and surgical treatments individually. In contrast, the studies on medical and surgical treatments individually reported varied evidence and efficacy for their respective options. Crohn's disease (CD) is a chronic disease characterized by transmural inflammation, which can involve the entirety of the gastrointestinal tract from mouth to anus . AccordiPerianal fistulas are a source of additional morbidity in CD patients. They can lead to the following symptoms: localized pain, discharge, and local tissue destruction, eventually leading to sphincter dysfunction . In addiDespite all these treatment options, healthcare providers still face several issues when attempting to treat perianal fistulas in CD. The effectiveness of medical therapy is limited as almost two-thirds of patients relapse after its cessation . In addiDue to the challenging aspects of maintaining remission in these patients and the emergence of newer drugs and procedures with differing levels of evidence supporting them, there is still no agreed-upon high-quality treatment regimen for perianal fistulas in CD. In light of this, we performed a systematic review to assess the various treatment options available and provide an overview of the current evidence.MethodsWe performed This systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines .Eligibility CriteriaThe characteristics of the studies we searched were: Full-text papers, papers published between 2012 and 2022, studies performed on human subjects, studies in the English language, study designs including meta-analyses, clinical trials, randomized control trials, systematic reviews, and case reports.Search StrategyIn order to gather articles relevant to the topic, two reviewers thoroughly searched the following databases . We performed the last search on April 14, 2022. Table Quality AssessmentTable ResultsSeven hundred thirty-nine records were identified from three databases: PubMed, Medline, Pubmed Central, Google Scholar, and ScienceDirect. We screened the first 300 articles from Google Scholar, the first 50 articles from ScienceDirect, and all 389 articles from PubMed, Medline, and PubMed Central, and we removed 15 articles as they were duplicates. In addition, we excluded 634 more articles for various reasons. Firstly, we removed articles with titles that did not include perianal fistulas on CD. Secondly, we removed articles with abstracts that focused on topics other than the treatment of perianal fistulas in CD. Thirdly, we excluded articles initially written in languages other than English. Finally, two independent reviewers assessed the remaining 35 articles for eligibility and excluded 27 as they did not achieve a 70% score on their respective quality assessment tools. After this process, we chose eight final articles and included them in this systematic review. This process is outlined in Figure This study investigates multiple treatment modalities within the medical and surgical disciplines, and naturally, the effectiveness of and evidence supporting these treatment options vary. Table DiscussionThe treatment of perianal fistulas in CD is complex and requires a multidisciplinary team; therefore, the discussion will focus on exploring the various treatment options within medical, surgical, or combination regimens.Medical TreatmentsAminosalicylates and corticosteroids: When used to treat perianal fistulas in CD, corticosteroids have shown no efficacy in improving the disease and have also increased discharge and the number of surgical consultations . SimilarAnti-tumor necrosis factor drugs: Out of all medical therapies, this class of drugs has the most convincing statistics supporting its role in treating perianal fistulas in CD. In a meta-analysis evaluating the efficacy of medical therapies in perianal fistulas in CD, anti-TNF drugs have been shown to increase the rate of therapeutic induction by 1.5 times and double the rate of remission and maintenance of therapeutic response . Data coAntimicrobials: The role of antimicrobials (ciprofloxacin and metronidazole) in the treatment of perianal fistulas in CD contributes to improving the fistula itself and managing septic complications that accompany it ,7,11. HoThiopurines: The evidence supporting thiopurines is lacking, and it points to them either having a moderate or no effect on perianal fistulas in CD when used alone ,6. Most  Ustekinumab is a monoclonal antibody that exerts its action by antagonizing the shared p40 subunit of interleukins 12 and 23 [Ustekinumab:2 and 23 . Promisi2 and 23 . Another2 and 23 . In conc2 and 23 .Vedolizumab: This drug is a monoclonal antibody that targets a4b7 integrin, which blocks the migration of T-cells into the gastrointestinal tissue . Much liSurgical TreatmentsAbscess drainage: Abscess drainage is commonly used in practice by physicians, and it aims to facilitate drainage of perianal abscesses, which usually coexist with perianal fistulas in CD. The goal of this intervention is to decrease the risk of septic complications which may be enhanced by administering immunomodulatory drugs . The most supported use of this treatment modality is to facilitate long-term drainage and promote healing [Setons: healing ,5. One s healing ,5,10. In healing . Due to  healing ,11. In c healing ,10. This procedure has the potential to cause incontinence; therefore, it is used cautiously and reserved for symptomatic, superficial, low (inter-sphincteric/chosen trans-sphincteric) fistulas where the risk of incontinence is low [Fistulotomy:e is low ,10. Genee is low . Figure Advancement flap: This technique aims to cover the internal fistula orifice with a flap derived from rectal mucosa. The goal is to close the fistula while sparing the sphincter system . It is rLigation of inter-sphincteric fistula tract: This surgical procedure ligates the mature, fibrotic tract of trans-sphincteric fistulas . The stuStem cell therapy: Due to their effectiveness in regulating immune cells, mesenchymal stem cells (MSC) have been considered a potential treatment option for perianal fistulas in CD . A systePlugs: A systematic review assessing surgical treatments for perianal fistulas in CD found a significant variation in the rates of favorable outcomes after fistula plug use, stretching from 15% to 86% . FurtherFibrin glue: A consensus has not been reached on the use of this modality. Two systematic reviews state that glues have either become obsolete or were not recommended in the first place, citing poor healing as a cause ,10. A syVideo-Assisted Anal Fistula Treatment (VAAFT)VAAFT is a relatively newer surgical technique that treats anal fistulas by attempting to achieve three goals. Firstly, a fistuloscope is inserted into the main track's outer orifice to identify and electrocauterize secondary tracks. Secondly, the inner orifice is sealed utilizing an advancement flap. Thirdly, removal of the main track is done when plausible . Data onOver-the-scope clip (OTSC): OTSC is another recently introduced procedure, which accounts for data sparsity on its use. For example, one case series reported on the use of this technique in 10 patients, six of whom had Crohn's trans-sphincteric fistulas. The study reported that all but one of the patients had successful results after a mean follow-up time of 230.5 days [Stoma and proctectomy: These two procedures are often interlinked when it comes to the treatment of perianal fistulas in CD. Their use is usually restricted to highly complex and severe cases of fistulizing CD . It is nCombined therapy: The presence of many treatment options with varying combinations and evidence levels supporting their use is one of the major roadblocks in formulating a concrete algorithm for managing perianal fistulas in CD. However, the evidence favors a combined medical and surgical regimen over only a medical or surgical regimen alone ,11. For LimitationsThis study is limited by the lack of data comparing individual surgical treatment modalities to each other and a lack of high-quality evidence for some of the surgical techniques. Moreover, specific indications for the use of surgical procedures are poorly defined. The conclusions for medical treatments were more definitive than those of surgical treatments, with studies having more decisive statements on individual options such as anti-TNF drugs, antimicrobials, and thiopurines. On the other hand, this was not the case for evidence on ustekinumab and vedolizumab, where the need for larger studies was highlighted to support their efficacy. Like many researchers investigating this topic, we faced the issue of clinical heterogeneity. It can often be challenging to select a cohort of patients with similar demographics, disease severity, and type of fistula. There were also differences in outcome measures and time of follow-up. The studies on combination therapies focused on the setons and anti-TNF drugs and did not incorporate other combinations of the many available treatment options.In conclusion, the treatment for perianal fistulas in CD remains challenging for physicians due to the availability of a plethora of treatment modalities with a mixed level of evidence supporting them. From medical treatment options, anti-TNF drugs were supported and agreed upon as either a monotherapy or adjunct to other medical or surgical treatments. Antimicrobials have an essential role in sepsis management and as an adjunct to anti-TNF drugs or thiopurines. Ustekinumab and vedolizumab have shown some promise, but larger studies are needed to establish their use truly. Surgical modalities with the most established and agreed upon use include abscess drainage to prevent sepsis and setons as a palliative option. Fistulotomy carries a risk of incontinence; hence, it should be implemented with caution in those with an elevated risk of this complication. Advancement flap use is recommended when used with immunotherapy/anti-TNF drugs, but its use is not possible when the fistula tract is fibrotic, or there is proctitis. OTSC, VAAFT, and LIFT require further investigation. Complications and a lack of supporting evidence limit the use of plugs and glue. Stem cell therapy has emerged more recently and has shown promise in treating cases not responsive to anti-TNF drugs with evidence of sound healing, tolerability, and long-term healing maintenance. Surgeons reserve the use of Stoma and proctectomy as a last resort for complex refractory cases. As the evidence favors combining medical and surgical treatments, the approach should focus on incorporating both gastroenterologists and surgeons. In order to do so optimally, future studies should focus on identifying which combination is the most efficacious and tolerable. Surgical modalities need to be directly compared, perhaps as part of a meta-analysis, to identify the most superior modality to incorporate into a combination regimen. Lastly, the modalities with insufficient evidence need to be further researched with more extensive studies. This study can serve as a reference point for future research as it summarizes the available evidence on various surgical, medical, and combination treatments. In addition, researchers can hopefully use this study to gain insight into what treatments are recommended and used and what treatments have limitations and require further investigation.


The aim of the study was to assess the effectiveness of the implementation of the best evidence in preventing postoperative sore throat in patients undergoing general anesthesia intubation.  The related topics of the postoperative sore throat of patients undergoing general anesthesia intubation were systematically searched in the database and evaluated using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Combined with clinical needs and evidence-based professional judgment, 20 pieces of evidence and 6 examination standards on the management process and evidence implementation plan for the prevention of postoperative sore throat in patients with general anesthesia intubation are summarized, implementing the best evidence into clinical practice in anesthesiology, general surgery, orthopedics, thoracic surgery, and gynecology. P < 0.05); the incidence of the postoperative sore throat in patients undergoing general anesthesia intubation decreased from 41.7% to 28.1%.  Nurses' knowledge scores and evidence compliance significantly improved after the implementation of the best evidence ( The i-PARIHS framework effectively prevents postoperative sore throat in patients, providing an effective case for translating evidence into practice based on the i-PARIHS framework. Postoperative sore throat (POST) is the nociceptive pain caused by the throat and tracheal mucosa injury during tracheal intubation under general anesthesia. The main clinical manifestations are postoperative sore throat, local congestion, and redness, accompanied by hoarseness, low voice, and cough. It will affect eating or even cause fatal injury in severe cases . It has This study uses the i-PARIHS framework and adopts a controlled before-and-after study. Clinical research was carried out in the anesthesia department, general surgery department, orthopedics department, thoracic surgery department, and gynecology department of a third-class hospital from June 2019 to June 2021, including baseline review before evidence implementation, practice reform, and effect evaluation after evidence implementation.Five wards in the Affiliated Hospital of Jiangsu University were selected. 151 patients with general anesthesia intubation, patients, and 140 clinical medical staff were included as research objects before and after the implementation of evidence.The inclusion criteria for patients are as follows: (1) adult (age ≥18 years old); (2) patients undergoing elective general anesthesia; (3) no other underlying medical conditions; (4) patients have no contraindications to anesthesia.The exclusion criteria for patients are as follows: (1) patients who suspend surgery for some reason; (2) patients who subjectively refuse to participate in the study; (3) patients who objectively cannot cooperate due to mental and audio-visual disorders; (4) patients who lacked complete medical record data; (5) patients who withdraw halfway through the course of treatment. The inclusion criteria for nurses are working for more than 6 months and obtaining a nurse practice certificate; the exclusion criteria for nurses do not agree to participate in the study.Evidence-based expert team and evidence review team include (1) establishment of a review team which consists of 10 members, including one head nurse of the anesthesiology department as the team leader, who plans the overall project and trains the team members to ensure the implementation of evidence transformation. One nursing department director ensures project resources; one teaching secretary is responsible for process decision-making and departmental consultation. Six head nurses and directors are responsible for project support and coordination; one graduate student is responsible for data collection and analysis. (2) There are two members in the evidence-based expert group, including one deputy head of the evidence-based committee who is responsible for the project quality control and guiding the practice plan. A tutor from the Evidence-based Center of Fudan University Nursing tracked, guided, and reviewed the whole project.In addition to the 12 members of the project team, two anesthesiologists from our hospital were invited to evaluate the best evidence of integration in four dimensions, namely, feasibility, suitability, clinical significance, and effectiveness according to the FAME principle.Combined with the clinical environment of evidence transformation and the resources of our hospital, we turn the items related to the best evidence for clinical implementation into 16 quality inspection indicators  and determine the inspection objects and methods of the inspection indicators one by one, as shown in (1) Incidence of postoperative sore throat (%) and (2) severity of postoperative sore throat (using Prince-Henry sore throat score ) are div(1) The Evaluation of the Grade. Scoring criteria are as follows: 1. Grade I: the patient drank it all at once, and there was no abnormality; 2. Grade II: the time is 0∼5 s, and there was no bucking after drinking twice; 3. Grade III: there is bucking, and the time is 5∼10 s after drinking once; 4. Grade IV: the cough is mild, and the time is 5∼10 s after drinking many times; 5. Grade V: frequent bucking, difficulty in drinking water, time >10 s; (6) comfort , receiver, and organizational environment .It can be seen from the analysis of the above obstacle factors that evidence needs to be further transformed into a form that is accessible and useable for nurses, such as nursing operation procedures or paths. However, the implementation of some evidence will change the existing procedures, such as preoperative assessment of a patient's throat. The willingness and ability of evidence recipients need to be strengthened and improved, for example, the lack of knowledge and skills related to intubation assessment. Therefore, there is a lack of resources in the organizational environment, especially human resources for anesthesia nurses.In the process of promoting the clinical transformation of evidence, establishing effective strategies is the guarantee to promote the success of the reform. We should seek available resources and take effective and feasible action plans to promote the success of the change based on understanding the obstacles. A focus group discussion was held to further qualitatively understand the obstacles and promoting factors according to the baseline survey results. Each group consists of 5–9 team members led by a head nurse, and the discussion lasts for 60–120 minutes, which continues until the theoretical arguments are saturated. In the baseline survey, the coincidence rate of 5 review standards in 16 review standards was less than 60%, of which the compliance rate of 2 standards was 0.As described above, the obstacle factors in the process of evidence transformation are analyzed from three dimensions: change, receiver, and organizational environment, and the change strategy will also aim at these three dimensions.The evaluation list of sore throat prevention after intubation under general anesthesia was determined, printed out, and used through a literature search.I-PARIHS framework helps promote the clinical implementation of research results and guides the analysis of obstacles and promoting factors in the implementation of evidence.Converting the contents and items of measures to prevent sore throat into a flowchart, which is easy to understand and operate.The nursing routine was revised. The content of evaluating intubated patients and the treatment of extubation for intubated patients were written into relevant systems and routines so that the content of the reform was clearly in place in the practice process.Clarifying the links of major changes in the nursing process, such as detailing the medical history of respiratory diseases related to POST and including it in the hospitalization evaluation sheet. Multidisciplinary cooperation is needed to complete the change plan. Unifying evaluation methods and tools. Strengthening the work habits of accurate intubation pipe diameters and operation of each link.Enhancing the recipient's willingness to change: it was found that nurses expressed their desire to do something for patients through the investigation, but they had no guidance and did not know how to do it. With these schemes, they could guide nursing work. In order to promote the health of patients, the nursing team retained nurses with relevant health education majors to guide patients and their families; holding a mobilization meeting to allow core personnel such as the director of anesthesiology to support the relevant personnel involved in the practice; any good outcome and the importance of bagging management in practice are important factors to enhance the willingness to change.Enhancing the receiver's knowledge and skills: adopting various forms of training, such as lectures, medical record explanations, watching videos, reading educational manuals, and sputum suction maps; strengthening the training and assessment of nurses and interns in intubation, sputum suction, extubation, and POST safety awareness; strengthening the training of anesthesiologists on the timing, methods, and tools of cuff pressure measurement.Empowerment: the visiting class will assess the POST risk of patients with general anesthesia one day before operation; strengthen the PACU responsibility system and meticulous nursing; and dynamically monitor patients to eliminate the causes of restlessness as soon as possible.Establishing a multidisciplinary team cooperation mechanism: using the Internet such as WeChat to establish communication channels and timely communicate and treat the illness. In-hospital consultation, specialist guidance, and formulation of a POST treatment plan can guarantee the effective implementation of perioperative throat pain care.The Department of Anesthesiology of our hospital is a training base for regular training and specialized training in Zhenjiang City. It has detailed operating procedures and training methods, which are convenient for training and assessment.Improving the allocation of human nursing resources: there are different forms of propaganda tools in each stage of the perioperative period, and human resources can be adjusted in different links.Formulating the perioperative management path of POST: based on the “Management Pathway for Throat Pain in Patients with Tracheal Intubation under General Anesthesia during Perioperative Period,” evidence was completed, which promoted the pathization of POST management.Optimizing the hospital information system: POST is used as a routine monitoring indicator after general anesthesia and tracheal intubation, and normalized monitoring after extubation and postoperative follow-up is included in the doctor's order system; cuff management standards are formulated and included in surgical quality management information quality control.Using of tools: using ultrasound or CT to measure the diameter of the trachea; applying for a patent for continuous measurement of cuff pressure; PACU is equipped with a system negative pressure gauge; contacting the instrument department to purchase a cuff pressure gauge. Through expert correspondence and evidence-based group discussion, the assessment record sheet for prevention of sore throat in patients with general anesthesia and intubation was jointly revised, including the contents of the recommendations.It lasted for 5 months . In June, preparations such as writing health education, nursing manuals, and training nurses were completed before the evidence was implemented. The training content is designed as a small video and courseware, which is placed on the Jingyi teaching platform in the hospital, allowing nurses to participate in the learning, and setting questions for nurses to participate. Evidence-based implementation was implemented from June 1 to October 30, and 192 patients were included.During the implementation of the evidence, nurses' knowledge of POST prevention was investigated using a questionnaire we designed and compared with the questionnaire in the baseline survey. The questionnaire content was designed based on the best evidence. After the questionnaire was completed, 3 anesthesiologists, 2 evidence-based specialists, and 1 otolaryngologist were consulted. The questionnaire was revised and improved according to expert opinion. The questionnaire consists of 3 parts . Including 37 questions, each question has a maximum score of 5 points and a minimum score of 1 point, with a total score of 185 points. Questionnaires are sent to nurses through online software. After nurses complete and submit the questionnaires, the system automatically scores the questionnaires. The study found that after the implementation of the evidence, the compliance rate of each item and the score of the questionnaire were improved compared with the baseline survey.Two graduate students and interns performed data collection according to the review methodology. During the baseline survey and evidence implementation, 5 participants from students studying in the anesthesia operating room participated in data collection. The intern did not know the grouping of patients, and the nurse did not know which patient was performing evidence implementation to avoid the Hawthorne effect. Two graduate students collected the data on the occurrence of POST in patients, and the patient record sheet included general information stating whether POST occurred on admission, and provided admission, operation time, ward, intubation status , difficult airway, successful extubation, medical information, and equipment involved in POST. To compare the incidence of postoperative POST in intubated patients with general anesthesia after the baseline survey and evidence implementation, patients participating in baseline surveys and evidence implementation should be different.n(%)]. By using χ2 test, the VAS score of comfort and the knowledge, belief, and behavior of medical staff were tested by independent sample T-test, and the test level α = 0.05, with P < 0.05 as the difference with statistical significance.The data were statistically analyzed by SPSS22.0 software, and the counting data were expressed by [  Step 1: preoperative evaluation to identify high-risk patients with respiratory diseases such as bronchitis and asthma, difficulty airway, and gastrointestinal surgery. In high-risk patients, preventive medication will be given.  Step 2: intubation management-item preparation: visual intubation equipment, airway nebulizer, ultrasound, tracheal tube, and preventive medication are on standby.2O, evaluation timing: after tracheal intubation, after a body position change, after pneumoperitoneum, the operation time >6 hours, and after entering the recovery room.  Step 3: cuff management-airbag pressure filling method: fixed volume injection method, minimum occlusion volume method, minimum lateral leakage test method, dynamic assessment of cuff pressure: 25–30 cm H  Step 4: extubation management-sputum suction pressure: 80–100 mmhg; extubation method: a large syringe exhausts the cuff contents and gently removes them to reduce extubation injury.  Step 5: after extubation, the patient's throat pain and other conditions were promptly assessed, and shifts were handed over and recorded.The clinical pathway of intubation for patients under general anesthesia was established see . New tecCompliance with evidence-based practices of medical staff: a method similar to the status review was used to review the compliance of the review indicators. A total of 16 indicators were reviewed before and after the implementation of evidence. The results are shown in The score of knowledge-belief-action evaluation of medical staff on the management of intubation prevention for sore throat in patients with general anesthesia: the biggest impact of evidence in the process of clinical translation is the change of practitioners' knowledge, attitude, and behavior see .Before and after the implementation of evidence, 151 and 192 patients with general anesthesia who met the inclusion and exclusion criteria were obtained, respectively. There was no statistical difference between the two groups in age, gender, lung disease, department, and body position see .P < 0.05). However, there was no significant difference in the incidence of the sore throat under swallowing before and after the implementation of the evidence (P > 0.05), as shown in By comparing the clinical outcome indicators of the two groups of patients, the incidence of the sore throat under resting state in patients with general anesthesia and intubation before and after the implementation of evidence, the effect of pain on eating and rest, and the patient's comfort were significantly different . The knowledge, attitude, and behavior were significantly improved, which is very beneficial for improving the compliance of nurses' clinical practice and cultivating nurses' evidence-based concept.This study shows that the implementation rate of the 16 review indicators before and after the implementation of evidence has increased significantly. After the implementation of evidence, in addition to the 62.25% in the first review indicator and the 58.28% in the second review indicator, the achieved rate of the 3 indicators has reached 100%, the rest of the achieved rates are above 60%, and nurses' POST-evidence-based compliance has improved. The evidence-based nursing practice of preventing sore throat in patients with general anesthesia intubation allows nursing staff to solve problems based on scientific evidence when they encounter problems and deal with problems at work, rather than solving problems by experience. For the sustainability of practice, we have repeatedly strengthened the concept of nursing staff from the observation records of baseline survey, training, implementation of the program, and re-examination, and trained and guided the content with low scores in the questionnaire, so that nurses can master nursing knowledge and practical skills, and adopted diversified training such as flowcharts, mission knowledge maps, videos, and case discussions. Propaganda and education are the keys to achieving knowledge, belief, and action that helps clinical staff establish risk awareness, understand the impact of postoperative sore throat, and enhance their execution ability later. The results showed that there was a statistically significant difference in the knowledge, belief, and behavior of clinical medical staff before and after the implementation of evidence (P < 0.05). However, there was no significant difference in the incidence of sore throat in the swallowing state before and after the implementation of evidence (P > 0.05). It shows that the implementation of an evidence-based nursing practice scheme can effectively reduce the incidence of sore throat in patients with general anesthesia intubation at rest. In this study, 20 best pieces of evidence were screened out, 16 review indicators were determined, and practical innovation was implemented. Before the implementation of evidence, the nursing management process of POST had not been established in our hospital, and there is a lack of unified and standardized assessment and preventive measures. Therefore, this study focuses on the concept of “prevention first,” aiming to prevent sore throat in patients with general anesthesia and intubation. The best evidence is applied in the aspects of risk assessment of sore throat in patients with general anesthesia, standardized operation of extubation, and personalized management of sore throat prevention, thereby reducing the incidence of postoperative sore throat and improving the comfort of patients. We can change our behavior and improve our self-management ability by listening to lectures, watching videos, and repeatedly strengthening our training.The results showed that the incidence of pharyngolaryngeal pain in patients undergoing general anesthesia intubation decreased from 41.7% to 28.1% after the evidence-based practice, and the effects of pain on eating and rest were all lower than before, with a statistically significant difference (Evidence-based practice of the best management strategy for sore throat after general anesthesia intubation has formed the nursing process of general anesthesia intubation, improved the nursing quality and practical compliance, cultivating evidence-based concepts, improved self-management ability, reduced the incidence of clinical sore throat, and effectively promoted the continuous quality improvement of sore throat management after general anesthesia intubation. However, this study was only carried out in one hospital. The sample size of nurses who accepted the reform was relatively small due to the limitation of conditions. Most of them were at risk of gender bias, which affected the authority of the results to a certain extent. In the future, the research program should be carried out in multiple hospitals to evaluate the credibility of its effects scientifically.In this study, the evidence retrieval, evaluation, and summary of the prevention and management of sore throat in patients with general anesthesia found that the i-PARIHS evidence-based framework effectively implements clinical management strategies.