Chronic diseases drive the burden of disease in many societies, particularly among men. Lifestyle behaviours are strongly associated with chronic disease development, and in a number of countries men tend to engage in more risky behaviours, and have lower health knowledge and attention to prevention, than women. This study investigated the correlates of men’s health literacy and its components about major lifestyle-related diseases, namely ischaemic heart disease and type 2 diabetes mellitus, to gain evidence to guide the development of policy and programs to improve men’s health.A systematic review was undertaken of observational studies that investigated men’s health literacy and its components related to ischaemic heart disease or type 2 diabetes mellitus, and their associated risk factors. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycINFO, Embase and the Cochrane Library databases were searched for articles published since 2003. The strength of the evidence was rated using the GRADE approach.n = 7) and personal skills (confidence) (n = 1). Twenty correlates were identified, primarily relating to the knowledge component, with the strength of the evidence for only one correlate, education, graded as being of moderate quality. The evidence for all other correlates was graded as being of low quality.After screening and review of 504 articles, the search elicited nine studies for inclusion: only one study examined health literacy (nutrition literacy). The majority of included studies focused on only one component of health literacy, namely knowledge (The limited body of research identified may have resulted from a lack of consensus about the definition of health literacy, and a concordant set of validated health literacy measures. Despite these limitations, broadening the search to include components of health literacy has identified that several factors are associated with men’s knowledge and awareness of ischaemic heart disease and type 2 diabetes mellitus that will assist in the development of men’s health promotion strategies. However, addressing the broader knowledge gaps and controversy in the health literacy field will deliver policy and program benefits to address these major contributors to the burden of disease among men. It is recognised that in many societies men experience a higher burden of chronic disease , cerebrovascular disease, type 2 diabetes mellitus (T2DM) and depression)  and are A range of socio-economic, biomedical and behavioural determinants influence men’s health outcomes and provide opportunities for health promotion action. While the influence of biomedical factors and risky lifestyle behaviours is well established, more recently, health literacy has assumed an increased importance . Health Health literacy may be understood in general terms as being concerned with the capacities of people to address health issues  in a complex society . HoweverPopulation studies in Australia , the UniUnderstanding the factors associated with men’s health literacy is necessary for tackling the preventable chronic diseases experienced by men. Indeed, it is recognised that gender appropriate strategies to promote health literacy are needed , 24. ThiA systematic review was conducted following the guidelines of the Cochrane Collaboration .et al.  wa framework as shown in Table Five databases were selected for the review and searched in August 2013: CINAHL, Medline, Embase, PsycINFO and the Cochrane Library. Each key term was searched by both heading and free-text terms. Additional studies were identified through reference and citation tracking.Included studies were those in which health literacy and its components  were treated as dependent variables.Eligible studies were those of observational or experimental design that were undertaken in a developed country , consistStudies were excluded if they were of a paediatric population, if the article was focussed on women, or was not published in English. In addition, studies targeting populations of persons practising in a health occupation were also excluded. Studies were restricted to those published from 2003 onwards (ten years prior to the search date).Cochrane Handbook for Systematic Reviews of Interventions [Descriptive information about each study was extracted by one of the researchers (JD) and tabulated, including author and year, study design, sample and location, components of health literacy measured, variables included in multivariable analysis and significant correlates identified. The methodological quality of the included studies was assessed using criteria relevant to observational studies identified in the ventions , namely:ventions . The quaventions , 31. BecThe search strategy yielded 647 citations, and an additional eight citations were located through reference checking. The number of articles excluded at each stage is shown at Fig. The characteristics of the included studies are summarised in Table n = 7) and personal skills (confidence) (n = 1).Despite the broad search strategy, only one study examined health literacy (nutrition literacy) . The majThree studies examined knowledge of disease, which was heart and stroke symptoms , 34 and et al. [χ2 test). The study by Kan and Tsai [Seven studies measured differences in components of health literacy dichotomously and the remaining two used continuous measures, one as a percentage-correctly-answered measure  and the et al.  presenteand Tsai  used ordet al. [et al. [Table et al.  and Sohn [et al.  used val [et al. , MONICA  [et al.  and the  [et al. , 34.TablThe factors found to have significant associations with health literacy or its components in two or more of the reviewed studies were education, age, health insurance status, income, marital status, overweight and obesity, and access to primary health care services. In addition, a diverse range of correlates were identified in single studies, including various measures of social connectedness, risk behaviours and information access.Six of the nine studies found an association between educational attainment and components of health literacy  Table . The diret al. [Five studies found an association between age and health knowledge. The direction of association in one study was negative, i.e., increasing age was associated with decreased health knowledge . The stret al. , which wTwo studies found an association between lack of health insurance and knowledge, the first of which had an odds ratio close to 2.0 and a narrow 95 % confidence interval , 34. OveThe two studies with the largest sample sizes showed a negative association between income and health knowledge , 34. HowTwo of three studies , 40 that2  showed a positive association between overweight or obesity and nutrition literacy [One of the three studies reporting an association between Body Mass Index (BMI) and components of health literacy showed a positive association between obesity and health knowledge, but no association between overweight and knowledge . In contliteracy . The eviet al. [The two studies by Lutfiyya et al. , 34 founet al.  comparedEach of the following factors was identified in a single study as being associated with components of health literacy and the quality of that evidence was assessed as low: level of community-connectedness (knowledge) ; friendsThe following factors were identified as being associated with components of health literacy, however, the quality of the relevant body of evidence was assessed as being very low: care deferred because of cost (knowledge) , 34; cogThis systematic review identified 20 different correlates of components of men’s health literacy related to IHD and T2DM. The review also highlighted a significant shortage of studies into men’s health literacy or its components; only 9 of 55 candidate studies focused exclusively on men or stratified their results by sex. There has been little attention to health literacy as an enabler of preventive action to reduce disease burden in men. This may, to some extent, be the result of the lack of empirical evidence concerning men’s health literacy , 24. A set al. [While there is not yet consensus around a conceptual framework that defines the elements of health literacy and their relationships with downstream health outcomes , 43, theet al.  have ideet al.  depict set al.  also notper se, the correlates identified in this study have assisted in identifying the evidence gaps about key components of men’s health literacy and have the potential to be applied to the development of a health literacy framework specifically targeting men.The variability in definitions and measures used in health literacy research has limited the ability to compare studies and advance the field to develop effective interventions targeting population groups with low health literacy , 46. TheTen of the correlates identified in this study matched, or were closely analogous, to the determinants of health literacy identified in these previous reviews and commentaries , 23, 43,Education was the only factor supported by a body of evidence that was graded as moderate or greater strength. All of the other identified variables were supported by evidence graded as either low or very low. The degree of heterogeneity in the correlates identified in this review is noteworthy: 20 correlates were identified, but only two (age and education) were supported by evidence from more than two studies. Furthermore, two studies did not control for educational attainment, and more than half of the studies did not control for income or economic status. The omission of these variables increased the risk of bias in the studies and further illustrates how the lack of a consensus on a conceptual framework hinders the development of a body of evidence about the potential correlates of health literacy.Prior illness and contact with the healthcare system have been identified as possible correlates of health literacy , and thiWhile it has been observed that the number of articles concerning health literacy in the academic literature has grown markedly since the 1990s , in thisUnderstanding the correlates of men’s health literacy and its components provides knowledge about those areas where policy and practice interventions may be directed to support men’s help-seeking behaviours and health outcomes . The rev


Typhoons  severely impact the half-billion population of the Asian Pacific. Intriguingly, during the recent decade, typhoon destructive potential  has decreased considerably (by ∼35%). This decrease, paradoxically, has occurred despite the increase in typhoon intensity and ocean warming. Using the method proposed by Emanuel (in 2007), we show that the stronger negative contributions from typhoon frequency and duration, decrease to cancel the positive contribution from the increasing intensity, controlling the PDI. Examining the typhoons' environmental conditions, we find that although the ocean condition became more favourable (warming) in the recent decade, the atmospheric condition ‘worsened' at the same time. The ‘worsened' atmospheric condition appears to effectively overpower the ‘better' ocean conditions to suppress PDI. This stronger negative contribution from reduced typhoon frequency over the increased intensity is also present under the global warming scenario, based on analysis of the simulated typhoon data from high-resolution modelling. Typhoon destructive potential has decreased by ∼35% in the last decade, despite an increase in typhoon intensity and ocean temperatures. Here, the authors combine observational and numerical modelling results to investigate this apparent paradox. Despite the severe impact of individual tropical cyclones such as Sandy in 2012)21 and Ha25656The PDI (Power Dissipation Index), Proposed by Emanuel in 2005 ref. , is a wiIn this study, we found that in the recent decade, the PDI-contributing factors  had made opposite contributions to PDI in the recent decade. Although there was some increase in typhoon intensity, the typhoon frequency and duration decreased at the same time. The negative contributions from the reduction in typhoon frequency and duration overpowered the positive contribution from the increased intensity; therefore, the PDI still decreased. Similar opposite contributions to PDI were suggested in the global warming scenario10The value of the typhoon-season (July–October) PDI in the recent pentad 2008–2012) was only ∼63% that of the 1993–1997 period see . To unde–2012 was1213141516171416319319PDI is determined not only by typhoon intensity  but also by duration (lifetime) and typhoon occurrence frequency (case number). The evolution of all of these parameters  shows thN), annual-averaged weighted typhoon duration over ocean  to PDI. This result is further quantified in −1, which represented an environment unfavourable for formation67222324222324r=0.56–0.88) found between the increase in the zonal VWS, decrease in vorticity, westward shift of the genesis longitude (1st lon), the reduction in typhoon duration  and lower (850 hPa) troposphere. Enhanced circulationr=0.83–0.91) between the easterly wind, SHAI at 850 hPa and zonal VWS  can be observed in the high correlations , the P value for the PDI time series was larger (P=0.465). It should be noted that due to the competing and offsetting impacts between typhoon duration/frequency and intensity, and between ocean and atmosphere, it was not possible for PDI to exhibit a clear trend because it was the residual result from opposing and competing contributors.In addition to the correlations between the different parameter pairs, statistical analyses of each individual time series were also performed. As shown in Therefore, from the typhoon perspective, the recent strengthening of the large-scale circulation induced a ‘worsened' atmosphere condition for typhoons and PDI, even though such strengthening also provided a ‘better' ocean because the increase in the easterly wind piled up warm surface water to the western North Pacific and increased D26 and UOHC, as discussed earlier192027Although the possibility of an increase in PDI  due to ocean warming was suggested beforeBecause PDI depends not only on the intensity but also on typhoon duration and number, even if the intensity increases due to ocean warming, it does not mean that typhoon duration and number will increase in tandem. This is especially true over the western North Pacific Ocean, in which these parameters are very much controlled by the dynamical factors in the atmosphere  than the thermal factors . As in These opposite contributions from the typhoon intensity versus the frequency/duration to PDI triggers an interesting question, that is, global warming implications89101112133536373839404142434445464748495051529101137444647et al.−1 versus 28.74 m s−1) higher than the current intensity. In addition, there was a slight increase of ∼3.2% in the duration. Although both the intensity and duration increased under global warming, there was an even larger typhoon frequency reduction of ∼25.7% (7 m3 s−3/1.91 × 107 m3 s−3) of the current value, showing a reduction in the typhoon destructive potential for the Asia Pacific region under global warming.It is intriguing to quantify and explore these possible cancellation effects on PDI. We conducted the PDI analyses using simulated typhoon data (for the late-twenty-first century projection) from a state-of-the-art high-resolution model, as in Zhao and Heldf ∼25.7% . As a reThese results suggest that we are seeing an important cancellation effect from co-existing and opposing PDI contributors  under both the global warming scenario and observations in the current climate epoch over the western North Pacific Ocean. In addition, results from the quantitative analyses suggested that the positive contribution from the increased intensity could be much smaller than the negative contribution from the frequency reduction and resultant PDI decrease.et al.However, it should also be noted that although the reduction in the western North Pacific typhoon PDI and the cancellation effect were observed under both the global warming projection and the current climate epoch observation, it did not necessarily mean that the associated climate forcing was of the same origin. The observed recent climate epoch over the Pacific (including the western North Pacific) was likely related to natural variability, whereas the simulation from Zhao and HeldFor the western North Pacific region, both types of climate conditions could result in the co-existence of an increase in typhoon intensity but a decrease in frequency. Another similarity is that although the ocean environment under both climate conditions could be more favourable, a more unfavourable atmospheric environment could co-exist to effectively suppress the occurrence frequency, resulting in the eventual reduction in destructive potential .et al.et al.Finally, although the reduction in PDI appeared to suggest a less destructive scenario for the Asian Pacific region under both the current climate epoch and global warming projection, it should be taken with caution. Despite its wide usage, PDI895410The domain of the western North Pacific Ocean is defined as 110–180°E, 0–45°N. Typhoon MDR is defined as 122–180°E, 4–26°N and the typhoon genesis region is 150–180°E, 10–17.5°N These parameters were obtained or calculated based on the US Joint Typhoon Warning Centre's best track data of the International Best Track Archive for Climate Stewardship (IBTrACS) database. For details, see below.in situ radiosound data is shown in The European Centre for Medium-Range Weather Forecasts's (ECMWF) monthly Interim Reanalysis database at each 1° grid was used. The data at 850 hPa were used for the relative vorticity and humidity. The VWS was calculated based on the difference in the vector wind between 2 heights (200 and 850 hpa). Similarly, the zonal VWS was calculated, but for the zonal wind only. Validation of this data using the The recent strengthening of the atmospheric circulation was characterized by an evident increase in the easterly trade wind. For the study, winds at 850 hPa from the ECMWF Interim data were used. The SHAI proposed by Liu and Chanr=−0.66; In addition, we defined an additional new index called the SHII. The SHII was associated with SHAI, but was based on the averaged geopotential height for the grids enclosed by the 5,880-gpm (for the 500 hPa level) or the 1,530-gpm (for the 850 hPa level) lines. Therefore, the SHII carried the intensity information of the subtropical high, whereas the SHAI carried the area coverage information. The results from these two indices were similar, although there was a higher correlation between the SHII (at 850 hPa) and the typhoon occurrence frequency r=−0.66; .in-situ Argo float observations1456Monthly, one-degree SST data from the UK Hadley Centre are used. The UOHC  over the typhoon duration (τ). The annual typhoon season PDI is the summation of all of the cases (N) in a typhoon season in a year. To avoid the possible over-weighted contribution from the long-duration in the genesis period, Emanuelwhere Vsmax is the lifetime peak intensity of the typhoon, i. As explained in Emanuelwhere Averaging Finally, an annual averaged intensity (in wind speed cube) is defined as follows:N × I. If we use the natural logarithm, then ln(PDI)=ln (N) + ln (I). EmanuelN, I to PDI. The results are shown in From above, the annually accumulated PDI in a typhoon season in a year is How to cite this article: Lin, I.-I. and Chan, J. C. L. Recent decrease in typhoon destructive potential and global warming implications. Nat. Commun. 6:7182 doi: 10.1038/ncomms8182 (2015).Supplementary Figures 1-33, Supplementary Tables 1-2 and Supplementary Notes 1-3 and Supplementary References.


The discipline of psychiatry has a plethora of guidelines, designed to serve the needs of the clinician. Yet, even a cursory glance is enough to discern the differences between the various guidelines. This paper reviews the current standard guidelines being followed across the world and proposes a unified guideline on the backbone of current evidence and practice being followed. The algorithm for pharmacological and psychosocial treatment for bipolar disorder, major depressive disorder, and schizophrenia is formulated after cross-comparison across four different guidelines and recent meta-analytical evidence. For every disorder, guidelines have different suggestions. Hence, based on the current status of evidence, algorithms have been combined to form a unified guideline for management. Clinical practice guidelines form the basis of standard clinical practice for all disciplines of medicine, including psychiatry. Yet, they are often not read or followed because of poor quality or because of barriers to implementation due to either lack of agreement or ambiguity. A unified guideline can go a long way in helping clear some of the confusion that has crept in due to the use of different guidelines across the world. Standard clinical practice is considered the hallmark of every clinician, which is usually dictated by adhering to certain clinical guidelines . A good Psychiatry, as a discipline, is relatively new in the field of evidence based medicine; yet, there exist several clinical guidelines designed to provide guidance of good clinical practice. Some of the most well-known and widely accepted guidelines are the APA guidelines by the American Psychiatric Association , the CanA Medline search on practice guidelines using terms “schizophrenia,” “depressive disorder,” “bipolar disorder,” “management,” “review,” and combinations thereof helped us retrieve relevant literature. In addition, salient references from obtained articles were followed upon. Standard textbooks of psychiatry  were also screened using the same keywords. The most common guidelines, namely, the CPA, the APA, the CANMAT, NICE, and the Maudsley guidelines, were also reviewed. Additionally, searches were performed in PsycINFO, Medline, Cochrane, and Embase databases for reviewing guidelines for management until June 2011. All literature compiled was then assessed by the authors separately and an algorithm was proposed for each psychiatric disorder, taking into consideration the various guidelines proposed for the management of the specific disorder.Several differences are apparent in the acute management of a manic episode among the various guidelines. While both the APA and Maudsley prefer mood stabilizers like Lithium or Valproate as first line management, NICE and the Canadian guidelines prefer the use of atypical antipsychotics like Olanzapine (Olanz/OLZ) or Risperidone (Risp). Recent reviews favor the use of either Lithium (Li) or Sodium Valproate  with/without antipsychotic (Level I evidence) in the management of the acute episode , 14. SinThere are no differences of opinion here with all guidelines and hence the unified guideline recommends the use of Valp as a first line management followed by Olanz or Quetiapine (Quet) .There are minor differences of opinion here, with Li being considered as first line by all the guidelines. However, while the use of Lamotrigine is favored by APA, Maudsley, and the Canadian guidelines, NICE discourages it and prefers a combination of Specific Serotonin Reuptake Inhibitors (SSRIs) with either Li or Valp. The combination of Olanz and Fluoxetine (FXT) has been recommended by almost all guidelines except by NICE, while Quetiapine is universally accepted. Yet, the evidence in favor of these is that of Level II , 15. TheOnly the APA and NICE guidelines comment on this issue with both recommending either Li or Valp or a combination of the two, with Level II evidence available for the same . AdditioLithium and Valp are universally recommended by all the guidelines, which is also the recommendation of the unified guideline.Lamotrigine is recommended as the first line by APA and Canadian guidelines while NICE and Maudsley ask it to be used as second line. Li and Valp have been recommended by all except APA, while Quetiapine has been recommended by both NICE and Maudsley. The unified guideline recommends Lamotrigine followed by Li, Valp, and Quet as drugs to be used in the maintenance of depressive episodes.Only APA and Canadian guidelines have given recommendations on the duration of acute and continuation phase, which, however, vary as seen in the table. The maintenance phase duration, however, is similar across all guidelines and hence the unified guideline recommends treatment in an acute phase up to 12 weeks, in the continuation phase up to 9 months, and in the maintenance phase as 2 years for 1st episode and 5 years to lifetime for subsequent episodes.The use of psychoeducation has been recommended by only Canadian guidelines with the NICE actively discouraging it. Both NICE and APA as well as recent meta-analysis  favor thSince both recent evidence –20 and aOnly the Canadian and NICE guidelines have recommended specific treatments for atypical depression. Recent evidence favors the use of either SSRIs or MAOIs (Monoamine Oxidase Inhibitors) as first line drugs , which iOnce again, only the Canadian and NICE guidelines have recommended specific treatments for melancholic depression. The unified guideline hence recommends the use of either Paroxetine (PXT) or Venlafaxine (Venla) as first line drugs, while recent reviews have also favored tricyclic antidepressants (TCAs) such as amitriptyline and clomipramine which have both noradrenergic and serotonergic activity .Both the Canadian and NICE recommend the use of either bright light therapy or Fluoxetine (FXT), which is also recommended by the unified guideline.No separate recommendations exist for anxious depression by either APA, NICE, or Maudsley. The Canadian guideline recommends the use of either SSRIs like Paroxetine or Sertraline (SRT) or SNRIs like Venlafaxine. This is also supported by the unified guideline.Since no separate recommendations exist except by the Canadian guidelines, the unified guideline recommends the use of either SSRIs or SNRIs as first line management.Almost all the guidelines recommend the continuation of the same antidepressant as was initiated for the acute management of the depressive episode. In addition, the Maudsley guideline recommends the use of either Sertraline, Citalopram, Reboxetine, or Venlafaxine, which have been found effective in prophylaxis. The unified guideline recommends the continuation of the same antidepressant, either SSRI or SNRI.There are differing recommendations on the duration of pharmacotherapy, with both APA and Canadian guidelines specifying the duration of acute phase as up to 12 weeks and continuation phase as up to 9 months. In contrast, the Maudsley and NICE guidelines offer no specific recommendation for the acute management. Long term management again differs, with APA and Canadian being similar and NICE and Maudsley differing on the duration. The unified guideline recommends an acute phase treatment of up to 12 weeks, continuation phase up to 9 months, and maintenance phase as 2 years for a first episode and 5 years to lifetime for subsequent episodes.CBT and interpersonal therapy (IPT) in 16–20 sessions (Level I evidence) are the recommendation of the APA, Canadian, and the NICE guidelines, as well as that of recent reviews [With the exception of the Canadian guidelines, all others recommend the use of either SGAs (first line) or FGAs (second line) as standard drugs. The Canadian guideline only recommends the use of SGAs such as Olanz, Risp, or Quetiapine. Based on recent evidence , the uniAll the guidelines and the unified guideline recommend the continued use of the same antipsychotic used to manage the acute episode for prophylaxis .The APA and Canadian guidelines recommend similar durations of acute, stabilization, and stable phase treatment. The NICE and Maudsley guidelines recommend acute treatment to last 2 years and give no specific recommendation on duration of prophylaxis. The unified guideline recommends the acute phase treatment to last at least 12 weeks, the stabilization phase to last at least 12 months, and stable phase to last at least 2 years for a first episode and 5 years to lifetime for multiple episodes.The APA and Canadian guidelines find evidence for and recommend the use of family psychoeducation lasting greater than 9 months, assertive community treatment (ACT), supported employment programs, social skills training (SST), and cognitive behavioral therapy lasting 16–20 sessions. This is also supported by the PORT treatment recommendations . The NICAlthough guidelines have been postulated to improve clinical practice, their implementation has been difficult to achieve due to the characteristics of the guidelines themselves, such as clarity, complexity of treatment recommendations, perceived credibility, use of evidence based medicine, and  sponsorship, which have been shown to affect clinicians' acceptance of guidelines –28. To iEarlier studies have attempted to compare the applicability and evidence strength  or the mIn addition, the authors feel that an internationally acceptable and culturally fair set of recommendations could be developed and form the framework for further elaboration on a national or local basis. This could be facilitated by independent and international organizations such as the WHO and the WPA, after which these could then be used for adaptation to different cultural, economic, and other backgrounds in collaboration with individual stakeholders of the respective countries and regions.


This goal is only fully achieved with primary prevention, which requires us to identify and prevent harms prior to human exposure through research and testing that does not involve human subjects. For that reason, public health policies place considerable reliance on nonhuman toxicological studies. However, toxicology as a field has often not produced efficient and timely evidence for decision making in public health. In response to this, the U.S. National Research Council called for the adoption of evidence-based methods and systematic reviews in regulatory decision making. The U.S. Environmental Protection Agency (EPA), the Food and Drug Administration (FDA), and the European Food Safety Agency (EFSA) have recently endorsed these methods in their assessments of safety and risk.The most essential goal of medicine and public health is to prevent harm . We discuss current progresses in this field produced by the Office of Health Assessment and Translation (OHAT) of the National Toxicology Program and the Navigation Guide works. We propose that adherence to the Cochrane principles is a fundamental prerequisite for the development and implementation of EBT.The adoption of evidence-based principles and methods will enhance the validity, transparency, efficiency, and acceptance of toxicological evidence, with benefits in terms of reducing delays and costs for all stakeholders .http://dx.doi.org/10.1289/ehp.1509880Mandrioli D, Silbergeld EK. 2016. Evidence from toxicology: the most essential science for prevention. Environ Health Perspect 124:6–11;  This goal is only fully achieved with primary prevention, which requires us to identify harms prior to human exposure. Toxicology, almost always involving nonhuman subjects, is the main source of such information. Bioethical principles of human subjects research have developed in response to several examples of morally reprehensible research involving humans over the past 70 years  recommendation to the U.S. Environmental Protection Agency (EPA) for the adoption of evidence-based methods, similar to those widely used in medicine and health care, in its assessments of chemical hazards and risks. The NRC report  includedToxicology: a matter (not just) for experts. The importance of toxicology is widely recognized and accepted in public health policy. However, the reliability and validity of many toxicological methods—from study design to statistical analyses—have been challenged. These limitations have significant impacts for both improving and protecting health. Recent reviews have demonstrated the low predictive value of preclinical testing in identifying novel pharmaceutics likely to have therapeutic benefits, as well as in detecting potential adverse effects early in drug development  was called on by the U.S. Congress to review National Toxicology Program (NTP) Report on Carcinogens listings of styrene and formaldehyde as carcinogens , 2014c. The limits of the discipline of toxicology and the delayed promulgation and application of effective regulatory policies based on the use of toxicological principles contributed to the impetus for the precautionary principle largely in order to empower timely preventive actions  action. Calls for the adoption of systematic methods to support the generation of evidence in toxicology are not new, and there are several organizations claiming to use “evidence-based toxicology,” although there is no common accepted definition of this term Transparent and replicable processes for research strategyTransparent methods of data extraction and presentationValidation of all methods and criteria in terms of relevance to reducing biasComprehensive assessment of risk of bias Transparent criteria for determining if data integration is appropriate and conducting data integration, such as meta-analysis.However, challenges in developing evidence-based methods specific for toxicology will also require new adequate methods that cannot be directly derived from Cochrane. For example, while sharing common problems (and perhaps some common solutions), nonhuman preclinical studies and toxicology tests require some different methods and policies because of their differing purposes: Preclinical studies investigate efficacy (benefits), and toxicology investigates safety (harms) . There aAttention to external validity of nonhuman toxicity tests for inferring risks to humansa) dealing with the diversity of nonhuman species currently used in toxicity tests as well as the use of in vitro systems, organotypic cultures, transformed cell lines, and ex vivo preparations; and b) assessing the validity of “toxicity pathway” studiesChallenges to integrating information: Determining the contribution and value of mechanistic studies to overall evaluation of evidenceMoving beyond harms: generating evidence to support decisions for setting regulatory standards .Handbook for Conducting a Literature-Based Health Assessment Using OHAT Approach for Systematic Review and Evidence Integration  egration  and the egration  are two egration . Particuegration . HarmoniImproving the methods of generating systematic evidence from toxicology will not only clarify and expedite the processes of decision making but will also enhance the international acceptability of a common evidence base that can be fitted into national policies . This isAppendix 1Collaboration: by fostering global cooperation, teamwork, and open and transparent communication and decision making.Building on the enthusiasm of individuals: by involving, supporting, and training people of different skills and backgrounds.Avoiding duplication of effort: by good management, co-ordination, and effective internal communications to maximise economy of effort.Minimising bias: through a variety of approaches such as scientific rigour, ensuring broad participation, and avoiding conflicts of interest.Keeping up to date: by a commitment to ensure that Cochrane Systematic Reviews are maintained through identification and incorporation of new evidence.Striving for relevance: by promoting the assessment of health questions using outcomes that matter to people making choices in health and health care.Promoting access: by wide dissemination of our outputs, taking advantage of strategic alliances, and by promoting appropriate access models and delivery solutions to meet the needs of users worldwide.Ensuring quality: by applying advances in methodology, developing systems for quality improvement, and being open and responsive to criticism.Continuity: by ensuring that responsibility for reviews, editorial processes, and key functions is maintained and renewed.Enabling wide participation: in our work by reducing barriers to contributing and by encouraging diversity.


There are several protocols in existence that guide clinicians in the implementation of effective, evidence-based psychological interventions for eating disorders. These have been made accessible in the form of treatment manuals. However, relatively few clinicians use those protocols, preferring to offer more eclectic or integrative approaches. Following a summary of the research that shows that these evidence-based approaches can be used successfully in routine clinical settings, this review considers why there is such poor uptake of these therapies in such settings. This review focuses on the role of service culture and on clinicians’ own attitudes, beliefs and emotions. Possible means of enhancing uptake are considered, but these cannot be considered to be ideal solutions at present. Protocols, usually codified in the form of treatment manuals, are key methods for the dissemination and reliable implementation of evidence-based psychological treatments. It is important to recognise a protocol for what it is intended to be—a broad set of methods, designed to be applicable to the patient in a way that is reflective of their individual case, but guided by a set of principles. The clinical skill and artistry in the delivery of evidence-based therapy lie in how the clinician implements the protocol for the individual patient . Howeverevidence-based practice is a more useful approach than the use of empirically supported interventions. Evidence-based practice combines those empirically-supported approaches  with clinicians’ own judgement and patients’ values. However, there are two issues to consider here. First, the evidence to date does not really support the superiority of this wider ‘evidence-based practice’ approach. In most cases, clinician judgement results in poorer outcomes than protocol-based approaches . Then, the treatment needs to be tested in routine clinical settings (‘effectiveness studies’). Both have been carried out in the field of treating eating disorders.A number of therapies had been identified that reduced the severity and presence of bulimia nervosa and binge-eating disorder, including cognitive-behavioural therapies (CBT), interpersonal psychotherapy (IPT), and dialectical behaviour therapy (DBT). Of those therapies, CBT had the strongest evidence of the greatest and most rapid effects.Those therapies were usually more effective if delivered in an individual, face-to-face setting.Medications had a limited role in the treatment of eating disorders, with some evidence for symptom alleviation in bulimia nervosa and binge-eating disorder, but no support for treating anorexia nervosa and no clear evidence for medication/psychotherapy combinations being superior. The studies were often hard to rely on as indicators of remission or recovery, as they had very short follow-ups.Younger adolescents with less long-lasting cases benefitted more from family-based therapies (FBT).Treatments for adults with anorexia nervosa had weak evidence, with weak outcomes (even when they include treatments delivered in more intensive settings), and little difference between therapies.There was virtually no evidence base relating to the treatment of atypical eating disorders (other than binge eating disorder), despite this category representing the largest single category of eating disorders .There is clear evidence from large research trials that some therapies are efficacious in working with eating disorders. That evidence had been well summarised up until a few years ago, in the form of a number of reviews with very consistent conclusions –24. A reCBT has been shown to be effective in the treatment of atypical cases of eating disorder where the patient is not underweight , though Outcomes for patients with anorexia nervosa are somewhat improved, particularly for CBT ••, 27, tSince those reviews were published, a number of important treatment trials have been published in the field. The key changes in our evidence base as a result can be summarised as:Other findings in recent years  simply rFinally, it is worth noting that the change in diagnostic criteria with DSM-5 does not appear to have altered outcome rates appreciably. However, it does mean that there is some doubt about the comparability of studies.Obviously, it is important to consider whether these evidence-based treatments can be delivered outside of highly resourced research settings. A common belief amongst clinicians is that the results from such research trials cannot be replicated in routine clinical settings, due to the patients in research settings being more carefully selected (e.g. to exclude comorbidity), an unachievable level of supervision and training for therapists, and greater resources being spent on the treatment than in routine practice. However, this is an empirical question—can the results from clinical research (efficacy) be replicated in everyday practice (effectiveness)?Fortunately, the past decade has seen the publication of several effectiveness studies that give a clear answer to this question, using large routine clinical populations of patients with different diagnoses –40, and Despite the evidence outlined above, the simple answer to this question is: ‘Not very widely’. The number of eating-disorder specialist clinicians who report adhering to evidence-based protocols and manuals is between 6 and 35 % , 42. FarEven when clinicians say that they are using an evidence-based therapy, that claim should be treated with caution. For example, many clinicians who state that they are delivering CBT or FBT report that they omit many of the key techniques that make up those treatments , 46•, 47A further complication is that the same label is used for therapies with different content. CBT is a classic example of this issue, with the content differing in important ways. For example, one might not be surprised that a form of CBT for anorexia nervosa that reduced or removed the emphasis on weight gain (the key outcome variable [21]) has relatively low rates of weight gain . SimilarTo summarise, the number of patients who receive evidence-based therapies is probably very low, outside of research settings. This pattern of therapist drift and the consequent evidence-practice gap are not confined to eating disorders , 4. Howeservice-centred reasons. Eating disorder services vary in their culture, and consequently, their willingness to change towards evidence-based methods. Possibly the best example of service-level reluctance is that provided by Lowe and colleagues  are untrained in the therapy that they are employed to deliver  startling 15–20 years . In someTraining clinicians is a challenging area . CommonlIt is commonly assumed that clinical supervision is a means of ensuring that clinicians should adhere to best quality practice. However, there are some worrying caveats to that assumption. First, does the supervisor have an adequate grasp of the necessary evidence and skills base to be able to teach the supervisee to be adherent? Given the time it takes for evidence to reach practice  and the Of course, a strong means of persuading clinicians to change their practice should be to require them to attend to patient outcomes. The existing effectiveness studies –40 show Where clinicians do attend to data, it is important that they should be encouraged to attend to the most clinically meaningful data. In the case of eating disorders, those key data appear to be those that demonstrate early change and symptom remission. There is clear evidence that behavioural and attitudinal change in the first few sessions of CBT is a critical indicator of subsequent improvement of eating disorder symptoms ••, 80••.There have been substantial advances in the treatment of eating disorders, based on the development and establishment of evidence-based approaches. Such approaches are codified in the form of manualised protocols •, 16, 17However, this review has identified a serious gap in our use of research to drive everyday practice when working with eating disorders. Clinicians use evidence-based approaches, manuals and protocols rarely , 48•—a f


To establish reference intervals for cognitive potential P300 latency using tone burst stimuli.Masbe, Contronic). Electrode placement was as follows: Fpz (ground electrode), Cz (active electrode), M1 and M2 (reference electrodes). Intensity corresponded to 80 dB HL and frequent and rare stimulus frequencies to 1,000Hz and 2,000Hz, respectively. Stimuli were delivered binaurally. This study involved 28 participants aged between 18 and 59 years. P300 recordings were performed using a two-channel device  were determined for adults aged 18 to 59 years using the protocol described. Long latency auditory evoked potentials (LLAEPs) can be used in clinical practice as an objective measure of cognitive processes to assess auditory abilities, such as discrimination, memory, attention and detection of stimuli. Long latency AEPs are thought to be one of the most promising electrophysiological tests for evaluation of central auditory nervous system (CANS) dysfunction and/or changes. These potentials are generated by several systems, primarily the thalamocortical and corticocortical auditory pathways, the primary auditory cortex and associative cortical areas, and reflect thalamic and cortical activity in particular. Long latency AEPs result from the superposition of all electrical currents within the brain; therefore, accurate identification of neural generators is difficult. Neural generators are simultaneously activated and each individual CANS structure is responsible for the processing of one specific aspect of a given stimulus or information.Long latency AEPs enable the assessment of auditory information processing over time. While some LLAEPs are sensitive to physical characteristics of the eliciting stimulus , others reflect cognitive processes, such as attention and stimulus categorization .Long latency AEPs are represented by a series of positive and negative waves.,7 P300 depends upon some abilities, such as attention, discrimination and memory, and reflects cortical activity.The P300 component, or cognitive potential, is a positive potential elicited by the recognition of a rare stimulus  within a series of frequent stimuli and corresponds to the largest positive wave after the N1-P2 complex.P300 latency is the most commonly used parameter to infer potential auditory processing changes in research settings. However, clinical applicability is limited by the variability in P300 latency reference values. Studies describing updated P300 latency reference ranges are lacking. however, wider latency ranges, of 220 to 38ms, were also reported. Latency ranges and protocol variability may explain why P300 is not routinely used in clinical practice. Still, P300 is a promising assessment tool that can be employed across several disciplines in different subject areas. Its application as an objective ancillary measure in early recognition of cognitive dysfunction and dementia,(10) assessment of altered emotional states and evaluation of cochlear implants and hearing aids, among other fields, has been described. Therefore, novel studies are warranted to accurately determine normality parameters that may support the routine use of P300 for early recognition of several CNS changes in clinical settings.P300 latency values between 250 and 350ms were established in adults by Kraus et al.To establish reference intervals for cognitive potential P300 latency using tone burst stimuli.Twenty-eight subjects aged between 18-59 years were evaluated, 15 of which were men.The inclusion criteria were as follows: age between 18 and 60 years, normal hearing ability, lack of auditory complaints, no middle ear pathology, no continuous-use medication and ability to understand test procedures. Patients suffering from hearing loss and chronic diseases were excluded.Patients were submitted to external auditory meatus inspection, pure tone audiometry and acoustic immittance testing prior to cortical potential investigation.Audiometry was performed in sound-treated booth using Audiotest 330 audiometer. Air conduction thresholds were investigated at 250, 500, 1,000, 2,000, 3,000, 4,000, 6,000 and 8,000Hz using the descending-ascending method. Normal hearing individuals were defined as those with three-frequency  pure tone averages ≤25 dB HL (decibels hearing level).Tympanometric curve and acoustic reflex assessment was based on acoustic immittance testing performed using middle ear analyzer AT 235 and 226Hz probe tone. Contralateral acoustic reflexes were investigated bilaterally at frequencies of 500 to 4,000Hz. Only subjects with type-A tympanogram and preserved acoustic reflexes were included in the sample.Masbe, Contronic). Patients remained awake throughout the procedure while comfortably seated on an armchair.Long latency AEPs were recorded in a silent room using a two-channel device , vertex  and mastoids  with Ten20 conductive paste and micropore tape. Inter-electrode impedance ≤5 Kohms was ensured prior to testing.The international 10-20 systemPatients were instructed to keep their eyes open, avoid eye movement and note deviant (rare) random stimuli within a series of similar (frequent) stimuli, which should be mentally counted. Stimuli were delivered via ER-3A insert earphones with 80 dB HL intensity.Frequent and rare stimulus frequency corresponded to 1,000Hz and 2,000Hz tone bursts containing 50 and 100 cycles, respectively, with 20% rise and decay time and trapezoidal envelope. Stimuli were presented in a rare-frequent  paradigm with 80 and 20% probability respectively. Pulse frequency was 0.8 pulses per second (pps).P300 waves were investigated using binaural stimulation to prevent patient fatigue. A minimum of two tracings containing 30 rare stimuli each were recorded per patient for increased reliability; tracings were then added together and a single resulting wave acquired. Electrical signals were filtered with 01Hz high-pass and 20Hz low-pass filters. A 1,000ms time window was employed.i.e., maximum wave amplitude). The protocol employed for P300 investigation in this study is described in P300 latency values were recorded at the highest peak , with a 95% confidence interval.Clínica Cóser.The procedures and assessments in this study were carried out as part of a partnership between a university and the Universidade Federal de Santa Maria (RS); protocol number CAAE: 25933514.1.0000.5346, committee opinion no. 612.754.All participants signed the Informed Consent Form (ICF) as proof of their agreement with procedures involved in the study. This project was approved by the Research Ethics Committee (CEP) of Mean age of participants was approximately 35 years. Latency and amplitude data of all variables considered are displayed in P300 component latency did not differ significantly between the left and right ears .P300 is currently thought to be a promising assessment tool for detection of central changes. Despite interdisciplinary applicability, P300 continues to have limited use in clinical settings, possibly due to high levels of variability in the test, including latency variability. given the relation between response amplitudes and the number of synapses in the cerebral cortex. Cognitive potential P300 is known to be present in children from 5 to 7 years of age, albeit with reduced amplitude and increased latency, with complete maturation occurring around adolescence.,18 Cortical potential values at 14 and 16 years of age are equivalent to those described in adults, according to Steinschneider et al. Participant age in this study (18 years or over) ensured CNS maturation.Long latency AEPs depend on maturation of peripheral and central structures, a fact that must be taken into account when interpreting test resultsi.e., studies reporting similar standard deviations were assumed to be in agreement with findings presented here.P300 latency values of approximately 305ms were documented in this study. Latency values did not differ between the left and right ears; data were therefore grouped and the values compared to similar studies based on standard deviations –  and may range from 1.7 to 20uV. According to some studies, amplitude is not a relevant parameter in data analysis.,23Wave amplitude is thought to be of limited clinical value in P300 assessment; hence, this parameter was not measured. P300 values very widely between studies, both in test and control groups, involving patients aged 18 to 53 years. Mean P300 values of 313.86, 320 and 298ms  were also reported elsewhere.,25,26 However, discrepant P300 latency values of approximately 341ms (Cz electrode) and 352.2ms have been documented. Participant age in those studies ranged from 7 to 34 years; therefore latency variations may have reflected the maturation process.Mean P300 latency in this trial corresponded to 305ms. Similar P300 latency values (298.1ms) were described in another study but differ from other ranges (220 to 380ms) described. Still, results of this study are in agreement with P300 ranges documented in the international literature (250 to 350ms), with greater similarities between minimum values. Maximum P300 latency values of 380ms reported by McPherson were not recorded in this trial.Minimum and maximum P300 values in this study (243.03 and 359.08ms) are consistent with previously reported latency ranges of 246 to 361ms, The lack of a consensus and the infrequent use of this test in clinical settings have been pointed out as by Frizzo et al. as potential factors behind the wide variability in cortical potential induction and capture methods among professionals. Electrode placement at Cz or Fz and physiological differences between patients are some of the factors potentially interfering with cortical potential capture. The subjective nature of P300 recognition and sampling may also contribute to the wide variation found in literature.Differences in equipment, patient attention level, patient age, time of data collection and stimulus counting method, among other factors, may explain latency variation between studies.,30 Data presented are expected to aid clinicians in the interpretation of test results, provided similar parameters are used. Further studies, including meta-analyses, are warranted for more accurate determination of P300 reference values, thereby supporting the evidence-based early diagnosis of central auditory changes.The major scientific contribution of this study lies in the scarcity of updated P300 normative values in literature.Mean P300 latency values obtained using the protocol described in this study corresponded to 305ms, with minimum and maximum acceptable latency values of 247.5ms and 362.5ms respectively (mean±2 standard deviation).


Local government services and policies affect health determinants across many sectors such as planning, transportation, housing and leisure. Researchers and policymakers have argued that decisions affecting wider determinants of health, well-being and inequalities should be informed by evidence. This study explores how information and evidence are defined, assessed and utilised by local professionals situated beyond the health sector, but whose decisions potentially affect health: in this case, practitioners working in design, planning and maintenance of the built environment.A qualitative study using three focus groups. A thematic analysis was undertaken.The focus groups were held in UK localities and involved local practitioners working in two UK regions, as well as in Brazil, USA and Canada.UK and international practitioners working in the design and management of the built environment at a local government level.Participants described a range of data and information that constitutes evidence, of which academic research is only one part. Built environment decision-makers value empirical evidence, but also emphasise the legitimacy and relevance of less empirical ways of thinking through narratives that associate their work to art and philosophy. Participants prioritised evidence on the acceptability, deliverability and sustainability of interventions over evidence of longer term outcomes . Participants generally privileged local information, including personal experiences and local data, but were less willing to accept evidence from contexts perceived to be different from their own.Local-level built environment practitioners utilise evidence to make decisions, but their view of ‘best evidence’ appears to prioritise local relevance over academic rigour. Academics can facilitate evidence-informed local decisions affecting social determinants of health by working with relevant practitioners to improve the quality of local data and evaluations, and by advancing approaches to improve the external validity of academic research. This study advances research into evidence-informed policymaking with a novel focus on local-level decision-making in policy areas outside the health sector that affect the social determinants of health and health inequalities.Participants were recruited from international settings and two distinct UK regions.This paper provides practical recommendations on how academics can more fruitfully engage with and support local-level decision-making.The sample size was relatively small and participants were purposively sampled within one particular policy area (the built environment).Participants may have agreed to take part in the study because of an a priori interest in evidence utilisation in decision-making.healthy public policy.7Social, economic and environmental factors contribute to population health and health inequalities, suggesting a need for public health strategies that extend their scope beyond health service delivery.Alongside calls to make public health decision-making multisectorial, there have been concurrent calls for ‘evidence-based’ or ‘evidence-informed’ decisions.16National and international initiatives have encouraged the production and synthesis of research evidence to inform decision-making across sectors,14However, a counter-current in the literature and policy debates has challenged the concept of evidence-informed policy. Some commentators have questioned the usefulness and appropriateness of evidence-informed policy in general.31Recent developments affecting local-level public health administration in England illustrate the need to know what different sectors in local government understand by evidence informed decision-making.36As the public health agenda continues to be integrated into local government, we argue that researchers need to know more about the types of evidence and information relevant to and sought by local government decision-makers.This qualitative study is based on three focus groups held in 2013. Local government professionals were asked to participate in focus groups that aimed ‘to discuss and to learn more about how policymakers in local, city or regional government use information and evidence in their policy-making processes in built environment sectors’. Participants were purposively recruited through professional contacts and snowballing. For pragmatic reasons influenced by the researchers’ locations, two groups represented two UK regions (London and North West England), while the third was an international group . We planned that the groups could capture perspectives across and beyond the UK.The focus group facilitator (MP) used a topic guide with open questions and prompts about how participants conceptualise and use evidence in their work. Our approach replicated previous studies exploring national policymakers’ and researchers’ perspectives on evidence use.A thematic analysis methodThree overarching questions framed the analysis: (1) Which types of evidence did participants consider useful for their practice? (2) Whether their status as built environment practitioners influenced their approach to evidence? (3) Whether their status as local practitioners influenced their approach to evidence? As the analysis progressed, we selected emergent themes which we report in the findings section and then return to the three overarching questions in the discussion.A total of 15 senior local government decision-makers participated in the focus groups; their respective work roles are presented in The emergent themes we identified are described below.scientist, variously referred to as ‘medical’, ‘biomedical’ or ‘pure science’. An international participant illustrated this point, implying that the need to make evidence-informed decisions was traditionally perceived to be a barrier to creativity, but the participant also provided the opinion that architecture and related professions were gradually moving towards more evidence-informed approaches:I think if you're talking about the design professions, architects, in particular, have never felt constrained by the need for evidence to do things…we don't care. So I think it's come slowly to the design professions, but it's growing. Participants across the three workshops juxtaposed a narrow view of health research as ‘pure science’  with the built environment as a form of creative ‘art’, a philosophy or in one participant's words, a ‘theology’. Participants sometimes compared themselves against the archetype of the when you get down to the built environment, it's a, it's not a pure science, right? It's science and it's art, and so therefore quantitative information is one aspect of it. But if you look at a great, healthy city…there's a qualitative aspect of it in there. Group discussions did tend to suggest that practitioner roles could combine artistic and scientific elements. However, discussions also referred to the visual arts, emphasising the physicality and visibility of urban design and planning. Evidence could still be relevant to practice, but it could be image rather than text based. Architectural drawings, simple sketches, photographs and design plans all become valuable and instructive sources of information. Qualitative research could also be highly valued as a means of assessing the opinions and experiences of different stakeholders.…it could be anything from having the sort of latest population census, the latest population forecast, to knowing, um, or having information around, say, assessing how much housing land you need…it could be, say, around having studies that have been done around the benefits from, say, putting green infrastructure, which could be a whole range of things, everything from health to, to preventing flooding to recreation to, to whatever. Um, so it can be, you know, from the sort of statistical side. Through forecasting, through, um, best practice studies. Um, it can be a whole range of things from our perspective. We found participants from all three focus groups gave examples of quantitative and qualitative data used to inform their decisions, but again the kind of evidence they referred to was not simply analogous to academic research. This ‘evidence’ could include routinely collected data, specially commissioned surveys, local maps and associated geographic information systems (GIS) data, evidence-informed guidelines, anecdotes, case studies, mathematical models and academic research. As a planning manager described:Increasingly the government is putting more evidence on, onus on, that viability side of things. What you can actually deliver. Rather than what you actually need. Participants frequently spoke about the need to demonstrate the ‘viability’ of interventions and services, with the focus on whether initiatives could be delivered, sustained and accepted by stakeholders and users. The demand for evidence on ‘viability’ was sometimes said to come from national government.And what's actually really powerful about [pilot projects] is that, one, they're small scale, and two, by doing it as a pilot project, what they're able to do is not, basically not freak everyone out, right? Interventions were considered non-viable if they were believed to be incommensurable with national legislation, finance, contractual obligations and government endorsed guidance for best practice or if they were unacceptable to local stakeholders, such as delivery partners, politicians and the public. Data that might provide evidence of acceptability could come from market research, surveys and routine data on service participation rates. Pilot programmes were viewed as particularly valuable because they gave stakeholders an early opportunity to see how an intervention could be delivered without making large-scale commitments.I'm being asked more questions around monetisation than we were in the past. And I think particularly with the link to viability of development. Cost was also identified by participants in each focus group as crucial to demonstrating that an intervention could be sustained. A strong emerging theme focused on the perception that the current economic climate led to budget constraints and straitened financial circumstances, which increased political pressure to demonstrate value for money.He [an elected official] will be interested in the job creation, now, and the number of homes, number of completions, so there's a lot of performance tracking, there's economic development activity. And that feeds into viability, you know. Participants said they used indicators, such as output delivery, economic development indices and growth surveys, to make the case for economic benefits that may have resulted from their work—but there was no mention of using or commissioning more formal cost-benefit studies. The following comment by a practitioner from the North West illustrates how participants framed their discussions of economic benefits in a narrative that associated successful delivery of project outputs with plausible (but not necessarily measured) impacts on the local economy:I think the outcomes is the difficult one. It's how do we attribute the outcomes to our housing intervention. Because both public health and built environment are such long term investments, right, in the life of a community and so to build the evidence…is tricky. Actually there's a load of really good health outcomes in terms of looking at housing intervention, you know…But it's a non interventionist government who actually don't really believe in evidence policy making, really, to be honest with you. In contrast to the repeated reference to ‘viability’, participants from the three focus groups tended not to emphasise evidence of longer-term intervention outcomes. Reasons given for this included the challenge of measuring and attributing long-term intervention effects, difficulties in accessing and interpreting (sometimes contradictory) research evidence, as well as a perceived lack of political interest in evidence of such outcomes.However, when discussing their own practice, some participants did identify occasions where there was an opportunity to consider academic evidence of intervention outcomes, particularly during consultations, assessments and drawing up of guidelines and standards. For example, one participant described an occasion ‘when we were working on the active design guidelines we found academics who were actually doing evidence-based research’ , outcomes from which were then incorporated into the guidelines.…essentially took GIS mappings of the city and looked at where the highest rates of obesity and diabetes were, and then we looked at…where supermarkets were located. Participants placed knowledge about their local area at a premium. Quantitative data aggregated at the level of the local authority helped practitioners compare their authority against its’ neighbours or against national indicators. Microlevel data, for example, street or address level which could be quantitative, qualitative or anecdotal, gave practitioners information about specific buildings, intervention/service delivery points or specific localities associated with certain problems or issues of interest. For example, one participant was involved in a local initiative that:We'd do a housing needs survey, and that should show us how much affordable housing we're short of. So then we would write a policy to say we want so many percentage of each development to be affordable. This fine grain local data was often not academic in origin, although academics may have been involved in its production. For instance, a participant from a London local authority described the UK Government’s Decennial Census as the initial starting point for much of their area level statistics. Local authorities also conducted their own data collection:Besides using formally-collected quantitative data, practitioners drew on personal local knowledge. As local practitioners work within relatively small geographical boundaries, they are able to build up detailed experience-based understanding (based on a kind of participant observation) of their own area's geography, organisations, processes and issues.…case studies are really valuable in terms of being able to show how a policy can be put in place and, and you can get an outcome that you're actually looking for. In addition, practitioners from all three groups also saw the value of ‘case studies’ from areas similar to their own.[It helps] to be able to say, well, this city of a similar size in a similar country, and preferably a neighbouring borough did it [i.e. delivered the intervention]. And not only did it achieve some of the things we thought it would, in terms of health outcomes or employability, whatever, but also, it didn't result in massive political damage. Case studies were described in different ways: they could be as simple as an anecdote or a site visit, or they could involve more formal attempts to collect data about an intervention's delivery, acceptability, cost and (sometimes) outcomes. The appeal of both formal and informal case studies lay in their perceived value in convincing local practitioners that a particular intervention had been successfully delivered in a similar area, by professionals similar to themselves and working within a similar regulatory and financial framework. This provided some assurance that the intervention could be delivered successfully in their own area.But I think often, I mean, we're talking about, you're talking about overseas evidence, and often the problem, I think, is where people use overseas evidence is that the planning systems are so different it's not easy to track for a local authority or another organisation to see how you can actually maybe translate that back into the British situation. In contrast, participants were less willing to accept evidence relating to interventions delivered in contexts perceived to be different from their own, including those reported in published academic studies in international journals.Hence, academic research could be discounted because of perceived problems with its external validity , irrespective of the internal validity of the evidence. The local relevance of evidence was generally seen to be more importance than its methodological rigour.We have used focus groups to explore how information and evidence are defined and utilised by local decision-makers working in design, planning and maintenance of the built environment. In particular, we aimed to explore (1) the types of evidence that non-health sector local practitioners consider useful for their practice; (2) whether practitioners specialising in the built environment have a particular view of evidence influenced by their professional sector and its culture; and (3) whether practitioners working at a local level may have a particular view of evidence that is related to the spatial scale at which they operate.Practitioners refer to various types of evidence besides that found in academic publications. This evidence includes ‘routine data’ produced by public and private sector organisations, sometimes with academic involvement, such as surveys, maps and audit data. Less ‘academic’ sources of knowledge include practitioners’ first hand experiences and anecdotal evidence. Practitioners also find case studies, defined in different ways, particularly useful for demonstrating that an intervention can be successfully delivered in a similar context.Previous research on models of evidence utilisation  has suggested that decision-makers may use academic research strategically to provide posthoc justifications for policies, actions and inaction.Built environment practitioners present narratives intended to explain why academic evidence is not always incorporated into decisions. One kind of narrative juxtaposed participants’ preference for a broad approach to knowledge  to a narrowly conceived depiction of ‘pure’ empirical science. Participants’ self-presentations also tended to emphasise artistic and creative aspects of their work, which they again contrasted with empirical science.Sociological literature on science, health and the health profession has problematised definitions and distinctions relating to science and other epistemologies.Local intelligence is crucially important to local practice—an obvious statement, but one that has far-reaching implications for evidence-informed decision-making. Even though academics often take seriously the need to provide evidence that can inform policy and practice, localism can be a barrier to knowledge translation. Local practitioners question whether articles published in international academic journals are necessarily relevant to their own context. They may consider locally specific routine data, locally commissioned surveys and qualitative data collection to be more useful because these data have a direct and obvious relevance to the specific settings within which local practitioners work.While the authors of this paper support the need for evidence-informed decisions, we would add that in order to deliver on evidence-informed policy and practice, more academics need to look at the evidence needs of local practitioners and tailor research to better meet those needs. We are not the first to advance this point of view. Previous discussions have often been framed around the kinds of evaluation questions practitioners find most useful ,The findings suggest why local practitioners working beyond the health sector may not always choose to prioritise academic research outputs among the different types of knowledge relevant to their work. However, they also highlight ways in which academics may help inform local decision-making through involvement in developing and analysing locally relevant data, improving practitioners’ skills for evaluation, and paying more attention to contextual issues, external validity and the transferability of study findings.Practitioners’ prioritisation of local knowledge, including quantitative and qualitative data, and experiential knowledge of a locality seems to be rational and unavoidable. Local government decision-makers face a complex set of limitations, levers and discretionary powers that frame what they may and may not be able to achieve within the political, legislative and financial landscape within which they operate. Given this complexity, practitioners may feel sceptical about how academic studies from a wide range of (often poorly described)and effective within their own area. Academics, who increasingly need to demonstrate that their research has been translated into practice and has ‘impact’, stand to benefit from this symbiotic relationship.However, practitioners do agree that case studies can be particularly useful, especially when they describe success stories delivered in similar contexts to their own practice. Case studies have also attracted the interest of some academics interested in evaluating social interventions.Focus group research presents the researcher with examples of how practitioners interact and construct narratives with their peers, and this may differ to how they would present their opinions if interviewed individually or indeed any opinions they might not want to voice. In this particular study we noticed a general consensus within and between groups. This may reflect genuine consensus, but it could also reflect possible methodological limitations: for example, self-selection ; researcher bias (participants framing responses around their beliefs about what the researchers wanted to hear); and group dynamics among professionals who may tend to seek out consensus. The groups were small and purposively sampled. We focused on built environment practitioners because of the well-established theoretical and empirical associations between built environment and public health, but we assume that this selection influenced our findings.Built environment practitioners in local authorities apply the word ‘evidence’ to a variety of knowledge sources including case studies.Practitioners seek evidence of viability, a conflation of terms relating to the feasibility of intervention delivery and sustainability.Emphasis is placed on immediate outputs and intermediate outcomes; evidence of long-term outcomes, including health outcomes, may be seen as unattainable.Local knowledge is vital to local practice. Academic evidence is frequently irrelevant to practitioners' local contexts.Academics could support work on the social determinants of health in local authorities more effectively by co-producing research with local practitioners, by developing geographical data at local authority level, and by improving local evaluation and research capacity through training.For some time, commentators with an interest in public health have advanced the view that decisions should be informed by the best available evidence. It is sometimes assumed that ‘best available evidence’ is synonymous with methodologically robust academic research. However, nearly two decades ago, Nutbeam pointed out that evidence-free policy was in part caused by ‘policy-free’ evidence: academic research that fails to adequately understand and address the needs of decision-makers.


To investigate the existing evidence base for the validity of large-scale licensing examinations including their impact.Systematic review against a validity framework exploring: Embase (Ovid Medline); Medline (EBSCO); PubMed; Wiley Online; ScienceDirect; and PsychINFO from 2005 to April 2015. All papers were included when they discussed national or large regional (State level) examinations for clinical professionals, linked to examinations in early careers or near the point of graduation, and where success was required to subsequently be able to practice. Using a standardized data extraction form, two independent reviewers extracted study characteristics, with the rest of the team resolving any disagreement. A validity framework was used as developed by the American Educational Research Association, American Psychological Association, and National Council on Measurement in Education to evaluate each paper’s evidence to support or refute the validity of national licensing examinations.n = 22) provided evidence of national licensing examinations relationships to other variables and their consequential validity. Overall there was evidence that those who do well on earlier or on subsequent examinations also do well on national testing. There is a correlation between NLE performance and some patient outcomes and rates of complaints, but no causal evidence has been established.24 published articles provided evidence of validity across the five domains of the validity framework. Most papers (The debate around licensure examinations is strong on opinion but weak on validity evidence. This is especially true of the wider claims that licensure examinations improve patient safety and practitioner competence. Medical regulation has historically involved establishing who is appropriately qualified to call themselves a medical doctor and keeping certain people, such as “barbers”  and “chaMuch of the attention has perhaps understandably focused at the beginning of clinical practice. This transition point from medical school into the workplace is also often a point at which international medical graduates enter the workforce. One way in which regulators have controlled entry into practice within their borders has been to establish national licensing examinations (NLE); the most notable of which is perhaps the United States Medical Licensing Examination (USMLE) from the National Medical Board of Examiners (NBME) .It is easy to understand why the concept of a licensing exam is hailed as important. They sit at the point at which medical schools graduate their students. Only those who achieve the required standards are then allowed to practice in the jurisdiction. In this way, the advocators argue, a nation’s population is reassured that only capable doctors who can practice safely are qualified. Moreover, the centrality of NLEs to the continuing debates within medical education concerning assessment is brought into sharper focus by the predictions of their inevitable proliferation. Swanson and Roberts have recently opined on this subject, arguing that, amongst other factors, the increase in the numbers and diversity of medical schools and the increasing mobility of the medical workforce will increase the demand for NLEs globally . But exaThe United Kingdom (UK) does not currently have a NLE but has historically relied on external examiners – visiting medical educators from other organizations – and General Medical Council (GMC) inspections to assure quality across UK medical schools. Doctors from overseas take a different route into licensure in the UK; predominately through the Professional and Linguistic Assessments Board (PLAB) examination .However at the end of 2014 the GMC announced that it planned to establish a NLE and in June 2015 it laid out a timeframe for the introduction of a ‘Medical Licensing Assessment’ (MLA) which will ultimately be taken by all UK graduates and non-European Economic Area (EEA) graduates who wish to practice in the UK by 2021 . As EuroAs part of the process of developing this new NLE, the GMC commissioned researchers at the Plymouth University Peninsula School of Medicine to undertake a systematic review of the international literature to establish the evidence base for the validity including the impact of NLEs and to identify best practice . The finWe conducted a systematic review following guidance on the conduct of narrative synthesis in systematic reviews .We carried out a systematic electronic search in Embase (Ovid Medline), Medline (EBSCO), PubMed, Wiley Online, ScienceDirect, and PsychINFO. These databases varied in relation to both subject content and size. In those databases with medical or healthcare profession sections, such as EBSCO and EMBASE, searches were only conducted within these areas.All databases were searched from 2005 to April 2015. We used a combination of relevant keywords to construct the search strategy including “national licensing examination”, “doctor”, “dentist”, “nurse”, “midwife”, “healthcare professional”, “international medical graduate”, “accreditation”, “credentialing”, “registration”, and “certification”.One author (NL) conducted the first screening of potentially relevant records based on titles and abstract, and four authors  independently performed the final selection of included papers based on full text evaluation. Consensus between the reviewers was used to resolve any disagreement supported by all the authors. A review of websites of medical regulators or those bodies with responsibility for licensing doctors and healthcare professionals in 49 ‘very high human development’ countries similar to the UK was also undertaken . The UniSecondly, and in addition to the search process, we contacted, via the GMC and the International Association of Medical Regulatory Authorities (IAMRA), medical regulators and licensing authorities in the 49 countries. We sought to gather information (grey or unpublished) which had shaped the thinking of regulators when planning, or excluding, licensure examinations.Finally, we reviewed the websites of each of the bodies involved in medical regulation in the 49 countries with the intention of identifying any source of underlying validity evidence, such as references to papers, assessment manuals etc., for NLEs where we found them.From the published literature, we included all papers that discussed national or large regional (State level) examinations for medical and healthcare professionals published since 2005. Papers were eligible if they were linked to examinations that were normally taken in early careers or near the point of graduation, and for which success in the examination was required to enter practice. There were no restrictions on language but only examinations in countries “comparable to the UK” were included . Specialconsequences domain, we can focus on the “impact, beneficial or harmful and intended or unintended, of the [national licensing] assessment”  impact on quality of care” across the international healthcare system [Second, there is mixed evidence on the relationship with other variables when NLE test scores are compared with criterion based outcomes around complaints and patient welfare. Sutherland & Leatherman concluded in a 2006 review that “e system . Since te system , or ratee system . HoweverThird, a series of papers each demonstrated that IMGs do less well in large scale testing , 40, 41.An important finding of this review is the lack of evidence that patient outcomes improve as a consequence of the introduction of national licensing exams. As noted above, there is evidence that performance in NLEs is correlated to improved patient outcomes and less complaints, but this has not been shown to be as a consequence of national licensing exams.consequence of introducing NLEs; this kind of before and after evidence is absent in the extant literature. One confounding factor to a causal link between testing performance and subsequent care is the fact that those who do well in the USMLE get the better jobs in the better institutions [Although the aforementioned studies by Norcini et al.  and Tambitutions , 42. TheOverall, some authors argue that NLEs are not real barriers to entry into the profession, and therefore do not protect the public. For example nearly everyone who takes the USMLE passes it in the end . Others There is no clear picture from the literature as to the impact of NLEs on the medical school curricula. One study on the introduction of a Step 2 Clinical Skills component of the USMLE surveyed medical educators in medical schools in the US. The study found that over one third of respondents reported changes to the “objectives, content, and/or emphasis of their curriculum” (p.325) . While tAt the same time however, this raises the question that NLE exams may encourage homogeneity or a lack of innovation in curriculum design. Yet aside from one dental example in Florida , there aThe literature we reviewed is characterized by diversity in terms of its methodological approach, the type of evidence it provides and its overall quality and utility. There is no doubt that there is now a high degree of sophistication in the testing and assessment involved in licensure exams, particularly the USMLE. For this reason perhaps, the technical aspects of NLEs are well evidenced in the literature , 47, 48,For example, studies demonstrate that candidates with lower NLE scores tend to end up working in less respected institutions , 42 and That there is validity evidence for the correlation, as opposed to causation, between NLEs and doctors’ performance may in itself be an argument for national licensing , but thiLastly, there are difficult questions raised about inclusion, exclusion, and fairness in respect to IMG doctors . In SwedOur review systematically approached a large literature. Much of it was not evidence based but strong on expert opinion and debate. We used a framework to help shape and focus those papers that provided evidence of validity . This frunequivocal evidence and an identifiable gap in knowledge on this subject [The weakness of the evidence base exists for those who argue against national licensure examinations , as well subject .and the apparent difficulties they present to regulators, this is an area of research that needs to be better understood.Our review suggests a significant knowledge gap exists around the impact of licensure examinations on subsequent patient care and on the profession, especially IMGs. Whilst a strong body of statistical evidence exists to show IMGs perform less well in licensure examinations than candidates from the host countries, , 59 the The research there is (at least that which met our inclusion criteria) suggests IMGs may, for a number of reasons, work in occupations that do not necessarily match their skills or qualifications , 47. If We have argued that the evidence for NLEs improving doctor performance and patient safety as a consequence of their introduction is weak, whereas the evidence for a correlation between test results and overall performance is strong. As such, the relative benefits of introducing a NLE may well be contingent upon the efficacy of existing regulatory systems. As such, policy-makers and regulators may consider moving beyond a one size fits all approach to NLE; evidence should be examined in light of existing regulatory systems and, as suggested above, the broader consequences of NLEs for issues such as workforce planning in relation to IMG doctors.The main conclusion of our review is that the debate on licensure examinations is characterized by strong opinions but is weak in terms of validity evidence. The validity evidence is particularly poor for the claim that NLEs improve, above and beyond existing assessments, either the competence of practitioners or the safety of patients. This is highlighted through mapping the evidence onto the APA framework: the evidence points to a relationship with other variables, including doctor performance and patient complaints, but there is not strong evidence that these outcome measures are a consequence of introducing NLEs. Nowhere, as yet, has staged a NLE to establish whether the introduction of such an examination significantly impacts upon measures of interest such as patient outcomes using a control group or a ‘control country’. While this raises significant political and practical challenges, in the absence of such evidence for these aspects of the NLEs, the debate looks set to continue.