The aim was to explore first line nurse managers’ experiences of opportunities and obstacles to support evidence‐based nursing.A qualitative study with a phenomenographical approach.Data were collected through focus group interviews with 15 first line nurse managers’ in four settings.Manage the everyday work vs. evidence‐based nursing; Uncertainties about evidence‐based nursing and nursing research; Time as a reality, as an approach; and Shaping awareness—towards an active approach to evidence‐based nursing. The overarching category of description has been formulated as follows: The internal relation—how active leadership influences evidence‐based nursing. The outcome space is presented as: The individual path—how to make vision and reality become a working entity around evidence‐based nursing.The results are presented in four categories of description headed:  Preliminary conceptions were identified and then discussed in the research group to reach agreement on the final formulation of conceptions . Four categories of description were formulated from the conceptions and were arranged hierarchically  with the overarching category as the highest level and the outcome space representing the relationships between the conceptions  . The study was conducted in line with the ethical statements made in the Declaration of Helsinki . Partici3The internal relation—how active leadership influences evidence‐based nursing,views the inner journey the FLNM has to form to be able to realize how one self can be the obstacle and also how one self with insight, can be the opportunity to become supportive towards evidence‐based nursing. In the different steps shown in the Figure In the result, obstacles and opportunities could be understood in different ways. The overarching category: Manage the everyday workvs. evidence‐based nursing; Uncertainties about evidence‐based nursing and nursing research; Time as a reality, as an approach;and Shaping awareness—towards an active approach to evidence‐based nursing.Those categories showed opportunities and obstacles in relation to the clarity the participants discussed around evidence‐based nursing and their own possibility to be supportive.The results are further presented in four categories of description, under the headings: The internal relation—how active leadership influences evidence‐based nursing.Finally, the outcome space was formulated as: The individual path—how to make vision and reality become a working entity around evidence‐based nursing.The overarching category of description was worded as follows: 3.1(Interview1)… because I feel that it would need a person, a special person with that knowledge, to be able to handle those questions in the group, it's got to be an enthusiast and as a first line manager you can be really supportive, but you have all the other questions and tasks to take care of, so I really think someone else should be responsible for this. (Interview 1)Yes, I think you are the FLNM, but still you are not and I think they [the hospital management] should change as well. I don't think we have a clear mandate in the hospital. During the interviews, the participants did not clearly identify themselves as the person in charge of evidence‐based nursing. Their everyday workload got in the way, which often caused frustration. The participants felt that someone else, or an external function, should be handling how to achieve evidence‐based nursing in the clinical work at the ward. They also expressed that achievement of evidence‐based nursing was everybody's responsibility or even the hospital managements:To summarize, the participants expressed a rather confused or frustrated approach towards their own ambition and possibility to support evidence‐based nursing; that is, they conceived the obstacle of being busy. The conception that evidence‐based nursing should be someone else's or, alternatively, everybody's or even the hospital managements’ responsibility was expressed.3.2(Interview 3)… because my feeling is that the nurses, they do not, in my ward no‐one even has a thought of doing research, just doing some nursing research; everything is based on the medical tradition when it comes to research in my ward. This category describes the participants’ way of approaching evidence‐based nursing from their point of view as FLNM's. What constituted research was described as unclear and imprecise. The participants themselves were vague and imprecise when talking about research use, for example. Nursing theory was not mentioned at all. Most of the participants said that they were aware of medical research being conducted and that the hospital had a strong medical research tradition:(Interview 1)Yes, at the hospital as in the culture dominated by production, you more or less get forced into it …. The participants talked about the working climate at the hospital as being focused on production and how that climate affected the way nurses thought and acted concerning evidence‐based nursing. For example, one participant expressed it this way:In this category, some of the participants expressed frustration and confusion about evidence‐based nursing, nursing research and accordingly their responsibility regarding implementation of the same. The participants conceived that it was other assignments during work hours that needed to be addressed before they could even start thinking about supporting evidence‐based nursing and that they never found themselves able to tackle the task. This frustration about the working climate was described as an obstacle.3.3(Interview 2)… I never end up there  because there is always so much work that I must do first; I put out the fires, I'm already planning the staffing for the summer and thinking how will we fix the staffing for Christmas.... (Interview 1)…but right now, it is as it is, that you cannot stand or there is no time for anything except to try to get it all to go around at the ward… (Interview 3)Yes, there is a lack of time due to the producing culture. The regret “if I only had more time” was frequently expressed in the focus group interviews. The participants repeatedly reported lack of time as an obstacle to be supportive to nurses when nurses wanted to use nursing research or nursing theories to improve the care. The participants seemed never get to the point where the possibility to provide support for evidence‐based nursing showed up. Their descriptions showed, however, that evidence‐based nursing was not their top priority. This was expressed as follows:This category highlights the important matter of time in health care. Lack of time is a reality; and this category is a way of looking at the FLNMs’ handling of time, which determined their ability to support the nurses to work in an evidence‐based way. The participants were aware of the importance of time, some of them in a more dejected way than others.3.4(Interview 4)When a question comes up, we think, well do we handle this right? Can we check this up and then we do that and you try to deal with the question the same afternoon when the nurses have their coffee break, we just take 45 min and discuss, we don't make a big fuss of it. This category is about starting a process towards an active approach to evidence‐based nursing. It is not always the FLNM know and formulate their own importance, but it is still obvious that an awareness is growing, as an opportunity. It was expressed like this:(Interview 2)Students often have a critical approach I think, or some of them. Of course, they can highlight that there have emerged for example new routines … they can ask, “Why do you do this the way you do?” and we can start to think “Yes, why do we do it that way?” That can result in for example new routines, so I think the students are important at the ward. The FLNM's understood the importance and benefit of having student nurses at the ward:The last category shows that insight is starting to take hold. Here, the participants expressed their views on evidence‐based nursing in a more active way. They sometimes downplayed their stand, but it was evident that it was important to them.3.5The overarching category of description gives a picture of an internal relation between reflection and an active approach to support evidence‐based nursing. When the leader takes the initiative to create a climate that supports evidence‐based nursing, then the process that influences thinking, attitude and behaviour will develop. The leader has established their approach to nursing research and has also taken an active position on the importance of evidence‐based nursing. The leader can, when this level is reached, articulate and understand the differences and similarities in research in general and can assess how nursing research increases the quality of nursing care through evidence‐based nursing.3.6The conceptions presented in the outcome space can be understood to depict a development from the lowest level, where the daily work as FLNM involves putting out fires and trying to get the clinical work done from one day to another, as seen in Figure 4The aim was to explore first line nurse managers’ experiences of opportunities and obstacles to support evidence‐based nursing. The results show a complex situation regarding the responsibility and the FLNM's view was unclear concerning their own leadership in this responsibility. Confusion regarding how evidence‐based nursing could be understood was presented, together with the participants’ own varying thoughts regarding how they could facilitate evidence‐based nursing, both can be understood as obstacles. To support something to which one has an unreflective or shallow approach is of course difficult and sometimes even impossible. In this climate, medical research becomes the norm. And, furthermore, there is a risk that nurses do not value research conducted to improve nursing care, in line with what other studies report, for example substantial contributions to conception and design, acquisition of data or analysis and interpretation of datadrafting the article or critically revising it for important intellectual contentAll authors are responsible for the reported research, and worked together with design, analysis and interpretation of data. All authors also approved to resubmit the paper to your journal. All authors agreed on the final version and meet at least one of the following criteria recommended by the ICMJE (


PRISMA guidelines were followed to the extent possible given the limitations inherent to a review largely based on qualitative studies. The identified literature was very context-specific and referred to mechanisms, practices from the field, and recommendations that were derived from planning or response efforts implemented at the national or local levels in specific countries. Integration of ERC functions into public health emergency preparedness, planning and response activities was influenced by reforming components of the leadership structure when needed, modifying organizational factors, and nullifying restrictions (including amending laws/ regulations) that might have been an obstacle to the timely release of information. Exercises and trainings were recognized as effective strategies to identify the barriers and successes in this process of integration. Key elements to enhance information sharing and coordination across organizations included the creation of networks, task-forces and committees across disciplines, organizations and geographic areas. Engagement of local stakeholders was also important to guarantee the flow of information up and down the incident command system. On the whole, few empirical studies, especially from low- and middle-income countries, related to the WHO research questions, demonstrating the need for research in these areas. To facilitate an accurate identification of the gaps, the authors suggest integrating current findings with case studies across the WHO regions to better understand the specific evidence that is needed in practice across the multitude of ERC functions.The World Health Organization (WHO) commissioned a systematic review of literature to facilitate evidence syntheses for the development of emergency risk communication (ERC) guidelines for its member states. The goal of this review was to integrate ERC best practices into governmental and non-governmental health systems for all emergencies of public health concern, by addressing three questions: (1) to identify best practices for the integration of ERC into national and international public health preparedness; (2) to identify mechanisms to establish effective intra-agency, inter-agency, and/or cross-jurisdictional information sharing; and (3) to identify methods to coordinate risk communication activities between responding agencies across organizations and levels of response. The review covered scientific and grey literature publications between January 2003 and February 2016, and searches were conducted in 17 English language electronic libraries besides Chinese, Portuguese and Spanish language databases. A mixed deductive-inductive process was used to synthesize findings across studies through identifying thematic areas. While 8,215 articles were initially retrieved, after a sequential screening process, the final evidence syntheses comprised of 21 articles for question (1) and 24 for questions (2) and (3) combined (due to overlap of themes). The  This screening ensured that only articles which clearly violated the above criteria were excluded. Subsequently, 880 full-text articles were reviewed to determine eligibility for inclusion based on the assessment that they addressed components of the WHO SPICE breakdown, the details of which can be found in the published WHO Guidelines . To determine if the research was addressing the WHO questions, two reviewers independently read the article (with the exception of articles in Chinese language), and based on the SPICE breakdown identified sentences (in the article) supported by empirical data that would provide information which directly answered a WHO question or was related to the question (indirectly answered the question). Subsequently the two reviewers met to discuss their judgment, and in case of disagreement a third reviewer was consulted. Furthermore all articles deemed to be indirectly related were discussed with the WHO team to make sure the information was related to the questions developed by WHO.Study title, first author, year of publication, type of publication , country/ region of the study, study design , population/sample studied or addressed , the type of disaster/crisis situation described and the phase of disaster  addressed were listed. The objectives of each study were noted, and the key topic area and principal findings and/or recommendations were carefully described. The relevance of an article to one or more of the WHO questions under consideration was critically judged and differences in opinion were resolved through consultations (as described earlier).An article was defined to be "directly relevant" to a specific WHO question if: (1) it had an empirical study design, and (2) the findings and/or recommendations directly answered that particular WHO question. If an article did not satisfy both these criteria, it was coded as "indirectly relevant" and not included in the final evidence synthesis.Four methodological streams were identified to classify and characterize the selected articles: 1) quantitative , 2) qualitative , 3) mixed-methods  and 4) case studies (description of the response to a particular emergency/crisis situation). The literature was then synthesized using the Best Fit Framework Synthesis described by Booth et al.  and BarnFor question 1, the syntheses of evidence is presented separately for English (n = 6) and Chinese language (n = 15) publications because of the different types of studies included in the two languages and difficulties in merging concepts and themes between the two. However, integration of the themes in a unified synthesis among articles in the two aforementioned languages was possible for questions 2 and 3, and therefore the evidence syntheses for these two questions  have been presented together.confidence in findings was assessed by the use of the Qualitative Evidence Syntheses  tool, and a level of confidence was assigned to each study (high/ moderate/ low/ very low) based on methodological limitations, relevance, coherence and adequacy of data [A number of tools were applied to assess the quality of each study based on the methodology and study design: the Critical Appraisal Skills Program (CASP) tools were used to assess cohort studies and qualitative studies  , the Mix of data . The GRA of data  for detaFor the overall conduct of this systematic review, the PRISMA guidelines were followed to the extent possible given the limitations inherent to a review largely based on qualitative studies .Among the 8,215 articles retrieved, 5,946 were in English (may have included other language publications that had English abstracts), 1,415 in Chinese, 481 in Portuguese and 373 in Spanish. Through title screening, 6,316 (77%) articles were excluded, while 1,899 (23%) abstracts were reviewed, leading to 880  full text articles for further scrutiny. After the final stage appraisal, 21 full text articles were selected for Question 1 (6 in English and 15 in Chinese), and 24 more for Questions 2 and 3 combined . Among the 21 articles identified as related to question (1), 6 28.5%) were qualitative, 6 mixed-methods, 5 24%) quantitative and 4 (19%) case studies. Most articles focused on ERC in China, Hong Kong and Taiwan , while the others covered ERC in Cambodia, Indonesia, Japan, Laos, Vietnam, Thailand and UK . Twelve (57%) of these 21 articles addressed all hazard situations , while 9 were based on pandemic influenza and other infectious disease outbreaks. Tables % quantit% were quAmong the 24 articles included for the final evidence syntheses for questions (2) and (3) combined, the majority  were qualitative in design, with 5 (21%) case studies, 4 (17%) quantitative and 3 (12%) mixed method approaches. Seven (29%) articles focused on the US, and 3 each on Netherlands and China (including Hong Kong and Taiwan). Other regions represented included Asia , the Middle East , Australia, New Zealand, Canada and Brazil. Among the disaster-types, 7 (29%) articles addressed all-hazard situations, 4 addressed pandemic influenza/infectious diseases, 3 described floods, 2 each addressed hurricanes/ tornados, volcanos, terrorism and anthrax scares, and 1 each described a wildfire, earthquake or other major accident. Evidence synthesis: (1) How can ERC best be integrated into national and international public health emergency preparedness planning and response activities?The articles identified as relevant to this question presented examples of mechanisms that might lead to the integration of ERC functions into the leadership structure. Such mechanisms were summarized under four themes: (1) placing ERC functions into the national leadership structure , 17; (2)Restructuring of existing organizational components of agencies engaged in preparedness and response efforts, as well as developing novel intra- and inter-agency coordination frameworks were often needed to achieve integration of ERC functions into the national preparedness/disaster response leadership. Yen et al.  describeAssessing pandemic influenza preparedness in six Asian countries , Hanvoravongchai and colleagues  observedCope  noted thFor each of these thematic areas, the overall synthesized evidence was considered to be of moderate confidence level . Most of the contributory publications (to each area) were individually judged to have only minor concerns regarding methodology, and/or adequacy of data, and/or coherence; hence these articles individually provided evidence of a "moderate" confidence level. The confidence in the pooled evidence is a reflection of such a majority of articles.The articles identified to respond to question (1) described practices across three functional areas: (1) how various government agencies used the micro-blogging platform "Weibo" for ERC –28; (2) Government agencies in China utilized the social media platform "Weibo"  for public communication during normal times as well as in public health emergencies  with the goals of achieving timely, open, two-way communications, monitoring public opinion, controlling rumors, addressing public concerns and improving government services. There had been a consistent national effort to expand the use of Weibo across China, and to establish a standardized operation, training and evaluation mechanism for its service performance. –28 In orA national hotline service  was developed by the Ministry of Health (MoH) and integrated into the emergency response system. This was successfully tested as an important channel of communication during the 2008 formula contamination crisis, 2008 Beijing Olympics, 2009 A(H1N1) pandemic, and the recent measles campaign. , 29, 30 Within China's governance framework, these novel approaches had helped integrating ERC as a system response involving multiple agencies and the target (affected) population. Further, the Chinese CDC had been working in close collaboration with its US counterpart to conduct assessment of ERC needs at local public health agencies, through conducting tabletop and functional exercises. –36Similar to synthesized evidence from English language publications, the overall synthesized evidence was considered to be of moderate confidence level  for each of these three functional areas.Evidence synthesis: (2) What are the best mechanism(s) to establish effective intra-agency, inter-agency, and/or cross-jurisdictional  information sharing for emergency risk communication? and (3) What are the best practices and protocols to ensure coordination of risk communication activities between responding agencies across organizations and levels of response?The articles  identified to respond to these two questions (combined) presented examples of mechanisms to enhance information sharing and coordination. Such mechanisms were summarized under three themes: (1) creation of task forces/committees –43 and nThe formation and functioning of collaborative platforms like task forces, networks and committees had been attributed to facilitate efficient information sharing between national and sub-national authorities, as well as between agencies. Chess et al.  cited thGresham  describeThe literature provided several examples where planned investment in communication infrastructure including better operationalization of wireless communication channels, increased coordination between responding agencies, and better understanding of communication needs improved the overall disaster management. This was specifically demonstrated during the response to two earthquakes, three months apart, in Turkey.  Thiago eDifferent mechanisms were proposed to engage local stakeholders in formulating and implementing ERC strategies. Ardalan  suggesteSimilar to the evidence syntheses for Question 1, for each of these thematic areas the overall synthesized evidence was considered to be of moderate confidence level .The functioning of ERC is intricately linked to the varying political and cultural landscapes present across nations. Therefore, in some circumstances, centralized ERC systems may work better than localized ones, or vice versa. Researchers had noted that decentralized health systems (e.g. as in Indonesia) faced greater challenges in implementing preventive and outbreak response measures, and the level of efficiency depended heavily on local political commitment.  In contrThe development of ERC policies and capacities through regional partnerships and guidelines seemed to be well received. For example, the European Union (EU) had enacted legislation on a cross-border integrated emergency response system, including coordination and information exchange between constituent nations. The Health Security Committee (HSC) Communicators’ Network under the EU provides crisis communication expertise and guidance as part of a comprehensive strategy for the successful management of public health threats. The information-sharing protocol is implemented through the establishment and activation of a list of contact points within the EU, the European CDC and the WHO. Geographic variations in capacity and practice of ERC strongly necessitated the formulation of evidence-based universal guidelines by the WHO to help member states develop frameworks to integrate ERC as a system response during emergencies of public health concern. Such communication needs to be transparent, timely and based on the best available scientific evidence, in order to ensure the maximal physical, social and economic well-being of citizens.The identified literature referred to mechanisms, practices from the field, and recommendations that were derived from planning or response efforts implemented at the national or local levels in specific countries, but did not provide direct evidence of transferability to other contexts. Factors that seemed to be related to the integration of ERC functions in national and international public health emergency preparedness, planning and response activities included renovation of components of the leadership structure when needed, modification of organizational factors, nullifying restrictions that might hinder the timely release of information, and amendments to laws and regulations where feasible. Exercises and trainings were recognized as strategies to identify barriers and successes in the integration of ERC functions into preparedness, planning and response efforts. Key elements to enhance information sharing and coordination across organizations included the creation of networks, task-forces and committees across disciplines, organizations and geographic areas. The functionality of information systems was a key element for the sharing of information by tailoring such systems to the needs of the users. Engagement of local stakeholders was equally important to guarantee the flow of information up and down the incident command system.Despite conducting a very thorough literature review across multiple language databases, the authors felt that more sensitive approaches may be needed to gather useful evidence in a non-Western non-English context, for example, when conducting region-specific case studies. It was observed that the Chinese language articles tended to be succinct in the methodology section and elaborative about policy or program implications, with an emphasis on status report and actions taken or recommendations for future steps. This utility-driven approach might be useful in offering actionable information to practitioners on the ground in the context of China, but presented a challenge in quality assessment. With the Spanish and Portuguese language publications, there was a general paucity of empirical literature on ERC. Risk communication in emergency preparedness was mainly addressed by the social health, communication and technology, and human sciences fields; very little of this work was produced by researchers or practitioners working in public health. In addition, differences in organizational response structure, especially in Latin America, contributed to this overall finding.On the whole, few empirical studies, especially from low- and middle-income countries were related to the WHO research questions. The authors attempted to circumvent this shortcoming by searching databases in Chinese, Portuguese and Spanish, as well as relaxing the strict definition for empirical literature to include more case studies and to reflect a broader distribution of country experiences and knowledge. However, this observed bias against empirical studies from low- and middle-income countries may be partly due to the limitations of the authors in their ability to assess a broader range of languages. Furthermore, the fact that ERC is still not precisely-defined as a field of research meant that there were challenges in identifying sensitive search terms and keywords that would incorporate the varied disciplines that cover this field. It is probable that in addition to differences in terms across disciplines, terms may also differ across nations, and even among professionals trained in similar disciplines.The authors believe that the lack of empirical studies across the questions solicited by the WHO demonstrates an overall need for research in these areas. However, an accurate identification of research gaps should be achieved by integrating the results of this review with case studies across the WHO regions to better understand what type of evidence is needed in practice across the multitude of ERC functions. Such an approach may ensure that research is produced in the topic areas of greatest need for practice.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.


Deleting a long noncoding RNA drives premature aging in mice. Related research article Kopp F, Elguindy MM, Yalvac ME, Zhang H, Chen B, Gillett FA, Lee S, Sivakumar S, Yu H, Xie Y, Mishra P, Sahenk Z, Mendell JT. 2019. PUMILIO hyperactivity drives premature aging of Norad-deficient mice. eLife8:e42650. doi: 10.7554/eLife.42650Aging is a complex process that affects most living organisms. Over a century of research has revealed that many different intrinsic and extrinsic factors contribute to our bodies growing old, but we are still a long way from a full understanding of all the mechanisms at play. Recent research has implicated molecules that do not code for proteins in this process, such as long noncoding RNAs. For instance, many of these so-called 'lncRNAs' are expressed differently in patients with age-related disorders, such as various forms of neurodegenerative disease and cancer .Norad accelerates aging in mice  that regulate a variety of targets in the cell, including some involved in cell growth and division  and colleagues – including Florian Kopp as first author – report that losing the long noncoding RNA  in mice . Previouan cells . The prodivision . Yet, itNorad. As the mutant animals grew, they displayed signs of premature aging: their fur thinned down and grayed faster; their spine showed the abnormal curvature associated with old age; their fat reserves dwindled more quickly; and they died earlier. Mice lacking Norad also exhibited several cellular hallmarks of aging (Norad-deficient human cells), as well as mitochondria that were showing defects. This was associated with the repression of PUMILIO targets that keep mitochondria working properly. Strikingly, mice engineered to over-produce PUM2 had similar characteristics, clearly indicating that the hyperactivity of PUMILIO drives the symptoms associated with a lack of Norad (To investigate this question, Kopp et al. – who are based at UTSW, the Nationwide Children's Hospital and Ohio State University – engineered mice that lacked of aging . Many ofof Norad .Pum2. Furthermore, in both Norad-deficient and Pum2-overexpressing mice, most PUMILIO targets are only affected very mildly, yet the animals exhibit striking phenotypes. Kopp et al. argue that repressing many PUMILIO targets at the same time, even weakly, may trigger the physiological damages observed in these rodents.On the flipside, a recent study in humans showed that halving the dose of PUM1 leads to developmental delay and seizures , and redNorad-PUMILIO axis is disrupted, certain cells or tissues are more likely to stop working properly, which in turn creates a snowball effect for the whole organism. For instance, the expression of Norad is highest in the human brain, but it decreases with age in a region that acts as a reservoir to regenerate brain cells (C. elegans, the nervous system acts on other tissues to coordinate pathways that keep proteins in their normal conformation, but these mechanisms become defective with age (Norad and PUMILIO are needed in specific tissues to ward off the effects of age.Still, it may also be possible that when the in cells . In simpwith age . It remaNorad is PUMILIO’s preferred target, and has several binding sites that are recognized by these proteins. This suggests that this lncRNA can bind a large number of PUMILIO proteins at any given moment, but it is still unclear whether Norad tempers the activity of PUM1 and PUM2 simply by competing with other targets of PUMILIO, or if another mechanism is at play ( at play .Norad is only found in mammals, whereas the PUMILIO proteins are found in all eukaryotes; it is therefore possible that RNAs with different sequences also buffer the activity of PUMILIO in other species. It remains to be seen how and why mammalian cells rely on Norad to tame the activity of these proteins, as opposed to other types of regulatory mechanisms. Ultimately, the work by Kopp et al. sets the ground for further enquiries into the role of noncoding RNAs and RNA-binding proteins in aging, which could potentially yield new therapeutic approaches for diseases brought by old age.Curiously,


Evidence-based guidelines are expected to provide clinicians with explicit recommendations on how to manage health conditions and bridge the gap between research and clinical practice. However, the existing practice guidelines(CPGs) vary in quality. This study aimed to evaluate the quality of CPGs of kidney cancer.We systematically searched PubMed, Embase, China Biology Medicine disc, and relevant guideline websites from their inception to April, 2018. We identified CGPs that provided recommendations on kidney cancer; 4 independent reviewers assessed the eligible CGPs using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. The consistency of evaluations was calculated using intraclass correlation coefficients (ICC).A total of 13 kidney cancer CGPs were included. The mean scores for each AGREEII domain were as follows: scope and purpose—76.9%; clarity and presentation—76.4%; stakeholder involvement—62.8%; rigor of development—58.7%; editorial independence—53.7%; and applicability—49.4%. Two CPGs were rated as “recommended”; 8 as “recommended with modifications”; and 3 as “not recommended.” Seven grading systems were used by kidney cancer CGPs to rate the level of evidence and the strength of recommendation.Overall, the quality of CPGs of kidney cancer is suboptimal. AGREE II assessment results highlight the need to improve CPG development processes, editorial independence, and applicability in this field. It is necessary to develop a standardized grading system to provide clear information about the level of evidence and the strength of recommendation for future kidney cancer CGPs. RCC comprises approximately 3.8% of all new cancers in the western world; the detection rate of RCC has been increasing in the past 10 years by approximately 1.7% per year. Since 2005, a number of new targeted agents have come into the market for the treatment of this disease. Although many of these therapies showing promising outcomes with improved progression-free survival and overall survival, diagnosis, treatment, and management of kidney cancer still remain the major challenge for clinicians.An estimated 62,700 Americans were diagnosed with kidney cancer and 14,240 died of the disease in 2016. However, the existing CPGs vary in quality and comprehensiveness, leading to difficulties with standardization of care, adaptation, and implementation, particularly in resource-limited settings. The usefulness of guidelines primarily depends on the quality, rigorous methodology, and transparency of development. It is important to determine whether the recommendations are, indeed, based on high-quality evidence.,8 At present, there is no literature comparing and evaluating the strengths and weaknesses of all available CPGs for the treatment of kidney cancer.Therefore, kidney cancer clinical practice guidelines (CPGs) drafted by local, national, and international organizations have been developed to standardize clinical practice and improve effectiveness of management. Ideally, evidence-based guidelines are expected to provide clinicians with explicit recommendations on how to manage health conditions and bridge the gap between research and clinical practice. We sought to identify gaps limiting evidence-based practice, and highlight potential opportunities for improvement.We aimed to assess and summarize the quality of all currently available international kidney cancer CPGs by conducting a critical review using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.2 and some related studies.–13 As it is a review of the previous works of literature, approval of the ethics committee was not required.We conducted a comprehensive evaluation of kidney cancer CPGs using the AGREE II instrument, and the study was performed according to the guidelines from Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)2.1http://www.g-i-n.net/), National Institute for Health for Health and Care Excellence website (https://www.nice.org.uk/guidance), National Guideline Clearinghouse (https://guidelines.gov/), Scottish Intercollegiate Guidelines Network (http://www.sign.ac.uk/), Clinical Practice Guidelines Portal website , New Zealand Guidelines Group website , BCGuidelines website , AQuMed Database website (http://www.aezq.de/aezq/publications). In addition, we searched Google Search Engine and checked the references of all the related guidelines to include more potential guidelines.PubMed, Embase, and China Biology Medicine disc databases were systematically searched up to April, 2018. We combined the terms “kidney cancer,” “renal cell carcinoma,” “renal tumor,” and a filter to identify guideline documents (practice guideline [pt] OR guideline [pt] OR guideline∗ [ti]). We also searched the websites of guideline development organizations: Guidelines International Network Web site  independently identified search results to determine eligibility guidelines, and extracted the basic information from included guidelines. Disagreements were resolved by consulting the third expert adjudicator (L.Y.X.).2.4 which includes 23 items on a 7-point Likert scale across 6 domains. Each domain captures a unique dimension of the CPG quality: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence. Items were scored based on a scale ranging from 1 (absence of item) to 7 . The standardized score for individual domain, which ranged from 0% to 100%, was calculated using the following formula: / × 100%. AGREE II protocol states that no overall score is calculated to determine if a CPG is recommended or not recommended. Each guideline was classified as: “recommended” for overall scores >60%, “recommended with modifications” for scores between 30% and 60%, and “not recommended” for scores <30%.Four independent reviewers evaluated the quality of each kidney cancer CPG according to AGREE II instrument,2.5We extracted the level of evidence and the strength of recommendations of each kidney cancer guideline if they adopted evidence grading systems.2.6 As a previous study described, the ICCs between 0.01 and 0.20 were considered minor, 0.21 to 0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 to 1.00 very good. A value of P <.05 indicated statistical significance. All tests were 2-sided. Statistical analyses were conducted using Excel2010 and SPSS version 21.0 .We calculated the standardized score of each domain for individual included CPGs, and determined the number of recommendations and the percentage distributions among quality of evidence and strength of recommendation classes. Agreement among 4 appraisers’ scores was tested using intraclass correlation coefficients (ICCs) with 95% confidence interval (CI) for each domain of all included guidelines.33.1,4,18–28 met inclusion criteria.Figure 3.2,20,21,28 were new, and the rest were updates; 12,4,18–28 were developed in high-income countries and only 1 was from middle-income country(China). The CPGs evaluated covered the different types of kidney cancers: 8 guidelines–25,27,28 focus on RCC, 3,21,26 for renal mass and localized renal cancer, and 2,19 for all stages of kidney cancer. The majority (8) of CPGs focused on the early management of kidney cancer,–23,25,28 and others,24,26,27 focused on the diagnosis, treatment, and follow-up.A summary of the characteristics of the included CPGs was presented in Table 3.33.3.1The ICC values indicated that the overall agreement among 4 appraisers received higher reliability scores, ranging from 0.57 to 0.92  of 9.5%, and all guidelines scored more than 50%. The lowest score was 63%, from SEOM clinical guideline for treatment of kidney cancer 2017 . The highest score was 90.3%, from the use of targeted therapies in patients with inoperable locally advanced or metastatic renal cell cancer: updated guideline 2017 .3.3.3This domain focuses on the extent to which the CPG was developed by the appropriate stakeholders and represents the views of its intended users. Scores fluctuated remarkably with a mean score ± SD of 62.85% ± 17.4%. Two (15.4%) kidney cancer guidelines scored lower than 50%, of which the lowest was 24% from SEOM .3.3.4This domain investigates the method and process of evidence search, grading, summary, and the formulation of the recommendations. The mean score and SD for this domain was 58.7% ± 18.4%. Three (23.1%) kidney cancer guidelines scored lower than 50%, of which the lowest was 27% from Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines .3.3.5This domain addresses the presentation and format of guidelines. The mean score and SD in this domain was 76.4% ± 13.8%. The lowest score was 50% from Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma .3.3.6This domain focuses on processes related to CPG implementation such as organizational facilitators and barriers, additional materials provided, cost implications, and monitoring or audit criteria. The mean score and SD of this domain was 49.4% ± 21.6%, among which 4 kidney cancer guidelines scored less than 50%, with the lowest score of 3% from SEOM clinical guideline for treatment of kidney cancer (2017) .3.3.7This domain considers funders and competing interests of experts involved in guideline development. The mean score and SD of this domain was 53.7% ± 18.1%, and 5 scored less than 50%. The lowest score of 25% came from Cardiovascular and Interventional Radiological Society of Europe (CIRSE) guidelines on percutaneous ablation of small renal cell carcinoma  and SEOM clinical guideline for treatment of kidney cancer . The highest score was 79.2%, from European Association of Urology Guidelines on Renal Cell Carcinoma 2015 .3.3.8This assessment concerns “the rating of body quality of the guidelines and whether the guideline would be recommended for use in practice.” According to the appraisal of the individual domains and overall scores, 2 kidney cancer guidelines overall scored >60%, and were rated as “recommended” by the appraisers; 8 were rated as “recommended with modifications”; and 3 as “not recommended”  system , 1  used GLIDES system , 1 used NCCN system , 1 used PHSGS system , 1 used CIRSE system , and 3,22,25 did not specify. Whereas, the codes of level of evidence and strength of recommendation in different grading systems vary , The Use of Targeted Therapies in Patients with Inoperable Locally Advanced or Metastatic Renal Cell Cancer: Updated Guideline 2017 , and Renal mass and localized renal cancer: AUA guideline  were the 3 CPGs with best results. Most of the included CPGs were developed by high-income countries, and are therefore minimally applicable in resource-limited settings. Apart from this, the distribution of level of evidence and strength of recommendations varied significantly among different kidney cancer CPGs.There may exist some kidney cancer CPGs published before 2008,applicability domain, suggesting that guideline developers have not paid sufficient attention to potential barriers affecting practical implementation of recommendations. Therefore, it is recommended that there should be a pilot test for the applicability of new guidelines before the release of clinical practice to ensure their feasibility. Guideline groups should provide recommendations and address the barriers as much specificity as the evidence permits. The guideline developed by AUA (2017)  was recommended (scoring 68.8%) in our appraisal as a good example in future guideline development for this domain.The appraisal CPGs obtained the lowest score in editorial independence domain, information related to potential conflicts of interest was scarce or not even mentioned, especially the guidelines developed by SEOM, CIRSE, SOS, and AOS. Because the conflicts of interest are the most common source of bias and often under-reported, CPG developers should explicitly declare whether potential conflicts of interest  will impact on guideline drafting, including the rigorous vetting process and the transparent and available rules for review. Recently, some studies have reported that developers of CPGs were affected by pharmaceutical or medical device manufacturers, so it is important to know how much these interactions could have affected the recommendations.,34Kidney cancer CPGs also performed poorly in Rigor of CPGs mainly focuses on the methodological process of guidelines development, because this domain can better reflect the quality of CPGs than the other 5 domains. Even though vast majority of guidelines contained references, many did not explicitly describe literature search and selection methods, and were ambiguous regarding how to appraise evidence and formulate recommendations. This step is crucial to determine whether the recommendations really depend on the best available evidence. The low score might be caused by the poor methodology and reporting, or unfamiliarity with criteria of CPG development, or missing performance of external peer review and updating process. To achieve this aim, the majority of guidelines applied grading systems to rate the quality of evidence so as to communicate clear message, quickly and concisely to help guideline users, readers, and stakeholders to understand the confidence of estimate of the effects and the strength of recommendations. The confidence of estimate of the effects reflects the extent to which confidence in an estimate of the effect is adequate to support a particular recommendation. Also, the strength of guideline recommendation reflects the extent of collective confidence that adherence to the recommendation will do more good than harm.,37 However, we found different grading systems with various systems of codes were used to rate evidence and recommendations in kidney cancer CPGs, which could confuse the guideline users to apply these guidelines. Therefore, it is important to develop a standardized grading system to provide clear information about the level of evidence and the strength of recommendation for kidney cancer CPG users, and good news is that we find some guideline organizations such as the American Urological Association (AUA) begin to adopt GRADE system instead of old systems in their new version of guideline development handbooks.,26As we all know, adaptation of existing guidelines to clinical practice may be a more valid and cost-effective means of achieving high-quality guidelines worldwide.There are several strengths of our findings. On the one hand, the strength of recommendations and level of evidence of each kidney cancer guideline were carefully extracted if these guidelines adopted evidence grading systems, which may indicate the overall quality of kidney cancer guidelines; On the other hand, our authors have different academic backgrounds, including methodological and medical experts, which ensured the reliability of our conclusions.,39Inevitably, our study has some limitations: Firstly, we only included guidelines published in English; guidelines for some other languages are not included and may affect the universality of the results. Secondly, AGREE II instrument places emphasis on methods of guideline development and the transparency of reporting, but could not assess potential impacts of recommendations on patient outcomes.5Our analysis of current CPGs for the kidney cancer revealed that methodological quality of CPGs was acceptable, but there is still plenty of space for improvement, especially in the editorial independence, applicability, and rigor of development in the CPG development. Kidney cancer CPGs should develop recommendations with the evidence of high quality, while minimizing bias with compelling methodological rigor, openness, and transparency. If possible, CPGs should underline the demand for additional studies to close the gaps in clinical care that has a significant effect on patient outcomes.Data curation: Xiaofeng Hou, Meixuan Li, Peijing Yan, Meng Wang, Wenbo He, Caiwen Han, Huijuan Li, Liujiao Cao, Biao Zhou, Zhenxing Lu, Bibo Jia, Jing Li, Xu Hui.Formal analysis: Xiaofeng Hou, Meixuan Li, Peijing Yan, Meng Wang, Wenbo He.Methodology: Xiaofeng Hou, Meixuan Li, Peijing Yan, Yunxia Li.Project administration: Yunxia Li.Resources: Caiwen Han, Huijuan Li, Liujiao Cao, Biao Zhou, Zhenxing Lu, Bibo Jia, Jing Li, Xu Hui.Software: Wenbo He, Huijuan Li.Supervision: Yunxia Li.Writing – original draft: Xiaofeng Hou, Meixuan Li, Meng Wang.Writing – review & editing: Xiaofeng Hou, Meixuan Li, Peijing Yan, Yunxia Li.


Users can request new terms or changes to existing terms through the project’s GitHub site. ECO is released into the public domain under CC0 1.0 Universal.The Evidence and Conclusion Ontology (ECO) contains terms (classes) that describe types of evidence and assertion methods. ECO terms are used in the process of biocuration to capture the evidence that supports biological assertions (e.g. gene product X has function Y as supported by evidence Z). Capture of this information allows tracking of annotation provenance, establishment of quality control measures and query of evidence. ECO contains over 1500 terms and is in use by many leading biological resources including the Gene Ontology, UniProt and several model organism databases. ECO is continually being expanded and revised based on the needs of the biocuration community. The ontology is freely available for download from GitHub ( Biocuration is the process whereby information about biological entities is collected and stored. Ideally, this is done electronically, in a standardized format, and kept in a central biological data repository so that it may be easily accessed by the research community . Over thAn annotation statement consists of at least three elements: the object being annotated, an aspect of the object that is being asserted and the evidence supporting the assertion. The Gene Ontology (GO) ,5 is in Biological assertions/annotations are routinely used for hypothesis generation as well as multiple kinds of bioinformatic analyses and thus can have far-reaching downstream effects. The ability to fully query and track all aspects of each assertion is important and serves numerous useful purposes. For example, queries of annotation databases allow one to know which types and sources of evidence were used for annotations, either individually or in aggregate. In addition, since many annotations are made in a transitive way  evidence documentation allows the tracking of provenance of information and chains of annotation. Thus, if one link in that chain is later shown to be invalid  it is then possible to quickly find all assertions that were based on that erroneous data and remove or correct them. Further, representing evidence information in a computationally friendly manner allows the establishment and enforcement of curation rules to promote and ensure best practices in annotation. For example, a group could establish that if a function is asserted for a protein based on sequence similarity to another protein, it is required that the matching protein must itself be experimentally characterized. The GO has established such rules .Since evidence comes in many flavors and its consistent storage is of such importance to effective annotation, a systematic way to organize types of evidence and apply them in annotations is essential. An ontology is the best solution to this challenge. An ontology is a controlled vocabulary of terms (or classes) related to each other in defined ways. The ECO  providesECO is structured around two root classes: ‘evidence’ and ‘assertion method’. Terms describing types of evidence are grouped under ‘evidence’ which is defined as ‘a type of information that is used to support an assertion’. All of the first level subclasses of this term can be seen in Figure Terms from the ‘evidence’ and ‘assertion method’ nodes have been combined to create cross-product terms that describe both features. All leaf nodes in the ontology are either a child of ‘evidence’ and ‘automatic assertion’ or ‘evidence’ and ‘manual assertion’. Although not all types of evidence have yet been used in an automated way, for the sake of logical consistency, all evidence types have been given both a ‘manual assertion’ and an ‘automatic assertion’ child term. Figure https://github.com/evidenceontology/) that results in additional new term generation.Currently, there are 1515 terms in ECO. Since the first ECO publication in 2014 , CollecTAll 1515 ECO terms have English definitions, most of which are in the Aristotelian (class-subclass) form. Of these, 613 additionally have been assigned logical definitions, i.e. a formal, computable definition distinct from the English one. Of these, 188 have logical definitions that link out to other vocabularies, such as GO and the Ontology for Biomedical Investigations (OBI) , and 425http://robot.obolibrary.org).Originally, ECO was developed in the Open Biological and Biomedical Ontologies (OBO) format using the OBO-Edit tool . HoweverROBOT is a command line tool developed to support OBO ontologies as part of the OBO Foundry . ROBOT chttp://precedings.nature.com/documents/3574/version/1).Another ROBOT function that we employ for our work with ECO is the “extract" function. With our commitment to collaboration and our ongoing work at developing logical definitions that link to other ontologies, we now need to import external ontology classes into ECO. Our main imports at this time are OBI and GO. Both of these, especially GO, contain many classes that are not part of ECO mappings and importing those would unnecessarily increase the size and complexity of ECO. Therefore, we only wish to import a relevant subset of classes using the ROBOT “extract" command. First, we identify the external classes used in ECO and compile these into a simple text file (a line-by-line list of the classes) for each imported ontology. ROBOT then uses these as input to pull the relevant terms and their dependencies from the source ontologies for our use in ECO. ROBOT supports multiple methods of extraction which results in different structures of the import modules. For ECO, we use the MIREOT  method to extract a simple hierarchy of classes from the import ontology while maintaining all necessary metadata about those classes  or the technique or assay used to generate the evidence (e.g. polymerase chain reaction-based evidence). This has created a situation where some terms that have related biological context are found under different unrelated nodes, causing confusion and difficulty for users to find the terms they need. Therefore, we have been screening ECO for grouping terms that describe only a technique or assay and these are being evaluated one-by-one. In general, we find that the children of these grouping terms can be relocated under other more context-dependent parents. At the same time, logical definitions for these terms are created with links to the relevant assay-based OBI terms. The assay-based grouping term is either renamed, merged or made obsolete, depending on the particular case. This ontology review has also led us to find and merge instances of duplicate classes, e.g. ECO:0000295 ‘RNA-seq evidence’ and ECO:0000357 ‘RNA sequencing assay evidence’, which were originally in different parts of the ontology. Changes made as a result of this review will make it easier for users to find the terms they are looking for and will reduce confusion due to ambiguous classes. It also sets a standardized design pattern for adding new evidence terms in the future.http://purl.obolibrary.org/obo/eco/gaf-eco-mapping.txt. Formally linking GO evidence codes to ECO terms facilitates interoperability with other resources that use ECO natively, such as UniProt (ECO has long supported efforts by the GO Consortium (GOC) to represent evidence in gene product annotations ,15. Curr UniProt , which ahttp://purl.obolibrary.org/obo/eco/gaf-eco-mapping-derived.txt). Of the 950 mappings, approximately half (483) map to “Inferred from Electronic Annotation" , which means that the annotation was assigned without a human curator’s judgement. A third of ECO’s classes point to “Inferred from Direct Assay" (IDA) or “Inferred from Experiment" (EXP), with 196 and 110 mappings, respectively. About 5% (56) point to “Inferred from Physical Interaction" (IPI). “Inferred from Expression Pattern"  and “Inferred from Mutant Phenotype"  together comprise another 6% of the total. The remaining 52 mappings (5%) are scattered amongst the other 21 GO evidence codes.Moreover, ECO maintains an additional file derived from the original mapping table that contains inferred subclass closure: every subclass of an ECO class that is mapped to a GO evidence code also contains a mapping to that same GO code, allowing for efficient bidirectional lookup of evidence  methodologies from more traditional approaches, several high-level ECO classes were created, starting with ECO:0006055 ‘high throughput evidence’, which is defined as “a type of evidence where data generation is automated with equipment to allow for assaying samples or molecules in parallel". This broadly defined term is parent to subclasses describing HT cell biology evidence, HT mutant phenotype evidence, HT genetic interaction evidence and others. Each HT evidence subtype has a corresponding ‘manual assertion’/‘automatic assertion’ cross-product term, as well. It should be noted that there is active discussion within the biocurator community about the nature of HT data, and this is ongoing work.Much recent ECO development has emphasized the normalizing of the ontology in order to facilitate usability and interoperability by broader resources. To accomplish this, ECO has been harmonizing with OBI, an orthogonal ontology in the biomedical domain . WhereasAs scientists in the community use ECO for their work, they find the need for new terms or for clarification of existing terms and relationships. Requests for new terms and/or term adjustments are regularly posted to our GitHub issue tracker. Addressing these user needs inevitably leads us to discover related areas of the ontology where new terms can be added or improvements made. Thus, our ECO development is dynamic and responsive as the needs of the user community evolve. Below we highlight some of the more large-scale efforts in this area.CollecTF is a resource that focuses on the capture of experimentally characterized bacterial transcription factors, their DNA targets and downstream regulated genes with an emphasis on the experimental provenance of curated records . This inThe OMP provides terms for the annotation of microbial phenotypes . The OMPhttp://www.geneontology.org/page/syngo-synapse-biology). The SynGo uses ECO evidence classes for asserting experimental evidence for synaptic localization and function. We have added more than 10 new evidence classes and revised the classification of some existing classes under ‘direct assay evidence’ and ‘microscopy evidence’ based on the group’s valuable suggestions.The Synapse Gene Ontology and Annotation Initiative (SynGO) is a collaborative project supported by the GOC, which aims to provide expert curated synaptic gene annotations by utilizing GO . Detailed technical instructions about the ECO release process can also be found on GitHub. The ECO is released into the public domain under CC0 1.0 Universal . Anyone is free to copy, modify or distribute the work, even for commercial purposes, without asking permission. Ontology files are also available for download from the ECO website (http://evidenceontology.org).As of March 2018, we have fully automated our release process through the use of ROBOT. The release workflow employs multiple ROBOT commands including “report”, “merge”, “reason”, “convert” and “filter” in our Makefile. The Makefile contains a set of “rules" to make “targets" as part of automated build processes. In this case, the rules are various ROBOT commands and the targets are the ECO release files. To generate a release, the developer only needs to run the single command: “make release". As part of our release process, we produce both OBO and OWL formated files through ROBOT “convert". Releases are generally made on a monthly basis and are available in our GitHub repository accompanied by release notes with highlights for that month (http://www.evidenceontology.org) with additional features for learning more about ECO. Highlights include a user guide with background about ECO and ontologies in the life sciences; links to download the ontologies; instructions on how to submit term requests and feedback; information about ECO staff and users; and a Twitter feed displaying recent tweets by ECO (@ecoontology)  and TreeView tools (https://www.npmjs.com/package/ols-treeview). This makes it very easy for users to quickly find terms of interest for use in annotations or to simply explore ECO. The simple and responsive ontology browser view is helpful for introducing students or interns to the concept of structuring scientific information in addition to give a survey of many types of scientific evidence.Prominent on the ECO home page is a link to an ontology browsing tool that employs the Ontology Lookup Service’s  GraphVieOntology releases are available at the website in both OBO and OWL format. For users who find that they need a term that is not yet in ECO, there are step-by-step instructions on how to request a term and a link that takes users to our issue tracking system on GitHub where new term requests are submitted and addressed. The GitHub tracker is also where users can request changes to existing terms or post questions or concerns. Additionally, it serves as a forum where the community can discuss the development of ECO.ECO has evolved over the years, not only in terms of the ontology architecture, depth of coverage and external references, but also with respect to the resource’s user community. ECO began as a small in-house ontology, specific to GO annotations made by the model organism databases. Next, it began to be used by gene expression pattern databases  and softIn addition to being a production ontology, ECO is also used for teaching as part of an intercollegiate competition focused on genome annotation. Originally piloted by the University of Maryland Baltimore County and the Texas A&M University, the CACAO (Community Assessment of Community Annotation with Ontology)-Phage Hunters competition has now spread to several other colleges . This cohttp://www.evidenceontology.org/about_us/#usergroups). This list was accumulated through literature citations and searching the internet. It is maintained and updated as we learn of new ECO adopters. The list contains references, so that our users may learn how others are using ECO. We encourage anyone using the ontology to contact us via the GitHub tracker (https://github.com/evidenceontology/evidenceontology/issues/new), not only for development requests, but also so that we may know about your project and add it to our list of users.For a complete list of known ECO users, please visit the ECO website (https://www.wikidata.org/wiki/Wikidata:Main_Page). Wikidata is to structured data what Wikipedia is to free text. ECO has become part of the Wikidata ecosystem. Not only has the whole ontology been imported and integrated into Wikidata, but the ECO identifier (https://www.wikidata.org/wiki/Property:P3811) is actively being used to provide machine-readable evidence assertions in Wikidata statements. Each Wikidata statement asserts a particular piece of information about a specific item in a machine-readable manner. ECO has become a part of the Wikidata ecosystem with the aid of the GeneWiki project , which is an instance of a gene and part of Operon 227  could be of high quality  or of low quality . Therefore another parallel system for capture of confidence information is needed. The Confidence Information Ontology (CIO)   proposesAt the time of this writing, there is ongoing discussion within the biocuration community about the meaning of “high-throughput" and there has been some confusion about the relationship between high-throughput annotations and automatic annotations. Although ECO has terms to describe high-throughput evidence types, we plan to further explore these nodes in collaboration with members of the community who have started to establish guidelines in this area (e.g. the Gene Ontology Consortium).https://github.com/evidenceontology/) and the project’s website (http://evidenceontology.org/). The ECO is released into the public domain under CC0 1.0 Universal.ECO is freely available from GitHub (


Liver health, fecal bile acid (BA) concentrations, and gut microbiota composition are closely connected. BAs and the microbiome influence each other in the gut, where bacteria modify the BA profile, while intestinal BAs regulate the growth of commensal bacteria, maintain the barrier integrity, and modulate the immune system. Previous studies have found that the co-occurrence of gut microbiota dysbiosis and BA metabolism alteration is present in many human liver diseases. Our study is the first to assess the gut microbiota composition in infantile cholestatic jaundice (CJ) and elucidate the linkage between gut bacterial changes and alterations of BA metabolism. We observed reduced levels of primary BAs and most secondary BAs in infants with CJ. The reduced concentration of fecal BAs in infantile CJ was associated with the overgrowth of gut bacteria with a pathogenic potential and the depletion of those with a potential benefit. The altered gut microbiota of infants with CJ likely upregulates the conversion from primary to secondary BAs. Our study provides a new perspective on potential targets for gut microbiota intervention directed at the management of infantile CJ. Clostridium, Gemella, Streptococcus, and Veillonella and the family Enterobacteriaceae and were negatively correlated with the fecal BA level and the CDCA/CA ratio but positively correlated with the serological indexes of impaired liver function. An increased ratio of deoxycholic acid (DCA)/CA was observed in a proportion of infants with CJ. The bacteria depleted in infants with CJ, including Bifidobacterium and Faecalibacterium prausnitzii, were positively and negatively correlated with the fecal levels of BAs and the serological markers of impaired liver function, respectively. In conclusion, the reduced concentration of BAs in the gut of infants with CJ is correlated with gut microbiota dysbiosis. The altered gut microbiota of infants with CJ likely upregulates the conversion from primary to secondary BAs.The co-occurrence of gut microbiota dysbiosis and bile acid (BA) metabolism alteration has been reported in several human liver diseases. However, the gut microbiota dysbiosis in infantile cholestatic jaundice (CJ) and the linkage between gut bacterial changes and alterations of BA metabolism have not been determined. To address this question, we performed 16S rRNA gene sequencing to determine the alterations in the gut microbiota of infants with CJ, and assessed their association with the fecal levels of primary and secondary BAs. Our data reveal that CJ infants show marked declines in the fecal levels of primary BAs and most secondary BAs. A decreased ratio of cholic acid (CA)/chenodeoxycholic acid (CDCA) in infants with CJ indicated a shift in BA synthesis from the primary pathway to the alternative BA synthesis pathway. The bacterial taxa enriched in infants with CJ corresponded to the genera IMPORTANCE Liver health, fecal bile acid (BA) concentrations, and gut microbiota composition are closely connected. BAs and the microbiome influence each other in the gut, where bacteria modify the BA profile, while intestinal BAs regulate the growth of commensal bacteria, maintain the barrier integrity, and modulate the immune system. Previous studies have found that the co-occurrence of gut microbiota dysbiosis and BA metabolism alteration is present in many human liver diseases. Our study is the first to assess the gut microbiota composition in infantile cholestatic jaundice (CJ) and elucidate the linkage between gut bacterial changes and alterations of BA metabolism. We observed reduced levels of primary BAs and most secondary BAs in infants with CJ. The reduced concentration of fecal BAs in infantile CJ was associated with the overgrowth of gut bacteria with a pathogenic potential and the depletion of those with a potential benefit. The altered gut microbiota of infants with CJ likely upregulates the conversion from primary to secondary BAs. Our study provides a new perspective on potential targets for gut microbiota intervention directed at the management of infantile CJ. Infantile cholestatic jaundice (CJ) is defined as jaundice caused by elevated conjugated bilirubin in infancy . The incThe common clinical feature of CJ is cholestasis, which is defined as reduced bile formation or flow, resulting in the retention of substances normally excreted into bile . Bile isThe gut microbiota is a large and diverse community of microorganisms that contribute to human health and disease . The humThe co-occurrence of gut microbiota dysbiosis and BA metabolism alteration has been shown in many human liver diseases, including nonalcoholic fatty liver diseases , 18, pri21–As shown in We used a targeted metabolomics approach to evaluate the fecal BA profiles in the 95 individuals enrolled in this study, including 54 infants with CJ, 25 infants with IHF, and 16 HC infants. The levels of all primary BAs were decreased in infants with CJ, and these decreases were significant for allocholic acid (ACA), CA, CDCA, and α- and β-muricholic acid (α- and β-MCA) . Reducedn = 56), infants with IHF (n = 25), and HC infants (n = 45). Alpha diversity, measured by the Shannon and Chao1 indexes, was significantly lower in infants with CJ than those with IHF and HC  (Clostridium sensu stricto (OTU2 and OTU46), Streptococcus (OTU13), and Veillonella (OTU40) and the family Enterobacteriaceae (OTU24) compared with the HC. Some taxa belonging to the genus Enterococcus (OTU68), Gemella (OTU45), and Streptococcus (OTU91) were more abundant in infants with IHF than in HC. The levels of potentially beneficial bacteria, such as Bifidobacterium (OTU96) and Faecalibacterium prausnitzii (OTU151), were significantly decreased in infants with CJ. The levels of the taxon Faecalibacterium prausnitzii (OTU151) were also significantly reduced in children with IHF. In addition, the relative abundances of some taxa belonging to the genera Bacteroides, Blautia, Coprococcus, Eggerthella, and Flavonifractor and the Lachnospiraceae were also significantly reduced in infants with CJ compared with the HC.We obtained 17 operational taxonomic units (OTUs) with a significantly different abundance among the three groups , impaired hepatic function (IHF), and healthy control (HC) groups. Download Copyright © 2019 Wang et al.2019Wang et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the Enterobacteriaceae family).BugBase software was applied to analyze the community-wide phenotypes of the stool microbiome. We observed that the proportion of aerobic bacteria was increased modestly in infants with IHF . The proPICRUSt (Phylogenetic Investigation of Communities by Reconstruction of Unobserved States) software was used to predict the relative abundance of KEGG functions, which were compared between children with CJ and IHF and the HC. We found that bacterial transporters were increased in children with altered liver function (both infants with CJ and infants with IHF) compared to the HC subjects . In addiClostridium sensu stricto, Veillonella, and Streptococcus and the family Enterobacteriaceae), were positively and negatively correlated with the levels of serum BAs  and fecal BAs, respectively. In contrast, the OTUs in cluster O4  were negatively and positively correlated with the levels of serum BAs and fecal BAs, respectively. Notably, clusters O1 and O4 were positively and negatively correlated with the ratio of secondary/primary BAs (DCA/CA), respectively.To examine the relationship between members of the gut microbiota and BAs, we calculated Spearman’s rank correlation coefficient for the 17 OTUs (those that were significantly changed in infants with CJ and/or IHF), serological indexes, and fecal BAs. We performed unsupervised clustering of OTUs, serological parameters, and fecal BAs, which revealed four distinct OTU clusters , serological indexes, and fecal BAs  resulted from applying Spearman correlations between the PICRUSt-predicted KEGG pathways representative of each group  and the alternative (acidic) pathways. The classical BA synthetic pathway produces about 90% of total BAs, composed of CA and CDCA in approximately equal amounts. In contrast to the classical pathway, the alternative pathway produces only CDCA . AlteratBifidobacterium and Faecalibacterium), and an overgrowth of potentially pathogenic bacteria (the Enterobacteriaceae family). Species of the genus Bifidobacterium are believed to confer beneficial effects upon their host, and their high abundance in the infant gut indicates saccharolytic activity toward glycans. Bifidobacterium appears to influence short-chain fatty acid (SCFA) production, either directly, by modulating the synthesis of SCFAs, such as acetate and formate   . Due to Functional analysis of the bacterial communities in the infants with CJ revealed the enhanced expression of ABC transporters. In the host system, ABC transporters serve as an important cytoprotective mechanism by eliminating toxins and drugs out of cells, thereby protecting the hepatocyte from toxicity due to BA overaccumulation. Bacterial ABC transporters are also able to protect the microorganisms from xenobiotic pressure . The appIn summary, infantile CJ is associated with a significant dysbiosis of the gut microbiota, which is featured by a general decline in bacteria with beneficial potential as well as those capable of processing the necessary enzymes to convert primary to secondary BAs and an enrichment of potentially pathogenic taxa. These changes in the gut microbiota might modulate the composition of BAs, disrupt the gut barrier integrity, and provoke and enhance inflammation.A total of 126 infants from Shanghai Children’s Hospital, Shanghai, China, were recruited to the study cohort between September 2016 and March 2019 . The dia18 column . The UPLC-mass spectrometry (MS) raw data were acquired in negative mode and were processed using the TargetLynx application manager  to obtain calibration equations and the measured concentration of each bile acid in the samples.Targeted metabolomics profiling was performed to measure the concentrations of 43 BAs in fecal samples according to previously reported methods . In brieStool samples were collected with sterile swabs by nursing staff at Shanghai Children’s Hospital and stored at −80°C. Genomic DNA extraction, PCR amplification, library preparation, and Illumina sequencing were conducted according to a protocol described previously . In briehttp://www.drive5.com/usearch. The depth of the sequencing data used for analysis was 10,000 reads per sample, based on the findings of the rarefaction analysis  program  with an ysis see . Taxonomysis see . The alpysis see . The lin10.1128/mSystems.00463-19.1FIG S1FIG S1, TIF file, 1.0 MB.Rarefaction analysis of the 16S rRNA genes in the fecal microbiome. Rarefaction plots of all 126 samples show the number of observed OTUs reaching the asymptote at the cutoff of 10,000 reads. Each sample is represented by a different color in the graph. Download Copyright © 2019 Wang et al.2019Wang et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the P value of <0.05 was considered statistically significant.Statistical analysis was performed with SPSS (version 20.0) software. The data are presented as medians and interquartile ranges  and compared by use of the nonparametric Mann-Whitney test (for two groups) or the Kruskal-Wallis H test (for multiple groups). The distribution of dichotomous variables was compared by the chi-squared test. A MTBLS1295. Raw sequencing data are available in the European Nucleotide Archive server under study accession number PRJEB33641.Raw metabolomic data for the bile acids are available in the Metabolights metabolomics repository under study accession number


How should the WHO most efficiently keep its global recommendations up to date? In this article we describe how WHO developed and applied a ‘living guidelines’ approach to its maternal and perinatal health (MPH) recommendations, based on a systematic and continuous process of prioritisation and updating. Using this approach, 25 new or updated WHO MPH recommendations have been published in 2017–2018. The new approach helps WHO ensure its guidance is responsive to emerging evidence and remains up to date for end users. Over the past decade, WHO has issued over 400 maternal and perinatal health (MPH) recommendations for global use, and the size of this portfolio presents a major challenge to ensuring that all recommendations are up to date.A dynamic ‘living guidelines’ approach has been developed and applied to respond more rapidly to new, important evidence that may affect specific WHO recommendations in MPH.The new approach uses an evidence-informed, consultative prioritisation process, rapid updating of prioritised systematic reviews and electronic consultations with ‘living guidelines’ panels.Using this approach enables WHO to efficiently use resources to execute its global mandate on normative guidance for MPH.Other guideline development organisations can also adapt this approach to facilitate more rapid and efficient updating of recommendations.WHO is the normative entity of the United Nations responsible for developing and disseminating evidence-based guidance on health issues. Since the establishment of the WHO Guidelines Review Committee (GRC) in 2007 to oversee the quality of WHO’s guidelines, WHO has issued 13 maternal and perinatal health (MPH) guidelines containing 295 clinical and health systems recommendations,16–19WHO Handbook for Guideline Development indicates that guidelines should include a ‘review-by’ date.There are no rules on how frequently guidelines produced by WHO should be updated, though the Conversely, many recommendations have seen little change in the underlying evidence base. For example, in 2011 WHO recommended the use of magnesium sulfate for preventing eclampsia in women with pre-eclampsia.Updating WHO recommendations is time-intensive and resource-intensive, requiring systematic collection and appraisal of the evidence related to benefits and harms, how stakeholders value the relevant outcomes, feasibility, acceptability, cost-effectiveness and implementation considerations. This evidence is then considered by an international panel of experts and stakeholders to formulate the recommendations.A WHO steering group  was established to lead the development of this new ‘living guidelines’ approach to prioritising, updating and developing individual WHO MPH recommendations.20The scope of work included several priority MPH topics, including health conditions , peripartum infections, preterm birth), interventions  and packages of care . As of December 2016, WHO had published 10 guidelines  on these topics.From March to October 2016, we conducted a focused literature search to identify existing frameworks and approaches relating to ‘living’ systematic reviews and guidelines.10.1136/bmjgh-2019-001683.supp1Supplementary dataIn December 2016, we established a new, independent Executive Guideline Steering Group on Maternal and Perinatal Health Recommendations (the Executive GSG) to play an advisory role in helping WHO maintain an up-to-date and balanced portfolio of recommendations.et al.Does the published recommendation still address a current topic for clinical practice or programmes?Are there any new studies or new information relating to the recommendation question?Will any new studies, information or data substantively change the evidence base for the recommendation or the recommendation’s credibility?In February 2017, the WHO steering group conducted an international stakeholder prioritisation exercise via an online survey. The group developed a long list of stakeholders in maternal and newborn health across a range of disciplines, organisations and settings for potential participation, including clinicians, researchers, implementing organisations, professional associations, United Nations agency staff and consumer advocacy organisations. The survey was also circulated to the executive boards and national society presidents of two professional associations . Some, but not all, of the individuals invited to participate had experience on WHO MPH guideline panels. The survey included the list of existing WHO MPH recommendations, and participants were asked to prioritise all questions as ‘low’, ‘medium’, ‘high’ priority for updating the recommendation. They were also asked to nominate any new questions they considered a priority. An ‘unknown’ option was available for situations where the survey participant felt they did not have sufficient expertise or information to make a ranking. Participants were asked to prioritise based on the following criteria which were developed to align with the framework in The question is of public health importance .There is new evidence that has the potential to change the existing WHO recommendation.There is new evidence that could impact on the credibility of the existing recommendation.There is potential for an updated WHO recommendation to significantly change clinical practice globally.Using the responses, a prioritisation score was calculated for each question . For example, one question was ranked by 91 participants: 36, 37 and 16 participants ranked this question as low, medium and high priority, respectively (2 participants responded ‘unknown’). The prioritisation score ((37+16) / 91) was 58.2% for this question.The online survey was conducted over a 6-week period in English only. A total of 264 stakeholders was invited to participate via email, with reminders at 2 weeks and 4 weeks. In total, 124 stakeholders participated (62% response rate), with all WHO regions represented (ranging from 5.6% of participants from South-East Asia to 28.2% participants each from Europe and the Americas) . Sixty-tIn parallel with the survey, the Technical Working Group  and the WHO steering group conducted an evidence mapping exercise for all recommendations underpinned by Cochrane reviews. The groups mapped the existing WHO MPH recommendations to their corresponding question and systematic review(s) of benefits and harms, and conducted new searches of the Cochrane Pregnancy and Childbirth’s Specialised Register of Controlled Trials to identify the number of new trial reports that had not yet been incorporated into the existing systematic review. For questions where a large number of new trial reports were identified, a brief, narrative overview of the findings of the trials with the largest sample sizes was prepared. These findings were summarised in a spreadsheet  and shared with the GSG members ahead of the face-to-face meeting described below.In March 2017, a face-to-face meeting of the Executive GSG was held. Five observers from partner organisations were also invited to attend . The objective was to reach consensus on a short list of questions that should be prioritised for recommendation development or updating over the next 2 years.At the meeting, the new approach was discussed and the GSG agreed on the definitions of priority levels they would assign to each question . Over th32Box 1There is a substantial number of new effectiveness or otherEstimates and CIs for specific outcomes.Certainty of the evidence for specific outcomes.Recommended dose or intensity of an intervention.Recommended timing of an intervention .Recommended subgroups for whom an intervention is effective .Recommended route through which the intervention is delivered/administered.Supporting interventions required.Level of care/type of providers for delivering/administering the intervention.2There is a substantial number of new efficacy studies/reports in relation to the question, and these studies have not yet been assessed or included in a systematic review. Not including these studies may undermine the credibility of the recommendation, even if this is already a strong recommendation.There is a new drug or intervention in relation to a health issue, and data are now available.The recommendation is ‘general’ in relation to a class of drugs  and does not specify the use of a particular drug. There is now new evidence that suggests that the recommendation needs to be narrowed to a particular drug/s or suggests that particular drug/s are not effective or are less effective.The identification of definitional, consistency or interpretation issues in existing recommendations:The definition of a clinical condition  or of other relevant issues, and/or how the clinical condition is diagnosed4The wording of the recommendation is ambiguous, unclear or could be improved substantially .There are inconsistencies between recommendations  that may lead to misunderstandings.Guideline users in service delivery settings have indicated that the recommendation is hard to understand or interpret.There have been wide-scale changes in technologies (or access to technologies) that impact on clinical practice  and/or what life-saving interventions that can be delivered.A related recommendation has changed or has been prioritised for updating.New synthesis methods  may give new findings and/or allow comparisons and subgroup analyses that were not possible previously.The Executive GSG is of the view that a recommendation should be viewed as a good practice statement (or vice versa).The question underlying the recommendation needs to be revisited:It is not clear if the question is still relevant.The question is still relevant but needs to be unpacked or broken down further into subquestions. For example, a recommendation that health promotion is recommended needs to be broken down to consider which kinds of health promotion interventions are effective and can be recommended.Where the development of an existing recommendation was driven strongly by evidence related to how people value outcomes, or the acceptability, feasibility, equity or cost-effectiveness of the intervention, and there are changes  in the supporting evidence regarding these criteria.1 For example, related to the acceptability, feasibility, equity or cost-effectiveness of the intervention.2 The GSG may flag recommendations that also have implications for changes to health systems recommendations.3 For example, if a clinical recommendation on a hypertensive drug is changed, WHO may also need to consider whether its recommendations on which cadre can deliver that drug also needs to be revised3 For example, new gold standard diagnostic test.4 Note that changes to definitions may have implications for multiple recommendations.After the meeting, the Cochrane Pregnancy and Childbirth editorial team initiated the creation or updating of Cochrane reviews on the effectiveness of interventions related to the high-priority questions and developed the corresponding evidence profiles. In order to help guideline panels make evidence-informed decisions, WHO staff developed GRADE evidence-to-decision (EtD) frameworks for each high-priority question.In June 2017, the WHO steering group identified approximately 50 experts and stakeholders from the six WHO regions to constitute a WHO MPH ‘living’ guideline development group (GDG). This is a diverse pool of stakeholders skilled in critical appraisal, guideline development, implementation, clinical practice, policy and programmes relating to maternal and newborn health. The mix of experts and stakeholders was based on considerations of previous GDG membership for existing WHO MPH guidelines, while allowing for introduction of new members with specific expertise relating to content, programmatic area or guideline development methods. ‘Living guidelines’ panels were drawn from this pool by matching recommendations under consideration with individual expertise. Thus a group of approximately 15–20 individuals from the MPH GDG  was convened virtually on an as-needed basis.20In accordance with WHO guideline development standards, the GDG reviews the EtD frameworks, including the evidence profiles for benefits and harms, how stakeholders value outcomes, resource requirements, cost-effectiveness, acceptability and feasibility and the intervention’s impacts on equity. During the ‘living guidelines’ panel meeting, the GDG formulates the updated or new recommendations, and prepares clarifying remarks, implementation considerations and research priorities. These recommendations are peer reviewed by external experts, and then reviewed by the WHO GRC as part of the organisation’s quality assurance process prior to publication.Between April 2017 and December 2018, 25 new or updated recommendations had been published based on the questions prioritised by the process described above.Box 2TXA is a competitive inhibitor of plasminogen activation, and it can reduce bleeding by inhibiting the enzymatic breakdown of fibrinogen and fibrin clots.On 26 April 2017, a large, randomised controlled trial—the World Maternal Antifibrinolytic (WOMAN) Trial—examining the effect of early treatment with TXA in women with PPH was published.63On 29 August 2017, WHO convened an online GDG of 14 experts to review the evidence and revise the recommendation. On 31 October 2017, WHO published the updated recommendation on early use of intravenous TXA (within 3 hours of birth) in addition to standard care for women with clinically diagnosed PPH following vaginal birth or caesarean section.Time from search for Cochrane systematic review to release of updated recommendation: 5 months, 3 days.Box 3Uterotonics (such as oxytocin) are routinely administered to all women during the third stage of labour to prevent PPH and its resulting complications. In 2012, WHO recommended oxytocin  as the uterotonic drug of choice, which was based on consideration of four Cochrane reviews of different uterotonic options; however, if oxytocin and/or skilled birth attendants are unavailable, other uterotonic options can be used.69As CHAMPION and other trial results became available, WHO collaborated with the NMA authorship group for a rapid update that included all WHO prioritised outcomes and comparisons . The updated review includes 196 trials involving 135 559 women.40 73Time from updated search of NMA to release of updated recommendations: 6 months, 24 days.Guideline developers worldwide are facing the challenge of ensuring that recommendations are up to date in the context of a rapidly evolving or growing evidence base.et al reported that many organisations that issue guidelines do not provide adequate guidance on methods and procedures for updating.This new approach to dynamically updating individual WHO recommendations brings several new challenges. There is not yet clear consensus on the most efficient and effective methods for prioritising the recommendation questions that should be updated, and such standards are needed.Qualitative evidence syntheses on the views and perspectives of all stakeholders and consumers are being used increasingly in the development of WHO guidelines.Evidence mapping is itself a time-consuming process, particularly with a large number of recommendations. For a ‘living guidelines’ approach to work, guideline developers need to implement systems for continuous, systematic literature surveillance, rapid appraisal of the potential impact of new evidence and (where appropriate) rapid updating of systematic reviews.et al have emphasised, ‘living’ recommendations require ‘living’ systematic reviews, evidence profiles, EtD frameworks, guideline panels and budgets.et al identified considerable variability in methods for prioritising updates of systematic reviews and guidelines; a prioritisation tool is under development.As Akl Updating individual recommendations also presents a challenge to dissemination, communication and subsequent implementation. WHO has a responsibility to ensure that recommendations on interventions that can impact health are made available to WHOMember States as soon as possible. However, it is likely that national healthcare decision-makers can only maintain a limited number of adoption and adaptation processes simultaneously, and these have not been developed with ‘living’ recommendations in mind. Prioritisation and updating processes would benefit from explicit consideration of the likely impact of updating recommendations on these stakeholders.BMJ’s Rapid Recommendations project and GRADEpro GDT) are also aimed at providing flexible, interactive digital platforms that can be easily updated if required.56–58MPH recommendations have historically been packaged within a thematic guideline as a static paper or electronic document. Digital tools or platforms that can reflect the latest, up-to-date recommendations while linking to the broader guideline will be needed to disseminate those recommendations developed or updated within this new approach. For example, the WHO Reproductive Health Library now hosts the latest version of all WHO’s MPH recommendations, with a brief history of the recommendation’s previous iterations and planned updates.Policymakers and clinicians will need to be kept informed of important changes in individual recommendations on a more continuous basis, and implementation tools  will also need to become more responsive to recommendation updates. Digital platforms that can connect guideline development and publication through to dissemination and implementation should be developed, to facilitate knowledge transfer to and uptake by end users.Developing and updating WHO MPH recommendations are now driven by a systematic and continuous process of prioritisation and evidence synthesis where the unit of update is individual recommendation rather than thematic guideline. This entails a shift towards a more efficient, responsive process that reflects the latest evidence, and leads to recommendations that optimise programmes and practice.


Dirofilaria immitis (heartworm) is a zoonosis, considered an endemic disease of dogs and cats in several countries of Western Europe, including Portugal. This study assesses the levels of D. immitis exposure in humans from Northern Portugal, to which end, 668 inhabitants of several districts belonging to two different climate areas  were tested for anti-D. immitis and anti-Wolbachia surface proteins (WSP) antibodies. The overall prevalence of seropositivity to both anti-D. immitis and WSP antibodies was 6.1%, which demonstrated the risk of infection with D. immitis in humans living in Northern Portugal. This study, carried out in a Western European country, contributes to the characterisation of the risk of infection with D. immitis among human population in this region of the continent. From a One Health point of view, the results of the current work also support the close relationship between dogs and people as a risk factor for human infectionDirofilariosis caused by  Dirofilaria immitis. Humans are accidentally infected in endemic areas, where dogs act as reservoirs of the parasite and the climate conditions favour the proliferation of the mosquito vectors , (18.7%)  and the  (18.7%) . There i (18.7%) , 33. RegPortugal , 41 and Portugal , 43.The overall results presented the highest seroprevalence in inhabitants under the age of 35 years old (7.1%) and above the age of 66 years old (8.0%), similar to previous studies in other endemic areas , 39.Although pulmonary dirofilariosis has been described in Portugal , awareneD. immitis infection in them).Some limitations of this study should be considered, namely the limited number of samples obtained in some districts (e.g. Aveiro and Braga) and the evaluation of only a few independent variables . The influence of other variables on the outcome would have been important to consider (e.g. spending time outdoors during the mosquito season, travelling to endemic areas, owning dogs and presence or absence of D. immitis and WSP in the human population living in several districts of Northern Portugal. The presence of dogs infected by D. immitis is a potential threat to public health [In conclusion, this study described, for the first time, the seroreactivity to c health , 25, 26.