Healthcare decision-making is complex and should involve healthcare professionals, patients and the best level of evidence. The speed of information production creates barriers against keeping up to date. In this light, methodologists have proposed a new type of study: overviews of systematic reviews (OoRs). The aim here was to introduce and demonstrate the role of OoRs in information synthesis for healthcare professionals, managers, researchers and patients. Time-series study conducted at the Brazilian Cochrane Center, jointly with the Postgraduate Program on Internal Medicine and Therapeutics, Discipline of Emergency Medicine and Evidence-Based Medicine, Department of Medicine, Federal University of São Paulo. To show the growth in the numbers of published papers that provide high-level evidence and thus demonstrate the importance of OoRs for synthesis and integration of information, three filters for study designs were applied to two databases. An equation for predicting the expected number of published papers was developed and applied. Over the present decade, the number of randomized controlled trials in Medline might reach 2,863,203 and the number of systematic reviews might reach 174,262. Nine OoRs and 15 OoRs protocols have been published in the Cochrane Library. With the exponential growth of published papers, as shown in this study, a new type of study directed especially towards healthcare decision-makers was proposed, named “overview of systematic reviews”. This could reduce the uncertainties in decision-making and generate a new hierarchy in the pyramid of evidence. One of the primary functions of this type of study is to summarize clinical information from several studies in order to answer a question relating to diagnosis, prevention or treatment in areas in which the results may or may not be in agreement, through critical evaluation of the evidence.,,,,Taking into consideration only the most important database of SRs, i.e. the Cochrane Library, more than 7,000 articles have been published.For didactic purposes, the present analysis will be published as a series of three articles. Part I, presented here, focuses on the growth of published papers presenting the best level of evidence for decision-making relating to healthcare, thereby justifying the creation of OoRs. Part II, to be presented in a forthcoming article, will describe the state of the art of OoRs from the Cochrane Collaboration. In Part III, a new hierarchical evidence pyramid will be proposed, taking this new type of study into consideration.The objective of this study was to introduce and demonstrate the role of OoRs in relation to synthesis of information for healthcare professionals, managers, researchers and patients.,This was a time-series study that included application of filters to study designs (to select studies that provide the highest level of evidence) in virtual databases, in order to show the growing number of published papers within the field of healthcare that provide high levels of evidence for decision-making and thus seek to demonstrate the importance of OoRs as a type of study that provides a synthesis of the evidence and integrates it. For this, two databases were selected  and three search filters for study designs were applied. The first filter used (filter A) was the sensitivity-maximizing version of the Cochrane Highly Sensitive Search Strategy.Subsequently, an equation to predict expected future numbers of published papers was modeled (designed). This equation was based on the fraction of the present decade that has already elapsed, in order to determine the cumulative frequency for the period. The equation thus developed is shown in Figure 1Up to the cutoff date of May 21, 2012, more than two million RCTs  were identified by applying filter A  were identified by applying filter B to the Medline database . Thus, up to the cutoff date of June 15, 2012, nine OoRs had been published, and 15 OoRs protocols were in this database .15,16,17http://www.ncbi.nlm.nih.gov/pubmed/) includes over 21 million citations for biomedical literature, comprising journals and books on the life sciences that are online through Medline. In 2011 alone, over 736,000 new references were published and, therefore, to acknowledge all of these new papers would have meant reading about 84 articles per day.The information from Medline, which is the world’s largest medical library,In this study, we chose to analyze the growth in the numbers of published RCTs, SRs and OoRs, because these study designs present the highest levels in the hierarchy of evidence for clinical decision-making.Medline was chosen as the database to assess because it is considered to be the most important search tool within the field of healthcare.An evidence-level hierarchy was previously proposed in order to provide the best evidence for decision-making in healthcare.The quality of published papers may be compromised for a variety of reasons, which may include methodological faults, conflicts of interest, data manipulation and so on. Thus, healthcare professionals not only need to keep up to date but also should know how to judge the quality of evidence. To do this, certain tools are recommended, such as the Cochrane Collaboration’s toolTo reduce the uncertainties in healthcare decision-making, all the relevant studies need to be found. Therefore, the search strategy should be highly sensitized, i.e. it should be able to detect Mesh terms  and free-text terms within titles and abstracts indexed in the databases considered.Another point to be noted is in relation to the predicted growth among the types of studies considered in the present analysis. These numbers represent numerical approximations based on the publication behavior of previous decades.Ecological evidence can be highlighted to explain the ascendency of RCT and SR publication: 1) the vertex of the growth curve of the cumulative number of RCTs occurs between 1970 and 1980 (,,Despite the limitations noted, the growth in RCTs and SRs has, as seen from the results, been exponential. Because healthcare decision-making is naturally complex, SR methodologists have proposed the use of overviews of systematic reviews,In Part II of this series of three papers, the state of art of overviews of systematic reviews and details of study design will be presented.Keeping up to date remains a challenge, considering the great quantity and varying quality of information available. Thus, SR methodologists have proposed a new type of study especially suited for healthcare decision-makers, named “overview of systematic reviews”. This new type of study was developed to provide a synthesis and integrate information from multiple studies in order to reduce the uncertainties in decision-making. This may generate a new hierarchy in the pyramid of evidence.


Physicians working in primary care respiratory medicine face growing demands on their time, not least in the aftermath of the Covid-19 pandemic. Keeping up with the latest, rapidly growing body of research to make evidence-based decisions in the best interests of their patients is just part of the challenge. This is especially prescient for those who treat both acute and chronic conditions—in the past year alone over 6000 research papers were published on COPD, and 9500 on asthma .For ground-breaking research to translate into clinical practice, this literature needs to be distilled.npj Primary Care Respiratory Medicine launched a Collection dedicated to systematic and scoping reviews and meta-analysis. The aim was for this to be a key reference for primary care physicians worldwide regarding respiratory care. Our multidisciplinary nature and online open-access policy allows primary care providers to reach and assess high-quality research that may ultimately impact their clinical practice, giving them the tools needed for a quick and objective decision-making.In early 2022, 1, such as systematic, scoping, rapid, literature (or narrative) and critical reviews. Each one of them provide different perspectives of the available evidence regarding a specific topic, either in a very narrow and objective manner, or in a more comprehensive or conceptual frame.Reviews are a useful type of publication that can provide such practical sources by compiling scientific knowledge into objective and practical conclusions. Many methods exist to develop a review paper2, and are useful tools to provide a wide, comprehensive, and integrated summary of available evidence on a specific topic. Scoping reviews3 provide a preliminary assessment of a specific topic, establishing the boundaries and extent of the available literature, and are useful tools to identify unmet and future research needs.Literature (or narrative) reviews are probably the oldest and most universal type4. Systematic reviews and meta-analysis were first used with interventional studies, with the aim to gather data and overcome discrepancies in results, and have been widely promoted by the Cochrane collaboration—an international network dedicated to developing this methodology (https://www.cochrane.org/). For synthesising research that focuses on observational studies, particularly those dedicated to real-world evidence, methods have been developed to overcome challenges with heterogeneity and potential bias, such as use of diagnostic tools and predictive algorithms5.With the rise of clinical trials as the gold-standard for interventional evidence, the need for a robust strategy to synthesise evidence in concise and clear recommendations has led to development of systematic review and meta-analysis. These allow for data synthesis alongside a critical appraisal of evidence qualitynpj Primary Care Respiratory Medicine Collection welcomes all types of review and so far covers several topics of interest such as COPD and Asthma management, emerging vape and e-cigarette use, lung cancer management, sleep-disorders, management for respiratory symptoms and Covid-19.The 6. Zhou et al. provide new evidence regarding the role of portable spirometers in COPD diagnosis, which may be of particular interest in areas and countries with limited access to certified and laboratorial assessment7. Another review from Silva et al. addresses pulmonary rehabilitation in COPD, highlighting the need for interventional studies to evaluate the role of supervision and long-term maintenance timeframes in relevant clinical outcomes, showing that benefits may wane over time after initial programes8.For instance, Boulet et al. synthesises evidence on Asthma management, with a special focus on the influence and bias of sex and gender during diagnosis, providing a tool for motivational communication competencies for clinicians10.Smoking is also a hot topic, regarding the emergence of alternative devices for nicotine use, such as vaping and e-cigarettes. Several questions are raised regarding their role in smoking cessation, and also their potential health risks. Systematic reviews in this Collection from Honeycutt et al. and Lyswinzki et al. highlight the need for longitudinal studies addressing the causal mechanisms, and also put the spotlight on younger populations that may be more vulnerable to becoming new users11.Besides increasing the risk for COPD and other chronic respiratory diseases, smoking is the leading cause of lung cancer worldwide. The need to further explore lung cancer management in primary care and develop interventions to recognise, refer and diagnose patients with lung cancer symptoms is discussed by Saab et al.14.Diagnosis of chronic respiratory diseases is also recognised as a challenge in primary care in this Collection. These can be hard to establish when many conditions share similar clinical features, and patients frequently present with comorbidities. The need to standardise and summarise practical tools and procedures for differential diagnosis in patients with respiratory symptoms is discussed, and readers can find evidence regarding breathlessness and chronic dyspnoea, a major clinical trait for most respiratory conditionsnpj Primary Care Respiratory Medicine aims to be the gold-standard journal for primary care health professionals that deal with chronic respiratory conditions. With this Collection, we will continue to foster scientific knowledge in order to give readers the necessary tools they need to help patients worldwide. We welcome all those who want to contribute to this mission by continuing to submit their papers to this Collection. With this, our aim is to narrow the gap between research and education, and between education and clinical practice.


Approximately half of patients with SLE will be diagnosed with lupus nephritis (LN), characterized by inflammation in the kidney, proteinuria, and progressive kidney damage that can lead to kidney failure.3 LN typically presents in patients who are aged 20-40 years,5 and it is the most common cause of death and disability in patients with SLE.Systemic lupus erythematosus (SLE) is an autoimmune disease that affects between 300,000 and 1.5 million Americans.7 Unfortunately, fewer than half of patients with LN respond to current combination therapy, so there is a large unmet need for new therapies.Guidelines for the treatment of LN recommend induction therapy with high-dose corticosteroids combined with either mycophenolate mofetil (MMF) or cyclophosphamide, followed by maintenance therapy with MMF.The US Food and Drug Administration (FDA) recently approved 2 new therapies for LN. Belimumab, a parenteral B-lymphocyte inhibitor already approved by the FDA for SLE, was approved for LN in December 2020. Voclosporin, an oral calcineurin inhibitor that is reported to be safer than other calcineurin inhibitors (less kidney damage), was approved in January 2021.https://icer.org/wp-content/uploads/2020/11/ICER_Lupus-Nephritis_Final-Evidence-Report_041621.pdf.The Institute for Clinical and Economic Review (ICER) conducted a systematic literature review and cost-effectiveness analysis to evaluate the health and economic outcomes of belimumab and voclosporin to treat LN. Complete details of ICER’s systematic literature search and protocol, as well as the methodology and model structure for the economic evaluation, are available on ICER’s website. Here, we present the summary of our findings and highlights of the policy discussion with key stakeholders held at a public meeting of the New England Comparative Effectiveness Public Advisory Council on March 26, 2021. The detailed report is available on the ICER website at 8 At 2 years, the proportion of patients receiving 5 mg or less of prednisone was also greater in the belimumab group (36.8% vs 27.8%). There were no significant increases in adverse events or discontinuations compared with standard induction therapy for LN.Belimumab increased the complete renal response (CRR) and primary efficacy renal response (PERR) at 2 years compared with standard therapy alone, with benefits seen after the first year and appearing stable at year 2  and markedly increased the partial response (PR) at 1 year compared with standard therapy alone .9 The prThe most important uncertainty is how these short-term rates of partial and complete renal response translate into meaningful long-term outcomes for patients. LN is a lifethreatening, lifelong illness, and the outcomes that matter most to patients are progression to kidney failure or death. It is also unclear from the available evidence how long therapy with these novel agents should continue. Finally, LN disproportionately affects non-White patients. The number of non-White patients enrolled by drug makers in pivotal trials was too small to determine relative effectiveness of either drug across racial and ethnic groups, which is important given the greater prevalence and severity of LN in non-White populations, as well as their lower response rate to conventional induction therapy.https://icer.org/wp-content/uploads/2020/11/ICER_Lupus-Nephritis_Final-Evidence-Report_041621.pdf).The cost-effectiveness analyses compared each drug to standard of care as delivered within the comparator arm in each of the pivotal trials. The model consisted of 2 parts: a short-term model concordant with data from the clinical trials, which feeds into a lifetime model using partitioned survival modeling based on long-term outcomes studies of patients with LN. A detailed description of the model can be found in the full report  and mean dose of 690 mg . Voclosporin costs were estimated using price per wallet  and average daily dose of 39.1 mg , using a 22.5% discount. It was assumed that patients in response states remain on the therapy for 3 years.In the base case , the incThere are no long-term follow-up data for either treatment, resulting in considerable uncertainty about the prognosis of patients beyond the trial periods. Robust utility data were lacking for patients with LN in the United States across the health states in the model, so data from other populations were used.The New England Comparative Effectiveness Public Advisory Council (CEPAC) is one of the independent appraisal committees convened by ICER to engage in public deliberation of the evidence on clinical and cost-effectiveness of health care interventions. The New England CEPAC is composed of medical evidence experts, including practicing clinicians, methodologists, and leaders in patient engagement and advocacy. Their deliberation includes input from clinical experts and patient representatives specific to the condition under review, as well as formal comment from manufacturers and the public. A policy roundtable concludes each meeting during which representatives from insurers and manufacturers join clinical experts and patient representatives to discuss how best to apply the findings of the evidence to clinical practice, insurance coverage, and pricing negotiations.The ICER report on new therapies for LN was the subject of a New England CEPAC meeting on March 26, 2021. Following the discussion, the New England CEPAC panel members deliberated on key questions raised by ICER’s report. The results of their votes on the clinical evidence were as follows: (1) the panel voted 12-0 that the clinical evidence was adequate to demonstrate greater net health benefit for belimumab plus standard therapy compared with standard therapy alone and (2) the panel voted 12-0 that the clinical evidence was adequate to demonstrate greater net health benefit for voclosporin plus standard therapy compared with standard therapy alone.The CEPAC panel also voted on “other potential benefits” and “contextual considerations” as part of a process intended to signal to policymakers whether there are important considerations when making judgments about long-term value for money not adequately captured in analyses of clinical and/or cost-effectiveness. The results of these votes are shown in As described in ICER’s Value Assessment Framework, questions on long-term value for money are subject to a value vote when incremental cost-effectiveness ratios for the interventions of interest are between $50,000 and $175,000 per QALY in the primary base-case analysis. Nine members of the 12 CEPAC panel voted that belimumab at the current discounted price represented high value for the money; 2 voted that it represented intermediate value; and 1 voted that it represented low long-term value for the money. Four members of the CEPAC voted that voclosporin at the current discounted price represented high value for money; 7 voted that it represented intermediate value; and 1 voted that it represented low long-term value for the money.https://icer.org/wp-content/uploads/2020/11/ICER_Lupus-Nephritis_Final-Evidence-Report_041621.pdf. Several key policy recommendations for the new treatments for LN follow:The policy roundtable discussion explored how best to translate the evidence and additional considerations into clinical practice and into pricing and insurance coverage policies. The full set of policy recommendations can be found in the Final Evidence Report on the ICER website: Both belimumab and voclosporin are judged to be priced in reasonable alignment with estimates of their benefits for patients, and this consideration should guide payers to design coverage criteria that do not narrow coverage from the FDA label, although coverage criteria may define terms left indeterminate in the FDA label to assure appropriate use. Given the significant uncertainty that remains about the longer-term safety and effectiveness of belimumab and voclosporin for lupus nephritis, it is reasonable for payers to use prior authorization as a component of coverage.All stakeholders have a responsibility and an important role to play in ensuring that effective new treatment options for patients with lupus nephritis are introduced in a way that will help reduce health inequities. People from diverse racial and ethnic backgrounds are at a higher risk of developing lupus and lupus nephritis. Unfortunately, patients from these communities are also at a higher risk of not receiving adequate education about their condition, face a longer time between diagnosis to initiation of any therapy, and are often late to receive guidance regarding new treatment options. All stakeholders should accept and act upon their responsibility to address these disparities.For voclosporin, given the FDA label language based on the potential for nephrotoxicity with prolonged use, physician attestation of a response to therapy of at least a 50% reduction in proteinuria after 6-12 months of therapy is not unreasonable. Current data support 1 year of therapy, but clinical experts and some trial data suggest that longer treatment duration may be appropriate in individual patients.


With the advent of drug manufacturing, the early apothecary evolved into a dispensary, which then grew into something much larger and more complicated to reflect the increasing volume of prescription medications and the advancement of treatments for chronic diseases. Pharmacy changed dramatically again in the late 1990s when, after decades of debate, the Accreditation Council for Pharmacy Education phased out the bachelor of science in pharmacy and replaced that entry-level degree with the more clinically focused doctor of pharmacy degree, which prepares pharmacists to play a more active role within the clinical care team.JAMA Internal Medicine.3 This review identified 44 eligible studies and concluded that there is insufficient evidence to determine the effect of MTM on most outcomes because of inconsistencies and imprecision in the studied populations and interventions. While the review’s conclusions have been debated and scrutinized, it is nevertheless clear that research evaluating outcomes of MTM are still somewhat scarce in the literature.With the recognition and reimbursement of the pharmacist’s cognitive services comes responsibility. It is incumbent upon our profession to generate the data to support the future of MTM and other pharmacist interventions, a responsibility that we have not always excelled at. In 2015, the Agency for Healthcare Research and Quality (AHRQ) published a systematic review of MTM evidence in JMCP, we noticed that there were several MTM and related studies—allowing us to do a themed issue on the topic. There was no call for papers on the topic, suggesting that the managed care pharmacy community is inherently interested or perhaps even responding to the call to action from AHRQ’s review.When preparing for the first issues of 2016 at JMCP explores several aspects of MTM and other pharmacist interventions, including factors associated with provider acceptance of pharmacist recommendations, impact on adherence and inappropriate medication use, and effect on clinical endpoints including glycemic control. One article reports on the development and validation of a patient satisfaction survey for MTM, emphasizing the importance of the patient perspective in managed care pharmacy.This series of articles in the January 2016 issue of Although our apothecary predecessors may be perplexed by the concept of comprehensive medication reviews or quality improvement initiatives, I believe that the pharmacist leaders of the 1990s would be pleased to see this generation critically assessing and building the evidence base for pharmacist interventions in population-level settings.


Vaccinium macrocarpon Aiton) is not well established despite increased production worldwide. We investigated the secondary metabolite composition among the cranberry fruit of nine cultivars produced in two major coastal North American growing regions that differ in climate. Using 1H NOESY NMR to generate metabolic fingerprints, principal component analysis revealed variation between the two regions and identified likely contributing metabolites. Triterpenoids ursolic and oleanolic acid, as well as citric and malic acids, were quantified using 1H qNMR, and anthocyanins and flavonols were determined by HPLC-DAD. Total proanthocyanidins (PACs), total soluble phenolics, and DPPH free-radical scavenging antioxidant activity were also evaluated. Across all cultivars, anthocyanins, flavonols, and total phenolic content were significantly higher in West Coast fruit than East Coast fruit, correlating with a regional trend of higher antioxidant activity in fruit grown on the West Coast. The opposite trend was observed for triterpenoids and organic acids, which were significantly higher across cultivars in East Coast fruit. These trends persisted over two growing seasons. The study demonstrates that climate plays an important role in the production of antioxidant and anti-inflammatory phytochemicals in cranberry plants.The impact of the growth environment on the production of health-promoting phytochemicals in cranberry fruit ( Vaccinium macrocarpon) is a native fruit of North America belonging to the Ericaceae family, with increasing worldwide production and consumption due to its unique flavor and potential health benefits. The United States ranks as the top producer worldwide of cranberries (Vaccinium macrocarpon), followed by Canada, Chile, Turkiye, and Azerbaijan [Cranberry  are the major flavonoids found in cranberries . Anthocyt health . We havet health . Non-polt health ,14, and t health . Among Vreported . These lOver 100 cultivars of cranberries are grown in North America , with a 1H NOESY NMR spectra of extracts were acquired, and principle component analysis (PCA) was used to identify key metabolites contributing to variation between sample sets. These metabolites were quantitated using qNMR and other established methods, and regional data were compared. The antioxidant activities of the extracts were evaluated using the DPPH free-radical scavenging assay and correlated with metabolite content. The data illustrates regional influences on phytochemicals in cranberry fruit associated with potential health benefits.The goal of this study was to determine how secondary metabolite composition varies between cranberry fruit produced in two major North American growing regions. Massachusetts on the East Coast and Oregon on the West Coast are approximately 3000 miles (4800 km) apart and vary substantially in climate, including rainfall, temperature, and humidity, providing an opportunity to study the resulting differences in fruit phytochemistry of common cultivars. To characterize variations in metabolite composition between regions, 1H NMR in a non-targeted approach to reveal some differences between sample sets, then followed up with quantification of key metabolites using qNMR and other quantitative methods. Non-polyphenol metabolites of interest in cranberries include triterpenoids, due to their anti-inflammatory properties and potential impacts on carcinogenesis [The present study examined variations in both polyphenol and non-polyphenol constituents of cranberry between multiple cultivars in two major growing regions. The genetic origins of the cultivars are shown in ogenesis ,23. For 1H NMR spectra has been used successfully to detect metabolic variations among plant sources, for example, ginsenoside and sucrose content across Ontario ginseng landraces [1H NMR to compare commercial cranberry supplements to authentic cranberry standards and to identify constituents contributing to sample variation [1H NOESY NMR data were collected for all fruit extracts (n = 5 per treatment) and analyzed using Bruker AssureNMRTM 2.0 and AMIXTM 3.9.15, using methods we developed previously [NMR can provide a profile of all metabolites present in plant extracts in a single experiment without requiring chromatographic separations. Chemometric analysis of andraces , and forandraces . We receariation . Principeviously .1H NMR, discussed below. Chemical shifts between 3.3 and 3.8 ppm are associated with sugars, which also appear to play a role in the variations between the two regions; however, the individual sugars were not identified. A 2018 study of ten cranberry cultivars harvested in New Jersey used nontargeted metabolomic analysis of UPLC-HRMS data to characterize variations in phenolics among the cultivars [PCA of all cranberry fruit samples  revealedultivars . In the 1H NMR data in the chemical shift range of 5.5 ppm to 13 ppm (PCA of o 13 ppm  indicate1H NMR (qNMR) methods were developed as a means to rapidly quantify triterpenoids and compare their content in cranberry fruit samples and supplements [Quantitative proton plements . Reverseplements ,29. Howe1H NMR (qNMR) has the advantages of universal detection of compounds without the need for chromatographic separation, simple, rapid analysis, and the ability to differentiate nearly identical compounds [Quantitative proton ompounds . Hicks eompounds . QNMR haompounds . For ourPCA identified ursolic and oleanolic acids as contributors to the regional variation in the secondary metabolite composition of the fruit. As these triterpenoids are also of interest from a health perspective, quantification was performed. Peak signals of selected metabolites were determined by comparison with previously reported NMR data by Turbitt and coworkers . Table 1The average content of triterpenoids over both the 2016 and 2017 seasons across all cultivars from MA was significantly higher than the average across OR cultivars. Ursolic acid averaged 10.4 mg + 2.4 per g dry weight of fruit in MA samples and 5.94 + 2.27 mg/g dry weight in OR fruit. Likewise, oleanolic acid averaged 4.01 + 1.3 mg/g dry weight in MA fruit and 1.72 + 0.49 mg/g dry weight in OR fruit. Our previous study reporting on Early Black, Howes, and mixed cultivar fruit grown in MA found between 0.460 and 1.09 g of ursolic acid per kg of fresh weight of cranberry fruit, roughly equivalent to 5.0–11 mg/g dry weight . SomewhaUsing PCA, citric and malic acid were found to contribute to regional variation in phytochemical content, and this was confirmed by qNMR using methods we developed for cranberry supplements. Content ranged from 38.94 to 104.78 mg/g DW and 25.95 to 84.59 mg/g DW, respectively . SK and 1H NMR data in the chemical shift range of 5.5 ppm to 13 ppm indicated that some of the region-to-region sample variation can be attributed to quercetin glycosides, cyanidins, and peonidins. We have found 1H NMR less suitable for quantitative determination of cranberry flavonoids due to lower sensitivity and overlapping signals preventing reliable quantification [Cranberries are a rich source of anthocyanins and flavonol glycosides. PCA of fication . HPLC-DAfication : cyanidification .Seven flavonol glycosides were identified as eluting between 23 and 32 min (monitoring at 355 nm) by matching retention time and absorbance patterns with those of authentic commercial standards and previously published data ,39: myriIn contrast with the triterpenoids and organic acids, the content of anthocyanins and flavonols, on average, was significantly higher in OR fruit than MA fruit . Total aThe total PAC content of cranberry fruit was determined by the BL-DMAC assay using a cranberry PAC standard. Samples ranged between 41.7 and 108 mg PAC/g cranberry dry weight. Cultivar-based differences in PACs were observed , consistThe Folin–Ciocalteu assay was used to estimate the total content of soluble phenolic compounds, or TPC a. This wCranberries are rich in flavonoids and other phenolics, which are likely to contribute to their antioxidant activity. The antioxidant capacities of cranberry crude extracts were determined by the DPPH free radical scavenging method. All samples were compared at the same extract concentration (250 μg/mL). In general, for both seasons and for most cultivars, extracts of the OR fruit samples inhibited free radical scavenging more effectively (53.32–85.93%) than their MA counterparts (26.05–60.56%) b. The av2 = 0.7189, p < 0.0001 and R2 = 0.7631, p < 0.0001, respectively) and over all treatments . This finding is consistent with positive correlations reported in a study of cranberry fruit grown in Poland [2 = 0.6351, p < 0.001; and R2 = 0.4364, p < 0.01, respectively) and over all treatments . Fruits with low total phenolic content demonstrated lower antioxidant activity, a trend also reported by Wang and Stretch [2 = 0.1449 for 2016 and 0.0824 for 2017, respectively) or overall (R2 = 0.0868). This was surprising, as PACs are widely regarded as antioxidants; their contributions to radical scavenging may be secondary to those of other phenolics in the fruit.Linear correlation analyses were performed for antioxidant activity vs. key secondary metabolite groups . Signifin Poland . In our  Stretch . However2 = 0.3513, p < 0.05 and R2 = 0.2707, p < 0.05 for 2016 and 2017 fruit, respectively; R2 = 0.224, p < 0.01 over all treatments). Reported antioxidant mechanisms for UA, OA, and related triterpenoids include upregulation of endogenous antioxidants such as catalase, superoxide dismutase, and glutathione, activation of the Nrf-2 pathway, and reduction of intracellular ROS production [In a related study of anti-inflammatory properties, we reported that concentrated extracts of the 2016 and 2017 SK and ST cranberry fruit from MA and OR significantly inhibited the LPS-induced expression of IL-6 in human THP-1 monocytes at 100 μg/mL . Severaloduction ,47. FurtCranberry fruit from multiple cultivars was harvested from east coast Massachusetts (MA) and west coast Oregon (OR) cranberry bogs during the 2016 and 2017 growing seasons. Nine cranberry cultivars have been selected for this study, including Crimson Queen (CQ), Demoranville (DM), Mullica Queen (MQ), Pilgrim (PI), Welker (WK), Haines (HA), Grygleski Hybrid #1 (GH1), Scarlet Knight (SK), and Stevens (ST). Cranberry fruit from MA was harvested at the UMASS Cranberry Experiment Station in East Wareham, Massachusetts  in late September and authenticated by Krystal DeMoranville. Cranberry fruit from OR was collected in late October from Bandon, OR  and authenticated by Cassie Bouska . Cranberry samples were selected randomly within each cultivar to yield five field replicates. All cranberry fruits were flash frozen with liquid nitrogen and stored at −20 °C until use.4,4-dimethyl-4-silapentane-1-sulfonic acid (DSS) and deuterated dimethylsulfoxide (DMSO-d6) were obtained from Cambridge Isotope Laboratories, Inc. . Reagent-grade methanol and ethanol were purchased from Fisher Scientific . Reagent-grade glacial acetic acid, hydrochloric acid, and acetone were purchased from Pharmco-AAPER , along with UV/HPLC-grade acetonitrile and methanol. HPLC-grade water was purchased from Honeywell . Quercetin-3-galactoside (hyperoside) standard was purchased from ChromaDex, Inc. . Standards of cyanidin-3-galactoside (assay ≥ 97%), and peonidin-3-galactoside (assay ≥ 95%) for HPLC analysis were obtained from Extrasynthese . Standards of ursolic acid (assay ≥ 90%), oleanolic acid (assay ≥ 97%) and 3,5-dinitrobenzoic acid were purchased from Sigma-Aldrich , along with N,N-dimethylaminocinnamaldehyde (DMAC) powder, 2, 2-diphenyl-1-picrylhydrazyl (DPPH), reagent-grade formic acid, gallic acid, and Folin–Ciocalteu reagent. Standards of benzoic acid and citric acid were obtained from J.T. Baker Chemical Co. . 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid (Trolox) for the DPPH assay was purchased from Aldrich Chemical Company . Cranberry proanthocyanidins (PAC) standard for the DMAC analysis was previously prepared from an isolated cranberry PAC fraction containing A-type flavan-3-ol oligomers , which wWhole cranberry fruits were partitioned into units of about 50 g (n = 5), freeze-dried via lyophilizer (LABCONCO FreeZone 4.5 L −84 °C), and ground to a fine powder (5~9 g). For quantitative analysis, cranberry powder from each replicate was split into sub-reps of 2.0 g and extracted in 100 mL of reagent-grade ethanol. Ethanol was chosen as a reliable universal solvent for most cranberry phytochemicals, including different classes of polyphenols and terpenoids. Solutions were stirred for an hour at room temperature and stored overnight at 0 °C. After vacuum filtration, the solid residue was re-extracted with 25 mL of ethanol, stirred for an hour at room temperature, then combined with the other extracts and rotary evaporated (Büchi Rotovapor R-200). Fruit extracts were freeze-dried to remove residual water and stored at −20 °C until use. These ethanol extracts were used for NMR, HPLC analysis, and DPPH assays.1H NOESY NMR, and a qNMR method was established to determine triterpenoids and organic acids in the whole cranberry extracts using the methods of Turbitt et al., 2020 [6 solvent. spiked with 0.1 mg/mL DSS as the internal chemical shift calibration standard, vortexed, and sonicated using a Fisher Scientific FS20H Sonicator  until fully dissolved. Samples were centrifuged, transferred to NMR tubes, and analyzed using a one-dimensional proton nuclear Overhauser effect spectroscopy experiment (1D 1H NOESY). NMR spectra were collected (ns = 8) at 298.0 K with gas flow at 400 lph on a Bruker AVANCE III 400 MHz NMR using Bruker TopSpinTM 3.5. Metabolite identification, quantification, and chemometrics were performed with Bruker AssureNMR TM 2.0 and AMIX TM 3.9.15, using an internal NMR spectral database  as a reference. 3,5-dinitrobenzoic acid was chosen as an external calibration standard according to the PULCON approach [2 = 0.9995 and 0.9998, respectively.A metabolomic fingerprint of each cranberry extract was acquired using l., 2020 . Brieflyapproach . Triterpapproach , with auv/v/v/v) as solvent B. Samples were dissolved in 25% methanol in solvent A and analyzed at room temperature with an injection volume of 20 μL. Anthocyanins and flavonols were identified by matching their HPLC peak retention time patterns and UV absorbance with those of authentic commercial standards and previously published data [High-Performance Liquid Chromatography with Diode-Array Detection (HPLC-DAD) was used to identify and quantify anthocyanins and flavonols within cranberry crude samples, according to previously published methods, with minor modifications . Analysihed data ,28,38. QTotal proanthocyanidins (PACs) content was determined using the BL-DMAC method described by Prior et al. with the cranberry PAC standard as previously described ,50. All v/v, 200 μL), briefly vortexed, then mixed with 700 mM aqueous Na2CO3 (800 μL) and incubated at room temperature for two hours. Samples (200 μL) were transferred to a 96-well microtiter plate, and the absorbance was read at 765 nm vs. a 95% methanol blank using a SpectraMax 190 microplate reader . Total phenolic content was determined as gallic acid equivalents by comparison to a gallic acid standard curve.The total soluble phenolic content of freeze-dried cranberry samples was determined in triplicate using a microplate Folin–Ciocalteu method as described previously . Briefly0 is the absorbance of the control solution, Ab is the absorbance of the blank, and A1 is the absorbance of the remaining DPPH▪ in the presence of a cranberry sample.The free radical scavenging capacities of cranberry samples were determined by the 2,2-diphenyl-1-picrylhydrazyl (DPPH) free radical scavenging assay using a modified microplate method . Cranber1H NOESY NMR data was performed using AMIX TM 3.9.15 software, as previously described [Non-targeted principal component analysis (PCA) of escribed . Brieflyescribed . Metabolescribed  using XL1H NOESY NMR data revealed specific metabolites  that contributed to the variance between Oregon and Massachusetts fruit. Quantitation of these metabolites confirmed significant regional variation. Fruit from Oregon, a major growing region on the West Coast, exhibited significantly higher total flavonol and anthocyanin content over two harvest seasons than fruit from Massachusetts, a major growing region on the East Coast. By contrast, we found that MA fruit was consistently richer in triterpenoids and organic acids than fruit from OR. The influence of growing region on PAC content among fruit in our study was less evident, but PACs varied substantially among the cultivars. A strong positive correlation was observed for the antioxidant activity of cranberry fruits with the content of flavonols and anthocyanins, as well as with total soluble phenolic content, with OR fruit possessing greater overall anti-radical scavenging potential than fruit from MA. We report for the first time a regional influence (MA > OR) on the content of the triterpenoids ursolic and oleanolic acid, compounds that are likely to contribute to the anti-inflammatory benefits of cranberry fruit. Understanding patterns in cranberry metabolite production will contribute to improving harvest strategies and product development relating to the health-promoting properties of cranberry fruit. Cranberry flavonoids and triterpenoids have demonstrated potential for human health by protecting against oxidative stress and inflammation. The development of horticultural practices that maximize the content of these important compounds can provide greater dietary health benefits.The present study illustrates a significant effect of the growing region in North America on the secondary metabolite composition and antioxidant properties of cranberries. PCA of


Background: An inadequate perinatal nutritional environment can alter the maturation of the intestinal barrier and promote long-term pathologies such as metabolic syndrome or chronic intestinal diseases. The intestinal microbiota seems to play a determining role in the development of the intestinal barrier. In the present study, we investigated the impact of consuming an early postnatal prebiotic fiber (PF) on growth, intestinal morphology and the microbiota at weaning in postnatal-growth-restricted mice (PNGR). Methods: Large litters (15 pups/mother) were generated from FVB/NRj mice to induce PNGR at postnatal day 4 (PN4) and compared to control litters . PF (a resistant dextrin) or water was orally administered once daily to the pups from PN8 to PN20 (3.5 g/kg/day). Intestinal morphology was evaluated at weaning (PN21) using the ileum and colon. Microbial colonization and short-chain fatty acid (SCFA) production were investigated using fecal and cecal contents. Results: At weaning, the PNGR mice showed decreased body weight and ileal crypt depth compared to the CTRL. The PNGR microbiota was associated with decreased proportions of the Lachnospiraceae and Oscillospiraceae families and the presence of the Akkermansia family and Enterococcus genus compared to the CTRL pups. The propionate concentrations were also increased with PNGR. While PF supplementation did not impact intestinal morphology in the PNGR pups, the proportions of the Bacteroides and Parabacteroides genera were enriched, but the proportion of the Proteobacteria phylum was reduced. In the CTRL pups, the Akkermansia genus (Verrucomicrobiota phylum) was present in the PF-supplemented CTRL pups compared to the water-supplemented ones. Conclusions: PNGR alters intestinal crypt maturation in the ileum at weaning and gut microbiota colonization. Our data support the notion that PF supplementation might improve gut microbiota establishment during the early postnatal period. The concept of the Developmental Origins of Health and Diseases (DOHaD) posits that the environmental conditions during the first 1000 days of life are critical for programming long-term health and disease . In partThus, prevention strategies aimed at reducing the later risk of intestinal diseases due to an early deleterious nutritional environment must be developed. Prebiotics are promising candidates, given their beneficial effects on the intestinal barrier and the immune system, implemented by positively influencing the intestinal microbiota composition. Prebiotics are substrate-selectively utilized by host microorganisms to confer health benefits . As they® diets R03-25, Augy, France). The PNGR model was induced by increasing the litter size (8 or 15 pups per litter), as described by Ley et al. [n = 4 litters) and further compared with control litters of 8 pups per mother  . From PN8, pups from the CTRL and PNGR groups were orogastrically fed once daily with either a PF  or water up to PN20. PF powder was resuspended in water (70% wt/vol) and administered as an oral solution using a lubricated polyethylene tube (0.3 mm diameter) mounted on a 30G needle. Supplementation was performed once daily in the morning from PN8 to PN20, and the feeding volume was 5 mL/kg body weight. The type of supplementation (PF or water) was randomly assigned among the litters (n = 2–3 litters per supplementation per group). Each pup within a litter was orally fed with the same supplementation, independent of its sex, to ensure a similar intervention within litters. The mice pups’ body weight was collected every second day until weaning (PN21) to adapt the feeding volume and validate PNGR. PNGR was validated for each pup of the PNGR group if its body weight was lower than the 10th percentile for the body weight distribution in the CTRL group from PN6 to PN21. Moreover, to avoid the sex-specific outcomes on gut barrier function observed following early life adverse environmental factors in suckling and weanling rodents [n = 9–20 per group) were euthanized for sample collection. Cecal contents and colonic feces were collected with cleaned tools, immediately flash-frozen and stored at −80 °C until analysis. Ileum and colon samples were fixed in 4% paraformaldehyde overnight, processed and embedded in paraffin wax using an automatic sample preparation system  for histological analysis.FVB/NRj mice aged 8 weeks  were housed in a specific pathogen-free environment (12:12-h light-dark cycle) and had ad libitum access to food and water. After 7 days of acclimation, 1 male mouse was mated with 2 to 3 females for 7 days. The pregnant mice were fed with a breeding diet . The selections were based on the males’ body weight at PN20 to represent the average body weight and standard deviation of their litter. At PN21, the ileal villus height and crypt depth, as well as the colonic mucosa thickness and colonic crypt depth, were determined using ImageJ software v1.53t  in a blinded manner by two independent observers .Hematoxylin and eosin (HE) staining was performed on four-micron paraffin-embedded tissue sections. A total of 8 male pups per group were selected for histological analyses (Genomic DNA (gDNA) was extracted from the colonic contents (mean weight: 14.2 g) of male pups at PN21 using an optimized tissue-specific technique, as previously described . The quav/v) was added and then vortexed. SCFAs were derivatized for chromatography–mass spectrometry (GC/MS) analysis using PCF. The SCFAs were extracted using 0.5 mL of hexane. The GC/MS analysis comprised a phase of liquid injection at 260 °C in the split mode and a separation phase on a 50 m × 0.25 mm, 0.25 μm, DB-5 ms capillary column. Quantification was performed with a single quadripole using electron impact ionization.The cecal content was weighted (mean weight: 74.9 g) and homogenized in 1.5 mL of a solution of NaOH at 0.005 M, including internal standards  using Precellys equipment. Total DNA was extracted following the described steps: 300 μL of supernatant was collected and transferred to a 5 mL glass tube; next, 500 μL of propanol/pyridine mix . Variables were expressed using the mean and standard error of the mean (SEM) or standard deviation (SD). Statistical analyses were conducted based on values obtained for each individual. Outliers were excluded using Grubb’s test. The variables’ normality was assessed using the D’Agostino–Pearson test. If necessary, a log10 transformation was applied to reach normality. Thus, depending on the variable normality test results, statistical differences were tested via mixed-effects analysis (Tukey’s post-test), one-way ANOVA (Tukey’s post-test) or the Kruskal–Wallis test (Dunn’s post-test) for group comparisons. For the microbiota analysis, the normal distribution of the values was verified with the Shapiro–Wilk test. Significant variations in alpha diversity were assessed using Kruskal–Wallis or Wilcoxon rank sum tests. Multidimensional scaling analyses (MDS) were performed on beta diversity distance matrices, and differences between groups were assessed using PERMANOVA and PERMDISP analyses (2000 permutations). LEfSe  analyses were used to determine significant variations in taxa-relative abundance . Each ban = 15 pups) and CTRL litters (n = 8 pups) were created at PN4 and supplemented with water or PF daily from PN8 to weaning , Firmicutes  and Desulfobacterota  phyla  phyla .p = 0.016), Bacteroides  and Parabacteroides  genera  genera .In this study, we aimed to investigate the impact of early postnatal PF supplementation on pup growth, intestinal structure and gut microbial colonization in PNGR mice. As expected, mice in the PNGR group showed significant growth restriction during lactation, indicating severe undernutrition . SurprisThen, we investigated whether a fermentable fiber supplementation during lactation could counter PNGR effects, particularly on microbiota colonization. We did not report significant effects of PF administration during lactation on body weight or intestinal morphology in the PNGR and CTRL groups. Similarly, other studies investigating the impacts of postnatal supplementation with different prebiotic compounds in rodents failed to induce significant body weight changes during lactation or at weaning ,36. AlthTo conclude, this study supports the notion that early postnatal nutrition is crucial for proper gut microbial colonization and that prebiotic fiber supplementation during this critical period of development might contribute to the improvement of the protective properties in altered nutritional environments. However, the consequences of such modifications for gut microbiota during postnatal development and in response to PNGR on later intestinal health and susceptibility to chronic intestinal diseases remain to be investigated ,41.


Currently, most evidence assessments in guidelines or health technology assessments (HTAs) rely on the assumption that a randomized controlled trial (RCT) is always the best source of evidence. However, if the outcome in a control group is certain, e.g. death within a short time with an almost 100% chance, or if an event can only occur in the treatment group, there is no need for a randomized control group; the evidence cannot be improved by a control group, nor by an RCT design. If a cause–effect relationship is certain (“primary or direct evidence”), a therapeutic effect can be diluted in the population of an RCT by cross-over, etc. This can lead to serious misinterpretations of the effect. While experts such as the GRADE group or Cochrane institutes recommend using all available evidence, the leading approach in many guidelines and HTAs is assessing “the best available trials”, i.e. RCTs. But since RCTs only deliver probabilities of cause–effect relationships, it is not appropriate to demand RCTs for certain effects. A control group can only diminish the net value of a treatment since the outcome in the control group is subtracted from the outcome in the treatment group. Therefore, under identical circumstances, an RCT will always show lower effect rates compared to a single arm study of the same quality, for desired as well as for adverse effects. Considering these inconsistencies in evidence-based medicine interpretation, the evidence pyramid with RCTs at the top is not always a reliable indicator for the best quality of evidence. Scientific theories and methods explaining the world or certain aspects of nature should be rational and logically consistent. Often, we accept what we learned and apply currently used proceedings without questioning them from time to time or from subject to subject. This can lead to serious mistakes. Daniel Kahneman, Nobel Prize winner and author of the book “Thinking fast and slow” would probably call this “theory induced blindness”. In this context, the authors would like to shed light on some misunderstandings of currently applied evidence-based medicine.According to the GRADE guidelines , the quaFor most therapies and methods, the best start for gathering evidence on cause–effect relationship and effect dimensions is to pretend that we know nothing about the intervention, related effects and safety. Therefore, a study that excludes bias and potential confounders as best as possible should be the measure of choice. This is, in general, an RCT.GRADE recommends assessing outcomes across studies and not to focus on all outcomes of one study. Furthermore, GRADE emphasizes the assessment of other factors that determine how much confidence can be placed in estimates of an effect . Here itThere are few, but in fact important therapies for which efficacy and safety can be successfully determined without an RCT. Sometimes, RCTs are even obsolete, more often unnecessary –6. By chThis manuscript is based on fundamental publications of evidence-based medicine theory from Sir Austin Bradford Hill over David L. Sacket to the GRADE group. The authors assessed the current proceedings and thoughts of today’s operationalization of evidence based medicine, revealed by study reports, medical guidelines and health technology assessments (HTAs). They then scrutinized the underlying logic and documented important but thus far often neglected logical facts as well as logical mistakes.RCTs are essential tools in the armory of evidence generation. However, few RCTs are conducted perfectly and therefore, correctness of RCT results cannot be taken for granted—as is applicable for any other study type. The conditions are artificial, there may be selection bias at enrolment, some prior assumptions may turn out as wrong, and important variables may not have been taken into account. If there is a structural mistake, a wrong estimation or a service missing that is mandatory if a therapy is used in real life, statistics cannot offset this fault. Study designs are always between ideal conditions to keep the effect as large as possible  and the real life clinical situation .any crossover in a trial with an effective therapy reduces the therapy effect towards the zero hypothesis in an ITT analysis. This ramification is irrelevant if there is no therapy effect and therefore, an ITT analysis disadvantages therapies with a real effect, while it increases the chance of reaching non-inferiority even with little or no true effect.While an RCT should answer the pivotal questions of cause–effect relationship and efficacy in the first place, today’s standard analysis type is intention-to-treat (ITT), which is blind for everything after randomization and therefore reflects rather clinical practice including potential compliance issues than the full capability of the therapy effect. Combining efficacy and effectiveness questions in one RCT may lead to rejection of a seemingly ineffective therapy due to compliance issues, while specifically addressing and fixing compliance issues would show a highly effective therapy. Furthermore, assigned to patients, PPA the result when a therapy is applied on patients. No analysis is better than the other, it depends on the recipient which answer is more relevant. For example, it is not of interest for a patient to know what effect a therapy offers if it is not appropriately applied . Here, the PPA would be more helpful  “clinical question.”


Dirofilaria immitis has not been reported in Brazil´s Amazonas state capital, Manaus, for over a century. Here, we report one imported and 27 autochthonous D. immitis infections from a microfilarial survey of 766 domestic dog blood samples collected between 2017 and 2021 in Manaus. An Overall prevalence estimate of 15.44% (23/149) was calculated from our two rural collection sites; a prevalence of 1.22% (4/328) was estimated at our periurban collection site, and an overall prevalence of 0.35% (1/289) was calculated from our two urban clinic collections. Our data suggest that in the urban areas of Manaus, where the parasites are very likely vectored by the same species of mosquito that historically vectored Wuchereria bancrofti (Culex quinquefasciatus), prevalence levels are very low and possibly maintained by an influx from rural areas where sylvatic reservoirs and/or more favorable vector transmission dynamics maintain high prevalences.The canine filarial parasite  Dirofilaria: Dirofilaria immitis and Dirofilaria repens  larvae can appear on X-rays and CT scans of human lungs as coin-like lesions , there was thus a clear and urgent need for an update on the distribution of these parasites in the city  as prophylactics to prevent their animals contracting ocieties . Althoug lesions . An accuf Manaus , there h00 years . Given tthe city .To investigate the current status of Dirofilariosis in and around the city of Manaus, canine blood surveys were carried out at: urban veterinary clinics within the city; a veterinary clinic on the city´s outskirts and at two rural settlements just outside the city. The urban surveys were performed in partnership with two city veterinary clinics: a Mobile Castration Unit of the Municipal Health Department headquartered in the heart of the city (03°04'45”S 59°55'59”W) and known in Brazil as SEMSA and a private veterinary clinic named here as VC1 See . As can Convenience sampling was conducted at all of the sampling areas. Urban collections made from the Mobile Castration Unit were performed between November 2016 and February 2017 and at the VC1 clinic between December 2017 and March 2018. The periurban collections at VC2 were made from May 2018 to December 2018. Rural collections were made between May 2019 and November 2019 in the Nossa Senhora do Livramento Community and in December 2021 at the Nossa Senhora de Fátima Community. Blood samples were drawn from adult dogs (aged between 2 and 15 years) by cephalic vein puncture, using a sterile needle and vacutainer tube containing EDTA. The collection tubes were labelled with unique identifiers, then placed in an isothermal box and taken to the Ethnoepidemiology Laboratory of the National Institute for Research in the Amazon (INPA) or the Leonidas and Maria Deane Institute (Fiocruz Amazônia) for analysis. At same time blood samples were taken, basic information about the dogs´ lives was collected from the animal´s owners, with specific attention being paid to where the animal had been born and resided. To visualize the microfilariae, whole blood samples were used to make thick blood smears. These were prepared using the method described by D. immitis of which only one was not born and raised in Manaus (having arrived in the city from Belem) giving our survey an overall D. immitis prevalence rate of 3.66% (28/766). D. immitis blood survey prevalence levels calculated for each of the five individual collections performed for this study. From this data it can be observed that our rural collections had the highest D. immitis prevalence levels of 15.44% (23/149) whereas our urban collections had the lowest prevalence levels corresponding to 0.35% (1/289) and that our periurban site had an intermediary prevalence level of 1.22% (4/328). It can also be seen in D. immitis infections in male dogs 16/271 (5.51%) than it detected in female dogs 12/467 (2.56%).In total we examined the blood of 766 animals: 287 males and 479 females. The sampling was performed as follows: 238 dogs from the Mobile Castration Unit; 51 dogs from VC1 site; 328 dogs from VC2 site; 73 dogs from the Nossa Senhora do Livramento Community and 76 dogs from the Nossa Senhora de Fátima Community. Of all the animal surveyed just 28 were positive for D. immitis in the hearts of two of the dogs they killed, as well as a second unidentified species of filarial parasite in the peritoneal of a third, and thus showed that ≥4% of the stray dogs that they surveyed were infected with D. immitis. Unfortunately, the blood survey carried out by D. immitis arrived in Manaus more than a century ago and, when taken together with our data, strongly suggest that the parasite has been endemic to Manaus ever since.In the D. immitis prevalence levels were notably higher at our rural survey sites than they were at our urban sites  that are targeted by Manaus´s arbovirus vector control programs  and in particular for hospitals serving the rural areas of Manaus. While there have not been any formal reports of D. immitis parasites from blood samples or biopsies, making these assays available to Manaus residents through public or private diagnostic service providers should thus now be encouraged (D. immitis infections and thus if Manaus veterinary practitioners and companion animal owners who live in the city are made aware of them the parasites transmission could be reduced (D. immitis infections are treated with a 28-day program of doxycycline in combination with ivermectin and melarsomine (D. immitis treatment options. In Europe and North America there are heart worm societies where concerned companion animal owners liaise with professional veterinarians to monitor disease transmission and exchange up to date advice on diagnosis and treatment (There are many reliable and cheap PCR assays that can be used to identify couraged . A heigh reduced . At presarsomine , howeverarsomine . There ireatment . At presD. immitis parasites, causing disease in humans (D. immitis parasites (D. immitis found in Manaus could thus help to determine if the D. immitis are like standard forms of D. immitis or more like those found in Para state and indeed what pathologies they are likely to cause in humans.Although non-human primate filarial parasites have been recently recorded in the state of Amazonas and indeed Manaus, as of yet, there have not been reports of these parasites, or indeed n humans . In Parán humans . Interesarasites . Future


To determine the level of evidence for innovative high-risk medical devices at market entry.We reviewed all Belgian healthcare payer (RIZIV-INAMI) assessor reports on novel implants or invasive medical devices  available between 2018 to mid-2019 on applications submitted for inclusion on their reimbursement list. We also conducted a review of the literature on evidence gaps and an analysis of relevant legal and ethical frameworks within the European context.Conformity assessment of medical devices is based on performance, safety, and an acceptable risk-benefit balance. Information submitted for obtaining CE marking is confidential and legally protected, limiting access to clinical evidence. Seven out of the 18 RIZIV-INAMI assessor reports (39%) included a randomized controlled trial (RCT) using the novel device, whilst 2 applications (11%) referred to an RCT that used a different device. The population included was inappropriate or unclear for 3 devices (17%). Only half of the applications presented evidence on quality of life or functioning and 2 (11%) presented overall survival data. Four applications (22%) included no data beyond twelve months. The findings from the literature demonstrated similar problems with the study design and the clinical evidence.CE marking does not indicate that a device is effective, only that it complies with the law. The lack of transparency hampers evidence-based decision making. Despite greater emphasis on clinical benefit for the patient, the provisions of the European Medical Device Regulation (MDR) are not yet fully aligned with international ethical standards for clinical research. The MDR fails to address key issues, such as the lack of access to data submitted for CE marking and a failure to require evidence of clinical effectiveness. Indeed, a first report shows no improvement in the clinical evidence for implantable devices generated under the MDR. Thus, patients may continue to be exposed to ineffective or unsafe novel devices. The Health Technology Assessment Regulation plans for Joint Scientific Consultations for specific high-risk devices before companies begin their pivotal clinical investigations. The demanded comparative evidence should facilitate payer decisions. Nevertheless, there is also a need for legislation requiring comparative RCTs assessing patient-relevant outcomes for high-risk devices to ensure implementation, including development and implementation of common specifications for study designs. Healthcare has an ethical dimension as it aims to prevent and alleviate human suffering. Healthcare has also developed into an important economic sector, with sales of services and products. Total European Union (EU) expenditure on healthcare (public and private) amounts to around €1.3 trillion annually, including €220 billion for medicinal products and €100 billion for medical devices. Healthcare spending represents about 10% of EU GDP [This paper is based on a report published by the Belgian Healthcare Knowledge Centre (KCE) that investigates whether the clinical trial data for medicinal products and medical devices leading to market entry also meet the needs of health technology assessment (HTA) bodies and healthcare payers for the assessment of added therapeutic benefit . This paThe research incorporated three different studies: an analysis of the international ethical frameworks and European legislation governing medicines and medical devices; an examination of assessors’ reports on applications submitted to the Belgian public healthcare payer, the National Institute for Health and Disability Insurance (RIZIV-INAMI); and a review of the literature on reviews of groups of medicines or medical devices examining their evidence base. The draft report was shared with forty-one experts who provided their feedback via email and during three expert group meetings . This feedback was incorporated into the final draft report and shared with industry representatives requesting their comments, eight of whom joined a stakeholder meeting to provide their feedback prior to publication of the report. The final draft report was shared with three external experts for peer review and comment . The policy recommendations were reviewed and accepted by the Board of the KCE, which is composed of representatives of the Belgian government as well as other healthcare stakeholders.In this paper, the focus is on innovative high-risk medical devices (Class IIb and III). Compared with pharmaceuticals, some medical devices present additional factors that affect their clinical assessment. For implantable devices, these factors include the surgical procedure itself, the learning curve, the outcome assessment, a possible volume-outcome relationship, and difficulty in determining the optimal time at which to conduct the randomized controlled trial (RCT) - all elements that need to be taken into account during evidence generation –5.Legal and ethical rules were examined since the European legal context is evolving, with the recent medical device regulation (MDR)  and a neWe reviewed all Belgian healthcare payer (RIZIV-INAMI) assessor reports available between 2018 to mid-2019 for eighteen novel implants or invasive medical devices  submitted for inclusion on the reimbursement list  [A systematic search strategy was developed using key words and controlled vocabulary terms for the concepts of ‘medical devices’ AND ‘evidence/evidence gaps’ AND ‘reimbursement/funding or market entry’ AND ‘Europe’. The searches were performed in PubMed, EMBASE, and the Cochrane Library in 2019 (17 September-17 December), revised in January 2021, and updated in August 2021. Searches were limited by date (published after June 1st 2011) based on the last search of a previous KCE report on this subject. Titles, abstracts, and selected full texts were screened in phases against the inclusion/exclusion criteria independently by two reviewers (FH and CPdJ). Reports were eligible for inclusion if they reviewed the evidence available for groups of high-risk medical devices at the time of market entry or application for reimbursement in the EU. The final update was screened by just one reviewer (CPdJ). Results were compared and differences were resolved through discussion and consensus. A narrative synthesis of findings regarding the quality of the evidence base and gaps identified is presented in the KCE report, with further details available on p.85–87; 152–208 [This article focusses primarily on the legal/ethical analyses. We also discuss the analysis of the reimbursement applications in the context of the findings of the literature review.In Europe, the regulatory framework for medical devices, including high-risk medical devices, differs greatly from the regulatory system for medicinal products. It also differs significantly from the Food and Drug Administration’s (FDA’s) approach to regulating medical devices in the United States (US).It is standard practice to conduct an RCT of a novel medicine during its development to demonstrate its clinical safety and efficacy, with discussions focussing on the appropriate choice of the comparator and study endpoints. However, despite a positive trend towards more RCTs for medical devices , this isIn the EU, medical devices are subject to Regulation 2017/745 (MDR) , which wBoth the MDDs and the MDR require clinical studies  for implantable medical devices. However, there are exceptions. These include implants that are classified as ‘sutures, staples, dental fillings, dental braces, tooth crowns, screws, wedges, plates, wires, pins, clips and connectors’, and, with certain preconditions, devices that are modifications of devices already legally placed on the market may also be exempted  [“CE marking” (Conformité Européenne) is a mark that indicates (though it doesn’t guarantee) compliance with the relevant legal requirements. The Commission notes that “a CE marking does not indicate that a product have been approved as safe by the EU or by another authority” . ManufacIn order to be deemed compliant, medical devices must “satisfy general requirements” with regard to their safety and performance in normal use, and show that their benefit/risk ratio is acceptable. Note that, in contrast to the US situation, the demonstration of effectiveness is not a requirement in Europe . In the The CE marking system remains largely based on an unsubstantiated trust that the necessary evidence of safety and effectiveness will be provided after the product is placed on the market , 16. ThuThe new MDR has tightened the rules somewhat by requiring that “clinical benefit” be demonstrated in addition to “clinical performance”. “Clinical benefit” is defined as the positive impact of a device on the health of an individual, expressed in terms of a meaningful, measurable, patient-relevant clinical outcome(s), including outcome(s) related to diagnosis, or a positive impact on patient management or public health  . In addiclinical evaluation consultation procedure (CECP)  [The MDR also introduces the possibility for the EU regulatory authorities and Notified Bodies responsible for high-risk devices to have access to independent Expert Panels via a procedure called the icle 54) . The lisicle 54) . In addiicle 54) . The HTAA clinical investigation under the scope of the MDR can only be conducted if authorised by a national competent authority (NCA) and if no negative opinion has been issued by a research ethics committee (REC) with regard to the clinical investigation  [Article 71 of the MDR requires that the NCAs assessing applications for clinical investigations must review, amongst other things, the reliability and robustness of the data generated in the clinical investigation, taking account of statistical approaches, the design of the investigation and methodological aspects, including sample size, comparator and study endpoints. This assessment must respect the strict authorisation process timelines applicable under the MDR for each clinical investigation. Provided the member state national REC has not issued a negative opinion, authorisation must be provided immediately following application validation for Class IIb devices and within 45 days of a validated application for Class III devices (or 65 days if expert panels are consulted), with designated pauses if additional information is requested  [However, the MDR does not specify how the RECs should conduct reviews of trial applications. Indeed, under the MDR, it is left to the member state where the clinical investigation is to be conducted to decide who is the appropriate authority to assess the clinical investigation application and to define the extent of the ethics review required.only if no proven treatment or standard of care is available or where it is required for compelling and scientifically sound methodological reasons as the only means to determine the efficacy or safety of an intervention [According to the Declaration of Helsinki, a control group receiving no treatment, a sham procedure, or a placebo may be justifiable as a comparator rvention . If thisIn contrast to medicinal products in Europe and medical devices entering the US market, clinical data on medical devices previously did not have to be made publicly available upon entry to the EU market. Whilst the MDR still maintains confidentiality of the data submitted for CE marking, nevertheless, its introduction is expected to improve transparency to a certain extent. It requires manufacturers of the highest-risk devices to provide a summary of the most important safety and performance aspects, as well as the results of the clinical evaluation of their devices, in a publicly accessible document, the Summary of Safety and Clinical Performance (SSCP)  . In partThe EU HTAR, which has only recently been enacted, is gradually being implemented . The JCAnot prevent products from entering the market so long as they perform as intended and have an acceptable level of risk, whereas, the remit for HTA is to synthesise the necessary evidence to ensure safe, effective, and cost-effective healthcare is provided.As depicted in Fig. The analysis is based on RIZIV-INAMI assessors’ reports on company applications for medical devices to be included on the reimbursement list of novel implants or invasive medical devices  . Of the According to the submission procedure at RIZIV-INAMI companies can indicate a level of added clinical benefit for their device. A claim was made for the highest level of added clinical benefit (Class 1) in 12 applications (67%), whilst for three the claimed level of added clinical benefit was not clearly reported in the application. The device’s intended use suggested a direct impact on quality of life for 11 devices. Six devices could potentially impact overall survival (OS) based on the intended use.We were given access to the assessor’s reports, which contained little detail, limiting their synthesis solely to aspects reported on. When assessors observed a major weakness in an application they might have based their conclusion on this weakness without going into further detail on all other possible weaknesses. The absence of a comment regarding a specific topic, therefore, does not mean the absence of an issue or problem. The findings from the assessors’ reports are summarized thematically using PICOTS.Application assessors reported as an issue that the target population for which the reimbursement request was submitted did not match the trial’s patient population for 2 out of 18 devices, and in another application this was unclear. For some target groups no evidence was shown of any additional benefit, and for one device the claimed benefit could not be demonstrated in the RCT’s planned analyses, but in a post-hoc sub-group analysis.Assessors noted in a few cases that it was unclear for what clinical indication and patient population the device was intended, making it difficult for them to clearly describe the target population.In two applications (11%), assessors explicitly expressed concern regarding the fact that the trial data presented in the dossier was on a completely different device to the one for which reimbursement was being sought.Seven applications (39%) included an RCT investigating the innovative medical device and for another two dossiers the RCT tested a device other than the device for which reimbursement was being sought. The lack of RCT data was explicitly mentioned as a problem in one of the assessor reports.Among the 9 applications containing RCT data, one of these demonstrated inferior efficacy compared with medical treatment; and 4 used surrogate outcomes, one of which showed no difference. Quality of life (QoL) was reported on for 4 (49%) of these devices. Regarding OS, this was either not mentioned as an outcome (n = 4), data were not presented (n = 4) or no effect was shown (n = 1).In half (9 out of 18) of the device reimbursement dossiers, applicants were seeking reimbursement on the basis of evidence from cohort studies, which suggests that these devices received their CE marking without undergoing an RCT. Eight had at least one prospective cohort, but one reported only on a retrospective cohort comparison. For seven devices (78%) only surrogate outcomes were reported. Only for 2 devices (22%) was QoL reported. Six devices (67%) had no data on OS. One reported on OS, which appeared to be favourable, but there were no comparators.Finally, for one device a comparison in outcomes between 2 populations was reported rather than between treatments in the population for which reimbursement was being sought.Overall, more than half (10/18) of the applications contained no data on quality of life or other patient-relevant outcomes, despite all devices being invasive and likely to affect QoL or functioning, either directly or indirectly. In one case this was reported as a major shortcoming by the assessor, and in another application the patient relevant outcome was evaluated in a post-hoc sub-group analysis while the RCT investigated surrogate outcomes.Overall, QoL outcomes were reported for five out of 18 devices, and some QoL improvement was found in four of these, including for two devices, where pain was assessed and showed improvement. Additionally, three applications contained outcome data on function .For 5 applications (28%), there was limited (one with 10 patients at 5 years) or no data (n = 4) on outcomes after one year, despite being implantable devices. In two applications, the lack of sufficiently long-term results was explicitly considered a problem by the assessor.Overall survival was not mentioned in 5 applications (28%), whilst there was explicitly no data available for over half (n = 11). Two reports included data on OS, for one of these it showed no difference, and for the other it appeared to be beneficial, but there was no comparative data.In conclusion, over 60% (11/18) of the medical device applications submitted to RIZIV-INAMI for reimbursement did not include an RCT on the actual medical device to be reimbursed. Other weaknesses included the reporting of surrogate outcomes only and the short duration of follow-up of patients who had received an implant.Compared with medicinal products, relatively few studies have reported on the level of evidence and the methodological shortcomings of pre-market clinical evaluations of medical devices in Europe. Medicinal products may have the necessary evidence for a reimbursement decision readily available at the time of regulatory approval, since the clinical development and results of the pivotal trials for each new drug are summarized in a document called a European public assessment report (EPAR). These are available on the European Medicines Agency (EMA) website and are often used as a starting point for studies reviewing the pre-market evidence base underpinning specific groups or categories of medicinal products. In contrast to medicines, there is no such public document yet available summarizing the clinical studies on a given medical device when it enters the European market. Therefore, researchers have had to find other ways to collect and evaluate the evidence base for groups of medical devices. Such reviews are further hampered by strong confidentiality requirements and the absence of a legal obligation under the MDDs to register device trials (assuming they exist). Furthermore, device companies possibly may not make medical device trial results publicly available. Consequently, relatively few studies have quantified the level of evidence and the methodological shortcomings of clinical evaluations of medical devices in Europe.We identified sixteen studies published since June 1st 2011 that reviewed the evidence for groups of high-risk therapeutic medical devices. They each used different methods, and presented their findings in different ways. The majority (11 out of 16) used levels of evidence to grade the quality of the evidence base included in their reviews, applying various different grading systems. Three others described individual elements of study quality, whilst the final one only included RCTs, evaluating their quality using the Cochrane Risk of Bias tool.Many of the review authors indicated a lack of RCTs for more than half of the devices they reviewed , 28–32. Authors noted that manufacturers can use clinical data from other similar medical devices to support applications for CE marking. Indeed, it is only the first generation of an innovative product that has to provide direct clinical evidence on its safety and technical performance, whilst follow-up products can be CE marked “on the basis of their technical equivalence to the first product” . This meThe main reason for a paucity of pre-market device RCTs seen in the past in Europe is most probably the fact that such RCTs were not needed to obtain a CE marking . Indeed,Due to the differences in the European and US regulatory approaches, innovative medical devices are often available more quickly on the European market, but this is on the basis of minimal clinical data, even for implantable devices. For example, this lower level of evidence was seen in the 2008 applications submitted for reimbursement in France , and wasWhere RCTs of medical devices do exist, they are generally poor in quality and multiple shortcomings have been reported, such as the lack of a clearly defined primary endpoint or the absence of a description on the handling of missing data, amongst others . For impWhere the target population and/or the clinical indication is not clearly specified, it is difficult for payers to control the diffusion of the intervention from populations where they have been proven to be beneficial into untested populations, a phenomenon known as indication creep. This was confirmed by the HTA experts whom we consulted, who see indication creep as a problem that may be more difficult to control for high-risk medical devices compared with medicinal products.While QoL data is of key importance for patients, it is often not included as an outcome in trials. When QoL data are collected, they are often inadequate. Ideally, QoL should be measured using both a disease-specific instrument and a generic instrument (e.g. EQ-5D-5 L), at several time points over a sufficiently long period of time, enabling the calculation of quality-adjusted life years (QALYs) over a longer period. Inexplicably, results for QoL are sometimes considered confidential by the company that sponsored the trial . TherefoStudies that do not meet the ethical requirements in the Declaration of Helsinki regarding the choice of comparator should be refused by ethics committees. Nevertheless, the MDR is not explicit regarding the comparator in clinical studies. From an HTA perspective, an RCT with a control group consisting of a cost-effective ‘standard care’ treatment, investigating patient-relevant outcomes is necessary to assess the added therapeutic benefit, if any, of the new device and to inform the calculation of its incremental cost-effectiveness ratio (ICER). The ICER is used for determining its comparative value and deciding whether it should be reimbursed or not. This applies to both medicinal products and medical devices. For high-risk medical devices, the lack of sound comparative clinical data hinders national reimbursement procedures , 40, 44.Ultrarare disorders may be an exception since the numbers are so small that it is unlikely that either RCTs or observational studies will be able to provide conclusive results. Nevertheless, randomization remains essential to balance any factors that influence outcomes besides the intervention (i.e. both the known and the unknown unknowns) across treatment groups, so as to minimize bias and justify any inferences being made. Observational study results that indicate that a device is efficacious may be contradicted when an RCT is performed, because well-designed RCTs minimize the influence of potential systematic biases and confounding factors . Large oRepresentatives of the medical device industry have argued that conducting RCTs for medical devices is often not possible or ethical. However, healthcare payers need to assess new interventions to see if they have any added therapeutic benefit. RCTs with medical devices are feasible , 48. HTAOther frameworks for generating comparative evidence have been proposed for implantable medical devices, with attention to device-specific critical elements in trial design and conduct , or thatAccording to Wild et al. (2014) there is a lack of transparency regarding how devices are approved and, particularly, the information assessed by Notified Bodies . SauerlaThere have been numerous calls and suggestions to rectify this. Fraser et al. (2018)  clearly all the steps in the IDEAL framework need to be taken [Several groups, including KCE, have recommended a stepwise approach to introducing innovative medical devices based on evidence generated , 41, 52.be taken , includibe taken  to limitbe taken , 57. AddComparative evidence during the pre-market clinical development can be generated more efficiently, reducing the cost and complexity of RCTs . PragmatDepending on the device under consideration, a more controlled post-market ‘use only in research’ phase might be considered for reimbursement by payers. An important question is who should pay for new treatments whilst additional information is being collected as part of any post-market obligations? Publicly-funded trials  can alsoA remarkable number of CE marked high-risk devices have either been recalled or failed to obtain FDA approval , 35. GivMulti-stakeholder initiatives, such as the EU-funded Coordinating Research and Evidence for Medical Devices project (CORE-MD), could help with starting a multi-stakeholder dialogue . In addiIt remains to be seen how the MDR will help companies and Notified Bodies in the generation of comparative evidence of the new device versus standard care treatment. Recent data from the German HTA body, IQWIG, show that for the first nine implants (May 2021 – March 2023) with an opinion provided under the CECP  only oneIt is important to be aware of the unintended adverse consequences to some patients of implementing the MDR, as manufacturers may withdraw relatively cheap, and therefore, low profit, devices from the market rather than paying the additional costs that meeting the requirements of the MDR would incur. A limited number of these devices may be essential for a group of patients, thus as Melvin et al. (2022) point out , specifiGovernments should invest in infrastructure to reduce the cost and improve the quality of medical device clinical trials, including the development of comprehensive patient registries. This will facilitate efficient designs that generate comparative evidence.Common specifications should be developed regarding the most appropriate pre-market study designs for evaluating specific categories of medical devices, and their use required by legislation.Studies that do not meet the ethical requirements in the Declaration of Helsinki regarding the choice of comparator should be refused by ethics committees.The EU should explicitly state that clinical data underpinning the CE marking cannot be protected by confidentiality requirements and must be made publicly available.HTA bodies and payers should not accept evidence that is too weak to come to meaningful conclusions on added therapeutic benefit.Healthcare systems should institute pro-active post-market surveillance systems.Clinicians and the public need to be educated about the lack of evidence for medical devices and the need for RCTs to demonstrate the effects of a treatment.A more complete set of policy recommendations can be found in the KCE report .There is a huge lack of transparency regarding the clinical evidence underpinning the legal placement of medical devices on the European market. The little data that is available suggests that studies are of low quality and there is a heavy reliance on evidence from other devices. Sometimes this evidence is from devices that have been withdrawn or known to be unsafe or ineffective. This means that devices are entering the market without reliable evidence to determine if they are safe and effective, putting patients at serious risk of harm.HTA bodies need RCTs to assess comparative effectiveness and added therapeutic value, without this, reimbursement decisions prove difficult and reimbursement may be delayed. The MDR does not sufficiently stimulate the generation of robust comparative evidence. The CE marking system for high-risk medical devices relies heavily on post-market data collection, yet this may take years and be too late to inform clinical decision-making for thousands of patients.Therefore, the transparency of the clinical evidence provided to obtain CE marking must be improved. RCTs need to be conducted at the earliest stage possible, preferably in the pre-market stage, and the quality of these trials also needs to be improved. Pro-active and multi-faceted post-market surveillance activities also need to be developed and introduced to detect poorly performing devices, and patient registries could be used for conducting more efficient trials to assess comparative effectiveness.


The purpose of this study was to estimate the minimum clinically important differences (MCIDs) in the Minnesota Living with Heart Failure questionnaire (MLHFQ), which targeted patients with heart failure treated with integrated Chinese and Western medicine, as a means of helping doctors and patients judge the effectiveness of intervention.A total of 194 patients with chronic heart failure were recruited from three general hospitals in Beijing. Anchor-based and distribution-based approaches were used to estimate MCID. The anchor was SF-36 item 2 , and the calculation methods included the mean change method, receiver operating characteristic (ROC) curve analysis, and linear regression model. For the distribution-based approaches, 0.2, 0.5, and 0.8 standardized response mean (SRM) values and standard error of measurement (SEM) value of 1 were used.The correlation coefficients of the MLHFQ scale information and HT were 0.346–0.583. Different MCIDs were obtained by the mean change method, ROC curve, and linear regression model. The minimum MCID in the physical domain, emotional domain, and total scores were 3.6, 2.0, and 7.4, respectively; the maximum estimates were 9.5, 2.5, and 13.0, respectively; and the average estimates were 5.7, 2.2, and 10.0, respectively. The average estimates were close to the result of the 0.5 SRM or 1 SEM.We established MCIDs in the MLHFQ using anchor-based and distribution-based approaches. It was recommended to round the average estimates of anchor-based approaches up to the nearest whole number for the MCIDs of the MLHFQ physical domain, emotional domain, and total scores. The results were 6.0, 2.0, and 10.0, respectively. In ChinIn the early 1990s, the primary outcomes used in the assessment of HF treatment effectiveness were mortality and re-hospitalization rates . BecauseThe Minnesota Living with Heart Failure questionnaire (MLHFQ) is a specific instrument commonly used in clinical studies to evaluate the quality of life of patients with HF . In clin2.2.1.This study was a secondary study using data collected by the National Natural Science Foundation of China (NSFC) project (no. 30873256). The details of the NSFC project design were reported elsewhere . A total2.2.The MLHFQ was used to evaluate the quality of life of the enrolled patients. The MLHFQ is a commonly used instrument for HF patients to self-assess their quality of life, and it is widely used globally –15. The 2.3.Item 2  of Short Form-36 (SF-36) was used as the anchor in the current study. The SF-36 instrument focuses on generic quality of life ; the HT 2.4.The Shapiro–Wilk test was used to analyze the normal distribution of continuous variables, and the nonparametric Wilcoxon signed rank test was used to analyze differences in the various domain scores of the MLHFQ before and after intervention. Spearman correlation analysis was conducted to analyze the correlations between anchor (HT) and MLHFQ information, and the correlation threshold for the anchor and scale information was 0.3–0.35, as recommended by Revicki et al. . MCIDs wThree statistical algorithms were used for the anchor-based approaches. The first was the mean change method, which is most frequently reported in the literature . The MCIdiff represents the standard deviation of MLHFQ scores before and after the intervention, SD0 represents the standard deviation of MLHFQ scores before the intervention, and r represents the reliability coefficient of the measurement instrument. For the measurement outcome of the scale, r generally indicates test-retest reliability, Cronbach's α can be used instead for test-retest reliability, and 1 SEM can be calculated as the estimated value of the MCID  and standard error of measurement (SEM) were used to estimate MCIDs .MCID=SRMthe MCID . MCID vathe MCID , 27.All statistical analyses were performed using SPSS 23.0 software.3.3.1.In the current analysis, 194 eligible patients were included, and the patient characteristics are shown in 3.2.P < 0.01). The correlations between the changes in MLHFQ scores and NYHA before and after intervention were 0.083–0.184, whereas those between MLHFQ scores and HT were 0.346–0.583.3.3.3.3.1.3.3.1.1.P < 0.05).The changes in the scores of the MLHFQ in various domains were not normally distributed before and after intervention, as determined by Shapiro–Wilk analyses . The results were lower than the MCIDs of the MLHFQ from Spanish heart failure patient, whose results of physical domain, emotional domain, and total score were 9.17, 3.39, and 19.14 respectively . The difAlthough distribution-based approaches are simple ways to estimate MCIDs, their use is debated by scholars because they relies solely on statistical inferences and do not reflect the clinical significance of the changes . DistribThe generic, stable MCIDs can more effectively help clinicians evaluate the effect of intervention.MCID may be affected by various factors such as patients’ demographic characteristics, baseline status, and method used , but theAs with all studies, our research has some limitations. First, there were few patients who exhibited deteriorating health status among the included subjects. Therefore, no MCIDs related to deteriorating health status were observed in our study. A study conducted in Spain showed that the MLHFQ is more responsive to health improvements than to worsening of health status and therefore does not adequately reflect changes in patients whose health deteriorates . Further5.In the present study, anchor-based and distribution-based approaches were used estimate MCIDs of the MLHFQ for patients treated with integrated Chinese and Western medicine. Based on our results, it is recommended that the average estimates of MCIDs of the MLHFQ physical domain, emotional domain, and total score determined using anchor-based approaches be rounded up to the nearest whole number. Using this approach, the results were 6.0, 2.0, and 10.0, respectively. These values represent the minimum change required for patients to perceive noticeable and beneficial accepted changes in their health following clinical interventions.