Digital health for EFfectiveness of INterventions with Evaluative Depth (Evidence DEFINED). Designed for real-world use, the Evidence DEFINED Quick Start Guide may help streamline DHI assessment. A checklist is provided summarizing high-priority evidence considerations in digital health. Evidence-to-recommendation guidelines are proposed, specifying degrees of adoption that may be appropriate for a range of evidence quality levels. Evidence DEFINED differs from prior frameworks in its inclusion of unique elements designed for rigor and speed. Rigor is increased by addressing three gaps in prior frameworks. First, prior frameworks are not adapted adequately to address evidence considerations that are unique to digital health. Second, prior frameworks do not specify evidence quality criteria requiring increased vigilance for DHIs in the current regulatory context. Third, extant frameworks rarely leverage established, robust methodologies that were developed for non-digital interventions. Speed is achieved in the Evidence DEFINED Framework through screening optimization and deprioritization of steps that may have limited value. The primary goals of Evidence DEFINED are to a) facilitate standardized, rapid, rigorous DHI evidence assessment in organizations and b) guide digital health solutions providers who wish to generate evidence that drives DHI adoption.Dozens of frameworks have been proposed to assess evidence for digital health interventions (DHIs), but existing frameworks may not facilitate DHI evidence reviews that meet the needs of stakeholder organizations including payers, health systems, trade organizations, and others. These organizations may benefit from a DHI assessment framework that is both rigorous and rapid. Here we propose a framework to assess Evidence in  Organizations like the American Medical Association3 and American Psychiatric Association4 encourage digital health adoption, and more than half of U.S. adults use DH to track their health5. While digital health holds promise, current practices in DH have been described as the “Wild West”6, with misleading claims being common9, and clinical evidence quality often poor14.Digital health (DH) has proliferated in recent years15, we define digital health interventions (DHIs) as digital technologies intended to improve health outcomes and change health behaviors. Digital health interventions include products within the digital health, digital medicine, and digital therapeutic categories 17.Building on prior workstakeholder organizations refers to these organization types. Such organizations may benefit from a framework that is rigorous enough to identify clinically valuable DHIs reliably, yet rapid enough to accommodate the fast pace at which new DHIs enter the market.Following a preliminary search to identify existing frameworks for DHI evidence assessment . The Evidence DEFINED Framework builds on extant approaches, but differs in its inclusion of unique elements that are designed to increase rigor and speed. Efficiency in DHI assessment is critical given the ballooning number of DH technologies available2.Critical gaps (detailed below) were identified in extant DHI assessment frameworks, making them poorly suited for rigorous and rapid evaluation of clinical evidence. A multidisciplinary workgroup of leading experts was assembled to develop a careful and efficient strategy for DHI evidence evaluation in stakeholder organizations. The workgroup developed a novel framework to assess Evidence in 18), (3) apply the Evidence DEFINED supplementary checklist . Such methodologies have undergone extensive development, with contributions from leading experts. Although many established evidence evaluation methodologies were designed for non-digital products , the principles pertain to DHIs. Rather than “reinventing the wheel”, the Evidence DEFINED framework utilizes established evidence assessment methodologies wherever possible.The third gap in extant frameworks is that they fail to leverage established evidence evaluation methodologies that were developed for non-digital interventions  may be useful for this purpose.A prior initiative, organized by the Digital Medicine Society (DiMe), developed a checklist to assess the evidence supporting fit-for-purpose biometric monitoring technologies (BioMeTs)10. DH equity is another critical domain; considerations may include language support, literacy, health literacy, digital literacy, numeracy, cultural appropriateness, and technical accessibility. Other frameworks have been proposed to assess these important domains40.We focus here on assessing clinical evidence for DHIs. Though out of scope for this initiative, other domains should also be evaluated. For example, DHI assessment should address patient experience, provider experience, product design, cost effectiveness, interoperability, etc. Data governance is a high-priority assessment domain, as inappropriate handling of health data can lead to serious patient harmsNote that DHIs may be in scope even if they are early in development and have yet to generate pivotal trial evidence. The potential value of young, innovative DH products should not be overlooked. Partnerships that help develop promising DH interventions should be encouraged, to spur needed innovation in healthcare. However, it is often appropriate to adjust adoption levels based on the maturity of a DHI’s clinical evidence. DHIs that have compelling evidence from high-quality trials may be appropriate to consider for widespread use, while those earlier in clinical development may be more appropriate to test in a limited number of patients. To guide DHI adoption levels that may be appropriate across varying levels of clinical evidence maturity, an evidence-to-recommendation framework is incorporated in Evidence DEFINED Table . An actiThe aforementioned types of stakeholder organizations often require quick decisions to meet deadlines and move faster than competitors. Two key strategies are incorporated to achieve efficiency. First, the Framework uses screening items to determine whether a DHI meets absolute requirements. Assessment ends if the DHI fails to meet any absolute requirement. For example, time is not invested in evaluating evidence for a DH product that is not an adoption candidate due to non-compliance with privacy and security requirements. Second, as detailed below, a streamlined approach is used, avoiding information gathering that may have limited value.Evidence DEFINED uses the following steps to facilitate rapid and rigorous evaluation of DHI evidence. We assume here that the DHIs under consideration have been identified. See Fig. 19), the appropriate clearance or approval has been obtained. The screening step is similar to procedures recommended in the American Psychiatric Association’s App Evaluation Model4.To avoid investing effort in DHIs that are not candidates for adoption, screen relevant DHIs for failure to meet absolute requirements. The screening step is applied flexibly; each stakeholder organization specifies their own requirements, per the organization’s needs. Screening requirements might include (a) a privacy policy that confirms compliance with HIPAA, (b) patient-facing language written at a targeted reading level , and (c) if subject to FDA regulation (detailed elsewhere41). Many stakeholder organizations already use such frameworks routinely.Apply an established evidence assessment framework that was developed for non-digital interventions  and may prioritize “checking the box” over developing a feature that has genuine value. There is often a wide gap between the minimum level of effort required to claim defensibly that a product has a given feature, and the effort required to develop the feature to a degree that contributes meaningfully to improved clinical outcomes. It is common for DHSPs to develop “minimum viable product” (MVP) versions of a featureIf stakeholder organizations have a strong preference for specific features, then a small number of features can be assessed. We recommend, however, keeping feature checklists short. Assessments organized around feature lists may incent DH solutions providers to offer numerous, low-quality features, encouraging an unfavorable ratio of breadth to depth. Given these limitations, Evidence DEFINED focuses on evidence of safety and effectiveness—critical considerations to assess clinical value.Note also that information sometimes gathered for DHSP assessment may have limited impact on decisions. Such information includes which venture capital firms fund the DHSP, the software development methods employed, corporate reporting structure, etc. Stakeholders should consider carefully how each piece of information will be used, and should consider foregoing information gathering that is unlikely to impact decisions.37, DiMe will establish a public website and collaborate with interested partners to update and disseminate the Evidence DEFINED Framework. The website will provide a suggestion form to gather input from the digital health community. Latest versions will be posted for the following Evidence DEFINED resources: the supplementary checklist of evidence quality criteria  is an appropriate body to coordinate the updating process for the Evidence DEFINED Framework. Following othersGiven rapid evolution in digital health, Evidence DEFINED updates will be implemented every 6–12 months. Suggested modifications will be evaluated by article authors and other subject matter experts from the Society. Following a comment period, updated versions of the aforementioned key resources will be posted. See Supplementary Discussion for details.45. The senior author (J.S.) facilitated the workgroup process and drafted initial materials, which were supplemented substantially and iterated upon by the multidisciplinary workgroup.Development of this Framework was organized by the Research Committee of the Digital Medicine Society, a nonprofit dedicated to advancing “safe, effective, equitable, and ethical use of digital medicine”Seventeen experts with diverse backgrounds were assembled, representing academic medical centers, health plans, pharmaceutical companies, DH solutions providers, professional societies, patient advocacy organizations, and contract research organizations. Expertise within the workgroup spans clinical care, scientific research, biostatistics, health plan administration, regulatory affairs, and corporate strategy. Group members hold senior leadership positions in their organizations. A patient perspective representative (C.G.) was also included.The workgroup agreed early in the process to develop a supplement–not a replacement–for established evidence assessment frameworks. Iterative feedback from workgroup members was solicited via asynchronous communications, four live workshops, and one-on-one discussions among workgroup members. The Evidence DEFINED Framework was refined based on edits and comments received during and following each live session. All group members provided feedback during at least one of the review cycles, and approved the final version.Herein we have proposed the Evidence DEFINED Framework—a rigorous, rapid approach to assess the effectiveness and safety of digital health interventions. Evidence DEFINED may be appropriate for use by stakeholder organizations including payers, PBMs, health systems, pharmaceutical companies, trade organizations, and professional medical societies. The primary goal of the Evidence DEFINED Framework is to support high-quality, evidence-based decisions around adoption of digital health interventions, and thereby encourage use of safe and effective DHIs. Evidence DEFINED improves rigor by rectifying key gaps in prior approaches. The Framework achieves efficiency through screening steps and avoidance of information gathering that may have limited impact on decisions.When assessing clinical evidence in digital health, details matter. Careful evidence assessment can mean the difference between identifying critical evidence flaws and failing to do so. This can, in turn, impact countless patients, by dictating whether patients get access to digital health interventions that are effective and safe. For some patients, rigorous DHI evidence assessment may mean the difference between medication adherence and nonadherence; between overcoming nicotine dependence and developing lung cancer; between resolution of affective symptoms and chronic emotional struggles. Because DHIs are scalable, relevant impacts may be magnified.Best practices should be developed for coordinated, interdisciplinary DHI assessment, integrating well-developed methodologies across domains. Key assessment domains may include patient experience, provider experience, product design, cost effectiveness, data governance, interoperability, and health equity, as well as clinical evidence. Templates should be developed to summarize findings of Evidence DEFINED assessments and broader evaluations. The interrater reliability of Evidence DEFINED should be quantified in future research, and adjustments should be implemented if necessary. The Evidence DEFINED Checklist , as well as any changes in safety or effectiveness, throughout the product lifecycle. Ultimately, DHI assessment will need to comply with an emerging regulatory framework, as well as quality assurance processes, to ensure consistency, appropriate evidence standards, and quality of the DHIs used by patients.46. We should encourage DH solutions providers to follow high standards—and hold DHSPs accountable to deliver the clinical value they promise. Evidence DEFINED may help guide DHSPs that wish to develop compelling evidence and drive adoption of digital health products.To realize the potential of digital health, we need stronger, standardized frameworks for DHI evidence assessmentEvidence DEFINED may also allow stakeholder organizations to assess DHI evidence in a more rapid, rigorous, and standardized manner. We hope this will promote evidence-based decision making, encourage adoption of effective DHIs, and thereby improve health outcomes across a range of conditions and populations.47 were used to identify prior evidence assessment frameworks for digital health interventions (DHIs). A scoping approach was consistent with our goal to generate a preliminary assessment of relevant literature and its gaps48. Evidence assessment frameworks were identified from (a) 4 prior reviews49, (b) updating of MEDLINE searches performed for these reviews  and (c) a grey literature search performed per best practices detailed elsewhere50 , (b) addressing evidence quality criteria that are specific to digital health interventions, (c) specifying evidence quality criteria that may require increased vigilance in digital health (given the current regulatory context), and (d) providing evidence-to-recommendation guidelines that state what levels of DHI adoption may be appropriate for varying degrees of evidence quality.A literature search was performed with the objectives to (a) generate a preliminary list of relevant frameworks proposed previously, (b) provide a preliminary assessment regarding key characteristics of prior frameworks, and (c) assess the degree to which prior frameworks meet criteria that the Workgroup believed may facilitate rigorous and rapid assessment of digital health interventions. The criteria were (a) leveraging established evidence assessment methods that had been developed initially for non-digital interventions  were published in peer-reviewed or grey literature during or before October, 2022; (b) were described in one or more English documents; (c) recommended at least one criterion or question to assess evidentiary support for the safety, efficacy, or effectiveness of digital health interventions; (d) addressed clinical evidence either exclusively or in addition to other assessment domains ; and (e) were intended for application to either DHIs broadly or to a subgroup of DHIs . Frameworks were excluded that (a) addressed quality of health information but not evidence of safety/efficacy/effectiveness or b) were proprietary frameworks with minimal description of methods available publicly.49. MEDLINE updates of prior searches were performed, to be current through October, 2022. Search strategies used for updating were the same as those described in the prior reviews49. Sources used for grey literature are detailed elsewhere50. These include Google Scholar as well as the websites of health technology assessment organizations, government agencies, and trade associations.Search strategies and information sources utilized in prior reviews are described elsewhereFurther information on research design is available in the Supplementary MaterialReporting Summary


Environmental oestrogens (EEs) as environmental pollutants have been paid much attention due to their impact on congenital malformation of male genitourinary system. Exposure to EEs for prolonged time could hinder testicular descent and cause testicular dysgenesis syndrome. Therefore, it is urgent to understand the mechanisms by which EEs exposure disrupt testicular descent. In this review, we summarize recent advances in our understanding of the process of testicular descent, which is regulated by intricate cellular and molecular networks. Increasing numbers of the components of these networks such as CSL and INSL3 are being identified, highlighting that testicular descent is a highly orchestrated process that is essential to human reproduction and survival. The exposure to EEs would lead to the imbalanced regulation of the networks and cause testicular dysgenesis syndrome such as cryptorchidism, hypospadias, hypogonadism, poor semen quality and testicular cancer. Fortunately, the identification of the components of these networks provides us the opportunity to prevent and treat EEs induced male reproductive dysfunction. The pathways that play an important role in the regulation of testicular descent are promising targets for the treatment of testicular dysgenesis syndrome. First, 3Skakkebaek et al. proposed that undescended testis, hypospadias, poor semen quality and testicular cancer are the manifestations of testicular dysgenesis syndrome, named by others as ‘the developmentally estrogenized male phenotype’.4In the second half of the 20th century, with the development of industrialisation, people began to realize the impact of EEs on male reproductive system. Initial studies showed that the male infertility rate in developed countries increased by 0.5%–1% every year, the proportion of cryptorchidism and hypospadias increased, and the quantity and quality of semen in industrialized countries declined.5Testicular cancer is the most common malignancy among men between 14 and 44 years old, and its incidence has risen over the past two decades in Western countries.6EEs do not cause instantaneous toxicity because of low concentration in the body. However, EEs can go through the blood‐placenta barrier to affect foetal development on maternal pregnancy.7As shown in Figure EEs inhibit testicular INSL3 expression and change the contractibility of gubernaculum. Many animal experiments have proved that pregnant rats were distracted by environment endocrine interference contamination such as phthalic acid esters (DEHP) or diethylstilbestrol (DES) and INSL3 expression decreased significantly.8Even small doses of EEs can significantly affect the gubernaculum, including morphological abnormalities, gubernaculum cell proliferation and small myofibrils in the muscle cells.9In androgen insensitivity syndrome patients and in animals with anti‐androgen treatment, testicular descent failed in inguinoscrotal stage.10Testosterone (T) is the most common androgen. The expression of P450 17α hydroxylase in testicular Leydig cell of male foetal rats decreased after the female rats were treated by EEs during pregnancy.11Leydig cells are an important source of androgen processing. Animal experiments indicated that dibutyl phthalate (DBP) disrupted rat testicular Leydig cell function and decreased the levels of T and INSL3, leading to increased incidence of cryptorchidism and hypospadias.12Sertoli cells secrete ABP with the help of FSH. Flutamide, an AR antagonist, could reduce the quantity of Sertoli cells via interference with the androgen in neonatal rats.13Exposure to EEs for prolonged time could hinder testicular descent and cause testicular dysgenesis syndrome. For male individuals, the incidence of reproductive diseases related to UDT keeps an increase trend in recent decades. Therefore, it is urgent to understand the mechanisms by which EEs exposure disrupt testicular descent. In this review, we summarize recent advances in our understanding of the process of testicular descent, which is regulated by intricate cellular and molecular networks. Increasing numbers of the components of these networks such as CSL and INSL3 are being identified, highlighting that testicular descent is a highly orchestrated process that is essential to human reproduction and survival. The exposure to EEs would lead to the imbalanced regulation of the networks and cause testicular dysgenesis syndrome such as cryptorchidism, hypospadias, hypogonadism, poor semen quality and testicular cancer Figure .Fortunately, the identification of the components of these networks provides us the opportunity to prevent and treat EEs induced male reproductive dysfunction. For example, our recent studies have identified the proteome involved in diethylstilbestrol induced dysfunction of testicular gubernaculum, among which calcium signalling pathways are crucial to the regulation of testicular gubernaculum development.Danli Li: Data curation ; writing – original draft . Hongyan Ping: Data curation ; writing – original draft . Ke Li: Data curation ; writing – original draft . Junjie Lin: Data curation ; writing – original draft . Xuewu Jiang: Data curation ; writing – original draft . Xuan Zhang: Conceptualization ; funding acquisition ; writing – review and editing .This study was supported by the Science and Technology Innovation Commission of Shenzhen (JCYJ20190809145809375), Guangdong Basic and Applied Basic Research Foundation (2021A1515010009), Project of Educational Commission of Guangdong Province of China (2020KQNCX011) and Pingshan Health System Research Foundation of Shenzhen (202270).The authors declare no conflict of interest.


Juvenile myelomonocytic leukemia (JMML) is a deadly pediatric leukemia with limited treatment options and poor clinical outcomes. Effective targeted treatment strategies are an urgent unmet need. To improve outcomes for this pediatric patient population, we examined the structure of the DNA comprising the genomes of leukemic cells from five JMML patients and compared these to DNA structures from healthy controls. These data allowed us to identify structural features that were unique to the JMML patient DNA. Identification of these JMML-specific changes could guide development of targeted drugs to effectively treat this devastating malignancy. Our work provides a rich resource for additional investigations aimed at identifying and testing strategies designed to treat JMML.RAS pathway mutations, of which >35% are gain-of-function in PTPN11. Although DNA hypermethylation portends severe clinical phenotypes, the landscape of histone modifications and chromatin profiles in JMML patient cells have not been explored. Using global mass cytometry, Epigenetic Time of Flight (EpiTOF), we analyzed hematopoietic stem and progenitor cells (HSPCs) from five JMML patients with PTPN11 mutations. These data revealed statistically significant changes in histone methylation, phosphorylation, and acetylation marks that were unique to JMML HSPCs when compared with healthy controls. Consistent with these data, assay for transposase-accessible chromatin with sequencing (ATAC-seq) analysis revealed significant alterations in chromatin profiles at loci encoding post-translational modification enzymes, strongly suggesting their mis-regulated expression. Collectively, this study reveals histone modification pathways as an additional epigenetic abnormality in JMML patient HSPCs, thereby uncovering a new family of potential druggable targets for the treatment of JMML.Juvenile myelomonocytic leukemia (JMML) is a deadly pediatric leukemia driven by  RAS pathway genes and DNA hypermethylation are major drivers of severe JMML phenotypes [Juvenile myelomonocytic leukemia (JMML) is a deadly pediatric hematologic malignancy characterized by excessive proliferation of monocytes/macrophages, elevated fetal hemoglobin, splenomegaly, and hypersensitivity of leukemia cells to granulocyte–macrophage colony-stimulating factor (GM-CSF) ,2,3,4,5.enotypes ,11,12,13enotypes ,15,16.Epigenetic changes play an important role in numerous malignant transformations, altering gene expression to promote tumor growth ,18,19. IPTPN11; encodes RAS/MAPK signaling pathway protein, SHP-2), which are found in ~38% of all JMML patients and correlate with aggressive disease and hypermethylated DNA [PTPN11 mutations [PTPN11-mutated JMML HSPCs. Finally, as a hallmark of JMML is splenomegaly, we characterize HSPCs isolated from JMML patient spleens.Here, we explore the hypothesis that JMML HSPCs carry significant alterations in HPTMs. We have focused this pilot study on JMML patients with gain-of-function mutations in Protein Tyrosine Phosphatase Non-Receptor Type 11  [We provide the first global comparison of HPTMs and chromatin accessibility in (EpiTOF) , our datIn parallel studies, we used the assay for transposase-accessible chromatin with sequencing (ATAC-seq) to examine the genomic impact of the JMML histone landscape. These data revealed altered chromatin profiles at loci encoding post-translational modification enzymes in JMML HSPCs, strongly suggesting their mis-regulated expression and supporting the reduction in HPTMs identified by EpiTOF. This first such analysis of JMML HSPCs reveals histone modification pathways as an additional epigenetic abnormality in JMML patient HSPCs, thereby identifying a new family of potential druggable targets for the treatment of JMML.n = 5) were purified from splenectomy preparations and cryopreserved at the biorepository of the EWOG-MDS, located at Freiburg University Medical Center, Germany. Healthy controls were umbilical cord blood (UCB) from Binns program at Stanford School of Medicine. All human samples were collected from donors with informed consent and compliance with relevant ethical regulations. DNA methylation categories were determined as described previously [Mononuclear cell samples from JMML patients (eviously .Cryopreserved JMML samples were thawed in pre-warmed RPM1 1640 media (Gibco) supplemented with 20% heat-inactivated FBS , 1% each of L-glutamine and Penicillin/streptomycin . Two sequential DNase1 treatments during thawing allowed optimal recovery of live mononuclear cells (MNCs). MNCs were filtered through 70 µm and CD34+ cells isolated using the CD34 ultrapure microbead kit .EpiTOF was as previously described ,38. BrieEpiTOF raw data (fcs file) were preprocessed on FlowJo software . Dead cells were removed, and de-barcoding of the palladium-based mass tags performed to select CD34+ cells and export individual sample fcs files.We applied a two-step process to normalize EpiTOF data. First, we transformed each measured abundance  in the raw EpiTOF data to reduce the dynamic range and influence of outliers present in the data:H3 and H4 as independent variables and using all cells from a single sample for the regression:We then applied a linear regression for each HPTM using H3 and H4 in cell i and j in cell i. We used the residual of the regression, j in cell i. This was completed to regress out the effect of H3 and H4 on the HPTM abundance.Here, We computed UMAP projections  on a subustering  was thenp-value computed from Wilcoxon rank-sum test to calculate the significance of the difference in proportions.We then evaluated the cluster-wise median HPTM abundances and sample-wise cell proportions using these 40,000 cells. We compared the sample-wise cell proportions between the healthy subjects (HCB) and patients with JMML (JSP) and used the FDR-adjusted p-value computed from Wilcoxon rank-sum test to calculate the significance of the difference in abundance. The computational methods and code used for EpiTOF data analysis are as previously described [To identify cluster-defining, we compared the single-cell resolution abundance of the HPTM in that cluster to the rest of the clusters. We used effect size, computed using Cohen’s D, and FDR-adjusted escribed .t-test  using GraphPad Prism v9 software .Student’s n = 5) and JMML patient spleen samples (n = 4) were washed 3x with 1XPBS (without Ca2+ and Mg2+). Transposition used the Nextera® DNA Sample Preparation Kit ; transposed DNA was purified using MinElute PCR Purification Kit (Qiagen). Preparation/amplification of ATAC libraries is in Corces et al., 2017. Libraries were quantified by qPCR against KAPA Library Quantification kit  and analyzed using Bioanalyzer High-Sensitivity DNA Analysis kit (Agilent); pmol/µL values between 150 bp and 1000 bp were noted for preparing equimolar sample pool for deep sequencing. Deep sequencing was on NextSeq500  with 50 million reads/sample of sequencing depth.Chromatin accessibility profiling used Omni ATAC sequencing . CD34+ c® Flow® software, v10.0 (Computer software) [® Flow® software, v10.0 [® GSA algorithm to account for varying response of each gene to differing data distributions by applying multiple statistical models. Data were filtered with FDR < 0.05, minimum fold change of +2-folds; and the high or low peak enrichments per gene locus represented as volcano plots, quantified in bar plots and genome tracks shown per sample group .The de-barcoded individual raw data files were extracted from NextSeq500 as fasta.gz files. Data were analyzed on Partekoftware) . Data proftware) . The mite, v10.0 . Reads wPTPN11-mutated JMML spleen-derived HSPCs .DNA hypermethylation is a prognostic feature of JMML, and the DNA demethylating agent azacytidine has shown promise NCT02447666) , but the666 , buted HSPCs A. We hyp samples . We focuJMML patients present with splenomegaly, for which they often undergo splenectomy; thus, the spleen provides a rich source of leukemia cells, as evident from the high number of CD34+ cells we recovered from most JMML patients  B. The leTo compare the distributions of the histone methylation marks in isolated CD34+ cells from JMML vs. HD UCBs, we first performed dimensionality reduction analyses using uniform manifold approximation and projection  and theClusters 3 and 4 had significantly higher proportions of JMML-derived HSPCs than HD UCBs, whereas clusters 5, 7, and 11 had significantly lower proportions of JMML HSPCs D. The reWe focused our attention on methylation marks that were significantly different in clusters enriched for JMML HSPCs (clusters 3 and 4) or clusters significantly enriched for HD UCB HSPCs , reasoning that these would reveal disease-specific features.Several methylation marks were uniquely lower in clusters 3 and 4, which were enriched for JMML HSPCs . The UMAIn contrast, clusters 5 and 7, which were significantly enriched for HD UCB HSPCs, showed a specific and significant reduction in median abundance of the histone methylation mark H4K20me2 . CuriousTo identify whether the histone hypomethylation patterns that we observed in the overall JSPs vs. HD UCBs might be driven by specific HSPC subsets, we performed dimensionality reduction analysis on isolated HSPC subsets see  from eacn = 4; pts #6, #12, #15, and #16) and HD UCB (n = 6) samples [Our data show that specific methylation marks are reduced in JMML HSPCs, suggesting alterations in the chromatin structure. Thus, we next analyzed chromatin accessibility profiles using bulk ATAC-seq on CD34+ cells from JMML  and demethylases (DNMT). ML HSPCs H,I. PRDMML HSPCs E. We conn = 5) to control HD UCB HSPCs (n = 5) by again performing dimensionality reduction with UMAPs followed by clustering with PhenoGraph  Kat6b , andWe also identified other loci for which the ATAC-seq data showed enriched peaks specifically in JMML HSPCs. Genes at these loci included mitogen-activated protein-kinase-associated protein 1 (MAPK-AP1), a component of the mTOR2 pathway , potassiPTPN11-mutated JMML spleen-derived HSPCs. To the best of our knowledge, these data represent the first such analyses.The largest hurdle in treating JMML patients is the lack of druggable targets . As revePTPN11-mutated JMML HSPCs exhibited significantly reduced histone methylation marks that are unique to JMML HSPC at H3K27me1-3, H3K9me1-2, H3K4me2, Rme2asy, Rme2sym, H4K20me1, and H3K36me3. Indeed, JMML-enriched UMAP clusters 3 and 4 had overall significantly reduced histone methylation marks when compared to all the other clusters, suggesting a consistent histone hypomethylation signature in JMML samples. We also found significant, although heterogeneous, changes at H2BS14ph, whereby one JMML-enriched cluster contained cells that were significantly increased for phosphorylation marks at this site, while another JMML-enriched cluster was significantly reduced. Additional JMML-HSPC-specific changes were observed at H3K27ac, which was significantly increased in a cluster enriched for JMML cells. We similarly identified HD-UCB-HSPC-specific HPTMs and observed (i) a significant reduction in the median abundance of the histone methylation mark H4K20me2 in two out of the three clusters (the third HD-UCB-enriched cluster showed an increase at this site), and (ii) significantly reduced levels of PAD14 and a significantly higher proportion of H3K14ac. Taken together, these data demonstrate significant differences in HPTMs between the two sample groups.We found that the spleen-derived Kat6b and Kat8 and methyltransferase PRDM8 but increased peak enrichments at histone deacetylases HDAC9 and HDAC5. Kat6b and Kat8 are specific for H4K16ac and H3K23ac, respectively. The concurrent loss of Kat8 and H4K16ac has been shown in aberrant gene expression in AML [Kat6b plays a tumor suppressor role in non-small-cell lung cancer wherein its loss leads to cancer growth [PRDM8 is also a strong tumor suppressor that is downregulated in hepatocellular carcinoma [PRDM8 in iPSCs led to impaired hematopoietic differentiation and myeloid-biased malignant transformation [Loss of HPTM marks such as those observed in our analysis of JMML HSPCs are signature events in numerous malignancies, including H3K23ac in solid tumor models such as breast cancer, KRAS-mutated colorectal cancer, and non-small-cell lung cancer ,57; H3S1n in AML ,64, suggr growth . PRDM8 iarcinoma ; thus, lormation .Increases in HDAC activity, as our ATAC-seq data suggest for HDAC5 and HDAC9 in JMML spleen HSPCs, have been identified in a variety of tumor types. Several class I HDAC inhibitors are approved for cancer treatment . However, these drugs do not inhibit class II HDACs, such as HDAC5 and HDAC9 . InsteadMAPKAP1 displayed peak enrichments. MAPKAP1/Sin1 is linked to RAS and mTOR2 pathways and is known to drive Akt phosphorylation [RAS pathway mutations, including elevation of pAKT, drive JMML, and preclinical evidence suggests a therapeutic role for mTOR inhibition in JMML [RAS and mTOR2 pathways in JMML via MAPKAP1, making this pathway a putative therapeutic target. We also found highly enriched peaks at the potassium channel gene KCNK9 in all JMML samples. Others have shown that overexpression of this gene promotes malignancy in several cancers [CD83 is a marker of AML LICs, and therapeutic targeting using CD83-CAR T cells has shown preliminary success in humanized mouse models of AML [CD200, had significantly higher read counts in JMML HSPCs when compared to UCBs. CD200 is upregulated in the most resistant pediatric AMLs and confers immunosuppressive properties when co-cultured with engineered T regulatory 1 cells [We also observed reduced peaks at numerous other loci. Indeed, overall, we observed largely closed, heterochromatic regions in JMML HSPCs, suggesting significant repression of gene expression. However, specific loci such as rylation ,72. RAS  in JMML . Thus, o cancers . In addis of AML , suggest 1 cells ,76. PTPN11 gain-of-function mutations and implicate the activity of PTM-modifying enzymes as responsible for the observed changes. We are currently exploring these changes, including confirming transcriptional profiles using RNAseq and isolating specific HSPC cell subsets to identify specific cell lineages in which these changes occur.Collectively, our data identify aberrant histone PTMs in splenic JMML HSPCs from patients carrying PTPN11-mutated JMML HSPCs and revealed differential accessibilities at the loci of the respective HPTM-modifying enzymes. Additionally, using ATAC-seq, we have shown significant heterochromatin (closed) at key genomic regions that encode for known tumor suppressors, HATs, and HMTs, suggesting their loss of expression. The newly identified signatures of aberrant histone PTMs, such as the targeted histone hypoacetylation and hypomethylation, may be used in the future as prognostic or predictive epigenetic markers in patients with JMML caused by PTPN11 mutation. Most importantly, we have identified surface markers such as CD96, CD83, and CD200 as potential targets for cell therapy.In conclusion, we have identified aberrant histone PTMs in splenic NF1, KRAS, NRAS, or CBL genes. Together with PTPN11, ~90% of patients harbor mutation in one of these five genes. Comparison of PTM profiles across these subtypes will likely reveal pan-leukemic as well as specific changes that drive JMML subtype dysregulation. Furthermore, we are currently validating the HPTM changes in the PTPN11-mutated JMML patient samples from this study, including identifying the transcriptional profiles using single-cell RNAseq to clarify if these changes occur in specific cell lineage(s). As our studies progress to other JMML subtypes, we will incorporate comparable analyses to develop an in-depth understanding of the landscape of histone modifications and chromatin profiles across JMML patients. Overall, our studies will inform common and distinct underlying features that highlight the rich biology governed by PTMs in JMML, thus revealing potential new therapeutic avenues.The data obtained in this pilot analysis will guide future work analyzing histone PTM profiles found in HSPCs from other JMML subtypes, i.e., those carrying causative mutations in the


Anterior cruciate ligament injury is a common knee joint injury. Anterior cruciate ligament reconstruction is a common surgical treatment to treat anterior cruciate ligament injury. It may have certain advantages to retain the ligament stump during the operation, but the results of systematic evaluation on whether to retain the ligament stump are different. The conclusion is still controversial, and the quality needs to be strictly evaluated.To evaluate the methodological quality, risk of bias, reporting quality and evidence quality of the systematic review of remnant preservation in anterior cruciate ligament reconstruction, and to provide reference for clinical work.We systematically searched the system evaluations in 8 electronic databases, the languages were limited to Chinese and English, and the time limit was from the establishment of the database to June 2023. Two reviewers independently screened literature and extracted data. The methodological quality, risk of bias, reporting quality and quality of evidence were evaluated by AMSTAR-2, ROBIS, PRISMA and GRADE tools.A total of 14 systematic reviews were included. The evaluation of results showed that the methodological quality of the included systematic reviews was relatively low, of which 5 were low quality and 9 were critically low quality. A small number of systematic reviews were low risk of bias. The system evaluation reports are relatively complete, but the lack of program registration is a common problem. A total of 111 pieces of clinical evidence were extracted from the included 14 systematic reviews. The quality of evidence was generally low, with only 7 pieces of high-quality evidence, 45 pieces of medium-quality evidence, and the rest were low and very low-quality evidence. Among the reasons for relegation, imprecision is the most common, followed by inconsistency and indirectness. The existing evidence shows that patients after anterior cruciate ligament reconstruction with remnant preservation have certain advantages in knee joint function, joint stability and proprioception recovery, which may be a more effective surgical method. However, it may also increase the incidence of postoperative complications and adverse reactions.Compared with Standard Technique, Remnant Preservation in Anterior Cruciate Ligament Reconstruction has more advantages in restoring joint function and stability and proprioception. But the potential risks should also be considered by surgeons. At present, the quality of evidence is generally low, and the reliability of the conclusion is insufficient. It still needs to be verified and further in-depth research is needed. The anterior cruciate ligament (ACL) is an important ligament structure in the knee joint, which plays an important role in maintaining the stability of the knee joint, especially in the forward and anteromedial rotation of the knee joint –3. ACL iSystematic review and Meta-analysis (SR) are currently considered to be the highest grade of clinical evidence and play a guiding role in clinical practice. At present, there are several SRs to analyze the advantages of retaining ACL stump compared with standard surgery –26. HoweAt present, there is still a lack of systematic evaluation overview of whether anterior cruciate ligament reconstruction with remnant preservation is superior to standard surgery. Therefore, we summarize the existing SRs on ACLR with remnant preservation, comprehensively summarize and review the methodological quality, bias risk, outcome indicators and evidence grade of existing SRs, in order to provide reference for clinicians, guideline makers and patients, and guide future high-quality SRs.http://www.crd.york.ac.uk/prospero), registration number: CRD42023433774.The protocol of this overview was registered on the International Prospective Register of Systematic Reviews (PROSPERO) , China National Knowledge Infrastructure (CNKI), WanFang database, VIP database and Chinese Biology Medicine (CBM) database by computer. The search time range was from the establishment of the database to June 2023, and the search language was limited to Chinese and English. We also searched the research registry and grey literature, such as academic papers and conference reports. We used population (P), intervention (I), comparison (C) and study design (S) strategies for overview. Narrative reviews, SR summaries and comments are excluded. The specific retrieval strategies are as follows:The detailed search strategy of PubMed is shown in Fig. Two independent reviewers imported all retrieved studies into Endnote (X9), filtered duplicate studies, and filtered titles and abstracts. After cross-checking, the full text of the qualified study was further independently evaluated by two evaluators. If there were differences, the third reviewer participated.Two reviewers independently extracted data, including: study characteristics , subject characteristics (sample size), methodological characteristics  and results , and contacted study authors to obtain missing data. If there is a disagreement, the third examiner is involved.A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) is an important assessment tool for systematic reviews, which can perform rapid and repeatable quality assessment of systematic reviews of randomized controlled trials, including defects that may be caused by improper review, and the items in AMSTAR 2 that deal with risk of bias identify domains specified in the Cochrane risk of bias instruments for randomized studies , 29. TwoThe risk of bias for inclusion in SR was independently assessed by two reviewers using the Risk of Bias in Systematic reviews (ROBIS). The tool is divided into three stages to help determine the risk of bias in the review process, results and conclusions .The quality of the reports included in the SR was independently assessed by two reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). PRISMA contains items critical to the transparent and complete reporting of SRs and is considered to be an evolution of the original Quality of Reporting of Meta-Analyses (QUOROM) guidelines. The PRISMA statement list covers 27 items in seven parts of SR: title, abstract, introduction, method, result, discussion and funding. Each item is described as ‘yes ', ‘partial yes’ and ‘no’, representing complete report, partial or incomplete report and missing report, respectively , 33.www.gradeworkinggroup.org), a widely used evidence quality rating tool. The quality of evidence was divided into ‘high’, ‘medium’, ‘low’ or ‘very low’. Evidence quality grading may be compromised due to five main aspects: the limitations of the study; inconsistency of the results, indirectness of the evidence, inaccuracy, and reporting bias [The quality of evidence was independently assessed by two qualified reviewers using the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) system (ing bias .http://www.guidelinedevelopment.org/).A narrative synthesis was used in this overview. The characteristics and results of each SR as well as the results of AMSTAR 2, ROBIS and the PRISMA were summarized by tabulation and figures. The GRADE evidence profile and summary of findings table were generated by using the GRADE pro GDT online software  were at low risk in Phase I(assessment of relevance) and in Domain 1 (study eligibility criteria). For domain 2 (identification and selection of assessment studies), all SRs (100 %) were rated as high risk. 13 SRs (92.9 %) were rated as low risk in Domain 3 . , 39–45. Overall, the systematic reviews are comprehensive, but some reports have flaws. We found that some SRs did not report or did not fully report research programs and registrations 12/14, 85.7%), complete search strategy , sources of funding for included studies , risk of publication bias 5/14, 35.7%), additional analysis  and funds . Only 2 SRs reported the design and registration of research programs in advance , 39. At .7%, addi, 85.7%, A total of 20 outcome indicators were extracted from the included 14 SRs. We divided the outcome indicators into 6 categories: Clinical score, Joint function and stability, Postoperative proprioceptive sense, Graft status, Postoperative complications and adverse reactions, and operation time.Clinical score: Postoperative Lysholm score, postoperative Tegner score, postoperative IKDC score, postoperative IKDC grade. Joint function and stability: postoperative KT1000 / 2000 joint measurement results, postoperative arthrometry side-to-side difference, postoperative Pivot shift test results, postoperative Lachman test results, postoperative knee flexion and extension activity (ROM). Postoperative proprioceptive sense: postoperative Proprioceptive sense difference, postoperative passive activity perception threshold (TTDPM), postoperative joint position sensation, postoperative passive angle regeneration test results, postoperative graft synovial coverage, postoperative tibial tunnel enlargement. Postoperative complications and adverse reactions: postoperative Cyclops lesions, postoperative complications, postoperative reinjury rate.The evidence grade of all Clinical scores is shown in Table A total of 14 SRs were included in the meta-analysis of postoperative Lysholm score. A total of 19 pieces of clinical evidence were formed, including 3 pieces in the high grade of evidence, 8 pieces in the low grade of evidence, and 8 pieces in the very low grade of evidence. The reasons for the degradation of the evidence grade are mainly due to the indirectness (100 %) of the outcome evaluation of the Lysholm score as the outcome index, the large heterogeneity (43.8 %) when merging the data, and the inaccuracy (50 %) caused by the failure to reach the minimum sample size or the excessive confidence interval.Meta-analysis of postoperative Tegner score was performed in 4 SRs , 39, 45.There were 10 SRs for meta-analysis of postoperative IKDC scores , 44, 45,6 SRs performed a meta-analysis of postoperative IKDC grade , 35–38. The evidence grade of postoperative knee joint stability and function are summarized in Table A total of 12 SRs conducted a meta-analysis of the postoperative KT1000 / 2000 arthrometer measurement results , 39–45, Meta-analysis of postoperative arthrometry side-to-side difference was performed in 2 SRs , 38, res8 SRs performed a meta-analysis of the postoperative Pivot shift test results , 41, 44,Meta-analysis of postoperative Lachman test results was performed in 9 SRs , 44, 45.Meta-analysis of postoperative knee flexion and extension activity (ROM) was performed in 3 SRs , 36, 41.An overview of the evidence grade for postoperative proprioceptive sense is shown in Table 3 SRs conducted a meta-analysis of postoperative Proprioceptive sense , 40, 43.2 SRs conducted a meta-analysis of postoperative passive motion perception threshold (TTDPM) to form two pieces of clinical evidence , 45, bot1 SR performed a meta-analysis of postoperative joint position sensation , and a t1 SR conducted a meta-analysis of the results of postoperative passive angle regeneration test , and a tThe evidence grade of postoperative Graft status is shown in Table 3 SRs performed a meta-analysis of postoperative graft synovial coverage , 43, 45.Meta-analysis of postoperative tibial tunnel enlargement was performed in 7 SRs , 43, 45.1 SR performed a meta-analysis of graft status . A totalThe evidence grade of postoperative complications and adverse reactions are shown in Table Meta-analysis of the incidence of postoperative Cyclops lesions was performed in 5 SRs , 40, 43,3 SRs performed a meta-analysis of postoperative complications , 37, 38,1 SR conducted a meta-analysis of postoperative re-injury rate . A totalThe evidence grade of postoperative complications and adverse reactions is shown in Table 2 SRs conducted a meta-analysis of postoperative re-injury rate , 40. A tWith the development of evidence-based medicine, many SRs have made a positive evaluation of the clinical effect of anterior cruciate ligament reconstruction with remnant preservation. However, the quality of SR seriously affects the reliability of its evidence, so the review of existing SR is of great significance for us to draw on its clinical evidence. At present, AMSTAR-2, ROBIS, PRISMA and GRADE are widely used in the review of SR to comprehensively review the methodological quality, bias risk, reporting quality and evidence quality of SR, respectively. The rigor of the review are widely recognized. By systematically summarizing and reviewing the existing SRs, we can effectively summarize the existing clinical evidence and provide targeted guidance for higher-quality SRs in the future. At the same time, the existing clinical evidence is summarized to improve the credibility of clinical evidence, and to better provide reference for the clinical practice of surgeons, so as to formulate a more scientific, rigorous and effective surgical treatment plan.Our study systematically reviewed the existing 14 SRs on the clinical effect of anterior cruciate ligament reconstruction with remnant preservation. We found that according to the clinical evidence provided by the existing SR, there are certain advantages in retaining the stump in the anterior cruciate ligament reconstruction. Retaining the stump can effectively enhance the stability of the knee joint and promote the recovery of the proprioception of the knee joint. But it also has the disadvantages of high incidence of postoperative complications and adverse events and long operation time. However, the quality of the existing SR is generally low, the grade of evidence is not high, and there are still many problems. It is challenging to find clinical evidence that is truly convincing. Therefore, we cannot make an accurate judgment on the clinical effect of anterior cruciate ligament reconstruction with remnant preservation.AMSTAR-2 is an internationally recognized and most widely used SR methodological quality evaluation tool. Its developers recommend focusing on whether there are methodological defects in key items and evaluating the overall quality of SR accordingly . After eROBIS is currently the most advanced SR bias risk assessment tool. It can not only assess the risk of bias in the process of SR production and result interpretation, but also evaluate the correlation between SR and the practical problems to be solved by its users . After eThe PRISMA checklist provides a reference for standardized writing and reporting of systematic reviews and meta-analyses , 33. StaGRADE evidence classification is a common and popular method for evaluating the quality of evidence, which divides the quality of evidence group into four categories: high, medium, low and very low . After eBased on the above review results, we recommend that in the future, we should strictly design large-sample, multi-center randomized controlled trials in strict accordance with the requirements of the CONSORT statement. We suggest that we should improve the scientific nature of the research design, strengthen the understanding of the sample size, carry out large sample and multi-center clinical research, pay attention to the use of blind method and the use of objective outcome indicators in the research process, and ensure the representativeness of the participants. In addition, strict inclusion and exclusion criteria, stratified design analysis, control of the combined effects of confounding factors, and reduction of bias in clinical studies are also crucial.http://www.crd.york.ac.uk/prospero) or Cochrane in advance to achieve transparency in the SR production process. In addition, attention should be paid to mentioning conflicts of interest or financial issues in the report. It is also necessary to conduct subgroup analysis or meta-regression analysis in the case of significant heterogeneity.At the same time, we should also recommend that researchers should follow the requirements of AMSTAR-2, ROBIS, PRISMA and GRADE when performing SR, especially to register or publish research programs on PROSPERO  This study only includes Chinese and English literature, which may miss some research in other languages, and there may be language bias. (2) The evaluation process of this study is subjectively evaluated by researchers according to the evaluation criteria, so the evaluation results may be affected by the grade of researchers and the differences in understanding; (3) At present, there is no clear specification and standard for the evaluation method of SR, so our evaluation may not be comprehensive and accurate.Compared with standard technique, remnant preservation in anterior cruciate ligament reconstruction has more advantages in restoring joint function and stability and proprioception. However, it may also increase the incidence of postoperative complications and adverse reactions. These potential risks should also be considered by surgeons. At present, the quality of evidence is generally low, and the reliability of the conclusion is insufficient. It still needs to be verified and further research is needed.


Health practitioner regulators throughout the world use continuing professional development (CPD) standards to ensure that registrants maintain, improve and broaden their knowledge, expertise and competence. As the CPD standard for most regulated health professions in Australia are currently under review, it is timely that an appraisal of the evidence be undertaken.A systematic review was conducted using major databases , search engines and grey literature for evidence published between 2015 and April 2022. Publications included in the review were assessed against the relevant CASP checklist for quantitative studies and the McMaster University checklist for qualitative studies.The search yielded 87 abstracts of which 37 full-text articles met the inclusion criteria. The evidence showed that mandatory CPD requirements are a strong motivational factor for their completion and improves practitioners’ knowledge and behaviour. CPD that is more interactive is most effective and e-learning is as effective as face-to-face CPD. There is no direct evidence to suggest the optimal quantity of CPD, although there was some evidence that complex or infrequently used skills deteriorate between 4 months to a year after training, depending on the task.CPD is most effective when it is interactive, uses a variety of methods and is delivered in a sequence involving multiple exposures over a period of time that is focused on outcomes considered important by practitioners. Although there is no optimal quantity of CPD, there is evidence that complex skills may require more frequent CPD.The online version contains supplementary material available at 10.1186/s12960-023-00803-x. Health practitioner regulators in Australia and other jurisdictions use registration standards to define the requirements that health practitioners need to meet to become, or stay registered. These commonly include standards for primary education in the profession, recency of practice (ROP) and continuing professional development (CPD).In 2010 Australia introduced the National Registration and Accreditation Scheme  which regulates 16 health professions under the Health Practitioner Regulation National Law as in force in each state and/territory . The National Law requires that National Boards must develop, consult on, and recommend certain registration standards to the Ministerial Council. These core registration standards are generally reviewed by National Boards every 5 years in line with good regulatory practice. The CPD standards for the majority of health professions regulated under the National Law are currently under review. The review of CPD standards requires an understanding of the contemporary evidence base.CPD has been defined as ‘The systematic maintenance, improvement, continuous acquisition and/or reinforcement of life-long knowledge, skills and competencies of health professionals’. CPD is Research over the past 10 years has demonstrated that while there is good evidence that CPD is effective in increasing practitioner knowledge, there is less evidence that it changes clinical practice, and even less linking it to improved patient safety –4. In 20The aim of this systematic review is to develop an up-to-date evidence base that will support the development of consistent, evidence-based, effective CPD standards.Is there evidence to support an optimal quantity of CPD to maintain competence? Does the evidence suggest any benefit or disadvantage in requiring CPD to be completed over a particular period, e.g., 1, 2 or 3 years? Is there a case for these to vary between health professions? Or to vary within the same health profession depending on differences in scope of practice/practice division/endorsement?Does the evidence indicate that some types of CPD  are more effective at improving practitioner competence and patient safety?Is there evidence to suggest that either self-directed CPD or mandated CPD are more effective at promoting practitioners’ competence and/or patient safety? Should some CPD be mandated? Is a mix of mandated and self-directed CPD more effective? If so, is there an optimal ratio of self-directed to mandated CPD?Is there any evidence that CPD that has been accredited or subject to some quality assurance process is more effective in maintaining clinical competency and/or patient safety outcomes? What factors should be taken into consideration in accrediting CPD?Under what circumstances could an exemption from CPD be justified? Is there evidence to suggest that a short gap in CPD, e.g., 1 or 2 years, has a negative effect on professional competency, including any specific timeframes for this effect to appear?Is there any evidence to suggest a benefit or disadvantage to requiring CPD that is more focused on maintaining a practitioners’ competence in their current scope of practice? What is the evidence about best practice in supporting CPD for practitioners who may wish to change their scope of practice? Is there any evidence to suggest that CPD contributes to other aspects of professional practice?Is CPD more effective when based on a practitioner’s assessment/reflection, peer review or based on curriculum to address their learning needs/skills gap rather than CPD that is based on meeting an externally set requirement, i.e., measured in hours or/points?Should practitioners who hold limited registration (or short-term temporary registration through the pandemic response sub-register) be required to carry out CPD?A systematic review was conducted examining the above research questions based on selection criteria, methods and analysis that are summarised below.The development of the research questions and search terms was informed by two unpublished reviews. These were a commissioned systematic review conducted by the Joanna Briggs Institute in 2012 and an update of that review by the Australian Health Practitioner Regulatory Agency (Ahpra), in 2015.The full protocol for the systematic review was recently published .The search terms and sources of literature selected for the review are based on the experience of the authors in conducting a systematic review of the evidence for CPD standards. The sources included journal articles and grey literature published between 2015 and April 2022, as well as preliminary testing.Search terms were selected for the health practitioner group, intervention, and outcome using a combination of the National Library of Medicine Medical Subject Headings (MeSH) and additional relevant search terms. Boolean operators were used to combine terms, and ‘wild cards’ were used to account for plurals and variations in spelling. MeSH is a standardised hierarchically organised vocabulary developed by the National Library of Medicine to index, catalogue and search biomedical and health-related information. The search strategy for this review is presented in Additional file Research databases including the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), PsycINFO and Allied and Complementary Medicine Database (AMED) (using the OVID platform) and the Cumulative Index of Nursing and Allied Health Literature (CINAHL)Search engines comprising Google Scholar and Google AdvancedGrey literature produced by other regulatory organisations, government bodies and professional associationsReference lists of papers and reports selected for review.The main sources of literature were:The focus of the report/article is CPD for those health professions regulated under the National SchemeReviews, original research, reports and thesesPublished from 1 January 2015 to 30 April 2022Written in the English languageFor research question 2, must include a comparator group.Articles and reports were included in the systematic review if they met the following criteria:Focussed on health and other professions not regulated under the National LawFocussed on students or internsFocussed on regulatory standards other than CPDOpinion pieces, newsletters, conference presentationsPublished before 1 January 2015Not written in the English language.Articles and reports were excluded from the systematic review if they met the following criteria:Titles identified from the search were checked and the abstract reviewed, where the title appeared to be relevant to the research questions. Where the abstract met the inclusion criteria the full article was downloaded and assessed against the inclusion/exclusion criteria.A Microsoft Excel spreadsheet was used to record bibliographic information about each article or report , the study population , intervention , main findings, study type, the Australian National Health and Medical Research Council level of evidence , decisioWhere the full text of the article was assessed as relevant to the research question(s), a quality appraisal was conducted independently by two people. The published protocol  was modiOur search strategy identified 20 732 studies through database searching, with an additional 96 records identified through other sources, resulting in 19 517 records after duplicates were removed. Of these, 569 records were screened based on their title and 18 948 records were excluded. Eighty-seven full text articles were assessed for eligibility based on their abstract, of which 49 full-text articles were excluded, because they did not meet the inclusion criteria.Thirty-seven studies were included in the review comprising: 11 systematic reviews , one randomised controlled trial, one quasi-experimental study, four cohort studies, one case–control study, three mixed methods studies, two semi-structured interviews, two correlational studies, four cross-sectional studies, four narrative reviews and four descriptive reviews.The quality of each study was assessed using either the CASP checklist for systematic reviews  or the qThe characteristics and quality assessment of the included studies are outlined in Table The systematic review found no direct evidence for an optimal quantity of CPD to maintain the competence of health practitioners. Indirect evidence comes from a medium quality cohort study that compares the effect of changes in CPD requirements for physicians in the United States, with their performance in a national maintenance of certification examination . This stThe review found no evidence to suggest any benefit or disadvantage in requiring CPD to be completed over a particular period. The College of Dental Hygienists of British Columbia extended the duration of their regulatory cycle from 3 to 5 years when they introduced their quality assurance program in 2010 . The lenThere is no evidence for the quantity of CPD to vary between health professions or within the same profession depending on scope of practice/practice division/endorsement. There is also no evidence as to whether CPD is more effective if it is carried out in smaller amounts, more frequently.There is good evidence, however, that the retention of knowledge and skills varies with the task, such that it would be beneficial for skills to be refreshed more frequently for more complex technical skills, such as surgical or resuscitation procedures, that are practised infrequently –19. For Two qualitative research studies found that medical residents and faculty staff perceive that skills decay is greatest in loss of technical skills, followed by a decrease in knowledge of procedural steps with the extent of perceived skill reduction related to the level of skill difficulty , 19.The systematic review identified three well-designed studies that provide an insight into the efficacy of different types of CPD in improving practitioner competence and patient safety –23. ThesIt can be seen from the table that didactic programs alone have very little impact on clinician performance or patient outcomes , althougRecent research looking at the impact of CPD on health practitioners’  clinical performance and/or patient outcomes found that of 63 syntheses included in the review, 38 (60%) included multi-component approaches, and 29 (46%) incorporated e-learning approaches, either singly or in combination with other interventions . While 4The systematic review identified a low quality meta-analysis of outcomes assessments of CPD, as well as four high quality systematic reviews, one a meta-analysis, and a medium quality quasi experimental study that compare an electronic learning (e-learning) approach with traditional learning for health professionals –30. The The meta-analysis of outcomes assessments of around 600 CPD programs for medical practitioners in the United States found that, in general, online activities  were more effective than live activities  and both were more effective than ‘enduring’ activities  . Mobile Fontaine et al.’s (2019) systematic review and meta-analysis of 21 studies (representing 3 684 participants) found that personalised e-learning significantly improved clinical skills compared to traditional forms of training . HoweverA Campbell Collaboration systematic review of 24 trials (representing 3 825 participants) found good evidence that a blended e-learning approach to training for evidence-based healthcare leads to a greater improvement in attitudes and behaviours than either face-to-face training or pure e-learning [A quasi-experimental study that examined the effectiveness of a web-based pedagogy program for nurse preceptors compared to face-to-face teaching found that, although participants of the face-to-face teaching program had significantly higher scores for clinical teaching and assessment behaviour in clinical settings immediately after the program, there was no difference in outcome between the groups 6 months later .The findings of the other three systematic reviews that compare e-learning to traditional learning were inconclusive –28. The . 2019 considered 22 systematic reviews that examined the efficacy of e-learning CPD activities for nurses [Finally, Rouleau et alr nurses . The sysThe systematic review identified two systematic reviews and a case series that examined the effectiveness of interprofessional CPD –33. A hiThe other high quality systematic review reported that simulation-based methods were widely used for inter-professional team-based CPD that included nurses, and were often combined with other learning modalities, such as web-based information or workshops . It founThe case series published by a joint accreditation board in the United States lends further support to the above findings . For exaThe systematic review also identified two medium quality systematic reviews and a low quality cross-sectional study that provide further insights into the efficacy of different types of CPD –36. The Finally, a low quality cross-sectional study of psychologists 2 months after attending the American Psychology Association’s 2019 continuing education sessions and workshops found that longer CPD sessions  and experiential approaches to instruction led to improved knowledge and translation of learning into practice compared to short CPD sessions (1–2 h) .The systematic review identified three cohort studies –39  who received a complaint with the Ontario regulatory body between 2002 and 2003, with those who had not . Using mA longitudinal study showed that the rate of complaints to the regulator for psychologists in Illinois  remained constant before and after the introduction of mandatory CPD . The aveAs identified above, a single study above showed that those who did mandated CPD training were more compliant with guidelines than those who did not .The systematic review identified a low quality pilot study that used a matrix based on the American Nurses Credentialing Center Primary Accreditation Criteria to determine whether learners observed differences in the quality of educational activities developed by organisations using accreditation criteria, compared with those who did not . The stuAccreditation inputs Accreditation process (application process and application review process)Accreditation output Quality improvement .An evidence-based accreditation framework was developed by the Global Forum on Quality Assurance of Continuing Education and Continuing Professional DevelopmentA similar process was used to develop a shared set of international standards for the accreditation of CPD for medical practitioners and health-care teams . The staSeveral authors have recommended that the provision of CPD should be independent of any potential conflicts of interest between pharmaceutical companies or commercial suppliers and health professionals –47. TherThe systematic review did not find any evidence to support any circumstances under which an exemption from CPD could be justified. There is no direct evidence to suggest that a short gap in CPD has an effect on professional competency. The limited evidence that we have on skills fade suggests that we cannot make an evidence-based recommendation for exemptions from CPD.There was no evidence to suggest a benefit or disadvantage to requiring CPD that is more focused on maintaining a practitioners’ competence in their current scope of practice.The systematic review was unable to identify any evidence about the best way to support CPD for practitioners wishing to change their scope of practice. The review identified a paper outlining CPD support provided by a Canadian college for occupational therapists wishing to change their scope of practice , and twoThe College of Occupational Therapists of British Columbia has implemented support for registrants who are changing scope of practice through their two-part annual continuing competency review . The firQualitative research into CPD support for the expanding scope of practice for pharmacists comprised a mixed methods study of pharmacists in Alberta, Canada and semi-structured interviews in Ontario, Canada , 52. In The second was a well-designed qualitiative study that comprised semi-structured interviews of 20 community pharmacists in Ontario, Canada to determine their CPD needs in respect of the expanding scope of practice for pharmacists . Seven eEvidence to suggest that CPD contributes to other aspects of professional practice is limited. Almost two-thirds of respondents to a national survey of osteopaths registered in New Zealand in 2016 reported that their communication skills improved as a result of CPD (62%), and over half indicated that CPD helped them develop their business 56%) . Semi-st% . Semi-Nurses and paramedics also identified personal fulfilment, improved self-esteem and self-confidence during practice as being another important outcome of CPD –56. A stThere was no evidence for the contribution of CPD to other aspects of professional practice, such as maintaining links with the wider professional community, ethical practice or cultural competency.There is limited evidence to suggest that CPD is more effective when based on a practitioner’s assessment/reflection, peer review or based on curriculum to address their learning needs/skills gap rather than CPD that is based on meeting an externally set requirement.A well-designed medium quality study comparing the effectiveness of CPD that was personalised following standardised assessment to self-directed CPD showed there is greater knowledge translation using a personalised CPD learning path . RheumatAn evaluation of an assessment tool implemented by the College of Dental Hygienists of British Columbia designed to guide registrants in their selection of CPD showed that although there was an increase of 9% in the number of registrants since its introduction in 2012 until the evaluation in 2017, there was no change in the number of complaints in the same period . The tooThe systematic review was unable to find any evidence as to whether practitioners who hold limited or short term temporary registration should be required to carry out CPD.Australian and international health practitioner regulators have specific CPD requirements to ensure that registrants who are actively engaged in practice regularly participate in CPD that is relevant to their scope of practice. Practitioners carry out CPD to maintain, update and enhance their knowledge, clinical skills and performance to help them deliver appropriate and safe care. In Australia, National Boards set mandatory CPD requirements, although the specifics vary between health professions.Mandatory CPD requirements are a strong motivational factor for the completion of CPD activities , 59, 60.The benefits of CPD are that it improves practitioners’ knowledge and behaviour, and evidence for improvement in clinical skills and patient outcomes is growing , 22, 24.The systematic review found good evidence that CPD is most effective when it is more interactive and uses a variety of methods, delivered in a sequence involving multiple exposures over a period of time that is focused on outcomes considered important by practitioners , 22–24. In Australia, CPD registration standards typically require health practitioners to complete a number of CPD hours over a defined period of time. Registrants are often encouraged to reflect on their practice to identify their own developmental needs, carry out the appropriate CPD activities to meet these identified needs, and reflect on how the learnings can be applied in practice, while identifying any further developmental needs. This is in line with international best practice; however, many jurisdictions embed their CPD requirements in broader quality assurance initiatives. For example, the College of Dental Hygienists of British Columbia help their registrant's selection of CPD activities with a self-assessment tool designed to identify areas of practice that may benefit from additional training as well as requiring annual completion of a jurisprudence module that provides information on legislation, standards and guidelines relevant to practice .As noted above, the primary goal of CPD requirements is to ensure health practitioner competence and public safety which has led to a call to use competence as an outcome measure , 64, 65.Researchers have highlighted the need to ensure that the CPD is provided independently of conflicts of interest between pharmaceutical companies or commercial suppliers and health professionals –47. TherA series of Institute of Medicine reports demonstrating the relationship between poor team performance and negative patient outcomes called on accreditors and regulating bodies to introduce policies designed to bring about change , 67, 68.Apart from one study of uncertain quality that reported better outcomes for e-learning compared to face-to-face learning or use of text-based learning , this syThe globalisation of access and provision of CPD which increases the availability of e-learning –81 has lThe main limitation for the systematic review was the lack of well-designed studies that address most of the research questions. Although there is a very large literature on the efficacy of different types of CPD, most focused on profession-specific issues that could not easily be generalised and most did not include a comparator group. There was a high degree of heterogeneity among these studies which varied widely in the characteristics of the study population and measured outcomes. Older studies relied on self-reported participant reactions or learning to gauge the effectiveness of CPD, whereas newer studies have started to use objective changes in behaviour and/or patient outcomes in their place. The lack of studies using newer objective outcomes is a further limitation of the review. The sample size for the majority of the studies were appropriate for the type of study.Non-English language articles were excluded, so there is a risk that relevant articles written in another language were not included in this analysis. Another limitation is that the systematic review only included articles published between 2015 to April 2022, which may have excluded important earlier work relevant to the research questions.This systematic review found CPD is most effective when it is interactive, uses a variety of methods and is delivered in a sequence involving multiple exposures over a period of time that is focused on outcomes considered important by practitioners. No direct evidence was found for an optimal quantity of CPD required to maintain competence, although there is some evidence that complex or infrequently used skills deteriorate between 4 months to a year after training, depending on the task.In comparable jurisdictions, there is a move toward output focussed CPD requirements that are embedded in a broader strategy that is designed to ensure competence, as well as increasing recognition of the need for inter-professional education targetting health-care teams and increasing acceptance of e-learning. These issues will benefit from consideration in the current review of National Board CPD registration standards.Additional file 1. Appendix A: CPD search strategy.