Gating latency is dependent on image acquisition, processing time, accuracy, efficacy of target tracking algorithms, and radiation beam delivery latency. In this report, clinical experience of the MRIBeam‐control latency was measured on a 0.35‐T MR‐LINAC system with four target tracking algorithms and two real‐time cine imaging sequences [four and eight frames per second (FPS)]. Using an MR‐compatible motion phantom, the delays between phantom beam triggering signal and linac radiation beam control signal were evaluated for three motion periods with a rigid target. The gating point was set to be 8 mm above the full exhalation position. The beam‐off latency was measured for a total of 24 combinations of tracking algorithm, imaging FPS, and motion periods. The corresponding gating target margins were determined using the target motion speed multiplied by the beam‐off latency.The largest measured beam‐off latency was 302 ± 20 ms with the Large Deforming Targets (LDT) algorithm and 4 s motion period imaged with 8‐FPS cine MRI. The corresponding gating uncertainty based on target motion speed was 3.0 mm. The range of the average beam‐off latency was 128–243 ms in 4‐FPS imaging and 47–302 ms in 8‐FPS imaging.4D QUASAR motion phantom in a 0.35‐T MR‐LINAC. The latency measurements include time delay related to MR imaging method, target tracking algorithm and system delay. The gating uncertainty was estimated based on the beam‐off latency measurements and the target motion.The gating latency was measured using an MRI Accuracy of treatment when real‐time targeting and gating is enabled depends on the latency of gating processes including imaging, target tracking, and radiotherapy machine control.Instead of using dosimetry devices, the gating latency can be measured by obtaining a beam‐control signal directly from the radiation delivery system.60Co) using the direct signal reading approach.Green et al. reported the gating latency of a 0.35‐T MRgRT system  was introduced for gating system tests including gating latency measurements. It has an interface to collect the beam‐control signal from the radiation delivery system and the gating signal from the motion phantom without an oscilloscope. In our institution, the gating latency measurements of a 0.35‐T magnetic resonance‐linear accelerator (MR‐LINAC) have been completed using an MRI4D QUASAR motion phantom after the MRgRT system was upgraded with four tracking algorithms and two imaging speeds (four and eight frames per second (FPS)). In this report, we discuss our clinical experience of using the MRI4D QUASAR motion phantom for latency measurements on a 0.35‐T MR‐LINAC. The following items are briefly discussed: (a) the new features of the imaging techniques and tracking algorithms of 0.35‐T MR‐LINAC, (b) the clinical experience of the gating latency measurements with two imaging speeds and four tracking algorithms, and (c) gating geometric uncertainty according to the measured gating latency.Recently the MRI2The gating latency depends on the speed of image acquisition and processing, accuracy and efficacy of target tracking algorithms, and radiation beam triggering latency. In the gating latency measurements, combinations of imaging and target tracking conditions were parameterized.2.AA 0.35‐T MRgRT system  was used for the gating latency measurements. The MRgRT system consists of a 0.35‐T split‐doughnut superconducting MRI for real‐time imaging and a 6‐MV flattening‐filter‐free (FFF) LINAC for radiation delivery.2.B2 with 5, 7, or 10 mm slice thicknesses, using a Cartesian acquisition trajectory. Imaging parameters were TR/TE = 2.1/0.91 ms, flip angle = 60°, rBW = 1351 Hz/pixel, FOV = 350 × 350 mm2, and imaging matrix = 100 × 100. The 8 FPS‐2D cine MRI protocol produces an acquired spatial resolution of 2.4 × 2.4 mm2 with 5, 7, or 10 mm slice thicknesses, using radial acquisition trajectory. Imaging parameters were TR/TE = 500/1.38 ms, flip angle = 110°, rBW = 890 Hz/pixel, FOV = 350 × 350 mm2, imaging matrix = 144 × 144 and spokes: 176 (44 spokes updated per frame). In the gating latency measurements, the clinical 2D cine MRI protocols with 7 mm slice thickness were used.Along with the system upgrade, an 8 FPS‐2D cine MRI protocol had been released to the clinic in addition to the previously available 4 FPS‐2D cine MRI protocol in a sagittal plane for use during MRgRT. The 4 FPS‐2D cine MRI protocol produces a set acquisition spatial resolution: 3.5 × 3.5 mm2.CIn addition to cine MRI with two imaging speeds, new tracking algorithms have been released to improve target tracking and gating.2.D2.D.14D QUASAR motion phantom was positioned on the phantom rack mounted on the couch top as shown in Fig. The MRI2 · 4H2O at 7ppm . One insert had an acrylic stem with a space for an ion chamber, inserted into the right cavity (a reference insert for dosimetric measurements). A dovetail collar was used to hold the reference insert in place. The other insert had an acrylic stem with a central cuboid target (3 × 4 × 5 cm3) for imaging and a space for an ion chamber (a moving insert for dosimetric measurements or imaging), inserted into the central cavity shown in Fig. The body of the phantom had two cavities for acrylic inserts filled with distilled water and an added aqueous solution of MnClAn electronic control box was placed in the radiofrequency (RF) cabinet room. Motor control cables were connected between the drive unit of the phantom in the MR room and the control box in the RF cabinet room through a waveguide with brass sponges to prevent RF interference. Using a CAT5e ethernet cable, a laptop was connected to the control box from the operating area. This allowed the gating signal from the motion phantom to be recorded and full control of the moving insert from the operating area. It is noted that beam‐control signal from the LINAC was sent from the control cabinet to the control box using a direct connection via coaxial cable  which was not digitally filtered and had an inherent latency of <1 ms, which was verified by the authors from vendors.2.D.23) with the imaging insert at the end of exhalation position (static condition) was acquired using 3D TrueFISP MRI prior to the gating latency measurements shown in Fig. Volumetric MRI of the phantom  was acquired to verify the target position. In the gating target setup, an 8‐mm margin was added to the target contour (yellow contour) as a gating boundary (red contour) shown in Fig. In the treatment delivery system (TDS) imaging window prior to the beam delivery screen, the imaging insert was shifted 8 mm inferior to touch the gating boundary using the phantom control software while cine MRI was acquired shown in Fig. Once the gating position was determined in the phantom control software, the imaging insert was programmed for sinusoidal motion with three periods , 10 mm in amplitude (20 mm for peak‐to‐trough), during the gating latency measurements. Gating latency was determined as the delay from when the phantom control software reached the defined gating position and when the beam control signal was generated by the LINAC. Each measurement included at least 10 beam‐on and 10 beam‐off events. The beam‐off latency was measured for a total of 24 combinations: three motion periods, two imaging speeds, and four tracking algorithms.2.D.3The beam‐off latency was utilized to estimate a beam delivery uncertainty to the target. The corresponding gating uncertainty were determined using the target motion speed multiplied by the beam‐off latency.33.AAverage (±standard error) beam‐off latency for the four tracking algorithms on three motion periods are shown in Table Average (±standard error) beam‐on latency for the four tracking algorithms with three motion periods are shown in Table 3.BGating uncertainty based on the target motion speed and average beam‐off latency was determined in Table 44D QUASAR motion phantom after the MRgRT system was upgraded with four tracking algorithms and two imaging speeds.In our institution, the gating latency measurements of a 0.35‐T MR‐LINAC were completed using an MRI4D QUASAR motion phantom. In the previous study, Green et al. reported the average latency of 394 ms (246–527 ms) for 4 s motion in 4‐FPS cine MRI using a CIRS motion phantom in a 0.35‐T MRgRT system (MR‐60Co). They utilized a physical sensor to detect motion of the imaging insert and generate the gating signal sent to the oscilloscope while the synchronized gating signal from the MRgRT system image processing routine was sent to the beam delivery system. Once the beam‐off signal from the MRgRT system was sent to the oscilloscope, the screen of the oscilloscope was captured to measure the beam‐off latency. In contrast, our study utilized a single software system to control motion of the imaging insert which generated the gating signal recorded by the software without an oscilloscope. The same synchronized gating signal produced by the MRgRT system image processing routine was sent to the beam delivery system and the beam‐control signal from the MRgRT system was recorded by the software. In this study, the beam‐control latency was measured using a single software system compared to the previous study which required the control software, physical sensor, and oscilloscope.The average beam‐off latency with the Default algorithm in 4 FPS cine MRI was 189 ± 25 ms for a 4‐s motion period, 128 ± 23 ms for a 5‐s motion period and 161 ± 23 ms for a 6‐s motion period using the MRIIn this study, we measured the beam‐control latency under 24 different scenarios: three phantom motion periods, two imaging speeds and four tracking algorithms, since the gating latency is affected by speed of image acquisition and processing, accuracy and efficacy of target tracking algorithms, and radiation beam delivery latency. First, the imaging time can have an intrinsic latency because images were displayed and processed discretely. The time interval depended on the imaging acquisition and processing. For example, the beam‐off latency was 159 ms in 4 FPS cine MRI but was reduced to 100 ms in 8 FPS cine MRI with Default tracking algorithm. Utilizing, however, view‐sharing for 8 FPS cine MRI did not always improve the gating latency, demonstrating that a high frame rate does not directly translate to improved latency. Second, detection of the target in the image processing routine of the MRgRT system is dependent on the accuracy and efficacy of target tracking algorithms. Since the target contour was generated using target tracking algorithms in real‐time, uncertainty of the target contour delayed the beam‐control decision. For example, the beam‐off latency was 231 ms using the Large Deforming Targets (LDT) tracking algorithm and was reduced to a 159‐ms latency when using the Default tracking algorithm in 4 FPS cine MRI. The LDT tracking algorithm was developed for large targets with a small motion but a large deformation such as whole organs , so the test imaging insert may not be appropriate to utilize the algorithm. Third, the phantom motion speed can affect the distance traveled by the target between each cine MRI acquisition during the gating process. Figure The beam‐off gating uncertainty were determined using the target motion speed multiplied by the beam‐off latency. The largest latency occurred with the LDT tracking algorithm when using 8 FPS cine MRI. Gating uncertainty based on the target motion speed was determined to be about 3.0 mm. In our institutional procedure, a target boundary with 3 mm expansion was practical to compensate for the largest beam‐off latency. These calculations are based on the uniform 4 s motion period of the phantom, which is different from real‐world respiratory motion. Respiratory motion follows a variable velocity and has inconsistent amplitude across respiratory cycles. These factors were not considered by this work to isolate the gating latency inherent to the system from additional uncertainty that may be imparted due to variability in motion pattern. However, because the gating position is set to end of exhalation where respiratory position is most consistent and rapid motion is not expected, the experimental setup resembles normal MR‐guided gating conditions. Sampling frequency can impact gating latency, true acquisition speed for 4 FPS images was approximately 210 ms (100 phase encoding lines and TR = 2.1 ms), and the 8 FPS acquisition utilizes view‐sharing so the full k‐space is not acquired within 125 ms. For these reasons it is unlikely that motion phase was matched across all measurements. Further imaging frequencies were not investigated because there are no additional cine acquisition sequences available in clinical mode.The beam‐on gating latency was much larger than the beam‐off latency measured in this study. This is not as critical clinically due to beam‐on occurring as the target moves fully into the gating boundary, while beam‐off occurs as the target leaves the gating boundary. Greater beam‐on gating latency for 8 FPS, compared to 4 FPS, may be due to the use of view sharing for 8 FPS acquisitions. The view sharing method utilizes previously acquired k‐space lines that may have been acquired while the gating target was further from the gating boundary, thus blurring the edges of the gating target. This blurring would be greater as the gating target enters the boundary because the object has moved further prior to entering the boundary than it would have prior to leaving the boundary. Gating parameter selection also had a more significant impact on the beam‐on latency than beam‐off latency, especially for 4 FPS vs 8 FPS acquisition with the beam‐on latency nearly doubling with 8 FPS acquisition compared to 4 FPS. Gating latency is also dependent on tracking algorithm, which may be due to the efficiency and accuracy of the automatic segmentation and tracking algorithm. A high beam‐on latency time also reduces the treatment duty cycle, potentially increasing treatment time. Reducing beam‐on latency is important for patients who cannot remain in the MRI bore for extended periods of time and for clinic efficiency.4D QUASAR motion phantom was a straightforward process. It did not require any additional software or devices, such as an oscilloscope or dosimetric devices. Measured data were handled by the control software, and comprehensive analyses and corresponding reports were generated in a user‐friendly format as shown in Fig. The beam‐control measurements using the MRIAs motion gating becomes more prevalent in radiotherapy, continued development of readily deployable QA methods for measuring gating latency, and the associated margins required for treatment, is required. The report from AAPM TG‐76 provides information relevant to current respiratory gating QA and compensating for gating latency. AAPM TG‐76 recommends that the total time delay for real‐tie tracking or compensation systems should be no more than 500 ms because of irregularities in the breathing cycle making tumor position prediction difficult.54D QUASAR motion phantom on a 0.35‐T MR‐LINAC. The latency measurements include time delay related to MR imaging method, target tracking algorithm and system delay. The gating uncertainty was estimated based on the beam‐off latency measurements and the target motions. The current clinical margin of 3 mm is sufficient to account for gating latencies for all 24 combinations of testing parameters used in this study. Our clinical experience using the MRI4D QUASAR motion phantom on a 0.35‐T MR‐LINAC can be applied to new tracking algorithms, cine MRI acquisition methods, and MRI systems. Further work is required to investigate the impact of irregular motion patterns on gating latency.The gating latency was measured using a MRI


Here, we examine a particular program, the “Argue with Me” dialogue-based pedagogical approach, having this objective. Reviewing approximately 30 studies that have used the “Argue with Me” (AWM) method with students of different backgrounds and educational levels—primary, middle, high school, and university—across five different countries, we examine its strengths and limitations in terms of what develops and how this development occurs. Dense engagement in goal-based activities involving extended dialogic practice and reflection is shown to be effective in fostering argument skills and dispositions. Studies examining the mechanisms of such development identify the role of meta-level understanding regarding the purpose of argument. This understanding is epistemological in nature and supports the development of dialogic skills at the strategic level. In addition to examining the AWM method as a means for supporting the development of argument skills, this review examines how empirical research employing the method in varying contexts provides insights into the nature of argument skills and their development, as well as the relations between argument skills and other skills or forms of understanding. For instance, we examine how studies employing the AWM method answer questions such as “How general or content-specific are argument skills?” or “How do dialogic argument and individual written or spoken argument connect as they develop?” We address these questions by examining evidence regarding the transfer of gains across topics, domains, and individual vs. dialogic modes of expression. Finally, the pedagogical implications of the “Argue with Me” approach are discussed, especially with regard to its potential both as a stand-alone method for developing argument skills and integrated into traditional literacy and social studies curricula.Philosophers, psychologists, and educators all acknowledge the need to support individuals to develop argument skills. Less clear is  The art of dialectics (διαλεκτικń) was born and, along with it, the need for methods to ensure the construction of better  arguments. The need to gain an understanding of the links between logic, rhetoric, reasoning, and cognitive development has been a pressing one since ancient times.The topic of argument skills is as old as the existence of human thought about reasoning, which came to light with some early philosophers’ work in ancient Greece and Rome, with Aristotle and Cicero the most representative examples. Among other contributions, Aristotle distinguished between the different types of common places (Argue with Me (AWM) approach, to developing argument skills and dispositions developed by Kuhn and colleagues  and argument-as-process . Moreover, from an informal logic point of view, the argument structures  manifested within arguments-as-products, or rhetorical arguments, presuppose the process of argumentation within which they are produced produced , 2019.a priori or in the course of dialogue itself, for example when certain norms of dialogic behavior are met, as in the case of a posteriori, after the arguments produced are assessed as being reasoned and of a certain dialogic quality . However, what can and should be done a priori, in Kuhn’s perspective, is the design of the argument learning environment on the basis of one main assumption: the goal-orientedness of the activities through which the gradual immersion in the argument-as-process nature and objectives is achieved. Although many educational researchers . The method, first fully implemented by AWM is structured into three main phases—Pregame, Game, and Endgame—with different cognitive and dialogic objectives in each. The goal of this paper was to provide an overview of the major outcomes of the 29 empirical studies that have applied the AWM method thus far.The development of argument skill is multifaceted and gradual . The worproduction of valid arguments, either individually or interactively, while the second is related to relevant forms of participation in argumentive dialogue. These two manifestations, previously described in the Introduction as argument-as-product and argument-as-process, will now be given a closer look in terms of their specific development reported in the AWM-related empirical research. We then proceed from skill development to gains in content knowledge.Argumentive reasoning development encompasses two main manifestations: the first is related to the functional support is highly important as it represents informal logic criteria, such as sufficiency and acceptability, as described by warrant in Toulminian terms) or (b) a justification of why this specific linkage between claim and support must be considered as evidence that the claim is true (backing in Toulminian terms). Without establishing connections neither with the informal logic criteria nor with Toulmin’s theoretical contribution of a valid argument structure, Kuhn and colleagues seem to be claiming something very similar with their simplified notion of a functional unit: for a claim to be characterized as evidence-based, the connection between the alleged evidence and the claim must be explicit, and the evidence must be accurate  are possible: the shared, i.e., based on a set of information made available to students, and the personal, i.e., generated from the students’ own personal knowledge.1 For both types, the same criteria of functionality apply. Pragmatic modifications can be of four main types, namely data used to support one’s own view, data used to support the other party’s view, data used to weaken the other side’s view, and data used to weaken one’s own view. These different functional uses of information as evidence give validity to an argument, as it is not the evidence itself that is more valid than another. This view explains also the fact that, for Kuhn see , two typA necessary counterpart of evidence-based reasoning is the skill of antilogos, namely the ability to identify contrary commonplaces to one’s own assumptions and positions, which may lead to totally different or even oppositional claims and positions . CoherenAddressing the question of what aspects of evidence-based reasoning and antilogos skills are promoted as result of the AWM curriculum, a common finding across the empirical studies reviewed is that, following participation, students more often search for and use evidence in their efforts primarily to support their own and undermine the other’s position, but also to a lesser extent to address evidence and arguments incongruent with their own position , and mordyadic intense dialogic interaction taking place during the Game, and characteristics of it thereof, as a major factor leading to argument gains, whereas others focus on particular elements of the AWM method to address this question, examining for example the role of reflective activities or the type and order of relevant information made available to the students during Pregame and Game. Each of these components is examined below.But what are the particular aspects of the dialogue-based method that render these gains possible? The AWM method is a complex, multicomponent intervention, and specific experimental dissection is required to isolate its effective components. Some of the reviewed studies suggest the The idea that dyadic argumentation is a means of cognitive engagement is rooted in the Vygotskian tradition highlighting the complementarity of social and internal thinking. A pioneering study by opposing view with individuals who engaged in discourse with peers who hold the same positions as themselves. Young adolescents were given access to identical relevant evidence and engaged in dialogues on a physical science topic. In the experimental condition, electronic dialogues were conducted with a series of peers who held an opposing view; in the control condition, dialogues were confined to same-side peers. The results showed differences in the extent and types of functional evidence-based argumentive idea units in individual final essays on both the intervention and a transfer topic, favoring the experimental condition. Extension of the study longitudinally to a second year with a new topic showed continued gains and condition differences, with the experimental group surpassing the control group. This study further suggests that adversarial argumentation, employing the aim to persuade, is a more productive means, compared to coalescent or collaborative argumentation, to support the development of argument skills. Subsequent studies implementing the AWM method further confirmed the role of intensive dialogic engagement in argument skill development. For example, Same-ability partners could flexibly scaffold one another with metacognitive support, taking on the role of support provider and support recipient interchangeably and as needed.Another group of studies aimed at examining whether the skills of the partner that one collaborates with while engaging in the AWM method function as a further scaffold for the observed individual argument gains. Another core element of the AWM method is engagement in reflective activities about one’s own argumentation. Significant advancements in students’ use of evidence were observed after their engagement in reflective activities that prompted them to reflect on the use of evidence in their arguments, when students’ progress was examined using a microgenetic method see . When anSome of the reviewed studies used prompts for reflection or to encourage the use of evidence. Incorporating scaffold prompts that exemplified functions of evidence in relation to a claim accelerated the prevalence of evidence-based claims in essays of low-performing middle schoolers compared to participants in the same year-long dialogue-based intervention who received no or a limited form of evidence prompts  or compaA subsequent study by structural relevance, i.e., how the argument components logically interrelate  meta-level awareness of the goals of argumentive discourse and the strategies used to achieve them , also caThe “learning to argue” and “arguing to learn” distinction  implies For example, In another study, The strength and value of instructional approaches lie in their ability to promote knowledge or skill gains beyond the specific context of instruction, given that transfer of learning is considered the ultimate objective of teaching . ParticiFollowing engagement in dialogic argumentation in the context of the AWM curriculum, individuals’ transition from egocentric presentation of their own perspective to addressing the other side’s perspective and using counterarguments was apparent not only in peer discussion but also in students’ individual writing  as well vice versa. However, a difference in the magnitude of transfer was observed, with only students in the science intervention condition able to transfer their skill gain to the social topic to the degree that these skills were mastered in the science topic. Thus, argumentive competence in the science domain is amenable to the same development as in the social domain, although specific engagement and practice within the science domain is warranted. The evidence for transfer across topics and generality observed is considerable, but we should not draw the conclusion that content makes no difference , remain to be established. Future research can also examine the specific challenges of different forms of evidence. Evidence in question-and-answer format has been shown to be more effective than traditional text ; howeverThe AWM method, which centers around dense engagement in peer dialogue, has been proven sufficient with little in the way of adult instruction. Future work can compare the achievements of the AWM method to those of more explicit direct instruction, in particular with respect to the development of writing. Also, determining how the AWM method can be best integrated into traditional curricular subjects and at different developmental levels requires more work. The method has been implemented thus far largely by researchers, or teachers who worked in close collaboration with researchers. We should not take for granted that all teachers will be interested in learning and implementing this method. Some teachers feel uncomfortable not having full control of what goes on in their classrooms . Some may not be convinced that student-to-student talk is productive. Therefore, future work should explore methods of professional development of teachers that enable them to try methods that may fall outside of their present comfort zones. The connection found between teachers’ own argument skills and their facility in supporting students’ argument skill development , as wellAnother avenue for future research is to study how the curriculum can be adapted to different cultural contexts. The AWM method has been implemented with success in Eastern as well as Western cultures , with coFinally, future research can examine the transfer of gains fostered by the AWM curriculum to real-life settings and its potential to affect not only thinking but also behavior. Do the gains of the AWM curriculum transfer to whole-class discussion and to discussions, as well as individual thinking, outside of the classroom? Although there is evidence that the AWM curriculum fosters gains in intellectual values and epistemological understanding, as assessed in paper-and-pencil measures, its potential to support critical thinking in real-life contexts needs further investigation. According to Both authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The identification of existing rehabilitation interventions and related evidence represents a crucial step along the development of the World Health Organization’s (WHO) Package of Interventions for Rehabilitation (PIR). The methods for such identification have been developed by the WHO Rehabilitation Programme and Cochrane Rehabilitation under the guidance of the WHO’s Guideline Review Committee secretariat. The aim of this paper is to report on the results of the systematic search for clinical practice guidelines (CPGs) relevant to the rehabilitation of adults with fractures and to present the current state of evidence available from the identified CPGs.This paper is part of the Best Evidence for Rehabilitation (be4rehab) series, developed according to the methodology presented in the World Health Organization’s (WHO) Package of Interventions for Rehabilitation (PIR) introductory paper. It is a systematic review of existing CPGs on fractures in adult population published from 2009 to 2019.We identified 23 relevant CPGs after title and abstract screening. According to inclusion/exclusion criteria, we selected 13 CPGs. After checking for quality, publication time, multiprofessionality, and comprehensiveness, we finally included five CPGs dealing with rehabilitative management of fractures in adult population, two CPGs addressing treatment of distal radius fracture and three the treatment of femoral/hip fracture.The selected CPGs on management of distal radius and femoral/hip fracture include few recommendations regarding rehabilitation, with overall low to very low quality of evidence and weak/conditional strength of recommendation. Moreover, several gaps in specific rehabilitative topics occur. Further high-quality trials are required to upgrade the quality of the available evidence.Level 1. The WHO has the strategic priority of achieving Universal Health Coverage (UHC), which means that “all people receive quality health services that meet their needs without being exposed to financial hardship in paying for the services” . UHC incThe development of the PIR takes a stepwise approach . The secThe worldwide incidence of fractures in the adult population is reported to range between 9.0 and 22.8/1000/year . Hip fraRehabilitation following fracture is mandatory to prevent complications, optimize functional recovery, and achieve independence of activities of daily living (ADLs) . In the The objective of this paper is to report on the results of the systematic search for CPGs relevant to rehabilitation of adults with fractures, limiting the search to the following sites: humerus, radius, femur/hip, and tibia. The specific objectives are to present the topics of the recommendations and the current state of evidence available from the identified CPGs.Systematic literature search: The following databases were searched for CPGs: PubMed, Pedro, CINAHL, Embase, Google Scholar, Guidelines International Network (GIN), US National Guideline Clearinghouse, UK National Institute for Clinical Excellence (NICE), Australian National Health and Medical Research Council clinical practice guidelines, National Library for Health Guidelines Database (UK), Scottish Intercollegiate Guidelines Network (SIGN), Canadian Medical Association Infobase of Clinical Practice Guidelines, l'Agence nationale d'accréditation et d'évaluation en santé (France), New Zealand Guidelines Group, eGuidelines, EBMPracticeNet, National Guideline Clearinghouse (NGC), WHO Guidelines, Haute Autorité de santé (HAS), France, Agency for Healthcare Research and Quality , National Health Service Evidence (UK), American Academy of Orthopaedic Surgeons (AAOS), British Orthopaedic Association (BOA), BOA Standards for Trauma and Orthopaedics January 2012, Société Française de Chirurgie Orthopédique et Traumatologique (SOFCOT), British Society for Surgery of the Hand (BSSH), and National Health Society (NHS). Considering the heterogeneity of the rehabilitation needs after fractures of different bones, we decided to limit the search to long appendicular bones, namely humerus, radius, femur/hip, and tibia. The search strategies are reported in Appendix 1. The search was performed on 27 February 2019, and included all documents from 2009 to 2019 regarding CPGs on fractures in both children/youths and adults, progressing as follows:Independent abstract and full-text screening of the retrieved documents by members of the Technical Working Group (TWG);Independent quality evaluation of the CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool by two members of the TWG , with a The final selection of a maximum of five CPGs for each age group (children/youths and adults), according to the following criteria: (1) quality, (2) publication time, (3) multiprofessionality, and (4) comprehensiveness. This decision was reached by agreement of the whole group;Data extraction using a standardized form, comprising information on the recommendation , the strength of the recommendation, and the quality of the evidence used to inform the recommendation.This systematic review of CPGs was developed in full compliance with the methodology presented in the introductory PIR paper , based oNo changes were made to the published protocol. The quality check and methodological support for this study were provided by Cochrane Rehabilitation.The topics addressed by each CPG for the different types of recommendation  were extracted. The topics from the first CPG were compared independently by two authors and integrated with those coming from the second. If required, agreement was reached by discussion involving a third author. This process was repeated for all the CPGs until final agreement on the topics was achieved.The results of the selection process are reported in Fig. After rating the remaining 13 guidelines, our TWG discussed and then excluded 6 CPGs from the final selection based on one of the following criteria: quality, publication time, multiprofessionality, and comprehensiveness –28. We fThe median AGREE II rating for the identified CPGs was 75 14–100), while that of the selected CPGs was 100 (99–100)  considered by the selected CPGs are summarized in Tables Regarding the recommendations on rehabilitation following distal radius fracture, the AAOS radius CPG recommends a home exercise program as an option for patients’ functional recovery  and the DHA radius CPG recommends providing only practical instructions on self-rehabilitation after distal radius fracture in uncomplicated cases  , 30. In Regarding management of hip fracture in adults, the ANZHFR hip CPG  containsWe performed a search for CPGs on rehabilitation management of adults with fractures, limited to the following sites: humerus, radius, femur/hip, and tibia. High-quality CPGs including information on rehabilitation were identified for distal radius and femoral/hip fractures only –33. As aIn patients with radius fracture treated with stable fixation or conservatively, available CPGs recommend, in all uncomplicated cases, nonsupervised exercises at home, active finger motion exercises, and use of ultrasound and/or ice , 30. HowFor adults with femoral/hip fracture, three CPGs were selected. The NICE hip and ANZHFR hip CPGs recommend to include a rehabilitative approach in a coordinated and multidisciplinary model of care. In this context, managing cognitive impairments and mobilizing patients from the day after surgery are the cornerstone of rehabilitation with the aim of enhancing functional recovery –33. In gAll the CPGs for adults with fracture provide a few recommendations for rehabilitation interventions based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to define the level of evidence supporting the recommendations provided. However, a substantial issue is the overall low to very low quality of evidence in the studies, resulting in a weak/conditional strength of recommendations, on the basis of consensus of expert opinions or uncontrolled case series.Therefore, well-designed randomized control trials and observational studies are required to enrich the evidence on rehabilitation management of adult patients with fracture.Few recommendations for rehabilitation interventions are presented, resulting in several gaps in relevant rehabilitative areas. Furthermore, the quality of the available evidence included in the CPGs is weak. There is a need for rigorous studies to inform the future development of guidelines on rehabilitation in patients with fracture to improve the state of the art and knowledge on rehabilitation for these very common health conditions. Future studies and guidelines should consider the specific situation in low- and middle-income countries.


Echocardiography (echo) is the primary imaging modality for infective endocarditis (IE). However, the recommendations on timing and mode selection for transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) vary across guidelines, which can be confusing for clinical decision makers. In this case, we aim to appraise the quality of recommendations by appraising the quality of various guidelines.A search of guidelines containing recommendations for the appropriate use of echo in adult IE patients published in English between 2007 and 2019 was conducted. The APPRAISAL OF GUIDELINES FOR RESEARCH & EVALUATION II (AGREE II) instrument was applied independently by two reviewers to assess the integrated quality of the identified guidelines. The recommendations of concern are extracted from related chapters.A total of 9 guidelines met the criteria, with AGREE II scores ranging from 36 to 79%, and the domain of “stakeholder involvement” received the lowest score. The most contentious issue is whether a follow-up TEE is mandatory in uncomplicated native valve IE with an initial positive TTE. Conflicting recommendations are presented with a low evidence level based on little evidence.In general, the recommendations proposed in the 9 identified guidelines on the appropriate use of echo are satisfying. The guideline quality score can be taken into account by the clinicians when evaluating the recommendations for clinical decisions. Additional studies with high evidence level should be conducted on the most controversial issues of whether a subsequent TEE is mandatory in uncomplicated native valve IE with an initial positive TTE.The online version contains supplementary material available at 10.1186/s12879-021-05785-6. Echocardiography (echo) is the primary imaging modality for infective endocarditis (IE). A positive echo is defined by vegetation or abscess, and new dehiscence of the prosthetic valve is included as a major modified Duke criterion along with positive microorganisms . In addiA literature search of current clinical practice guidelines that contain recommendations on IE imaging was conducted on PubMed, Embase, Web of Science and websites of guideline development societies  scope and purpose, ii) stakeholder involvement, iii) rigor of development, iv) clarity of presentation, v) applicability, and vi) editorial independence. Two reviewers evaluated 23 items across 6 domains independently by providing scores ranging from 1 to 7, where 1 represents strong disagreement due to no relevant information given or the concept being barely addressed, and 7 represents strong agreement due to exceptional reporting quality or fully meeting the criteria of AGREE II. The final score for each domain was obtained by the calculation formula given by AGREE II: the scaled domain score = (obtained score – minimum possible score)/(maximum possible score – minimum possible score). If the difference between the scores given by both reviewers for a certain item was greater than 20% of the lower score, a third reviewer reviewed and evaluated the guidelines . The guiExcept for the guidelines of the Chinese Society of Cardiology, version 2015 and the Swedish Society of Infectious Diseases, version 2007  without the report of Conflicts of Interest (COI) , 11, we All recommendations on the appropriate use of echo, including the timing and mode (TTE and TEE), were extracted from the relevant chapters. In an effort to avoid phrasing confusion, the recommendation class and level of evidence quoted from SSID 2007 were converted into a unified form that is consistent with those used in other guidelines . The recA total of 1015 records were searched during the literature search, and 1006 records were removed after the review of the title, abstract, and full text  includes items on the overall goal, the specific health issues contained in the guideline, and its target population. In contrast with other domains, guideline performance in this domain is nonspecific; that is, most of them generally summarized the concerning issues without any further elaboration. NHAM 2017, BSAC/BHRS 2014, and BSAC 2011 , 15, 17 Domain2 (stakeholder involvement) concerns whether the guideline was developed by appropriate stakeholders and whether the views of its intended users were considered. This domain received the lowest average score, with two-thirds of the guidelines were scoring no more than 33%. Only NHAM 2017, BSAC/BHRS 2014, and JCS 2017 , 15, 16 Domain 3 (rigor of development) comprises the processes of evidence synthesis, the formulation of the recommendations and update procedures. CSC 2015 and SSID 2007 , 11 repoDomain 4 (clarity of presentation) involves the clarity of the description and the format of the guideline. The guidelines received the highest average scores in this domain, and the variation in the scores was the smallest among all domains.Domain 5 (applicability) addresses practical implementation, efforts for improving uptake, and resource implications. Additional disseminating materials were provided by only NHAM 2017 ESC 2015 and AHA 2015 –14. Few r = − 0.081 P = 0.863) for the rest of the guidelines.Domain 6  pertains to transparency declarations, including the funding body and competing interests of the members of the guideline-development group. Nor information on the funding body or its influence on the content was mentioned by JCS 2017, CSC 2015 or SSID 2007 , 11, 16.P = 0.015), “applicability” (P = 0.005) and “editorial independence” (P = 0.024)  received scores lower than 60%. According to the independent-sample t-test, t’-test  and Wilcoxon rank-sum test (clarification of presentation), the guidelines classified as “Recommended with modification” were significantly different from those classified as “Strongly recommended” in the domains of “rigor of development” (24) Fig. . With reThe recommendations for various clinical scenarios were organized and listed in Table Seven of the 9 guidelines included recommendations on the first-line modality of suspected IE. Except for the contradictory and inconclusive statement of SSID 2007, all other guidelines (6 out of 7) agreed that TTE should be the first choice .Five of the 9 guidelines recommended further TEE, when first-line TTE is proven to be nondiagnostic due to its poor echocardiographic window, due to the higher sensitivity of TEE  .For patients with suspected IE under a prosthetic heart valve/intracardiac device, TEE was recommended by 5 of the 9 guidelines . Furthermore, suggestions for patients with implantable cardiac electronic devices (ICEDs) were given by the guidelines of BSAC/BHRS 2014, recommending that echo should be conducted for patients with implantable cardiac electronic device lead infection (LCED-LI), implantable cardiac electronic device-associated native or prosthetic valve endocarditis (LCED-IE) and suspected generator pocked infection concurrent with ICED-LI or ICED-IE (level of evidence: B-C) .S. aureus bacteremia (SAB) by 7 of the 9 guidelines .Echo is recommended for patients with Follow-up echo (no mode was specified) was advised by 5 of the 9 guidelines after the onset of a suspected IE . Among them, ESC 2015 and CSC 2015 further specified the clinical manifestations of a complication include new murmur, embolism, persisting fever, heart failure, abscess, and atrioventricular block , 14, whiFor patients under medical therapy, 3 of the 9 guidelines recommended follow-up echo . In addition, follow-up echo is recommended only for complicated IE in SSID 2007 (strength of evidence: II C) and IE with suspected development of complications in AHA 2015 (strength of evidence: I B). Moreover, SSID 2007 stated that TEE is not needed for uncomplicated IE or those with good response to treatment (strength of evidence: II C) , 13.An intraoperative echo examination for IE patients requiring surgery was recommended by 3 of the 9 guidelines  and was mentioned by BASC 2011 with no formal recommendation . MoreoveAt the completion of antibiotic therapy, TEE is recommended by 6 of the 9 guidelines .Regarding whether a follow-up TEE is needed for suspected IE with a positive TTE, the guidelines offered varied guidance based on the features of the target population. For example, BASC 2011 suggested that a positive TTE should be considered to indicate the need for a subsequent TEE, except the isolated right-sided native valve endocarditis (NVE) with good quality TTE examination  . ESC 201As shown in the lower part of Fig. This is the first time that the controversies among recommendations on the appropriate use of echo were evaluated using the AGREE II score of guidelines.Of the 9 guidelines, the methodology sections of NHAM 2017 and BHRS 2014 indicated that the entire content was compiled based on the AGREE II principle, and both of these guidelines received a score higher than 60% , 15. HowIt should also be noted that some studies have shown that exposure to information provided directly by pharmaceutical companies is associated with higher prescribing frequency, higher costs and lower prescribing quality. Therefore, disclosure of potential COI could be necessary , 20. HowBased on the comparison of the recommendations and viewpoints presented by the guidelines, the algorithms for echo use were similar in most cases. Differing recommendations were mainly given on more specific clinical scenarios, and these recommendations were complementary and without conflict. However, there are 2 issues still up for debate.TTE has been proven to have a sufficient negative predictive value for NVE in patients with low to intermediate risk when strict negative criteria were applied , 22. ForFor the most controversial issue of whether a subsequent TEE is mandatory in uncomplicated NVE with initial positive TTE, ESC 2015, JCS 2017 and BASC 2011 recommended TEE for all patients except those with isolated right-sided NVE , 16, 17,According to AGREE II and compared with guidelines classified as “Recommended with modification”, those guidelines classified as “Strongly recommended” were more rigorously developed, and the recommendations involved in these guidelines were of higher quality. Clinicians can rely on the guideline quality score when evaluating the recommendations for clinical decision making. In addition, it is also expected that updated to the guidelines will lead to better performance in the domain of “stakeholder involvement”. For the most contentious issue, i.e., whether a subsequent TEE is mandatory in uncomplicated NVE with initial positive TTE, related studies are rarely seen. Therefore, more research on this issue, especially studies with high evidence levels, is desired in the future.Additional file 1: Table S1. Websites of organizations and societies.Additional file 2: Table S2. The detailed search strategy of databases.Additional file 3: Table S3. References of 9 included guidelines.Additional file 4: Table S4. The AGREE II scores of six domains for the included 20 guidelines.Additional file 5: Table S5. Recommendations with controversies.Additional file 6: Table S6. Recommendations without controversies.


Clinical interpretation of changes measured on a scale is dependent on knowing the minimum clinically important difference (MCID) for that scale: the threshold above which clinicians, patients, and researchers perceive an outcome difference. Until now, approaches to determining MCIDs were based upon individual studies or surveys of experts. However, the comparison of meta-analytic treatment effects to a MCID derived from a distribution of standard deviations (SDs) associated with all trial-specific outcomes in a meta-analysis could improve our clinical understanding of meta-analytic treatment effects.We approximated MCIDs using a distribution-based approach that pooled SDs associated with baseline mean or mean change values for two scales , as reported in parallel randomized trials (RCTs) that were included in a systematic review of cognitive enhancing medications for dementia (i.e. cholinesterase inhibitors and memantine). We excluded RCTs that did not report baseline or mean change SD values. We derived MCIDs at 0.4 and 0.5 SDs of the pooled SD and compared our derived MCIDs to previously published MCIDs for the MMSE and ADAS-Cog.We showed that MCIDs derived from a distribution-based approach approximated published MCIDs for the MMSE and ADAS-Cog. For the MMSE , we derived a MCID of 1.6 at 0.4 SDs and 2 at 0.5 SDs using baseline SDs and we derived a MCID of 1.4 at 0.4 SDs and 1.8 at 0.5 SDs using mean change SDs. For the ADAS-Cog , we derived a MCID of 4 at 0.4 SDs and 5 at 0.5 SDs using baseline SDs and we derived a MCID of 2.6 at 0.4 SDs and 3.2 at 0.5 SDs using mean change SDs.A distribution-based approach using data included in a systematic review approximated known MCIDs. Our approach performed better when we derived MCIDs from baseline as opposed to mean change SDs. This approach could facilitate clinical interpretation of outcome measures reported in RCTs and systematic reviews of interventions. Future research should focus on the generalizability of this method to other clinical scenarios. In communicating research findings to knowledge users , researchers must describe the statistical and clinical significance of their findings, which can be challenging when changes in health status are reported with a clinical scale. For example, although cholinesterase inhibitors and memantine are associated with statistically significant improvements in cognitive function in persons with dementia, the clinical meaningfulness derived from treatment with cholinesterase inhibitors and memantine is unclear , 2. The There are two main approaches for determining the MCID: anchor-based and distribution-based . An anchUntil now, approaches for determining MCIDs were based upon individual studies or surveys of experts , 6, 12. We used data from a published systematic review and network meta-analysis of the comparative effectiveness and safety of cognitive enhancers  for treating Alzheimer disease . Specifipooled) from parallel RCTs included in a systematic review reporting the scale of interest, where ni is the number of participants per study arm, and SDi is the standard deviation associated with each mean change or baseline scale score per study arm . Wh. Wh19]. We demonstrated how a distribution-based approach using systematic review methods can estimate MCIDs for scales reporting an outcome of interest. We found that our distribution-based approach derived MCIDs that were similar to accepted MCIDs for measuring changes in cognitive function in persons with Alzheimer disease , 20. HowOur derived ADAS-Cog and MMSE MCIDs are similar to published MCIDs Table  6, 20, , 20, 22.There are advantages to deriving MCIDs using systematic review methods and a distribution-based approach. Systematic reviews use explicit methods to synthesize evidence, which minimizes bias in the derivation of effect estimates and their associated measure of uncertainty . Systemapooled) estimated from systematic review data can also facilitate back-transformation of standardized mean differences derived from meta-analyses to mean differences. To derive a mean difference (MDj) from a standardized mean difference (SMDj), multiply SDpooled by each standardized mean difference (SMDj), as follows: MDj = SMDj x SDpooled. Researchers often either interpret a standardized mean difference with respect to thresholds first proposed by Cohen  or they back-transform standardized mean differences to mean differences, as described in the Cochrane Handbook of Systematic Reviews for Interventions [If an outcome in a meta-analysis is reported with more than one scale, the pooled standard deviation  for treating Alzheimer disease might not be generalizable to MCIDs for these scales if using a nonpharmacologic intervention ; however, MCIDs for determining meaningful changes in pain scores for patients with osteoarthritis did not vary across pharmacologic , nonpharmacologic (i.e. rehabilitation), or surgical  interventions . And, siWe demonstrated how a distribution-based approach using systematic review data can estimate MCIDs for scale-based outcomes in a systematic review of interventions. Given that MCIDs represent thresholds for clinically discernible changes as measured on a scale, it is important for researchers to have a way of estimating MCIDs for outcomes derived from systematic reviews that can be communicated with knowledge users. We believe this distribution-based approach will help knowledge users to better understand the clinical importance of outcomes reported in systematic reviews and meta-analyses and it can estimate MCIDs where no published estimates exist, thereby facilitating shared decision making. Future research should focus on the generalizability of this method to other clinical settings by using scale-based outcome measures from systematic reviews of RCTs of interventions in other healthcare disciplines. Our method could also be used in the design of future trials of interventions to estimate sample sizes required to show clinically meaningful differences for patients and to help patients and clinicians interpret trial outcomes.


N = 1392), parents (N = 584) and school staff (N = 317). Results: Exploratory factor analysis (EFA) suggested the six items of the Well-Lit 6 form an independent construct, empirically distinguishable from other wellbeing-related constructs . Convergent analyses showed wellbeing literacy was positively related to wellbeing and negatively related to illbeing. Incremental validity analyses showed wellbeing literacy predicted variance in wellbeing and illbeing after controlling for participant demographics, resilience, and emotion regulation, showing initial evidence of incremental validity. Conclusions: Our results provide preliminary evidence that wellbeing literacy is a distinct construct from wellbeing and illbeing, and it also demonstrates significant unique variance in these constructs over and above resilience and emotion regulation. The Well-Lit 6 is a useful provisional measure of wellbeing literacy, although we suggest a fruitful avenue for future research is to develop a more comprehensive scale of wellbeing literacy that denotes specific facets of communication, allowing a fuller exploration wellbeing literacy, its components, and their antecedents and consequences. We offer further recommendations for future research and discuss limitations with our approach.Aims: Wellbeing literacy is the intentional use of wellbeing relevant vocabulary, knowledge and language skills to maintain or improve the wellbeing of oneself, others and the world. In this study, we operationalize the human aspects of the concept of wellbeing literacy and empirically test its relationship with wellbeing and illbeing. We also assess its incremental variance in wellbeing and illbeing, after controlling for existing and well-established predictors of these constructs within education settings. Methods: We developed and empirically tested the Wellbeing literacy 6-item (Well-Lit 6) scale to assess the concept of wellbeing literacy in the education context. The scale was developed based on a working definition of wellbeing literacy, in combination with the Australian Curriculum, Assessment and Reporting Authority (ACARA)’s definition of literacy. The Well-Lit 6 was administered via a cross-sectional survey to three Australian samples that comprise different elements of Australian education systems: students ( Wellbeing is an important concept in public health and the social sciences. The World Health Organization (WHO) defines health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” . This deEducation is a systematic way to improve public health. It allows for nourishing psychosocial environments that support human development , work , and helps to foster health knowledge and behaviours . There aHealth literacy is defined as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”  (p. 357)Definitions and measurement tools of health literacy ,10 contiMental health literacy was proposed as a related yet complementary construct to health literacy, differing insofar as it calls people’s attention to mental, rather than physical, health ,15. The Several kinds of mental health literacy interventions have been implemented in schools and communities to decrease the prevalence of mental illness , with soWellbeing literacy is defined as vocabulary, knowledge and language skills that may be intentionally used to maintain or improve the wellbeing of oneself or others ,19. WellWellbeing literacy holds promise as a means to enhance wellbeing because it is not an intervention per se, but rather is a language-based capability; that is, a repertoire of skills and options one has available to influence their wellbeing. The notion of building capabilities is conducive to the growth-based emphasis of holistic conceptions of wellbeing, such as that proposed by WHO, that comprise both the absence of illness as well as the presence of positive mental health. Moreover, unlike mental health literacy, wellbeing literacy shifts the focus to what is possible, rather than what is broken. Despite growing conceptual arguments for wellbeing literacy ,29,30,31To address these issues, the present study seeks to operationalize and validate a short, empirical measure of the construct of wellbeing literacy, which we have titled the Wellbeing Literacy 6 item (Well-Lit 6) scale. The scale was developed from an initial item pool to be included in broader and established batteries of psychological questionnaires that are regularly offered throughout Australia to assess wellbeing in education systems. Specifically, Well-Lit 6 was included in three batteries that are designed to uniquely examine the wellbeing of students, their parents, and school staff across Australia. Because Well-Lit 6 was included in these questionnaires, a requirement was that it was brief in order to capture the breadth of the population. Hence, the scale was developed based on the working definition of wellbeing literacy, as well as its five necessary conditions, with consideration also given to existing health literacies . This produced an item-pool of 6-items, displayed in As shown in the We assert that wellbeing literacy is a capability, and hence different from wellbeing per se, which we view as an experienced state, and subjective in nature. Wellbeing literacy as a capability involves the potential to use language in the service of wellbeing. This is an important distinction directly relevant to this study. Stated simply, some educators may assert they are “teaching wellbeing”. Rather, we claim that they are using language to enable students to learn about how to improve their wellbeing or the wellbeing of others. The potential and re-usable language used by the teacher, and hopefully the learner, constitutes wellbeing literacy, not wellbeing itself. The experience of wellbeing is exactly that—an experience—therefore the language used to teach about and for wellbeing is literacy. A cognitive evaluation of an experience over time, such as life satisfaction, is also different from wellbeing literacy, as it represents a subjective evaluation of a state, rather than the building of a capability. A wellbeing literate individual may, however, find it easier to evaluate their experiences of wellbeing. Because construct proliferation and construct redundancy are major problems in the social sciences today , an impoTo do this we use three approaches. First, to establish convergent validity, we evaluate whether wellbeing literacy is related in expected directions with constructs covering related conceptual terrain. Relations should be substantive although not strong enough to suggest duplication . PositivAlthough wellbeing literacy is a novel and important construct that could inform psychological and educational research, there has yet been limited endeavour to develop a quantitative measure of the construct that could be used in research. It is therefore currently unknown whether wellbeing literacy is empirically distinguishable from related constructs that are thought to represent its consequences, such as wellbeing or illbeing. Moreover, there is no existing evidence about whether wellbeing literacy will serve as an important antecedent to these outcomes. The aim of this research is to investigate the construct of wellbeing literacy in educational settings, examining the first available measure of wellbeing literacy (Well-Lit 6) and its position in the nomological network. In conducting our research, we hypothesize that:Hypothesis 1 (H1):There will be a significant positive relationship between wellbeing literacy and wellbeing, including life satisfaction and positive mental health  .Hypothesis 2 (H2):There will be a significant negative relationship between wellbeing literacy and illbeing, including depression, anxiety, stress  .Hypothesis 3 (H3):Wellbeing literacy will load on its own factor when placed into a broader exploratory factor analysis (EFA) model containing related wellbeing and illbeing constructs  .Hypothesis 4 (H4):Wellbeing literacy will predict incremental variance in wellbeing after controlling for resilience and emotion regulation  .The present study was completed across three samples of participants, including students, parents, and school staff. The student sample consisted of 1392 students, comprising 722 girls and 603 boys (67 other). Their mean age was 14.47 years (SD = 1.77). The parent sample consisted of 584 parents . Their mean age was 42.69 years (SD = 6.32). The sample of school staff consisted of 317 employee respondents, including 251 females and 61 males (5 other). Their mean age was 42.45 years (SD = 11.95). All participants were recruited from Victoria in Australia, and informed consent was obtained prior to participation in the study. The study was approved by the Human Research Ethics Committee at the University of Melbourne  and the Victorian Department of Education and Training (#2019_004002). All three samples of participants were recruited as part of a larger community-wide wellbeing project. All samples completed a survey battery comprised of wellbeing literacy, as well as different aspects of wellbeing and illbeing. The measures contained within each battery are listed in As shown in The wellbeing literacy 6-item (Well-Lit 6) scale was developed from the working definition that wellbeing literacy is vocabulary, knowledge and language skills that may be intentionally used to maintain or improve the wellbeing of oneself or others , and wasWe measured wellbeing with the Mental Health Continuum-Short Form (MHC-SF) . The MHCWe also assessed life satisfaction with a 2-items adapted from the Student’s Life Satisfaction Scale (SLSS)  in the sWe broadly measured illbeing using more specific items to evaluate Depression, Anxiety, and Stress. Depression and anxiety were both assessed with 2-items from the Patient-Health Questionnaire-4 (PHQ-4) . Stress To assess the incremental validity of the Well-Lit 6 scale, we evaluated whether it showed additive variance in the wellbeing or illbeing measures over and above established predictors, including emotion regulation and resilience. To measure emotion regulation, we used a collection of items across encompassing emotion and cognitive emotion-regulation subdomains. The emotional components included reappraisal  and suppression  and were adapted from the emotion regulation questionnaire (ERQ) . We measTo measure resilience, we used 5-items adapted from the brief resilience scale (BRS) . A samplR2 were used to support incremental variance explained over and above these existing constructs. Finally, we estimated Cronbach’s alpha reliability coefficients to determine the internal consistency reliability of the scale.To establish preliminary evidence for the reliability and validity of the Well-Lit 6 we used several approaches. First, to determine discriminant validity, we used EFA with principal components estimation and oblique rotation to test whether the items of Well-Lit 6 can be empirically differentiated from other variables purported to measure similar, yet conceptually different constructs. Should wellbeing literacy load on its own factor, it provides some evidence of discriminant validity. As recommended by Costello and Osborne , a valueTo examine the convergent validity of the Well-Lit 6, the 6-items were correlated with other variables with which they should theoretically be related. These results are shown in To examine the discriminant validity of the Well-Lit 6, we used exploratory factor analysis with principal component estimation and oblique rotation to examine whether the 6-items loaded on their own factor when alongside a variety of other well-being measures. For space reasons, we present the results of these analyses in our R2. Thus, age and gender were added first into the model (step 1), after which emotion regulation and resilience were added (step 2), and finally, wellbeing literacy was added in the final stage (step 3). As shown in R2 after adding wellbeing literacy, with the largest observed change for life satisfaction: ΔR2 = 0.027 (p < 0.001); β = 0.209 (p < 0.001). This suggests wellbeing literacy has incremental validity in predicting life satisfaction over resilience and emotion regulation. Similarly, using the same procedure, wellbeing literacy displayed significant incremental benefit in predicting variance in anxiety, depression, stress, and loneliness over and above demographics, resilience, and emotion regulation, although the ΔR2 values were notably smaller, ranging from 0.003 to 0.006. Taken together, these results lend support to H4. The incremental validity tests were employed to examine the additive value of wellbeing literacy over and above existing wellbeing related predictors, and are shown in We examined the reliability of the Well-Lit 6 using internal consistency reliability (Cronbach’s α). As shown in The aim of the present study was to investigate the construct of wellbeing literacy in educational settings, establish preliminary evidence for a new 6-item scale of wellbeing literacy (Well-Lit 6), and to test whether wellbeing literacy is empirically distinguishable from wellbeing, illbeing, and their predictors. Additionally, we examined whether wellbeing literacy explained additive variance in wellbeing and illbeing over and above emotion regulation and resilience. Supporting H1, wellbeing literacy was positively associated with wellbeing, including life satisfaction, emotional wellbeing, psychological wellbeing, and social wellbeing. Results also showed wellbeing literacy was negatively associated with illbeing, including depression, anxiety, stress, and loneliness (supporting H2). Wellbeing literacy was empirically separable from other wellbeing and illbeing related scales, loading on its own factor (H3), and explained additive variance wellbeing and illbeing after controlling for emotion regulation and resilience (H4). We take these results to offer preliminary evidence for the validity of the Well-Lit 6 as a short measure of wellbeing literacy.Our study provides preliminary evidence that the new construct of wellbeing literacy differs from existing variables across various domains of wellbeing and illbeing. We also showed that wellbeing literacy explained incremental variance in wellbeing and illbeing after controlling for emotion regulation and resilience. These results provide preliminary evidence that wellbeing literacy is a unique construct that offers predictive validity in wellbeing and illbeing outcomes beyond existing constructs. Our study provides evidence for the first empirical scale of the new construct of wellbeing literacy and we expect that it can be used as a preliminary measure for future research and practice. In particular, the Well-Lit 6 offers researchers a path to establish empirical literature on wellbeing literacy, providing a means to establish evidence for its antecedents, correlates, and consequences. Moreover, it will allow researchers to evaluate whether wellbeing literacy mediates and/or moderates relations between interventions designed to enhance wellbeing and wellbeing outcomes, as has been previously proposed . While tOur regression analyses demonstrated that wellbeing literacy yielded smaller relations with illbeing than wellbeing related factors. There has been a long discussion about whether wellbeing and illbeing are bipolar or orthogonal constructs ,61, withAs discussed, existing health literacies are limited as they are focused almost exclusively on physical health , and mental illness . They therefore do not capture the positive side of mental health and may offer a limited means to enhance public health. Wellbeing literacy differs insofar as it is focused more on human capability and growth potentials, therefore providing a means to advance the positive side of mental health. We expect this difference will offer practitioners at all levels of public health a promising means to improve human welfare beyond just relieving physical or mental health symptoms. Further, wellbeing literacy would offer a model for wellbeing science and have positive implications for practices in the domains of work and family .In general, the new scale of wellbeing literacy (Well-Lit-6) demonstrated reliability and construct validity. These findings support the construct of wellbeing literacy and provide an empirical base for further investigation. However, it should be acknowledged that the present study has several limitations. First, the Well-Lit 6 was required to be a short scale to gain access to the broad education-based populations. As a result, it was not possible to develop and validate separate measurements for its sub-components that reflect its necessary conditions. Thus, future research should work to develop more comprehensive measures of wellbeing literacy that incorporate these dimensions.A related limitation is that the data were from an existing dataset that was not aimed specifically for research on wellbeing literacy. Hence, the variables measured in the student sample did not precisely correspond to those used in the parent and staff samples. This meant that all analyses of incremental validity were performed only in the student sample and need to be replicated. Moreover, our tests for incremental validity only covered the most central wellbeing predictors in the literature (emotion regulation and resilience). Future research should further test the incremental validity of wellbeing literacy beyond other predictor variables  to evaluate the additive value of this new construct.Finally, all measures are self-reported, which may produce common method bias , resultiThe present study evaluated the Well-Lit 6 as a new 6-item scale of wellbeing literacy. We found that wellbeing literacy demonstrated convergent validity by relating in expected directions with wellbeing and illbeing. The scale demonstrated discriminant validity by loading on its own factor when incorporated into a broader EFA model containing several indicators of wellbeing and illbeing. Finally, the scale demonstrated incremental validity in wellbeing and illbeing after controlling for emotion regulation and resilience. Taken together, we accept these data to suggest that the Well-Lit 6 offers a preliminary yet valid measure of the new construct of wellbeing literacy.


The published literature has produced several definitions for the sense of presence in a simulated environment, as well as various methods for measuring it. The variety of conceptualizations makes it difficult for researchers to interpret, compare, and evaluate the presence ratings obtained from individual studies. Presence has been measured by employing questionnaires, physiological indices, behavioral feedbacks, and interviews. A systematic literature review was conducted to provide insight into the definitions and measurements of presence in studies from 2002 to 2019, with a focus on questionnaires and physiological measures. The review showed that scholars had introduced various definitions of presence that often originate from different theoretical standpoints and that this has produced a multitude of different questionnaires that aim to measure presence. At the same time, physiological studies that investigate the physiological correlates of the sense of presence have often shown ambiguous results or have not been replicated. Most of the scholars have preferred the use of questionnaires, with Witmer and Singer's Presence Questionnaire being the most prevalent. Among the physiological measures, electroencephalography was the most frequently used. The conclusions of the present review aim to stimulate future structured efforts to standardize the use of the construct of presence, as well as inspire the replication of the findings reported in the published literature. Presence, which refers to the sense of “being there” in a simulated environment, is a critical concept in the discussion of new technologies and mediated environments . These characteristics, even if connected with the sense of presence , do not directly represent the subjective sense of presence.Performance in a VR scenario was directly investigated by a recent study , also known as electrodermal activity (EDA) or SC [sometimes in the literature as skin conductance responses (SCRs)], which measures how the electrical variations in the skin trigger eccrine sweat glands, a phenomenon that allows SC measurement. In the present article, the abbreviation “SC” will be used to refer to this methodology. The use of SC is well-documented in the literature on human emotion and cognition , even though researchers are still in the process of understanding the exact meanings of those different components of SC  has also been investigated as a possible correlate of presence. In the present review, we do not focus on the various HR analysis methods. However, the most used methods in psychophysiological research are heart rate (HR) and heart-rate variability (HRV). HR is the calculation/estimation of the average heartbeats per timeframe . HRV, instead, is the measure (in milliseconds) of the changes  between successive heartbeats. This time period is called the R-R interval  is a rather simple experimental methodology in which a sensor records the temperature of the participant. Even though the use of skin temperature in psychological research date back many years  is a technique for recording the electrical activity produced by skeletal muscles. Its setup is easy and inexpensive. However, it finds limited application within the field of cognitive psychology. As subject muscle activity is strongly related to the EMG signal, it has been extensively used in clinical and sports medicine Steele, . HoweverWhile physiological measures could be more objective indices of the level of presence experienced by a subject, there is no consensus on which measure is the best to use. Furthermore, many of these measures have methodological limitations  and therefore cannot be applied for all situations and in all VEs.A third approach for measuring presence is behavioral. It is a sign of a higher level of presence when participants in a VE behave as if they are in a real environment. Some examples of this phenomenon include user behaviors related to conflicting multisensory cues that emanate from both real and simulated environments Slater, , posturaHein et al. , in theiThe methodology utilized here was a systematic literature review of published research articles, following the guidelines stated in the Preferred Reporting Items for Systematic Reviews  were also excluded. Finally, 18 articles were included in the review. The scientist that worked on the selection of the article did not have any conflicts of interest in evaluating the inclusions. However, a degree of subjectivity in choosing the inclusion/exclusion criteria as well as selecting the articles fitting those criteria may have affected the selection of the articles included in the final phase of the review . This represents a limitation to the systematicity of the present review.The study results are presented in the following paragraphs. They are firstly analyzed regarding the questionnaires used, and in the following section of the review, regarding the physiological measures. A critical overview of the measures and the main findings of the analyzed articles is also presented.The most utilized method for evaluating presence is by self-reporting questionnaire , but intrinsic differences exist due to the designer's conceptualizations of presence, as noted by Slater  in his cWith the proliferation of technologies that aim to simulate interactions between people and environments, there is a need to evaluate presence metrics to build measurements that can consistently predict the sense of presence of the users (based on a unified theory). Thus, developing questionnaires to measure presence properly is still an ongoing scientific endeavor. Factor analysis was used in the analyzed articles to test the construct validity of the MPS, IPQ, and IEQ specifically reported in that article. The predictive validity of the questionnaires is sometimes stated in the original article. As reported in Items for many of the analyzed questionnaires were sometimes unclear or difficult to grasp for a naïve participant, e.g., “How is your memory of the scenario similar to being in real places?”  are coherent with previously published reviews  were found in the literature . Construct validity of the scales was generally assessed by reviewing the already existing literature; sometimes, factor analysis (IEQ or MPS) was utilized to assess it. Human performance was used directly to validate the effectiveness of the most-used scales , and the difficulties related to the communication of the feeling of presence Slater, .Presence is the sensation of being in the place presented in a VE  of the dorsolateral prefrontal cortex in the experience of the sense of presence and on the role of the insula. However, Clemente et al.  reportedThe reviewed literature showed that little effort had been made to replicate the physiological indices proposed for the feeling of presence, despite the ambiguous results sometimes reported and the variety of different methods used for indexing the phenomenon. When replication was deliberately attempted, the early results were not always successful  with the sense of presence  may profoundly influence the physiological data. Only systematic replicative efforts of published studies, as well as future investigations that aim to isolate the phenomenon of presence and reduce the influence of confounding factors, can help to identify reliable physiological correlates of presence. An optimal physiological correlate of presence should be able to discriminate the level of the user's presence with a high correlation with self-reported questionnaires and independently from the content of the VE experience.Moreover, VE content can affect the recorded data and thus constitute an uncontrollable variable when comparing among different experimental settings. It may be challenging to isolate the phenomena of “presence” Immersive media are currently used as a popular source of entertainment . Considering that in the coming years, VR technology users will probably increase in number, there is a need for research on standard practices and standardization in the area to understand the effect of those technologies on the end-user, as well as to help in the development of better ones in the future.At the current state of research, no physiological measure has collected enough evidence to be considered “good enough” to be reliably used alone, without the user giving their subjective evaluation of the experience. The nowadays quite outdated study of Meehan et al.  comparedPhysiological measures, especially SC and EEG, showed widespread use. However, despite contrasting results in the literature, little effort has been invested in systematically replicating already published studies. In this regard, when talking about new technology, it is essential to acknowledge that technical progress evolves very quickly, and several of the reviewed studies were conducted more than a decade ago. Thus, their findings may have still-relevant but limited implications for recent technology . As such, more studies should be performed based on current technology and devices. Furthermore, some studies should aim to replicate old findings using new devices. This line of research can help with the development of a more comprehensive theoretical framework for presence and related constructs.Future research should also focus on the role of presence in shaping human performance. The role of presence in new media and its relationship with user performance may be of great interest for applied research in the field of IVTs. More empirical research is needed to understand better how the sense of presence  may represent a positive or a negative factor for human performance, depending on different uses of IVTs. The authors of the present review wish to stimulate the replication of the published scientific research on the physiological correlates of presence, especially in those cases where the published studies have reported conflicting or inconclusive results. At the same time, this review underlines the theoretical problems with the definition of presence as a psychological construct.SG was responsible for retrieving and reviewing the current literature, writing the drafts of the article, including figures and tables, and revise all the previously submitted versions of the manuscript. KL provided funding for the project, extensively commented on the earlier drafts of the manuscript, and revised the manuscript at every stage of its development. Both authors agreed on and commented on the final version of the manuscript prior to submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.