The sea surface temperature (SST) drops rapidly when a typhoon passes over the western North Pacific, and the cold SST is known as cold wake. In general, more intense typhoons on the day of arrival cause stronger SST cooling via turbulent oceanic vertical mixing. Moreover, after intense typhoons have passed, there are cases in which the SST decreases further, and the cold conditions persist for approximately 2 weeks. In this study, we suggest possible mechanisms by which long-lasting cold SST responses to typhoon forcing are related to the generation of cold-core-like ocean circulation. The atmospheric surface cyclonic circulation causes divergent anticlockwise upper ocean currents owing to the Ekman transport, which in turn induces further upwelling and strengthens the cold SST. In the European Center for Medium-Range Weather Forecasts Ocean Reanalysis System 5, cold-core-like ocean current responses were strong in 5 typhoons among the 12 intense typhoons that passed through 30°N in the western North Pacific region from 2001 to 2019. The favorable conditions for a cold-core circulation to occur can be summarized as a slow typhoon migration speed with strong intensity, well stratification of vertical ocean layers, and the absence of large-scale strong background currents. Typhoons are usually accompanied by heavy rainfall, strong winds and low pressure, causing storm surges, swell waves, wind-driven Ekman currents, and vertical ocean mixing8. The ocean vertical mixing or upwelling generally causes cold temperature and additional biogeochemical processes such as increased nutrient supply, primary production, and particulate organic carbon flux18. Cold sea surface temperature (SST) anomalies known as “cold wakes” occur following the typhoon trajectory22. When a strong typhoon impacts on the ocean, the SST drops by approximately to 8 °C, as per in situ observations, and cold wakes continue for days to weeks23. The occurrence of a cold wake has a significant impact on the marine environment and ecosystem; in the case of a slow-moving typhoon, the cold wake interacts with the typhoon and plays a role in reducing the typhoon precipitation by ~ 15%24.Typhoons are important weather phenomena that have a significant impact on the environment and human activities over the northwest Pacific and East Asia25, (2) wind-driven enhanced evaporation26; (3) oceanic turbulent vertical mixing27, and (4) upwelling by Ekman transport28. Except for radiative cooling, all other processes are related to surface wind forcing. Many prior studies have shown that stronger typhoon surface winds lead to stronger ocean upwelling, turbulent mixing, and cold temperature responses30. Typhoon strength can be defined as the maximum wind speed or minimum pressure. In Table Cold wakes occur following the typhoon track, and the major SST cooling mechanisms are known as follows: (1) radiative cooling induced by the reflection of solar short-wave radiation27. However, the reasons why a cold SST persists for a few days or weeks after a typhoon has passed have not been clearly elucidated. This study analyses the possible physical mechanisms that maintain the cold SST after an influence of vigorous typhoon. However, in-situ observations are rare for a strong typhoon to pass directly through, and even when we have that, the observed data is often not available properly due to instrument failure. Therefore, the ocean dynamical and thermodynamical response induced by strong typhoon forcing was analyzed using up-to-date ocean reanalysis and satellite observation data, for typhoons passing through the western North Pacific domain  with intensity classes above 3  passed near the IORS in 2019; Typhoon Danas  was the closest to the IORS on 20 July, 2019, Lekima  was closest to the IORS on 11 August, 2019, and Lingling  was on 07 September, 2019. A rapid SST drop was observed at the IORS, and even in the OISST satellite data when these typhoons passed through the adjacent ocean; the cold SST persisted for 1–2 days before returning to normal state  phase of the typhoon means strengthening (weakening) period of the typhoon intensity in tropics (mid-latitudes), and the mature phase denotes the strongest period in subtropics. These background thermodynamic characteristics are shown in Fig. S436; however, the background temperature distribution is not the always same before the typhoon events due to influence of various climate factors.The ocean subsurface temperature 5 days before the typhoon arrival can be regarded as the normal state or climatology Fig. . The mix39. Not only does each typhoon’s mean migration pace differ, but each typhoon’s propagation speed also varies during its lifecycle .Slow typhoon migration speed for the generation of ocean currents.Ocean layer vertical stratification for upwelling of subsurface cold water.Mid-latitude location with large planetary vorticity to generate cold-core-like vortex currents by the Ekman transport.Of the 12 strong typhoons that passed through the northwest Pacific from 2001 to 2019, 5 typhoons generated cold-core-like horizontal currents at 30°N, wherein the anticlockwise vortex current and divergence were induced, and the cold SST lasted for 2 weeks. In particular, the cold SST peak was noted 4 days after the typhoon passed away. Favorable conditions and possible mechanisms for future SST cooling and long-lasting cold SST signals are as follows:The rapid SST cooling on typhoon affecting day is definitely caused by turbulent vertical mixing; however, the delayed negative peak and cold SST over a long period may be related to the anticlockwise ocean current and the subsequent upwelling. The cold SST persists longer in the subtropics or at mid-latitudes than that in the tropics (not shown) because the Ekman transport and anticlockwise cold-core-like vortex current are stronger at higher latitudes owing to the large planetary vorticity. Meanwhile, the magnitude of the cold SST anomaly peak is stronger when a typhoon is located south of 30°N due to the stronger typhoon forcing.Different background conditions such as large-scale currents and mixed layer depths can cause diverse ocean responses. For example, the ocean circulation and vertical temperature structure in the open ocean and near shore are different. In addition, as shown in Fig. https://www.metoc.navy.mil/jtwc/jtwc.html?western-pacific). The best track data are available from 1945; however, detailed typhoon structure and minimum pressure observation data are available from 2001. From 2001 to 2019, 13 typhoons with intensity category three typhoons coming through the western North Pacific domain  were listed in Table https://www.weather.go.kr/w/typhoon/typ-history.do).The Joint Typhoon Warning Center of the U.S. Naval Pacific Meteorology Oceanography Center in Hawaii  best-track datasets from 2001 to 2019 were extracted  from 1993 to 2019, currently; however, we downloaded data from 2001 to 2019 corresponding to the period of other dataset. The anomaly values shown in this study is calculated as the deviation from the daily climatological calendar mean from 2001 to 2019. The ORAS5 data is made by assimilating the satellite and global in-situ observations44, and has an eddy-permitting 0.25° horizontal resolution and 75 vertical layers from 0.5 to 5902 m. In this study, the upper 25 layers from 0.5 to 108 m were analyzed to focus on the wind-driven currents and upper-level thermodynamic structures. Horizontal divergence and vorticity were calculated using the centered finite difference method from the zonal and meridional components of the currents. Daily NOAA Optimum Interpolation Sea Surface Temperature version 2 (OISST)45 satellite data (https://psl.noaa.gov/data/gridded/data.noaa.oisst.v2.highres.html) were used for the same period as the other datasets. However, the satellite observations and ocean reanalysis data are not always fit well with the in-situ observations regarded as true values. Therefore, for the validation, we have compared the satellite and ORAS5 data with in-situ observation. In situ measurements at the Ieodo Ocean Research Station (IORS) are provided to the research community via the Korea Ocean Research Stations Project website (http://kors.kiost.ac.kr/en/). Danas, Lekima, and Lingling were typhoons that closely approached or passed through IORS in 2019, but they all had an intensity of 0–1 at approach. Figure The daily product of the European Centre for Medium-Range Weather Forecasts Ocean Reanalysis System 5 (ORAS5)46. Here, g = 9.8 m s−2, and H1 = 30 m  km h−1 at 30°N in the Northern Hemisphere47. In the high latitude, the typhoon moving speed tends to become faster; on the contrary, the oceanic baroclinic wave speed is slower due to shallow upper ocean layer depth.The phase velocity of the first baroclinic shallow water wave C is defined as Supplementary Information.


Engaging in regular physical activity requires continued complex decision-making in varied and dynamic individual, social and structural contexts. Widespread shortfalls of physical activity interventions suggests the complex underlying mechanisms of change are not yet fully understood. More insightful process evaluations are needed to design and implement more effective approaches. This paper describes the protocol for a process evaluation of the JU:MP programme, a whole systems approach to increasing physical activity in children and young people aged 5–14 years in North Bradford, UK.This process evaluation, underpinned by realist philosophy, aims to understand the development and implementation of the JU:MP programme and the mechanisms by which JU:MP influences physical activity in children and young people. It also aims to explore behaviour change across wider policy, strategy and neighbourhood systems. A mixed method data collection approach will include semi-structured interview, observation, documentary analysis, surveys, and participatory evaluation methods including reflections and ripple effect mapping.This protocol offers an innovative approach on the use of process evaluation feeding into an iterative programme intended to generate evidence-based practice and deliver practice-based evidence. This paper advances knowledge regarding the development of process evaluations for evaluating systems interventions, and emphasises the importance of process evaluation.The online version contains supplementary material available at 10.1186/s12889-021-12255-w. There is substantial evidence that social structural factors such as deprivation, ethnicity, gender and age influence health-related risk, health outcomes and mortality rates –3. Physiworsen health inequalities, as they are often less accessible and effective for more deprived populations, due to lesser material resources and ‘leisure’ time )An embedded research team is critical for the development of research-practice partnerships, which facilitates evidence-based practice, and the development of practice-based evidence through the JU:MP programme . HoweverThe process evaluation outlined within this paper forms part of a wider evaluation approach, which includes an effectiveness evaluation . Process evaluations can be complementary to outcome evaluations, as the approaches produce different types of knowledge about a phenomenon that can be combined to further advance knowledge , 73. TheDespite significant efforts to address children’s physical inactivity by researchers, practitioners and policy makers, physical activity levels are socially stratified, which can serve to perpetuate health inequalities . Sport EAdditional file 1. JU:MP neighbourhood map. A geographical map of the JU:MP neighbourhood boundaries within the LDP area. File extension: png. The map depicted in Additional file 1 is adapted from QGIS Geographic Information System (2021). Open Source Geospatial Foundation Project. http://ggis.osgeo.org.Additional file 2. JU:MP programme plan. A table providing a description of each of the 15 JU:MP work streams.Additional file 3. Influences on behaviour questionnaire. A survey, adapted from Keyworth et al. [h et al. , used toAdditional file 4. Network mapping survey. A survey to map connections and relationships between different stakeholders and organisations within JU:MP neighbourhoods.Additional file 5. Observational framework. A framework designed to guide the collection and recording of observational data.Additional file 6. JU:MP thematic framework. The framework used to index data as part of the qualitative framework analysis.


The multi-agent information fusion (MAIF) system can alleviate the limitations of a single expert system in dealing with complex situations, as it allows multiple agents to cooperate in order to solve problems in complex environments. Dempster–Shafer (D-S) evidence theory has important applications in multi-source data fusion, pattern recognition, and other fields. However, the traditional Dempster combination rules may produce counterintuitive results when dealing with highly conflicting data. A conflict data fusion method in a multi-agent system based on the base basic probability assignment (bBPA) and evidence distance is proposed in this paper. Firstly, the new bBPA and reconstructed BPA are used to construct the initial belief degree of each agent. Then, the information volume of each evidence group is obtained by calculating the evidence distance so as to modify the reliability and obtain more reasonable evidence. Lastly, the final evidence is fused with the Dempster combination rule to obtain the result. Numerical examples show the effectiveness and availability of the proposed method, which improves the accuracy of the identification process of the MAIF system. With the increasing popularity of artificial intelligence, agent technology has become a hot topic in the field of distributed artificial intelligence. Agents with autonomy and collaboration can deal with complex, collaborative, and unpredictable problems. They can modify their goals with changes in the environment, expand their knowledge, and improve their ability. Due to the constraints of ability and relationships with other agents, it is impossible to solve complex problems using a single agent. Artificial intelligence is maturing. It is committed to solving more complex, more realistic, and larger scale problems. These problems are beyond the capability of a single agent. Therefore, the multi-agent system (MAS)  has emerInformation fusion  is an apAs an uncertain reasoning method, Dempster–Shafer evidence theory (D-S theory) has a strong ability to express and process uncertain information. It serves as a powerful tool in the representation and fusion of decision making with uncertain information. It has been widely used in the fields of information fusion , target In modern engineering applications, electronic information systems tend to be highly integrated, multi-component, and complex functions. Therefore, concurrency, suddenness, and complexity are the three major problems that may occur when the equipment fails ,14,15. IThe MAIF system mainly studies the communication, coordination, and conflict resolution between multiple agents. It is an autonomous solution to the problem of information fusion among agents in MAS. It focuses on the analysis of information fusion between multiple agents rather than the autonomy and development of a single agent. In the process of MAIF, even if all agents use the same original detection data, the conclusions given may be inconsistent, because the reasoning model used by each agent is not necessarily the same. There have been many attempts to improve performance, such as distributed weighting  and relaD-S theory is a good choice for uncertain information processing in MAIF. However, D-S theory may fail in highly conflicting situations, which makes it difficult to guarantee the fusion result. This may lead to unreasonable results . Two metIt is feasible and extensible to integrate evidence theory into the MAIF system. However, D-S theory may result in counterintuitive results in highly conflicting situations. In order to address D-S conflicting information fusion in MAIF, the method based on nbBPA and evidence distance is proposed.In the improved MAIF method, nbBPA provides a kind of prior information to preprocess the data. The evidence distance is used to judge the difference between the bodies of evidence. The weight of each belief function is calculated according to the evidence distance so as to recalculate the revised BPA.The main contributions of this method are different from those of a large number of existing methods and are summarized as follows:The following remainder this paper are organized as follows: D-S theory was first proposed by Dempster in 1967  and thenThe perspective of the discount correction model is the overestimation of the composite result. Because the D-S combination rule is used to fuse the relevant evidence directly, the relevant parts of the evidence are repeatedly calculated. The basic idea of this kind of method is that the relevant evidence should be discounted. The discount coefficient depends on the degree of correlation. Compared with independent evidence, relevant evidence has overlapping information that cannot be given the same weight in the fusion process.Yager proposed a weighted fusion method of relevant evidence with the relative independence degree set as weight . The so-Tessem  designedIn addition, in order to solve the conflicting data in uncertain information, some methods attempt to assign initial belief to events in the frame of discernment (FOD). A new strategy to consider the initial belief degree of propositions in the power set of FOD is proposed in , but it Assuming that there is a problem to judge, all possible solutions N identified in this problem are described as a set. N are mutually exclusive and exhaustive. The set is also known as the framework of discernment (FOD). The FOD is shown as follows:Its power set ism is the mass function of the FOD A, which represents how strongly the evidence supports the proposition A. If m(A) > 0, A is called a focal element.D-S theory assigns a probability to each possible solution within the framework of discernment (FOD), which is called basic probability assignment (BPA). The corresponding assignment function is called the mass function. BPA satisfies the following conditions:k represents the conflict degree between two bodies of evidence. If k = 0, k = 1, The D-S combination rule is a key step in synthesizing the information produced by multiple hypotheses. Two independent mass functions, The D-S combination rule may result in counterintuitive results when data with high conflict are fused. Thus, the bBPA is proposed to modify the BPA before data fusion.Let The initial belief allocated between basic events can introduce prior probability information to elements. In the unknown case, the average distribution of belief maximizes the entropy. The maximum entropy principle shows that when the entropy is maximum, the possible loss is small.bBPA is combined with the initial BPA to modify the BPA before data fusion, and it is defined as follows:In order to resolve the problem that the D-S combination rule produces, namely, counterintuitive results when fusing conflicting data, a previous study proposed a theory of evidence distance to measure the difference between two bodies of evidence. Then, some studies calculated the weight of each belief function based on the evidence distance so as to recalculate the modified BPA.N mutually exclusive and exhaustive hypotheses. The distance between D is an Let From the previous definition, another way to write In general, if a body of evidence is well supported by other bodies of evidence, the evidence is more important in the final fusion. On the contrary, if one piece of evidence conflicts with other bodies of evidence, it should have a smaller proportion in the final fusion. That is, the more similar one piece of evidence is to another, the higher its proportion in the final fusion.The similarity between two bodies of evidence is denoted as k, we can construct a similarity measure matrix (SMM) by obtaining all of the degrees of similarity between the bodies of evidence; Supposing the number of bodies of evidence is i = 1,2, …, k) is defined asThe support degree of a body of evidence The credibility degree MAE) is given by assigning the weight:It is clear that K is the number of elements corresponding to the set The uncertainty of the recognition set is related to the number of elements it contains. The more elements a recognition set contains, the more uncertain its information will be, which corresponds to higher uncertainty. In order to gradually reduce the uncertainty, a reconstructed BPA proposed . It builn is the group number of the mass functions where at least one single element is a focal element. The following is an example of calculating the nbBPA. For FOD bBPA is proposed for uncertain information processing, which equally distributes the probabilities to each BPA . Althougn = 4.In Mx(a) = 3.In Mx(b) = 1.In a) = 0.75, b) = 0.25.Thus, c) = a,b) = b,c) = a,c) = a,b,c) = 0.Then, The method of the MAIF system is presented below, and the comprehensive processing flow chart is shown in Step 1The data of agent Step 2nbBPA is generated by Equation , and it Step 3The reconstructed BPA is generated according to Equation , and norStep 4The distance among different BPAs is measured with Jousselme evidence distance in Equation .Step 5Evidence modification based on Equations  and 14)14).Step 6Evidence combination with the D-S combination rule in Equation .In real life ,49,50, tThe data monitored by agent (1) The form of mass function is converted as follows:(2) The nbBPA is generated, and the initial BPA is modified:BPA is normalized:(3) The original BPAs are reconstructed and normalized, and the results are shown as (4) The SMM is obtained by calculating the Jousselme evidence distance: (5) The support and corresponding credibility degree are obtained by Equations  and 13)13).Sup((6) The credibility weights is assigned to the mass functions for MAE.(7) Evidence is fused using the MAE four times, and the fusion result in the MAIF system is as follows:In some practical engineering applications, the objects identified from the system may change over time . In thisFrom In , Yuan etIf only the D-S combination rule is used, the fusion result may be illogical because of the zero value. Therefore, according to the method shown in a is the highest. According to the final results, the samples are obviously a. In addition, in the BPA of the proposed method, a is higher than that in the original method. The experimental results verify the effectiveness and rationality of the method.From the combination of the two methods, we can see that the BPA of proposition Due to the variability and interference of multi-source information, it is very important to consider the uncertainty relationship in the process of multi-source fusion. When processing information of multiple sources, it is easy to cause data conflicts due to various external factors, such as equipment damage. At the same time, the traditional D-S combination rule may produce counterintuitive results when addressing highly conflicting data. The nbBPA can be used as a method to solve this problem. nbBPA is based on the basic event. Other uncertain events in the power set of the FOD may not help in the process of decision making. Therefore, we only specify the initial base beliefs regarding the basic events. In this study, we improve the modeling of the uncertain relationship between the recognition objects in the MAIF system, and in this paper, an uncertainty model is established by adding nbBPA before reconstructing the BPA, combining it with the evidence distance factor and using the uncertainty relationship in evidence theory. The experimental results show that the method is effective and reasonable, especially when the multi-agent is faced with a highly unfavorable situation. This method can obtain correct results more accurately and quickly than other methods can, even in the case of equipment failure. Thus, it can be stated that this method improves the accuracy of the identification process of the MAIF system.The following abbreviations are used in this manuscript:


Despite international guidelines providing evidence-based recommendations on appropriate management of infants with bronchiolitis, wide variation in practice occurs. This results in infants receiving care of no benefit, with associated cost and is potentially harmful. Theoretical frameworks are increasingly used to develop interventions, utilising behaviour change techniques specifically chosen to target factors contributing to practice variation, with de-implementation often viewed as harder than implementing. This paper describes the stepped process using the Theoretical Domains Framework (TDF) to develop targeted, theory-informed interventions which subsequently successfully improved management of infants with bronchiolitis by de-implementing ineffective therapies. Explicit description of the process and rationale used in developing de-implementation interventions is critical to dissemination of these practices into real world clinical practice.A stepped approach was used: (1) Identify evidence-based recommendations and practice variation as targets for change, (2) Identify factors influencing practice change (barriers and enablers) to be addressed, and (3) Identification and development of interventions (behaviour change techniques and methods of delivery) addressing influencing factors, considering evidence of effectiveness, feasibility, local relevance and acceptability. The mode of delivery for the intervention components was informed by evidence from implementation science systematic reviews, and setting specific feasibility and practicality.n = 20)) with 23 behaviour change techniques chosen to address these domains. Final interventions included: (1) Local stakeholder meetings, (2) Identification of medical and nursing clinical leads, (3) Train-the-trainer workshop for all clinical leads, (4) Local educational materials for delivery by clinical leads, (5) Provision of tools and materials targeting influencing factors, and prompting recommended behaviours, and (6) Audit and feedback.Five robust evidence-based management recommendations, targeting the main variation in bronchiolitis management were identified: namely, no use of chest x-ray, salbutamol, glucocorticoids, antibiotics, and adrenaline. Interventions developed to target recommendations addressed seven TDF domains (identified following qualitative clinician interviews (A stepped approach based on theory, evidence and issues of feasibility, local relevance and acceptability, was successfully used to develop interventions to improve management of infants with bronchiolitis. The rationale and content of interventions has been explicitly described allowing others to de-implement unnecessary bronchiolitis management, thereby improving care.The online version contains supplementary material available at 10.1186/s12913-021-06724-6. Changing clinicians’ practice is challenging, in part due to the difficulty of improving quality and safety in healthcare  and exacBronchiolitis is the most common cause for hospitalisation of infants less than 1 year of age. Management is well defined  with allThis paper details the development of targeted, theory-informed interventions to address influencing factors identified previously , with thWe used a stepped approach to develop targeted, theory-informed bronchiolitis interventions Fig. . This loStep 1: Who and what is needed to improve bronchiolitis management?Step 2: Using a theoretical framework, which barriers and enablers need to be addressed?Step 3: Which intervention components (BCTs and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers?In 2015 the Paediatric Research in Emergency Departments International Collaborative (PREDICT)  developeThe literature was searched to review current data on adherence with evidence-based bronchiolitis guideline recommendations from which to target improvement efforts.Semi-structured qualitative interviews were conducted with 20 ED and inpatient paediatric unit nurses and doctors. Interview questions used the TDF domains to explore barriers and enablers to practice variation and factors that may influence the uptake of evidence-based bronchiolitis recommendations . For exaTo select BCTs most likely to effect change for each of the key evidence-based guideline recommendations, we used the BCT matrix validated by Cane et al . This maAn implementation development panel of eight members including clinicians (senior nurses and doctors from ED and paediatric inpatient units with direct responsibility for the management of infants with bronchiolitis) and an implementation scientist, reviewed the identified TDF domains and related BCTs, with feasible methods of implementation delivery discussed.’s summary of interventions [The Cochrane Effective Practice and Organisation of Care (EPOC) group have published systematic reviews of interventions to improve both healthcare systems and healthcare delivery –36. Addiventions  were disThe implementation development panel and research group considered factors to maximise the likelihood that the interventions were feasible, relevant and acceptable in the acute care environment to which they were to be implemented e.g. consideration of education sessions of appropriate length for an acute care environment; clear and succinct feedback reports of regular audits.Proctor et al. [Recommendations from the Workgroup for Intervention Development and Evaluation Research (WIDER) , the Temr et al.  were useThe Australasian Bronchiolitis Guideline  identifiThe search of the literature identified a large study conducted by Paediatric Emergency Research Networks (PERN) in 38 EDs in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal where more than 30% of infants received non-evidence-based supportive care . In Aust.Interviews with 20 clinicians  from four Australian and New Zealand hospitals were conducted between July and October 2016. The detailed findings from these interviews have been reported separately . The key2Twenty-three BCTs were selected to target barriers and enablers for the evidence-based management of bronchiolitis from seven TDF domains. The domain of social professional role and identity had no specified BCTs in the Cane et al.  matrix, As the five evidence-based recommendations being targeted are not independent, a pragmatic approach was taken where we assessed each of the domains and associated BCTs against all targeted behaviours we were aiming to influence. For example, the domain beliefs about consequences was identified for CXR, salbutamol and glucocorticoids. Using BCTs such as persuasive communication and feedback were deemed by the panel and research group as feasible and acceptable for all three targeted behaviours. Table Additional Table Findings from Cochrane EPOC reviews that focused on the effectiveness of interventions to influence the identified behaviours in the acute care setting were considered. The feasibility of delivering each of the proposed bronchiolitis interventions was discussed with the clinician panel and research group members e.g. delivering an education presentation to all staff in departments that have regular rotations of new staff; monthly audit and feedback cycles. With this in mind, we used a real-world approach using the group’s knowledge of the acute clinical demands, organisational context and constraints in order to make decisions on the feasibility and acceptability of the interventions.Discussions resulted in the agreement on six bronchiolitis interventions: (1) Local stakeholder meetings, (2) Nomination of clinical leads , (3) Train-the-trainer workshop , 4) Local educational materials targeting specific influencing factors, with delivery facilitated by clinical leads, (5) Promotional and other educational materials, and (6) Audit and feedback . Table 2 Barriers and enablers identified for bronchiolitis target behaviours by Theoretical Domains Framework.


The implementation of evidence-based approaches by general practitioners (GPs) is new in the primary care setting, and few quantitative studies have evaluated the impact of contextual factors on the attendance of these approaches.In total, 892 GPs from 75 community healthcare centers (CHCs) in Shanghai completed our survey. We used logistic regression to analyze factors affecting the number of evidence-based chronic disease programs attended by GPs and whether they had held the lead position in such a program.A total of 346 (38.8%) of the practitioners had never participated in any evidence-based chronic disease prevention (EBCDP) program. The EBCDP interventions in which the GPs had participated were predominantly related to hypertension, diabetes, and cardiovascular disease. However, the proportion of GPs in the lead role was relatively low, between 0.8% (programs involving prevention and control of asthma) and 5.0% (diabetes). Organizational factors and areas were significantly associated with evidence-based practices (EBPs) of the GP, while monthly income and department were the most significantly related to GPs who have the lead role in a program. The results indicated that GPs who had taken the lead position had higher scores for policy and economic impeding factors. GPs who were men, had a higher income, and worked in prevention and healthcare departments and urban areas were more likely to take the lead position.Evidence-based programs for chronic diseases should be extended to different types of diseases. Personal, organizational, political, and economic factors and the factors of female sex, lower income, department type, and suburban area environment should be considered to facilitate the translation of evidence to practice. The emergence of chronic diseases is becoming a predominant global health challenge, and preventing and controlling chronic diseases have gradually become a long-term health policy project in many countries and are included in the Healthy China 2030 strategic plan . After CExisting studies have indicated that population-based preventative interventions through the application of scientific evidence can significantly increase work efficiency , 7. For In recent years, evidence-based practices (EBPs) for chronic disease prevention have been increasingly encouraged among health practitioners . In WestIn this study, we conducted a quantitative investigation to assess the EBPs of GPs that include the number of evidence-based programs they had participated in and the role they played in such programs. Additionally, we examined the possible comprehensive impeding factors for EBPs to emphasize measures to promote EBP implementation.We used a random number generator to select 39 suburban and 39 urban CHCs from 246 CHCs in Shanghai, but 3 suburban CHCs did not participate in our study. To make the results reasonable, we randomly selected 6 junior GPs, 6 mid-level GPs, and 1 senior GP in each selected CHC according to the composition of GPs in CHCs. From April to July 2019, we distributed a total of 975 questionnaires, of which 892 valid questionnaires were returned.The questionnaire was adapted from a study comparing the use of EBCDP processes , 18. At In our study, the demographics consisted of gender, age, education, employment title, working years, monthly income, department, and area. Educational qualifications were divided into associate's degree or below, bachelor's degree, and master's degree or higher. GPs were awarded junior, mid-level, and senior titles according to their work experience and achievements. The GPs worked in CHC departments of general medicine (Western medicine), prevention and healthcare, general practice , and other departments, such as medical technology and rehabilitation. The urban and suburban areas were defined according to the geographic regions where CHCs were located.The possible influencing factors comprised four aspects, each of which contained various questions. As shown in In this study, we measured attendance and role of GPs in evidence-based programs through two variables: (1) the number of chronic disease programs participated in by GPs and (2) whether they held the leadership role in such a program. Evidence-based chronic disease programs, usually funded and initiated by provincial or regional CDCs or health administrative institutions, use evidence-based methods to prevent the onset of chronic diseases and manage the population with chronic diseases. Different from ordinary chronic disease programs, evidence-based chronic disease programs require GPs to use evidence to intervene in community residents. In a specific program, the person with the lead role is usually the founder of the program, and the person is responsible for program planning and takes the leadership role for the entire program from the application to conduction. The main performer assists the leader in carrying out the program, and the participants implement intervention measures in CHCs. The assessor evaluates the investment and output of the program. A GP may or may not participate in one or more evidence-based programs for chronic diseases at their discretion. To facilitate the respondent's recall of the number of participating programs, we set 15 chronic disease categories  and asked them to fill in whether they participated in the programs and their role in the programs. Finally, we counted the total number of programs involved in all categories as the number of chronic disease programs participated in by GPs. The number of evidence-based programs for various diseases was analyzed first as the dependent variable to assess the overall effects of the impeding factors. Furthermore, we used the variable of whether respondents had held the leadership role to explore the key influencing factors for GP leaders.p < 0.05 was considered statistically significant.SPSS 22.0 was used for statistical analyses. The demographics of the respondents were summarized using the mean and SD for continuous variables and frequency and percentages for categorical variables. Regarding the number of evidence-based programs attended by GPs, ordinal logistic regression was used to identify possible influencing factors. In terms of whether the GPs had held the leadership position, a binary logistic regression was utilized to identify various related levels of factors. Associations were measured by odds ratios (ORs) with 95% CIs. A total of 892 GPs, 50.9% of whom were women, responded to our survey. As shown in p = 0.05) and organizational factors  attended fewer evidence-based programs. However, the results show that the higher the scores of policy and economic impediments were, the greater the number of evidence-based programs the GPs had attended . In addition, compared with GPs in suburban areas, those from urban areas had attended more programs . Additionally, compared with GPs practicing in Western medicine departments, GPs in prevention and healthcare departments  and other departments  had attended fewer evidence-based programs.p = 0.01). As their age increased, the GPs were less likely to take leadership roles . Additionally, those who were men  and had a higher income  were more likely to play a leadership role. Regarding the GPs' departments, those in prevention and healthcare departments  were more likely to be responsible for evidence-based programs than those in general medicine (Western medicine).Regarding whether the GPs had held leadership roles, the binary logistic regression indicated that GPs who had taken leadership roles perceived higher scores for policy and economic impeding factors  China's top-down tiered healthcare delivery system determines that GPs in primary healthcare systems do not have much decision-making authority in either clinical or population-based health interventions. When dealing with complicated and severe medical disorders, they need to refer patients to superior hospitals. When carrying out interventions in communities, GPs need to obtain permission from leaders and cooperation from community neighborhood committees before obtaining funding from the government , 27. (2)In our study, we found that organizational factors are also impediments to EBPs, and a lack of internal policy to ensure that interventions in the organization are evidence-based should be considered. GPs will not use evidence-based approaches or participate in any evidence-based programs if they are not encouraged or rewarded for doing so. A system should be developed to maintain GPs' motivation EBPs. “Not enough staff assisted” is another factor worth noting and coexists with “lack of time” at the personal level. The primary health system faces a critical shortage of qualified GPs due to various issues, such as insufficient training and less pay than specialists , 30. WidWe found that the policy and economic factors significantly influenced both the number of evidence-based programs in which the GPs had participated and whether they had taken the leadership role. Additionally, these subfactors had the highest scores. Among them, “not enough financial support from government” had the highest score. Financial constraints are always impediments to EBP implementation , 33, 34.However, it was interesting that GPs who had participated in fewer evidence-based programs were more likely to report personal and organizational factors, while GPs who had participated in more evidence-based programs and played a leadership role in the programs were more likely to consider policy and economic factors to be greater impediments. If personal and organizational factors, such as “lack of capacity to develop evidence-based interventions” and “lack of internal policy to ensure interventions are evidence-based”, were overcome, policy and economic impediments tend to become bottlenecks in GPs' implementation of EBPs.Compared with participating in evidence-based programs, whether the GPs had held a leadership role was more likely to be influenced by demographic characteristics. Male GPs, those with a higher monthly income, those from urban areas, and younger GPs, were more likely to have been in the leadership role in evidence-based programs. However, these factors have no significant influence on the number of evidence-based programs they had participated. Both the number of evidence-based programs and whether the GPs had held the leadership role differed between different departments. Compared with GPs from general medicine (Western medicine) departments, GPs from prevention and healthcare departments had participated in fewer EBP programs but were more likely to have taken the leadership role. Although GPs from prevention and healthcare departments dominated the evidence-based programs, the influence of the programs was limited, and the programs attracted fewer of these GPs than those from general medicine (Western medicine) departments. More resources need to be allocated to the prevention process to promote EBPs.The limitations of this study should be noted. First, Shanghai is located in China's economically developed region, and GPs' EBPs may therefore be better there than in the central and western regions of China. Second, the content of the questionnaire was mainly subjective, which may cause bias. Finally, all data were self-reported, and it was difficult to verify the accuracy.Evidence-based programs for chronic diseases should be extended to address the types of diseases encountered by GPs. Capacity-building courses are needed to help GPs find and translate evidence into practice in China. More resources should be allocated to GPs, especially those who are men, have a lower income, and live in suburban areas. GPs from prevention and healthcare departments should be given more opportunities to take leadership roles compared with those from Western medicine departments. Moreover, efforts should be made to overcome the difficulties of a lack of staff and insufficient time of GPs. Internal policy development and leadership expertise building should be accelerated to create an appropriate environment for EBPs. Policy and funding support is needed to facilitate the generation of more high-quality evidence and implementation of preventative interventions at the population level in the future.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by Tongji University (Ref: LL-2016-ZRKX-017). The patients/participants provided their written informed consent to participate in this study.All authors made a significant contribution to the work-reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas, took part in drafting, revising, or critically reviewing the article, gave final approval of the version to be published, have agreed on the journal to which the article has been submitted, and agree to be accountable for all aspects of the work.The design of this study involving some previous investigation was supported by the Shanghai Excellent Young Talents Project in Health System (2018YQ52). Data extraction was funded by the Natural Science Foundation of China (71774116 and 71603182) and the Shanghai Public Health System Construction Three-Year Action Plan (GWV-10.1-XK15). The analysis and interpretation of the data guided by the statisticians were funded by grants from the National Key R&D Program of China (2018YFC2000700). The writing and revision, including the language improvement, were supported by Shanghai Pujiang Program (2019PJC072).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 reviewer YS declared a shared affiliation with some of the authors XGa, HJ, NC, YY, and JS to the handling editor at time of review.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In view of the lack of effective information fusion model for heterogeneous multi-sensor, an improved Dempster/Shafer (DS) evidence theory algorithm is designed to fuse heterogeneous multi-sensor information. The algorithm first introduces the compatibility coefficient to characterize the compatibility between the evidence, obtains the weight matrix of each proposition, and then redistributes the basic probability distribution of each focal element to obtain a new evidence source. Then the concept of credibility is introduced, and the average support of evidence credibility and evidence focal element is used to improve the synthesis rule, so as to obtain the fusion result. Compared with other algorithms, the proposed algorithm can solve the problems existing in DS evidence theory when dealing with highly conflicting evidence to a certain extent, and the fusion results are more reasonable and the convergence speed is faster. In the greenhouse intelligent control, in order to accurately judge the environmental conditions in the greenhouse, it is necessary to use the multi-sensor information fusion technology to integrate the environmental information of the greenhouse, so as to provide the greenhouse managers with accurate environmental information.3, but with the help of modern statistical theory, this problem can be effectively solved to a certain extent8. As an important branch of statistical theory, DS evidence theory is widely used in the field of multi-sensor information fusion due to its ability to represent uncertain and unknown information clearly and its strong operability12. Although Dempster's rule of combination in this theory can reasonably combine the evidence and fuse the expected experimental results, it has a high requirement on the degree of evidence conflict. When the degree of conflict is high, the fusion results are often inconsistent with the actual situation, and some fusion results even seriously violate common sense15.At present, there is no effective fusion model and algorithm for information fusion of heterogeneous multi-sensor informationDS evidence theory was first proposed by Dempster and then further developed by his student Shafer, which is an uncertain reasoning method with confidence function as the metric standard. Because DS evidence theory has general conflict, one-vote rejection, robustness and failure of synthesis rules, it will make the results of evidence synthesis deviate from the fact or fail to be synthesized, and then lead to wrong reasoning results, affecting the reliability of fusion results. Therefore, it is necessary to improve DS evidence theory and form an improved DS evidence theory that can overcome the above four problems, so as to form a fusion result that conforms to common sense and can provide decision makers with higher reliability.The algorithm in this paper can be used to accurately judge the environmental condition of greenhouse and implement the corresponding control measures, so that greenhouse crops can grow in a suitable environment.In this study, an improved DS evidence theory algorithm is designed, which starts from both the improvement of combination rules and the modification of evidence source. First, the compatibility coefficient is introduced to modify the evidence source, and then the reliability and the average support degree of evidence focal elements are introduced to improve the combination rules.Based on the basic idea of evidence support and evidence distance, this study believes that although there is a conflict between conflicting evidence, such a conflict is not absolute, and there must be consistent information that can be used effectively. Based on these ideas, this paper introduces the concept of inter-evidence compatibility coefficient. The definition is as follows.Identify frame According to the above equation, when the BPA of any focal elements in The degree of consistency between the evidence in the evidence set can usually be expressed by the expected value, which can be expressed by the average evidence. Therefore, the higher the mutual support between the expected value and the evidence, the higher the credibility of the evidence and the corresponding weight should be.Using the calculation idea of compatibility coefficient, when there are n pieces of evidence in the evidence set, the mutual support degree between each piece of evidence and the average evidence can be expressed as:It can be seen that the weight matrix of each evidence regarding each proposition is:Then, each focal element of BPA in each piece of evidence is redistributed using the above weights, namely:BPA distribution for focal elements of evidence is as follows:Set the evidence set, Kij is the size of conflict between every two evidences in the evidence set, which reflects the sum of the magnitude of conflict between a certain focal element in evidence i and other focal elements in evidence j, and can effectively reflect the degree of conflict between evidences.c is defined as the average conflict degree of the evidence set, then:d in Eq. .Analysis of Eqs.  and 7)  7) showsThis paper introduces inter-evidence credibility and improves Dempster's rule of combination as follows: are Eq. , \documeAccording to Eq. , when k Against sun quan combination rules, the k increases or ) in Eq. , when thThis study improves the DS evidence theory from two aspects. On the one hand, it introduces the compatibility coefficient to assign different weights to the focal elements that cause conflicts in the consistency information among evidences, so as to minimize the influence of evidence with low reliability on the fusion results. For evidence, on the other hand, the conflict between information, introducing the credibility of evidence, the evidence for integration, support for highly give fully affirmation of evidence, the evidence than major, of low trust evidence for the separation, to make it small in proportion of evidence, in highly conflict evidence, greatly reduce the uncertainty of the fusion results, reduce the correlation between low interference in the process of integration of evidence, makes the result more clear and reasonable.According to above analysis, the processing of conflict evidence in this study should be started with revised data first. Then it will use compatible coefficient to modify source of conflict evidence. After the new source of evidence is get, using introduction credibility of evidence and evidence focal element average support synthesis rules in the new source of conflict evidence combination of evidence, concrete evidence conflict process is shown in Fig. It can be seen from the above processing process that the steps of processing conflict evidence are summarized as follows:Step 1: Calculate the weight coefficient corresponding to each focal element in each piece of evidence by Formula ;Step 2: According to the weight coefficient of each focal element in each evidence, BPAF is redistributed according to Eqs.  and 5)  5) to obStep 3: Calculate the conflicts between every two pieces of evidence in the evidence set Step 4: Obtain the fusion result through Eq. .In this paper, Dempster's rule, Murphy's method, Yager method, Sun Quan method and this research method were respectively used to fuse conflicting evidence of the four problems existing in D–S evidence theory, and the fusion results were compared and analyzed to verify the effectiveness of this algorithm. Taking the following evidence as an example, the evidence includes general conflict evidence, focal element rejection evidence, focal element fine-tuning evidence and complete conflict evidence.Set the identification framework In the evidence set, The evidence collection of mentclass2pt{minimFrom the evidence sets entclass1pt{minimaThe evidence collection of mentclass2pt{minimFrom the evidence sets In this paper, based on the analysis of the classical evidence combination rule improvement algorithm, an improved DS evidence theory synthesis algorithm is studied and designed for the problems of general conflict, one-vote veto, poor robustness and synthesis rule failure of DS evidence theory algorithm. The algorithm introduces the concepts of compatibility coefficient and credibility, and uses the compatibility coefficient to correct the original evidence on the one hand, and the credibility to improve the Dempster combination rule on the other hand, and finally verifies the effectiveness of the algorithm in this paper through experimental comparison and example verification. The experimental results show that: compared with other algorithms, the algorithm in this paper can solve the problems of classical D–S evidence theory to a certain extent, and the inferred fusion results are more reasonable and converge faster.


Background: Contact heat evoked potentials (CHEPs) is used to diagnose small fiber neuropathy (SFN). We established the normal values of CHEPs parameters in Chinese adults, optimized the test technique, and determined its reproducibility.Methods: We recruited 151 healthy adults . CHEPs was performed on the right forearm to determine the optimal number of stimuli, and then conducted at different sites to establish normal values, determine the effects of demographic characteristics and baseline temperature, and assess the short- (30 min) and long-term (1 year) reproducibility. N2 latency/height varied with age and sex, while P2 latency/height and N2–P2 amplitude varied with age. The optimal number of stimuli was three.Results: N2 latency/height  and P2 latency/height  decreased and N2–P2 amplitude  and visual analog scale score  increased with increased baseline temperature (35 vs. 32°C). CHEPs parameters did not differ with time (baseline vs. 30 min vs. 1 year).Conclusion: We established normal CHEPs values in Chinese adults. We found that CHEPs parameters changed with baseline temperature and that the short- and long-term test reproducibility were satisfactory. Small fiber neuropathy (SFN) is a peripheral neuropathy that affects small-caliber thinly myelinated Aδ and unmyelinated C fibers . No cons2 latency, P2 latency, and N2–P2 amplitude—can be used to appraise the function of small peripheral nerve fibers  is a neuroelectrophysiologic technique in which heat stimuli consisting of rapid changes in temperature (70°C/s) are applied to the skin to evoke cerebral electroencephalographic responses conveyed by Aδ fibers . The rece fibers ,2013. The fibers . In SFN,e fibers . Furthere fibers .However, to diagnose SFN using CHEPs, the establishment of normal CHEP values is vital. A CHEP study of 35 normal controls was performed in Taiwan , and anoTherefore, it is necessary to establish normal CHEP values in the Chinese population. Furthermore, different studies have used differing numbers of CHEP stimuli . In thisIn this study, we aimed to optimize the CHEP testing technique , determine the short-term and long-term reproducibility of the CHEP test, and establish the normal values of CHEP parameters in a large sample of healthy Chinese adults.Healthy participants were recruited from hospital volunteers and through advertisements between November 20, 2014 and December 31, 2016. All participants underwent neurological examinations, laboratory examinations, and nerve conduction studies (NCS) at outpatient departments in a comfortable, temperature-controlled room. Neurological examinations and NCS were performed by two experienced neurologists. Laboratory examinations were performed by two clinical laboratory physicians of Chinese PLA General Hospital. To be eligible for inclusion in the study, participants were required to meet the following criteria: (1) age ≥ 18 years; (2) no sensory symptoms or signs on neurological examination; (3) normal results on laboratory tests; (4) normal results on NCS; (5) absence of diseases that may cause polyneuropathy ; (6) no alcohol abuse   or smokiThis study was approved by the Ethics Committee of Chinese PLA General Hospital and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from each participant enrolled in this study.The following laboratory tests were conducted: complete blood count, erythrocyte sedimentation rate, C-reactive protein, renal and hepatic function, lipid profile, fasting glucose, glycosylated hemoglobin, oral glucose tolerance test, folate and vitamin B12, thyroid function, antinuclear antibody, anti-extractable nuclear antigens antibody, serum protein electrophoresis, and tumor markers. The diagnoses of impaired fasting glucose, impaired glucose tolerance, and diabetes were based on the diagnostic criteria published by the All participants underwent NCS. Skin temperature was maintained at 32°C or above during the examinations. NCS were performed on the median, ulnar, tibial, peroneal, and sural nerves using the Keypoint electromyography (EMG) system . The results were measured according to the normal reference values used by the EMG Laboratory of Chinese PLA General Hospital.CHEP stimulation was conducted at the following sites:(1)Forearm (FA), at approximately the upper border of the distal third of the volar aspect of the right forearm (Dermatome T1),(2)Leg (LE), above the lateral malleolus at the upper border of the distal third of the right leg (Dermatome L5),(3)Cervical spine (C7), at the spinous process of C7 (Dermatome C3) and(4)Thoracic spine (T12), at the spinous process of T12 (Dermatome T12).Five sessions of CHEP stimulation were performed . SessionThe visual analog scale (VAS) was used to evaluate pain intensity during the CHEP sessions. The VAS comprises a 10-cm-long horizontal line anchored by verbal descriptors of no pain (score of 0) and worst pain imaginable (score of 10). The participants were asked to place a line perpendicular to the VAS at the point that represented the average pain during CHEP stimulation.2. It was used to deliver contact heat stimuli by increasing the baseline temperature from 32°C to a peak temperature of 51°C at a rate of 70°C/s.CHEP stimulation was performed in a temperature-controlled room maintained between 20 and 24°C. A CHEP stimulator  was used to apply heat pulses at different body sites. The thermode had a diameter of 27 mm and an area of 572.5 mm2 latency, P2 latency, and N2–P2 amplitude at the four body sites were independently determined by two researchers. Disagreements between the two researchers were resolved through discussion. N2 and P2 latency were presented as “N2 latency/height” and “P2 latency/height” (latency divided by height) . The interstimulus interval was set between 10 and 18 s. The researchers kept the thermode in contact with the skin surface by using pressure. Two experienced researchers evaluated the recorded cortical responses and recordings with blink, muscle, or movement artifacts or other stimulation or recording interferences were eliminated. Impedance was kept below 5 kohm during the test. N height) .2 latency, P2 latency, and N2–P2 amplitude) of different number of stimuli . Logistic regression analysis was conducted to determine the relationship of CHEP parameters with age and gender, as well as their interaction. Normal values were established using the normal distribution method. The paired t-test and non-parametric test were performed to determine the effects of different baseline temperatures (32 vs. 35°C). Test-retest reproducibility was performed to assess the short- and long-term reproducibility of CHEP . A non-parametric test  was performed to compare CHEPs parameters  were enrolled into this study and the mean age of the participants was 37 ± 14 years  . All of 2 and P2 latency are related to height, the data were presented as “N2 latency/height” and “P2 latency/height” , 30–39 years , 40–49 years , 50–59 years , and 60–69 years . As N/height” . The ave2 latency/height  and P2 latency/height  did not significantly differ with the number of stimuli. However, N2–P2 amplitude  significantly decreased with an increase in the number of stimuli  was performed involving CHEP stimulation of the right FA with a varying number of stimuli . The mean age of the participants was 35 ± 12 years . The median values of the CHEP parameters according to the number of stimuli is shown in  stimuli .2 latency/height at the FA and significant effects of age on P2 latency/height at T12 and N2-P2 amplitude at the right LE  and P2 latency/height  significantly decreased and N2–P2 amplitude  and VAS score  significantly increased with an increase in baseline temperature  could be used to elicit responses if these were not detectable at a lower baseline temperature (32°C). Furthermore, the short-term (30 min) and long-term (1 year) repeatability of CHEP testing were excellent.This research established normal values of CHEP parameters in a large sample of healthy Chinese adults. We found that N2 latency/height at the FA, while age affected the values of N2 latency/height at the FA, P2 latency/height at T12, and N2–P2 amplitude at the LE. These findings are not completely consistent with those of previous studies  the higher baseline temperature reduces the time required to reach the peak temperature of 51°C, leading to the activation of a greater number of nerve fibers, and (2) at the higher temperature, the ultra-late C-fiber response does not influence the late Aδ response .We also confirmed the short-term and long-term repeatability of CHEP testing by showing that CHEP parameters did not change significantly with time (baseline vs. 30 min later vs. 1 year later). Most studies have focused on the short-term reproducibility of CHEP stimulation, and found excellent reproducibility , which iThe correlation of CHEP parameters with age, sex, and body height differs among different studies, and thus, studies with larger sample sizes are required to further investigate this issue.We have established the normal values of CHEP parameters in a relatively large Chinese cohort, which facilitated the diagnosis of SFN in China. Only 3 stimuli were required to obtain reliable results on CHEP testing, and this has possibly simplified the examination technique. We found that CHEP parameters changed significantly with baseline temperature, but the short-term and long-term reproducibility of CHEP stimulation was excellent, which is useful in the diagnosis and follow-up of SFN.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of Chinese PLA General Hospital. The patients/participants provided their written informed consent to participate in this study.BS and XH designed the study. BS and ZC conducted the study. BS, HW, and ZC collected and analyzed the data. HW, FC, and FY contributed samples collection and intellectual input. BS drafted and wrote the manuscript. XH revised the manuscript critically for intellectual content. All authors gave intellectual input to the study and approved the final version of the manuscript.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To (1) describe the (evidence-based) reimbursement process of hospital individual services, (2) evaluate the accordance between evidence-based recommendations and reimbursement decision of individual services and (3) elaborate potential aspects that play a role in the decision-making process in Austria.The reimbursement process is described based on selected relevant sources such as official documents. Evidence-based recommendations and subsequent reimbursement decisions for the annual maintenance of the hospital individual service catalogue in Austria between 2008 and 2020 were analysed using a mixed methods approach, encompassing descriptive statistics and a focus group with Austrian decision makers.118 evidence-based recommendations were analysed. There were 93 (78.8%) negative and 25 (21.2%) positive evidence-based recommendations. In total, 107 out of 118 evidence-based recommendations (90.1%) did not lead to a deviating reimbursement decision. We identified six aspects that may have played a role in the decision-making process for the annual maintenance of the hospital individual service catalogue, with clinical evidence being the most notable. Further aspects included quality assurance/organisational aspects , costs , procedural aspects , “other countries”  and situational aspects (such as the COVID-19 pandemic).There is good accordance between evidence-based recommendations and reimbursement decisions regarding hospital individual services in Austria. Beyond clinical evidence, organisational aspects seem to be considered often with regard to quality assurance but costs do not appear to play a major role. The Austrian system has mechanisms in place that can restrict widespread adoption of novel hospital individual services with uncertain clinical benefits. Future studies could investigate how well these mechanisms work and how they compare to other health systems in Europe.The online version contains supplementary material available at 10.1186/s12913-022-07531-3. Coverage decision making is challenging because of concerns with incremental novelty of new interventions, their ever rising costs as well as a significant increase in expectations from patients . With anDecision makers’ interest in health technology assessment (HTA) as a tool to support decisions by summarising best available evidence  has growConsequently, new concepts such as early scientific advice, early awareness systems, as well as post-launch observation, re-assessment and potential disinvestment have increasingly been implemented . In AustWhat are the specifics of the decision-making process for the reimbursement of novel hospital medical services in Austria beyond what has already been described in international literature?In how far were reimbursement decisions of hospital individual services based on clinical evidence?What other factors are taken into account in the decision-making process that may lead to deviations from the evidence-based recommendation in Austria?This system has been described and partly evaluated in earlier publications, concluding that clinical evidence is being well considered in decisions on in-/exclusion of services in the hospital catalogue, but proposing that other factors seem to influence the final decisions as well , 16, 17.To describe the reimbursement process of hospital individual services in Austria, we analysed official documents of the Ministry of Health (MoH) and further manually searched for literature describing the Austrian health system in detail. Content from the focus group (see below) was used to validate and enrich this information.The recommendations from all evidence syntheses of (new) medical services from 2008 to 2020 were analysed and contrasted to the reimbursement decisions for the annual update of the Austrian hospital individual services catalogue. A mixed methods approach was applied:As the first step, the existing dataset including all evidence syntheses and their evidence-based recommendations and reimbursement decisions until 2016  (…). Had we had a videoconference or a meeting at that time, we would have discussed/ do we decide for a service that requires authorisation [=restricted reimbursement], and take it into the standard funding or do we leave it as a NUB. We would have done one of the two variants in any case. We have given ourselves the minimum variant here, so to speak, (…). I cannot say how this would have turned out if we had discussed it. It's possible that we would now have two more services requiring authorisation.” The COVID-19 pandemic was identified as a situational aspect hindering the reimbursement of medical services. The COVID-19 pandemic hindered a physical meeting for two medical services that received a positive recommendation. In both of these cases, the reimbursement decision was negative, although the medical services were included in the hospital individual services catalogue for the purpose of documentation. With respect to the question as to why the reimbursement decision was not positive, the focus group responded that the cases.too strict in excluding a medical service, which should have been partly reimbursed followed by close monitoring and re-evaluation at a later stage. However, in this specific scenario the focus group did not remember the reasons behind the decision, as it had taken place over ten years earlier.Focus group participants recalled a specific scenario, in which they believed that they may have been 118 evidence-based recommendations were analysed. There were 93 (78.8%) negative and 25 (21.2%) positive evidence-based recommendations. In total, 107 out of 118 evidence-based recommendations (90.1%) did not lead to a deviating reimbursement decision. We identified six aspects that may have played a role in the decision-making process for the annual maintenance of the hospital individual services catalogue. The clinical evidence was the most notable aspect. Further aspects included quality assurance/organisational aspects service, costs , situational aspects (such as the COVID-19 pandemic), procedural aspects  and “other countries” .The results of this analysis complement older analyses of the evidence-based reimbursement process of hospital medical services in Austria. A descriptive analysis  regardinSurprisingly, the quality of the evidence and the risk classification of a medical device were not specifically mentioned in the focus group in our study. However, it must be noted that the quality of the evidence indirectly plays a role (through the role of evidence as such). This is somewhat in contrast to a retrospective analysis of 78 medical device syntheses (time period: 2008–2015)  that triAlthough there are clearly mechanisms in place in Austria that hinder widespread adoption of promising novel technologies without clear clinical evidence, transparency within the decision-making process could be further enhanced. A health system should be explicit about the resource allocation process . There aMore specifically, the steering committee could make the reasons of their decisions public. This could foster a deliberative process  that notTo increase accountability and encourage a stringent use of transparent criteria based on specific values, multi-criteria decision analysis (MCDA) could further be a tool considered for the Austrian context. MCDAs can not only inform funding decisions based on diverse criteria, but can further help to synthesise complex value trade-offs to support priority-setting decisions in a healthcare system using a rational and transparent approach , 27. In The results of this analysis should be interpreted in light of its limitations: Firstly, in the calculation of the accordance between evidence-based recommendation and reimbursement decision there was sometimes not a clear cut-off between existing categories. However, we still believe that the dichotomisation of both variables is useful for capturing the accordance between recommendations and decisions quantitatively.Secondly, we did not conduct regression analysis or logistic analysis as done in a previous study  that triThirdly, the reader must be aware that the results of the focus group are not generalisable to all steering committees. This analysis is limited to the annual maintenance of the hospital individual services catalogue in Austria that includes medical devices, outpatient services and some oncological drugs in the hospital . AlthougThere is overall good accordance between evidence-based recommendations and reimbursement decisions of hospital medical services in Austria. While the aspects that played a role for specific decisions are difficult to ascertain, it is clear that they went beyond clinical evidence. While quality assurance and organisational aspects seem to be considered often, costs do not appear to play a major role. It appears that the Austrian system has mechanisms in place that can restrict widespread adoption of novel hospital medical services with uncertain clinical benefits. Future studies could investigate how well these mechanisms work and how they compare to other health systems in Europe.Additional file 1.


Assessment of spleen size is an important part of the clinical skills of medical students and physicians. Many diseases can affect the size of the aforementioned organ, ranging from infective processes to malignant disorders. However, to detect changes, prior knowledge of the actual normal size of these viscera is required in the population being studied. Establishing a customized chart and curve for a specific population of the same sociodemographic characteristics enables a better interpretation of sonographic assessments.A hospital-based cross-sectional study design was conducted among 403 children in primary and referral hospitals of the east and west Gojjam zone. Data were collected using a structured questionnaire, physical examination, and ultrasound. The collected data were entered into Epi Data version 3.1 and exports to SPSS version 24 for analysis. Descriptive data were analyzed using descriptive statistics. A Pearson product-moment correlation was run to determine the relationship between age, anthropometric measurements of children, and ultrasound measurements of the spleen. Reference intervals were established using non-parametric reference limits (2.5th -97.5th ) and (5th – 97th ) percentiles by MedCalc software version 20.0.3.3. The height and body surface area of children were best correlated with sonographic dimensions of the spleen. Reference intervals were established using height, age, and body surface area specific for clinically practical dimensions of the spleen.Four hundred three children aged from 7 to 15 years were included in this study. The mean sonographic longitudinal (length), anteroposterior(depth) and transverse (width) dimension of the spleen was, (8.24 ± 1.26 cm), (3.98 ± 0.57 cm), and (4.26 ± 0.59 cm) respectively. The mean volume of the spleen was 75.04 ± 23.92 cmAccording to this study, the children are considered as having enlarged longitudinal dimension of the spleen if he or she has a size above 97.5th percentile based on their respective height. Assessment of spleen size is an important part of the clinical skills of medical students and physicians, and determination of spleen span is essential. Many diseases can affect the spleen size, ranging from infective processes to malignant disorders. However, to detect changes, prior knowledge of the actual normal size of these viscera is required in the population being studied . We can The clinical assessment of spleen size remains an important part of a physical examination, and knowledge of its normal values at different ages is essential in children and adolescents. This procedure is usually the first step in detecting the abnormal size of the spleen . The splMedical imaging techniques permit the observation of anatomical structures in living people and the study of their movements in normal and abnormal activities. Being able to identify normal structures on radiographs makes it easier to recognize the changes caused by disease and injury .However, routine computed tomography and magnetic resonance imaging for the diagnosis and serial follow-up of patients for suspected enlargement of the spleen is difficult to justify because of the radiation exposure, the cost, and limited availability in many areas of the world, particularly in developing countries. So, ultrasonography is an established, safe, fast, and reliable method for the measurement of spleen sizes , 7. In aUnfortunately, there is still no consensus on how to define splenomegaly in pediatric patients. The evaluation is challenging because the normal size varies because of nutritional factors, body habitus, geographical location, physical activities, genetic differences, race, and ethnicity –13.The normal limit of the size of visceral organs according to age, body parameters have not been specified in northwest Ethiopia for school-age children. Hence, our currently used nomograms in primary and referral hospitals are based on the western database, which might lead to under or overestimation of the size of the spleen.This study aimed to assess and document the splenic sizes in apparently healthy school-age children in an Ethiopian population in the Amhara region and thereby serve as a baseline for comparison in cases of splenomegaly using transabdominal sonography. In addition to this, we evaluated the relationship between splenic measurements, chronological and auxological data, and body proportions.The institutional-based cross-sectional study design was conducted among 403 school-age children, from December 2019-June 2020 in Debre Markos referral hospital, Finote Selam general hospital and Bichena primary hospitals of east and west Gojjam zone, northwest Amhara.All apparently healthy children of 7 to 15 years that came to the hospitals’ pediatrics departments during study periods for a follow-up examination for mildly treated conditions; or who were examined because of problems unrelated to the spleen or a routine check-up were included in the study. However, in children who did not have normal height and weight curves, a history and physical examination finding of oncologic and hematologic disorders or infectious causes of splenic enlargement or splenic trauma, and the accidental discovery of one or more accessory spleens were excluded.We calculated the sample size using online sample size calculators for designing clinical research developed by the University of California San Francisco (UCSF) clinical research program; assuming a power of 80 %, correlation coefficient of 0.145 of age, and splenic length among female subjects / 3600) . The abdnce*3.14 . All antSonographic evaluation: All children were asked to lie down in a supine position or a lateral position to get optimal images. We measured: longitudinal dimension: between the highest superior-medial and the lower inferior-lateral points of the spleen; anteroposterior dimension: between the anterior and posterior surfaces; transverse dimension: between the hilum and the superior-lateral edge of the spleen. Scanning was conducted three times, and the average dimension was taken. The volume of the spleen was calculated using the prolated ellipsoid formula (Length *Width*Thickness* 0.523) .To maintain the quality of the research, the data collectors were trained. There was close monitoring and supervision during the data collection period.The dependent variables were sonographic dimensions  of the spleen. Whereas socio-demographic; height, weight, waist circumference, body mass index (BMI), body surface area, abdominal volume, and xipho-pubic distances of children were independent variables.Apparently healthy children: refers to the absence of disease of the spleen based on clinical signs and symptoms, normally assessed by history, physical evaluation, and routine laboratory methods available in the hospitals .We used EPI-Data Version 3.1 for data entry and SPSS Version 24 and mainly MedCalc version 20.0.3 for analysis. Descriptive statistics for continuous variables were described using the measure of central tendency (mean) dispersion (standard deviation). A one-way ANOVA was conducted to compare the means of anthropometric measurements among children of each age group. A Pearson product-moment correlation was run to determine the relationship between age, weight, height, waist circumference, xiphopubic distance, body surface area, abdominal volume, and sonographic measurements of the spleen. Pediatric non-parametric reference limits (2.5th —97.5th and 3rd – 97th percentiles) for spleen measures are reported. Model-based specific reference intervals were computed with age, height, and body surface area modeled as fractional polynomials. Transformation of variables was conducted before model fitting and then plotted against height body surface area and age.p < 0.001) for height; F  = 73.06, p < 0.001) for weight; F  = 24.97, p < 0.001) for waist circumference; F  = 101.95, p < 0.001) for xiphopubic distance; F  = 103.61, p < 0.001) for body surface area, and F  = 44.53, p < 0.001) for abdominal volume  = 191.66, 3. The longitudinal dimension of the spleen was moderately correlated with height . The anteroposterior dimension (thickness) of the spleen was best correlated with the weight  and body surface area  of the children. Similarly, the volume of spleen showed moderate correlation with the weight  and body surface area  of the children but best predicted by their age. However transverse diameter of the spleen showed a weak correlation with body parameters , anteroposterior(depth) and transverse (width) dimension of the spleen was, (8.24 ± 1.26 cm), (3.98 ± 0.57 cm), and (4.26 ± 0.59 cm) respectively. The mean volume of the spleen was 75.04 ± 23.92cmModel-based body parameter-specific reference intervals were computed, using MedCalc version 20.0.3. We established smoothened height for the longitudinal dimension of the spleen Table ; body suAccording to our study, the children are considered as having enlarged longitudinal dimension of the spleen  if he or she has a size above 97.5th percentile based on the respective height.In the literature, there are few detailed studies to interpret the spleen dimensions in school-aged children in Africa and Ethiopia. Sonographic determination of pathologic changes in the size of the spleen necessitates knowing the normal ranges of its measurements especially concerning anthropometric assessments in school-age children. The morphology of the spleen varies from person to person. During the maturation process from infancy through adolescence, the growth of the spleen shows a high correlation with gains in height, weight, and body surface area , 18.To the best of our knowledge, our study, which aimed to investigate the normal limits of the spleen of school-aged children, comprises one of the largest series in the literature from Ethiopia, including the age group of 7 to 15 years.There is no agreement on which anthropometric measurements are generally acceptable for exploring the normal limit of organ measurements , 19–21 aAssessment of longitudinal dimensions (length) of the spleen is more practical either by palpation and percussion or using ultrasound. The estimation of spleen width and volume is less solid and questionable in diagnosing splenomegaly . In thisIn most studies, sizes between the 5th and 95th percentiles were the accepted normal limits , 34. ThiThe normal limits of the spleen are important parameters during a sonographic examination. Reference intervals were established based on the best-correlated and predictor anthropometric measurements. Children with the longitudinal dimension of spleen above 97.5th percentile values with their specific height are considered as having splenomegaly. We hope this study contributes to daily practice in radiology clinics to interpret the normal sizes of the spleen of school-aged children in northwest Ethiopia.Calibration of measuring tools in the hospitals were not conducted frequently.


Breast cancer is a common disease in Tunisia and is associated with high mortality rates. The “Instance Nationale de l’Evaluation et de l’Accréditation en Santé” (INEAS) and the Tunisian Society of Oncology decided to develop practice guidelines on the subject. While the development of de novo guidelines on breast cancer screening is a demanding process, guideline adaptation appears more appropriate and context sensitive. The objective of this paper is to describe the adaptation process of the European Guidelines on Breast Cancer Screening and Diagnosis to the Tunisian setting in terms of the methodological process, contextual differences between the source and adoloped guideline, and changes in the recommendations.We used the ‘Grading of Recommendations Assessment, Development and Evaluation’ (GRADE)-ADOLOPMENT methodology to prioritize the topic, select the source guideline, and prioritize the questions and the outcomes. Once the source guideline was selected—the European Breast Cancer Guidelines—the European Commission´s Joint Research Centre shared with the project team in Tunisia all relevant documents and files. In parallel, the project team searched for local studies on the disease prevalence, associated outcomes’ baseline risks, patients’ values and preferences, cost, cost-effectiveness, acceptability, and feasibility. Then, the adoloping panel reviewed the GRADE evidence tables and the Evidence to Decision tables and discussed whether their own judgments were consistent with those from the source guideline or not. They based their judgments on the evidence on health effects, the contextual evidence, and their own experiences.The most relevant contextual differences between the source and adoloped guidelines were related to the perspective, scope, prioritized questions, rating of outcome importance, baseline risks, and indirectness of the evidence. The ADOLOPMENT process resulted in keeping 5 out of 6 recommendations unmodified. One recommendation addressing “screening versus no screening with ultrasound in women with high breast density on mammography screening” was modified from ‘conditional against’ to ‘conditional for either’ due to more favorable ratings by the adoloping panel in terms of equity and feasibility.This process illustrates both the feasibility of GRADE-ADOLOPMENT approach and the importance of consideration of contextual evidence. It also highlights the value of collaboration with the organization that developed the source guideline. Breast cancer represents the second most prevalent cancer in the world affecting 2.1 million women each year [To address this public health problem, the “Instance Nationale de l’Evaluation et de l’Accréditation en Santé” (INEAS) and the Tunisian Society of Oncology decided to develop practice guidelines on the subject. Indeed, guidelines can enhance evidence-based practice and reduce variability in practice .However, developing guideline de novo  can be a demanding process in terms of time, human, and financial resources. Alternative options to de novo development include adopting or adapting guidelines developed by others , 4. WhilA methodological survey identified eight methodologies for the adaptation of health guidelines . The ‘GrThe objective of this paper is to describe the project in terms of the methodological process, contextual differences between the source and adoloped guideline, and changes in the recommendations.The process of this project is based on the steps of the Guidelines 2.0 checklist , and theThe EtD table includes information on the following criteria: desirable and undesirable effects, certainty of evidence, certainty about or variability in values and preferences, cost, and cost-effectiveness, equity, feasibility, and acceptability –11. The We describe below the methodological aspects of the project most relevant to the ADOLOPMENT process.INEAS is an independent public authority that contributes to the regulation of the health system in Tunisia through quality and efficiency. The guideline project was a collaborative effort between INEAS and the Tunisian Society of Oncology. The Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH funded the study, while the ‘American University of Beirut’ (AUB) GRADE  center provided the methodological support.Two major groups were involved: the project team and the guideline panel. The project team consisted of four members from INEAS  and two members of the AUB GRADE center . The guideline panel consisted of 12 local experts including medical and surgical oncologists, gynecologists, family medicine, radiologists, guideline methodologists, and governmental representatives. None of the panelists had financial conflict of interest.The project team initially considered the following four topics: breast cancer screening, colorectal cancer screening, hypertension, and management of pain. The team then conducted a priority setting exercise to prioritize one of those topics , 14. TheThe project team systematically searched for existing guidelines on breast cancer screening published after 2016, to ensure they were up to date. The group searched MEDLINE, GuidelineCentral, Guideline International Network database, and websites of guideline producing agencies such as the National Institute for Health and Care Excellence, National Comprehensive Cancer Network, Scottish Intercollegiate Guidelines Network, World Health Organization (WHO), Belgian Health Care Knowledge Center, and Agency for Healthcare Research and Quality.The search identified 124 unique citations. The title and abstract screening yielded seven citations as potentially eligible (on breast cancer). The full-text screening of the seven citations identified two relevant guidelines that were based on systematic reviews and developed using the GRADE approach , 16. TwoFor prioritizing the questions and the outcomes, the project team organized a face-to-face panel meeting in September 2018. The panelists anonymously rated the importance of each of the nine screening questions addressed in the source guideline at the time this ADOLOPMENT process was started. They used a scale of 1–9 (least important—most important) and considered the relevance of the populations and interventions addressed by each question. Then, the panel discussed the rating results and selected the final set of questions through consensus.Similarly, the panel rated the importance of the outcomes defined in each of the questions of the source guideline on a scale of 1–9  [For the evidence on health effects, the ECIBC team (ZSP) shared with the project team the evidence syntheses reports and other relevant documents from the source guideline, including the GRADEpro files for GRADE evidence tables and EtD frameworks. Updating the search for the health effects evidence was not required to identify new evidence given the short timeline between the publication of the source guidelines and the ADOLOPMENT process by the Tunisian panel.For the contextual evidence, the project team searched for local studies on the disease prevalence, associated outcomes’ baseline risks, patients’ values and preferences, cost, cost-effectiveness, acceptability, and feasibility. As the team did not identify much of the needed data from published studies, it solicited them from panel members and searched for studies from contexts similar to that of Tunisia . The local baseline risk was integrated in the evidence summary tables. Then we adapted the standard EtD table in GRADEpro to use in the ADOLOPMENT process, as the GRADEpro-GDT ADOLOPMENT module had not been developed at that point. For each criterion we reproduced the ‘research evidence’, the ‘additional considerations’, and the ‘judgments’ from the source guideline. In addition, we added under ‘research evidence’ any identified local data Fig. .Fig. 3DiIn December 2018, the panel reviewed the GRADE evidence tables and the EtD frameworks. For each healthcare question, and for each EtD criterion, the panel started by reviewing the ‘research evidence’, the ‘additional considerations’, and the ‘judgments’ from the source guideline, as well as any identified ‘research evidence’ from the Tunisian setting. Next, they added their own ‘additional considerations’ for each criterion and discussed whether they would modify the judgments from the source guideline Fig. . After gWe present in Table Figure The ADOLOPMENT of the European Guidelines on Breast Cancer Screening and Diagnosis to the Tunisian setting illustrates the feasibility of carrying out this process with limited resources and in a short period of time (3 months). We have highlighted the complete methodological process followed which led to six contextual differences between the source guideline and the Tunisian one, and changes in the recommendations.A major facilitator to this ADOLOPMENT project was the collaboration between the two teams of the source and ADOLOPMENT guidelines. The ECIBC guideline project team allowed the unrestricted use of their recently published guideline and related material as the basis for the ADOLOPMENT process . AnotherA clear advantage of guideline adaptation is the ability to present the adoloping panel with evidence that has already been synthesized for the source guideline. However, it is not clear whether the panel should be also presented with the EtD sections completed by the source guideline’ panel. These sections include ‘judgments’ and ‘additional considerations’ made for the different EtD criteria, and the final ‘recommendation’. In principle, there are three possible approaches to sharing information from the source guideline with the adoloping panel, as illustrated in Table Approach A would allow the panel to build on the source guideline’s full information and decide whether to modify any of the judgments or recommendation. Approach B would allow the panel to build on the source guideline’s information except for the recommendation. The panel would decide whether to modify any of the judgments but develop the recommendation independently. Approach C would allow the panel to make their judgments and develop the recommendations independently, taking into account only the evidence synthesized for the source guideline and the contextual evidence. This approach C would require more extensive discussions and time compared with the two other approaches. It could be used in scenarios when judgments and additional considerations are not available, when there are concerns about the judgments made by the source panel, and when preferred by the adoloping panel.for each EtD criterion, the synthesized evidence on health effects, judgments, and additional considerations already made by the source guideline panel (reproduced from the source guideline);for each EtD criterion, the contextual evidence, judgments, and additional considerations, to be made by the ADOLOPMENT guideline panel;the recommendation developed by the source guideline panel (reproduced from the source guideline);the recommendation to be developed by the adoloping panel.While we have used approach C in previous ADOLOPMENT projects –25, we oHowever, including the elements from the source guideline (#1 and #3 above) are optional to allow the panelists select one of the three approaches discussed above Table .The information from the source guideline is reproduced but not editable. For the adoloped guideline, a blank section allows the project team to add any local evidence, and the adoloping panelists to include their own judgments, their own additional considerations, and their own recommendation. Figure This project illustrates a number of facilitators for guideline ADOLOPMENT, including (1) collaboration with the organization that developed the source guideline; (2) same methodology (GRADE) used for the source guideline development and the adoloped guideline; (3) availability of contextual evidence; (4) availability of an adaptation module in a guideline development tool ; and (5) engagement of panelists in the ADOLOPMENT process.An organization aiming to facilitate the adaptation of its recommendations need to strategically optimize their ‘adaptability’. This can be achieved through using structured methodology, such as GRADE, making explicit detailed judgments related to the certainty of evidence and strength of recommendation. Such a methodology would also allow the presentation and judgment of the health effects and of the contextual factors separately, as the latter are more likely to be judged differently during the adaptation process. Providing open access to all relevant material  would also optimize adaptability of recommendations.As illustrated by Fig. This process illustrates both the feasibility of GRADE-ADOLOPMENT approach and the importance of consideration of contextual evidence. It also highlights the value of collaboration with the organization that developed the source guideline.