Clinical guidelines should be based on a thorough evaluation of the evidence and generally include a rating of the quality of evidence and assign a strength to recommendations. Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance warns against making strong recommendations when the certainty of the evidence is low or very low, but has identified five paradigmatic situations (e.g. life-threatening situations) where this may be justified.We aimed to characterize the strength of recommendations and certainty of the evidence in Irish National Clinical Guidelines using the GRADE approach.All National Clinical Guidelines from the National Clinical Effectiveness Committee (NCEC) website using the GRADE approach  were included. All recommendations and their corresponding certainty of the evidence, strength of recommendations and justifications were extracted. Authors classified instances of strong recommendations with low certainty evidence (referred to as discordant recommendations) into one of the five paradigmatic situations. Descriptive statistics were calculated.From the 29 NCEC Clinical Guidelines available at the time of analysis, we identified 8 guidelines using GRADE with a total of 240 recommendations; 38 recommendations did not use the GRADE approach and were excluded. Half of the included guidelines focused on emergency situations. In the final dataset of 202 recommendations, 151 (74.7%) were classified as strong and 51 (25.3%) as conditional. Of the 151 strong recommendations, 55 (36.4%) were supported by high or moderate certainty evidence and 96 (63.6%) by low or very low certainty evidence and were considered discordant. Of these 96 discordant recommendations, 55 (73.7%) were consistent with one of the five paradigmatic situations. However, none were specifically described as such within the guidelines.The proportion of discordant recommendations identified in this analysis was higher than some previous international studies , but similar to other guidelines focused on emergency situations. The majority of discordant recommendations could be mapped to one of the five situations, but no National Clinical Guideline explicitly referenced this. Guideline developers require further guidance to enable greater transparency in the reporting of the reasons for discordant recommendations.The online version contains supplementary material available at 10.1186/s12874-023-01895-8. Clinical guidelines are part of the landscape of evidence-based healthcare and are considered a key foundation for quality improvement in healthcare in many countries , 2. TheyThe Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, used internationally, presents a methodologically rigorous and transparent system for making judgments about the certainty of evidence and strength of recommendations . There aFor the development of trustworthy guidelines there should be concordance between the quality (certainty) of the evidence and the strength of the recommendations. However, guideline developers may need to supplement evidentiary factors  with considered judgment  to increase the usage of guideline recommendations in clinical practice . In certGuideline implementation is a complex process that is often hindered by a variety of individual, organisational, and system level barriers. In particular, communicating the guideline content, both the message of the recommendations themselves and the perception of the evidence being correct and sufficient, deeply affect a guideline’s implementability , 16. ThuThe National Clinical Effectiveness Committee (NCEC) National Clinical Guidelines (NCGs) provide robust evidence-based guidance to inform health care decisions in the Irish health system. The NCEC recommends the use of guideline methodology based on GRADE since 2019 . The aimth June 2022, there were a total of 29 NCGs published since 2013, by the Department of Health in Ireland, available on their website .This study was a cross-sectional analysis of a suite of existing, published NCGs. As of 30We reviewed all 29 NCGs and included those that described the use of GRADE methodology, either fully or partially, for the grading of recommendations within the guideline.Certainty of the evidence Strength of the recommendation ○ Did the guidelines reference one of the five paradigmatic situations Table  (yes/no)Any justifications providedWas a completed Evidence to Decision Making (EtD) framework presented (yes/no).For each guideline  we extracted descriptive data including year of publication, the guideline development methodology Specific reference to one of the five paradigmatic situations was noted: 1) Life-threatening  situation 2) Uncertain benefit, certain harm; 3) Potential equivalence, one option clearly less risky or costly; 4) High certainty in similar benefits, one option potentially more risky or costly; 5) Potential catastrophic harm (Table Data was extracted by one reviewer (MCC) and cross-checked by another (BC). All data was extracted to Microsoft Excel. The reviewers  resolved all disagreements by discussion.Descriptive statistics were used to report the frequency (proportions) of ratings of the certainty of the evidence, strength of the recommendations, and discordant recommendations. The overall rate of discordance across the dataset was calculated as the proportion of all strong recommendations that were based on no studies, low or very low certainty evidence.From the 29 NCEC National Clinical Guidelines available at the time of analysis, eight guidelines published between 2019 and 2022 . A total of 38 recommendations were excluded as they did not use the GRADE approach. This included 18 best practice statements, which are recommended to be designated as such without a formal GRADE rating . Therefon = 151), 55 (36.4%) were based on high or moderate certainty evidence. The remaining 96 (63.6%) were considered discordant recommendations as follows: 60 (39.7%) had very low certainty of evidence, 18 (11.9%) had low certainty, and 18 (11.9%) had no studies included. Of the 51 weak/conditional recommendations, 1 (2.0%) was based on high certainty evidence , 55 6.4% wereThe proportion of discordant recommendations varied across individual guidelines, ranging from 6 to 100% of strong recommendations being based on low or very low certainty evidence or no studies within individual guidelines Fig. . The remn = 78, excluding those based on no studies) to determine if they were consistent with one of the five paradigmatic situations , 63.1% could be retrospectively justified as ‘life-threatening ’, 24.6% justified as ‘uncertain benefit, certain harm,’ and 10.5% justified as ‘potential equivalence, one option clearly less risky or costly’ by the study team  despite rating the evidence as low certainty , 33. Whilife-threatening  situation. Similar to previous reports, we found that none of the guidelines specifically referenced the paradigmatic situations within the accompanying guideline, therefore we were required to make assumptions that may not be reflective of the guideline developers’ original discussions [In keeping with previous studies, , 34 we fcussions , 12. As In this study, 18 strong recommendations were based on no studies. The majority of these were from one guideline, Stratification of Clinical Risk in Pregnancy . This guUnexpected Intraoperative Life Threatening Haemorrhage’, to health behaviours such as ‘Stop Smoking’. In addition, all included NCGs were published within the last three years, reflecting up to date practice. This study was however, limited to a relatively small sample size of eight guidelines—as the NCEC has recommended the use of guideline methodology based on GRADE since 2019 [Strengths of our study include the inclusion of a full suite of National Clinical Guidelines across a wide variety of topics, ranging from emergency situations such as ‘nce 2019 , the remnce 2019 . Two autWhile discordant recommendations should be infrequent in guidelines, they are justifiable options in high-risk situations where stronger evidence is lacking. Our results are reassuring in that the majority of discordant recommendations can be attributed to one of the five paradigmatic situations . HoweverThe proportion of discordant recommendations identified in this analysis was higher than some previous international studies , but similar to other guidelines focused on emergency situations. The majority could be mapped to one of the five paradigmatic situations, but no National Clinical Guideline explicitly referenced this. Guideline developers require further training and guidance in this area to enable them to be more transparent in their reporting of the reasons for discordant recommendations.Additional file 1: Appendix 1. Worked example of coding. Appendix 2. Summary of all guidelines. Appendix 3. Guidelines and the five paradigmatic situations.


Clinical equipoise is characterized by genuine uncertainty within the medical community about the effectiveness of a medical intervention. Its existence is often deemed necessary for clinical trials and signals a need for higher quality evidence, most often with randomized controlled trials, before the intervention can be considered effective. A leading official of the United States' Centers for Disease Control and Prevention Director, when testifying before Congress in February of 2023, indicated there was no need for randomized controlled trials of masking because, owing to overwhelming evidence of benefit, there was no longer equipoise about masking children for COVID-19. We disagree with this statement and outline the reasons why in this piece. We review the concept of clinical equipoise specifically using the example of child masking. We list reasons equipoise still exists for masking children, including a lack of consensus among experts, contradictory medical evidence and recent and ongoing randomized efforts. Finally, we differentiate between clinical equipoise and ethical appropriateness. Despite ongoing equipoise about masking children, we outline why, owing to lack of evidence of net benefit, recommending this intervention does not currently appear to be medically ethical. The CDCThe position that equipoise does not exist for masking children for COVID-19 is contradicted by threer lines of evidence: 1. Disagreement among experts and variations in guidelines, 2. Ambiguity of evidence and 3. The presence of recent and ongoing randomized efforts.We review the concept of equipoise, describe how equipoise appears in real life and at what point it may no longer exist. Finally, we discuss how, even if there is equipoise for masking children, most would consider it medically unethical to recommend any intervention when the totality of evidence fails to find a net benefit.1.1believed worked went on to be found ineffective in randomized studies [The use of randomized trials to assess medical interventions dates back to a 1940s trial of streptomycin for tuberculosis . At this1.2Beliefs about the effectiveness and appropriateness of mask-wearing for respiratory infections vary widely by geographic location, type of mask, age and circumstance. The U.S. CDC, as of September 2023, continues to recommend  that chiMultiple international experts have argued against masking children citing both a lack of high-quality evidence of benefit and concerns about harms to learning and development , especiaHowever, practically speaking, fewer and fewer people are wearing masks, even in most healthcare settings. This suggests there is a growing consensus about masking among the general public. At the same time, in the summer and fall of 2023, a number of educational programs continue 1.3” The authors stated data were “very uncertain” about N95/P2 respirators.A fundamental reason for the continued lack of consensus about mask-wearing for respiratory viruses is ambiguity of evidence. However, data from the two existing Cochrane Reviews of randomized data have been consistent, and unsupportive of masking. These reviews published in 2020 and 2023 ,17, incl1.4Numerous observational studies conducted during the COVID-19 pandemic found mask wearing to be associated with lower case rates . HoweverObservational studies are designed to look for an association between masking and lower case rates, but are, with very few exceptions, unable to infer causality. Some natural experiments can also substantially reduce confounding by choosing a situation where the only meaningful variable that differs is mask use. This appears to have been the case with a regression discontinuity study from Catalonia, Spain , which tHowever, other natural experiments, where a mask mandate disappears for one group but not another may face the challenge of not being able to adjust for confounding factors that change along with the mandate ,22. Rand1.5The presence of numerous recent randomized trials of masking in the community and healthcare setting speaks to the fact that multiple independent expert groups simultaneously assessed the landscape of evidence and found it also compatible with equipoise. Randomized studies of masking were recently completed in Denmark, Bangladesh, Canada, Egypt, Israel, Pakistan, Guinea Bissau and there is one ongoing randomized study of masking in Norway. Notably, this ongoing study is not recruiting anyone younger than 18, thus will not provide specific data for children.1.6genuine uncertainty about masking children for COVID-19. In other words, is there still equipoise?Most of the world's population has immunity to COVID-19 and the severity of the disease has decreased drastically . One stuAs late as September of 2023, a group of experts and the US CDC  continueHowever, a careful discernment of the evidence reveals a lack of evidence of net benefit of this intervention. Thus ethically, according to the principle of non-maleficence, the intervention would be considered unethical. As public awareness increases about the absence of high-quality data demonstrating benefit, equipoise may disappear, though may once again reappear with the emergence or resurgence of another respiratory disease threat. At that time, it will be indicated to obtain high-quality evidence from randomized trials before concluding based on low-quality evidence that the benefits of masking children will outweigh the harms, even for a limited period of time.2A leading CDC official stated no randomized trials of masking were done in children due to a lack of equipoise, citing overwhelming benefits found in observational studies. However, the presence of widespread disagreement among experts, remaining ambiguity of evidence, with pooled randomized trials being negative, and the presence of recent and ongoing randomized investigations all support the presence of equipoise. At the same time, weighing the current high-quality evidence with known and potential harms , recommeNone.The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Vinay Prasad's Disclosures. (Research funding) Arnold Ventures  Johns Hopkins Press, Medscape, and MedPage (Honoraria) Grand Rounds/lectures from universities, medical centers, non-profits, and professional societies. (Consulting) UnitedHealthcare and OptumRX. (Other) Plenary Session podcast has Patreon backers, YouTube, and Substack. Tracy Beth Høeg's Disclosures. (Honoraria) Brownstone Institute, Global Liberty Institute. (Consulting) Florida Department of Health (Other) Substack, payment for writing at The Atlantic, Los Angeles Times, New York Times, The Hill and Tablet Magazine. Dr. González has no disclosures to report.


Background: Herbal medicine can provide adjunctive therapy for adults with post-stroke depression. This study summarizes the latest evidence regarding the harms and benefits of herbal antidepressants.Methods: The literature searched from the Cochrane Library (using the OVID platform), Embase, PubMed, the China National Knowledge Infrastructure (CNKI), the Wan Fang Data Knowledge Service Platform, and the China Scientific Journal Database (VIP) from their inception to 18 August 2021, for randomized controlled trials of herbal medicine in adults with post-stroke depression, were included in this systematic review and network meta-analysis. The search was updated on 1 December 2022. To summarize the evidence, the frequentist random-effect network meta-analyses were conducted. To categorize interventions, rate the certainty of the evidence, and present the findings, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) frameworks were carried out. The registration number of this study on PROSPERO website is CRD 42021273956.Findings: Of 1132 citations identified from the search, 51 randomized clinical trials, totaling 4,507 participants, met the inclusion criteria for this study. For response rate, Shugan Jieyu capsule (SJC) plus selective serotonin reuptake inhibitors (SSRI), Jie-Yu Pills plus SSRI, and Wuling capsule plus SSRI were shown to be among the most effective with moderate certainty of evidence . In terms of mean changes in Hamilton depression scale (HAMD) score after the completion of treatment, Wuling capsule plus Hypericum and Wuling capsule plus SSRI were found to be among the most effective in reducing symptoms of depression with moderate certainty of evidence . The network meta-analysis (NMA) showed that SJC may be a safer intervention than SSRI in terms of both total gastrointestinal and total nervous system events with moderate certainty of evidence .Interpretation: SJC plus SSRI, Jie-Yu Pills plus SSRI, and Wuling capsule plus SSRI were among the most effective in terms of HAMD score reduction response rates. Low to very low certainty of evidence revealed no increased risk of gastrointestinal and nervous system events.Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=273956; Identifier: CRD42021273956. Post-stroke depression (PSD) is the most common psychiatric disorder associated with stroke and affects approximately one-third of stroke survivors . The PSDTherefore, antidepressants are strongly recommended (class I recommendation) by the American Heart Association/American Stroke Association in their acute ischemic stroke guideline for 2019 . BecauseIn recent years, due to the concerns regarding the benefits and risks of these commonly accepted antidepressants, herbal medicines that contain traditional Chinese medicine (TCM) are gaining interests and recognitions . The effOur present analysis was strictly performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-2020) guidelines and the extension statement for network meta-analysis (PRISMA-NMA)  Supplem. The proFor the searching of literature, the Cochrane Library (using the OVID platform), Embase, PubMed, the China National Knowledge Infrastructure (CNKI), the Wanfang Data Knowledge Service Platform, and the China Science and Technology Journal Database from their inception to 18 August 2021 were used. By cross-checking the reference list of the key reviews , the seaThe strategy for the search was constructed using the free terms, such as “herbal medicine”, “phytotherapy”, “plant extracts”, “medicinal plants”, “Chinese herbal drugs”, “Chinese traditional medicine”, “Ginkgo biloba”, and “Eleutherococcus”  for binary outcomes such as response rate and mean differences (MDs) (change in HAMD and NIHSS score) for continuous outcomes. The missing standard deviation of change score from baseline was determined by a method from the Cochrane handbook .The frequentist random-effect network meta-analysis with graph-theoretical approach using R package “netmeta” was used for the analysis. Supplem. To estiTo assess the risk of bias of individual studies for Randomized Trials, the Cochrane Risk-of-Bias Tool (RoB-2) was used by X.C. and J.Z. independently. Another researcher (S.M.) was also employed to resolve the disagreement.To rate the levels of evidence , the GRADE approach was utilized. Following the GRADE assessment for network meta-analysis (GRADE-NMA), we downgraded the evidence based on the seven domains, including imprecision, inconsistency, intransitivity, publication bias, heterogeneity, indirectness, and risk of bias. To draw the results from network meta-analysis, the minimally contextualized framework was conducted by categorizing the interventions into the most effective/harmful, intermediate and least effective/harmful interventions. This framework involved minimal contextualized judgement and adopted no effect as the GRADE assessment decision target. Meanwhile, drugs were categorized based on whether they were significantly better or worse than reference drug or other drugs. We also divided the drugs into two groups : one groOf the 1132 citations identified, 264 potentially eligible articles were retrieved. Ultimately, 51 unique randomized control trials fulfilled all the inclusion and exclusion criteria, which included 4,506 adult subjects in total . All 51 11 combined interventions and 9 monotherapies were included in these trials. SSRI were the most frequently used comparators across all studies. The median length of the follow-up was ranging from 4 weeks to 3 months. Of the recruited patients, 43.0% were inpatients, 4.0% were outpatients and 53.0% were mix of both inpatients and outpatients . Most ofThe median age of the participants was 62.1 years old. Approximately, 46% of them were female. A complete description of the participants and studies are presented in There were some general concerns or high concerns for the risk of bias for the randomization due to the lack of information regarding the allocation concealment. The risk of bias for the deviation was predominantly high, because of the lack of detailed methods to clearly indicate whether the participants were aware of their assigned intervention during the trail. Forty-nine trials presented with an unclear risk of bias and two trials with a low risk of bias for the measurement of the outcomes. Forty-five out of 51 publications presented with an unclear risk of bias for the selection of the reported results, because there were no advance announcement of the protocol .The response rate was described by 38 RCTs . SJC plus SSRI, Jie-Yu Pills plus SSRI, and Wuling capsule plus SSRI proved to be among the most effective with moderate certainty of evidence . Wuling capsule plus Hypericum and Free and Easy Wanderer (FEW) proved an intermediate effect with moderate certainty and showed the same effect as SSRI . Other drugs showed low or very low certainty of evidence .In the analyses of mean changes in HAMD score after treatment completion, 50 trials and 4,427 participants were included. Wuling capsule plus Hypericum and Wuling capsule plus SSRI were found to be among the most efficacious in reducing symptoms of depression with a moderate certainty of evidence . FEW proved intermediate effect with moderate certainty of evidence and showed the same effect as SSRI . Other drugs showed low or very low certainty of evidence .Five trials reported drop out events due to any reason with 486 participants. No significant differences were found in the effect of these tested interventions, including Hypericum, SJC plus SSRI, Wuling capsule plus SSRI, usual care, SJC, Wuling capsule, and Free and Easy Wanderer, in comparison to SSRI with moderate to low certainty of evidence .For the mean changes of the NIHSS scale score , Jie-Yu Pills plus SSRI , SJC plus SSRI , and Wuling capsule plus SSRI  were superior to SSRI. Wuling capsule plus Flupentixol/Melitracen, SJC plus SNRI, Ginkgo biloba extract plus SNRI, SJC, Wuling capsule plus SNRI, usual care, and Flupentixol/Melitracen were comparable to placebo .The NMA for the total gastrointestinal events consisted of 25 RCTs , and SJC were the only intervention that may be safer than SSRI with moderate certainty of evidence . FEW and standard care demonstrated intermediate safety with certainty of evidence and showed the same safety as SSRI . Other drugs had low or very low certainty of evidence .For the total evens of nervous system, 24 RCTs  were included. Additionally, SJC was the only intervention that may be safer than SSRI with moderate certainty of evidence . FEW and usual care still proved intermediate safe with moderate certainty of evidence and showed the same safe as SSRI . Other drugs showed low or very low certainty of evidence .In the present study, the network meta-analysis was conducted for 51 randomized controlled trials that enrolled a total of 4,507 patients assigned to 20 different herbal medicines and first-line antidepressant drugs. We found that SJC plus SSRI, Jie-Yu Pills plus SSRI, and Wuling capsule plus SSRI are among the most effective agents for treating PSD patients. The three interventions mentioned above markedly reduced the HAMD score by more than 50% with a moderate (Wuling capsule plus SSRI) or a low (SJC plus SSRI and Jie-Yu Pills plus SSRI) certainty of evidence. Interestingly, Wuling capsule plus Hypericum and FEW was statistically not inferior to SSRI and was demonstrated to be among the most effective intervention to significantly improve the HAMD score. All the aforementioned treatments showed no additional risks of gastrointestinal and nervous system events with low to very low certainty of evidence. In particular, SJC had a significantly lower safety risk compared to SSRI.The mechanism of action for these treatments are largely unknown. However, some links between the Chinese herbal medicines highlighted in this study and PSD can be discerned. Several evidence suggest that the underlying mechanisms of PSD include decreased neurotrophic factors such as Insulin-like growth factor 1 (IGF-1), Brain-derived neurotrophic factor (BDNF)) and monoamines (5-hydroxy tryptamine(5-HT), dopamine (DA) and norepinephrine (NE)), increased inflammatory factors, glutamate-mediated excitotoxicity, and disruption of the axis regulated by hypothalamic-pituitary-adrenal (HPA) . Wuling Hypericum perforatum (HP). SJC might improve the cognition of mild to moderate depression (MMD) patients, which may be realized partly through the regulation within two brain regions, ventral caudate (vCa) and orbitofrontal cortex (OFC) (SJC is a Chinese combined extract of Eleutherococcus senticosus (ES) and ex (OFC) . SJC canex (OFC) . The antex (OFC) .Hypericum perforatum . , PI3K/Akt, and Ras/MEK/ERK, enhancing the phosphorylation of cyclic adenosine monophosphate response element binding protein, associated with depression in primary hippocampal neurons and PC12 cells . . Hyperfo12 cells .Unlike the other herbal medicines above mentioned, Jie-Yu Pills is composed of Ganmaidazao (GMDZD) decoction and FEW . It has been found that Jie-Yu Pills can reverse neuro-endocrine-immune dysfunction and exert antidepressant-like effect by reducing the excessive concentration of corticosterone (CORT), adrenocorticotropic hormone (ACTH), tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) in a rat model of unpredictable stress . The depTo summarize, to our knowledge, this is the first study to systematically examine the efficacy of herbal medicine alone or in combination with classic antidepressants  to attenuate the depressive symptoms in PSD adults. Previous reviews on the efficacy of traditional Chinese medicine for PSD have mainly focused on Wuling capsule and have concluded that it may provide some benefits when combined with SSRI, such as sertraline, paroxetine and citalopram . We perfIt is worthy to note, however, that the current study does come with certain limitations. First, the conclusions drawn in the current study regarding the effectiveness of traditional Chinese medicines are based on a meta-analysis, which means that future clinical studies will need to be performed to confirm the efficacy of the treatments showing evidence of efficacy for PSD in the current study. Second, the main focus of our study was on the efficacy of the herbal medicines and the combination of these herbal medicines with classic antidepressants. Therefore, in-depths analyses of the standard non-herbal antidepressants and combinations of these non-herbal antidepressants are out of scope of this current study. Third, a few studies reported drop outs, the impact of which could not be fully evaluated on the final results of such studies. Future research should focus on long-term acceptability (treatment discontinuation measured by the proportion of patients who withdrew for any reason) of treatments which significantly connected to the highest remission rates and response in the PSD patients. Last but not least, it should be noted that majority of our findings indicated low to moderate certainty of evidence. Therefore, the conclusions that, for example, some of the herbal medicines can provide superior antidepression effect compared to the classic antidepressant alone should be taken with a caution.Post-stroke depression is a serious condition that affects one-third of stroke patients every year, yet an effective treatment with minimal adverse effects is currently limited. To our knowledge, the current study is the first study to systematically examine the efficacy of traditional Chinese medicine alone or in combination with the primary treatment of PSD, such as SSRI and SSRI for treating the depression symptoms in PSD patients. We conclude that Wuling capsule, in particular, and other SSRI combinations, such as SSRI plus Wuling capsule, SJC, or Jie-Yu pills, hold a great promise for treating the depression symptoms in PSD patients. Future clinical research is needed to directly confirm these findings and to advance the current treatment strategy for PSD.


We are grateful to them for highlighting important work from this setting that we did not cite in our review. However, we disagree that our recommendations are not supported by evidence. Antimicrobial resistance (AMR) represents a global threat and the ATTIRE trial demonstrated that in the United Kingdom, clinicians may be prescribing antibiotics to double the number of hospitalized patients with advanced cirrhosis than to those who actually have evidence of infection.3 and await the results in 2025.Furthermore, we do not view not prescribing prophylactic antibiotics to patients when there is insufficient evidence of benefit in doing so as marginalization. To be clear, in no way are we suggesting that any patient should be denied safe and effective treatments based on the etiology or severity of their disease. On the contrary, we are questioning the safety and effectiveness of prescribing prophylactic antibiotics beyond what is supported by existing evidence. Like Haddadin et al, we strongly encourage well-designed and appropriately powered clinical trials in this area to guide practice. With this in mind, we have now completed recruitment to the ASEPTIC trial4 We also note in the feasibility trial for REDUCe2 that the baseline rates of previous spontaneous bacterial peritonitis (SBP) for the LTAD and large-volume paracentesis groups were 7% and 13%, respectively, and the incidence of peritonitis during the 12-week trial was 6% and 11%, respectively, despite all participants taking prophylactic antibiotics.5 It is not clear to us whether AMR is an outcome of interest in this trial. To conclude, Haddadin et al justly warn that in the absence of evidence, “withholding treatment could have unintended consequences”; our concern is that the same is also true of giving treatments beyond the evidence. We need a higher level of evidence to endorse antibiotic prescribing beyond current evidence-based recommendations: antibiotic prescribing is not a zero-sum game.The systematic reviews cited by Haddadin et al do highlight the increased incidence of peritonitis in patients with long-term abdominal drains (LTADs) for cirrhotic versus malignant ascites (17.4% vs 5.9%). However, this does not necessarily mean that prophylactic antibiotics will improve the outcomes, including patient-reported outcomes, for these patients. We look forward to the results from the REDUCe2 study comparing palliative LTADs with large-volume paracentesis in refractory cirrhotic ascites. The authors have pragmatically chosen to prescribe prophylactic antibiotics to all participants; thus, evaluating the safety and effectiveness of this practice will be a challenge. The consensus document quoted in support of this decision highlights that, although the risk of peritonitis is high in this patient group, “there are no evidence-based guidelines on use of prophylactic antibiotics in setting of LTADs.”


To date, the discussion concerning bile acids (BAs) during gestation is almost exclusively linked to pregnancy complications such as intrahepatic cholestasis of pregnancy (ICP) when maternal serum BA levels reach very high concentrations (>100 μM). Generally, the placenta is believed to serve as a protective barrier avoiding exposure of the growing fetus to excessive amounts of maternal BAs that might cause detrimental effects . However, little is known about the precise role of the placenta in BA biosynthesis, transport, and metabolism in healthy pregnancies when serum BAs are at physiological levels . It is well known that primary BAs are synthesized from cholesterol in the liver and are later modified to secondary BA species by colonic bacteria. Besides the liver, BA synthesis in extrahepatic sites such as the brain elicits neuroprotective actions through inhibition of apoptosis as well as oxidative and endoplasmic reticulum stress. Even though historically BAs were thought to be only “detergent molecules” required for intestinal absorption of dietary fats, they are nowadays acknowledged as full signaling molecules. They modulate a myriad of signaling pathways with functional consequences on essential processes such as gluconeogenesis -one of the principal energy sources of the fetus- and cellular proliferation. The current manuscript discusses the potential multipotent roles of physiologically circulating BAs on developmental processes during gestation and provides a novel perspective in terms of the importance of the placenta as a previously unknown source of BAs. Since the principle “not too much, not too little” applicable to other signaling molecules may be also true for BAs, the risks associated with fetal exposure to excessive levels of BAs are discussed. N-acyltransferase (BAAT). These enzymes promote the conjugation (or amidation) of CA and CDCA with taurine to form tauro-CA (TCA) and tauro-CDCA (TCDCA), respectively. In addition, some primary BAs are conjugated with glycine to form glyco-CA (GCA) and glyco-CDCA (GCDCA), respectively (The primary bile acids (BAs) in humans, cholic acid (CA) and chenodeoxycholic acid (CDCA) are cholesterol derivatives produced in the liver through multistep synthetic processes involving several specific enzymes. These enzymes are hosted in subcellular compartments including peroxisomes. The BAs, bearing a pentanoic acid side chain and one to three hydroxyl groups are positioned at α3, α7, and α12 of the cholane, and are synthesized through two major routes, the classic  pathway and the alternative (or acidic) pathway  Figure . The claectively .The amino acid-conjugated BAs exhibit increased hydrophilicity and enhanced transmembrane transport, resulting in reduced cellular cytotoxicity. Within the intestinal lumen, primary BAs are deconjugated and dehydroxylated at the 7α-position under the enzymatic action of intestinal bacterial microflora , giving The regulation of BA biogenesis is, among other factors, subject to diurnal variations. In rats and mice, BA synthesis peaks during the dark phase when they feed the most , while iBAs exhibit marked effects on placental functions  as well vice versa  expressed on the apical and basal sides of the syncytiotrophoblast . BAs areGPBAR1/TGR5 was detected in several tissues including the placenta and brain (The G protein-coupled bile acid receptor 1 (GPBAR1), also known as Takeda G protein-coupled receptor 5 (TGR5), is activated by both primary and secondary BAs. It is mainly responsive to LCA, with the following affinity rank: LCA > DCA > CDCA > CA > UDCA . In the nd brain .1 at the protein level , a natural ligand of the sphingosine-1-phosphate receptors (SP1R), is abundantly present in red blood cells, vascular endothelial cells, and activated platelets . Expressin level , and thein level . The acttastasis . S1PR sutastasis . S1P andtastasis  and plactastasis . Thus, t1-M4 were also detected (Previous data further indicate that muscarinic acetylcholine receptors (M), a subfamily of GPCRs that regulate numerous fundamental functions of the central and peripheral nervous system, exhibit a high binding affinity for BAs . The M sdetected . The fundetected .BA species are transported to their sites of action by membrane proteins of the ATP-binding cassette (ABC) transporter and solute carrier (SLC) families. Some of these membrane transporters, such as the organic anion transporting polypeptide (OATP)1B1/SLCO1B1, OATP1B3/SLCO1B3, ABCG5, multidrug resistance-associated proteins (MRP) type 1 (MRP1/ABCC1), and bile salt export pump (BSEP/ABCB11) are known to be important for maintaining BA homeostasis in the human liver  and inteABCG2 gene expression has been shown to both increase and remain unchanged across gestation  in the third compared to the first trimester in humans , a disease that can occur as early as the seventh week of gestation but appears more frequently in the third trimester. It is characterized by high levels of maternal BA concentrations with a cut-off value of 10 μmol/L  and up tSLCO3A1 mRNA in ICP patient treated with UDCA as compared to controls  mRNA were detected in both species. It should be also noted that, even though mRNA transcripts of CYP7A1 were not consistently detected in the human placenta, they were found in isolated primary cytotrophoblast and syncytiotrophoblast cells. The apparent discrepancy between placental tissues and cell-based data could have resulted from a dilution effect occurring in placental tissue, which contains a myriad of cell types. The findings reported by (https://www.proteinatlas.org, supplemented with mRNA data from (in situ in the placenta because BAs locally synthesized in the placenta may directly affect placental performance and fetal development (In a recent study, we reported the presence of mRNA transcripts of most of the BA synthesizing enzymes in the placentas of healthy mice and humans and proposed this organ as a potential new source of BA . In thisorted by  are in lorted by . To dateorted by . Availabata from , are comata from . Howeverata from  and confelopment  (Figure elopment . Consideelopment , and theelopment , the preelopment  should belopment . Althougelopment , their rin situ BA secretion on the regulation of placental performance, fetal organ growth and maturation, as well as fetal programming of various vulnerabilities.The present manuscript discusses the physiological importance of BAs as signaling molecules and reviews the membrane proteins and mechanisms that sustain the transport of BAs across the placenta, which subsequently contributes to the BA levels in fetal and maternal circulations. Furthermore, the placenta may act not only as an exchange interface but may also serve as a steroidogenic organ capable of synthesizing BAs. These placentally synthesized BAs are possibly added to the maternal and fetal BA pools and may additionally exhibit receptor-mediated autocrine and paracrine effects. Although additional investigations are needed to unequivocally ascertain the capacity of the placenta to synthesize BAs, this possibility opens avenues to explore the importance of


Evidence theory is widely used to deal with the fusion of uncertain information, but the fusion of conflicting evidence remains an open question. To solve the problem of conflicting evidence fusion in single target recognition, we proposed a novel evidence combination method based on an improved pignistic probability function. Firstly, the improved pignistic probability function could redistribute the probability of multi-subset proposition according to the weight of single subset propositions in a basic probability assignment (BPA), which reduces the computational complexity and information loss in the conversion process. The combination of the Manhattan distance and evidence angle measurements is proposed to extract evidence certainty and obtain mutual support information between each piece of evidence; then, entropy is used to calculate the uncertainty of the evidence and the weighted average method is used to correct and update the original evidence. Finally, the Dempster combination rule is used to fuse the updated evidence. Verified by the analysis results of single-subset proposition and multi-subset proposition highly conflicting evidence examples, compared to the Jousselme distance method, the Lance distance and reliability entropy combination method, and the Jousselme distance and uncertainty measure combination method, our approach achieved better convergence and the average accuracy was improved by 0.51% and 2.43%. As an uncertain reasoning method, evidence theory ,2 needs To address the issue of conflicting evidence fusion, scholars have presented many outstanding studies. When there are conflicts in original evidence, traditional DS theory cannot be applied and it needs to be improved. In recent years, a large number of scholars and experts have improved evidence theory from two aspects. The first is to improve the fusion rules of DS evidence theory. Sun promoted the concept of credibility, believing that the credibility of all evidence is equal, and modified the Dempster rule by weighted summation . Yang esIn this field, domestic and foreign scholars and experts have achieved excellent results in a particular range. However, in the application of single target recognition, there is only a single result, i.e., U be a domain set representing all values of X, and all elements in U are not integrated. Then, U is called the recognition framework of X.Let The research objects in scientific theory compose a nonempty set, which is called a domain.Definition 1.Let U be a recognition framework, then the function satisfies the following conditions:(1) ;(2) .A, A is called a focal element.Then, U, and the focal elements are Hypothesis K is the conflict factor, which reflects the degree of conflict between evidence. Then,N evidence as Define the system identification framework as A is the proposition of original evidence and B is a simple subset proposition in A.In single target recognition, the fusion recognition result often only has a certain target. In the framework of DS evidence theory, when evidence contains multiple subset propositions, the fusion result also contains multiple subset propositions, which increases the computational complexity. This work improves the pignistic probability function to transform the multiple subset propositions into single subset propositions, in which the BPA of multiple subset propositions is distributed according to the weight of single subset propositions. The weight is allocated according to the information of each single subset proposition provided by the evidence itself, which reduces the computational complexity and information lost in the process of transforming the pignistic probability function  from theAfter the pignistic probability function is conserved, the BPA is converted into a single subset BPA The distance between evidence  can effeThe Manhattan distance between two pieces of evidence is calculated as: The distance between evidence is negatively correlated with the support.The calculation of the evidence support of The support degree is obtained based on the Manhattan distance between evidence. The support is normalized to obtain the support coefficient of the evidence The angle between the two pieces of evidence can be used to structure the consistency between the evidence subjects, and the results obtained can be used to measure the similarity between the two evidence subjects. The formula for the evidence angle  is as foThe larger value of The similarity between evidence is measured based on the evidence angle. The similarity is normalized to obtain the similarity coefficient of the evidence In evidence theory, the amount of information content that evidence carries can be measured by information entropy. The higher the information entropy, the more information the evidence carries, and the lower the probability of occurrence in the real world, the higher the uncertainty. The calculation formula for information entropy is as follows:The uncertainty coefficient of each piece of evidence The evidence fusion coefficient integrating the Manhattan distance, the evidence angle, and the reliability entropy is: The fusion coefficient All the initial evidence is replaced with The flow graph of the method proposed in this paper is shown in In the following, we verify the effectiveness of the method through two conflicting examples: those that only contain single-subset propositions and those that contain multiple-subset propositions.An example of single-subset proposition conflicting evidence can be found in reference . An evidThis example is a simple subset proposition, and the conversed BPA is obtained by Formula (1). Apply Formulas (5)–(8) as follows to obtain the evidence support coefficient, the distance matrix, and support matrix as: The support based on the Manhattan distance between evidence is: The evidence support coefficient Apply Formulas (9)–(11) as follows to obtain the the evidence similarity coefficient The evidence similarity coefficient Apply Formulas (12) and (13) as follows to obtain the evidence uncertainty coefficient The support coefficient and similarity coefficient represent the certainty of evidence, and the uncertainty coefficient represents the uncertainty of evidence. The final evidence fusion coefficient is obtained by applying Formulas (14) and (15): Modify the evidence againFormula (16) is applied for fusion four times, and the fusion results are shown in Suppose there is a multi-sensor-based target recognition system, then the recognized targets are According to Formula (3), the conversed BPA is as shown in As calculated by Formulas (4)–(15), the coefficients are shown in We obtained the final evidence of the BPA: Evidence fusion was performed four times by the Dempster rule, and the fusion results are shown in As shown in the figure above, applying the Dempster fusion rule leads to counter-intuitive results.The fusion results of single- and multi-subset conflicting evidence are discussed in this section. Analyzing Analyzing Experiments have shown that the method proposed in this article can effectively extract mutually supportive features between various evidence sources when there are sufficient evidence sources and can achieve good results.In this article, we proposed a novel evidence combination method based on an improved pignistic probability function. Considering evidence characteristics and information richness, this paper proposes a novel method to solve the problem of highly conflicting evidence fusion in DS evidence theory. Through experiments, it has been shown that we have achieved good results in dealing with single target recognition problems and an improved fusion accuracy of the evidence theory framework in target fusion recognition. Evidence theory has a strong ability to handle uncertainty problems. Our next work will further investigate how evidence theory can be extended and applied in the real world.


Hulu‐mur is a Sudanese traditional nonalcoholic beverage that is made from sorghum flour. This work determined the secondary metabolites and antioxidant activities of traditional Sudanese nonalcoholic beverage Hulu‐mur from two local sorghum landraces Abjaro and Hegarii. The changes on the total phenolic content (TPC), total flavonoid content (TFC), carotene content, tannins, and antioxidant activity  were estimated during the preparation of the Hulu‐mur flasks. For both landraces, a significant (p < .05) effect on the phytochemical compound and the antioxidant activity was observed during malting and fermentation of sorghum flour. However, the most increase in the TPC and carotene content was observed, whereas tannin and TFC were decreased in the Hulu‐mur flasks compared with the malted and fermented samples. The antioxidant activity DPPH, TRP, and FRAP was significantly (p < .05) higher in Hulu‐mur flasks than those of raw and processed flour. The partial least squares regression test stated a positive validation score of the Hulu‐mur flasks prepared from the both landraces. In conclusion, Hulu‐mur drink from Abjaro and Hegarii landraces contain high antioxidants compound, which could improve the health‐promoting metabolites in Sorghum‐based food. Hulu‐mur is a Sudanese traditional nonalcoholic beverage made from sorghum Hulu‐mur was prepared from sorghum landraces Abjaro and Hegarii. Hulu‐mur contains secondary metabolism with a higher antioxidant response. Production of Hulu‐mur could improve sorghum health‐promoting compounds. Moench) is one of the foremost vast cultivated carbohydrate‐rich crops of the Gramineae family and originated in Africa , porridge (Aceda), thin fermented gruel (Nasha), alcoholic beverages (Merissa), and local nonalcoholic beverages (Hulu‐mur).Sorghum , protein (14.3%), lactic acid (3.8%), ash (3.5%), and starch (41%). Mariod et al. , and essential amino acids . Interestingly, the significant component that presumably goes into the solution is when the flakes are soaked in the sugar. Therefore, it is sensible to assume that Hulu‐mur has been contrived to provide a readily absorbable sugar, necessitating bridging the leeway in blood sugar caused by fasting  flour.2.2To prepare malt flour locally named “Zurriea,” approximately 2 kg of grains of each landrace were soaked in tap water overnight. Subsequently, the softened grains were spread on trays in a layer of roughly 4 cm and instantly covered with a wetted jute sack. The soaked grains were kept moist by frequent sprinkling with tap water for almost 4–5 days. After the germination occurred, and the plumule and radicles protruded out of the seeds coat, water spraying was stopped, and grains were kept dry for 2 days until their color turned reddish. Eventually, the sun‐dried reddish malt is then ground into a fine flour  using a laboratory mill for further use in dough fermentation.Hulu‐mur dough was prepared using the conventional Sudanese household method as previously described by Dirar , the batter is spread toward the near side of the “Saj.” As the edge of the Saj is approached, the remainder of the batter carried by the gergeriba is piled back onto the baking sheet's surface. This process was repeated, spreading the extra batter backward and forward until all the batter aliquots were killed on the saj surface. Eventually, the Hulu‐mur flakes were ground and passed via a 0.4 mm screen for further analysis.of Dirar . Hereto,2.3The extracts of the samples were prepared in methanol at a ratio of 1:25 (w/v) as described by Talhaoui et al. . The col2.4R2 = .99743). The total phenolic content was then expressed as mg GAE/g DW.The total phenolic content (TPC) of the samples was determined spectrophotometrically following the Folin–Ciocalteu's reagent method . The TFC was expressed as mg CE/g DW.The total flavonoid content (TFC) of the samples was measured according to the colorimetric assay  was estimated using the vanillin–HCl method as previously described by  of the extracts was made using U.V./visible spectrophotometer (593 nm) according to Benzie and Devaki  method. 2.8.3Hulu‐mur ingredient samples was determined by  was used as a reference standard using the spectrophotometer, and results were expressed as AAE/g.The total reducing power (TRP) of the 2.9p < .05). The main effects of Sudanese sorghum landraces, the Hulu‐mur production process, and their interactions were statistically analyzed by the two‐way analysis of variance (ANOVA) (GLM procedure in SAS) using the SAS 9.1 (SAS Institute) package for Windows. Treatments with significant differences were analyzed using Tukey's HSD post hoc test. The scatter plots between antioxidants assays and phytochemical compounds were developed using SigmaPlot software (version 14.5). Multivariate analysis was conducted using HJ‐Biplot PCA algorisms using XLSTAT software Version 2020.1.3 (Addinsoft) as described in Vidal et al.  TPC and TC variations among the sorghum landraces. While for total tannin and TFC, no noticeable varietal variation was encountered  change was observed for almost all measured secondary metabolites. Except for total carotenoid, the interactions between the sorghum landraces and the Hulu‐mur production process remained significantly (p < .05) different  of sorghum landraces were described in Table ed Table . Regardint Table .Hulu‐mur flakes, and was significantly (p < .05) higher than the other Hulu‐mur preparation ingredients. However, the lowest tannin concentration was detected in the raw flour (Table p < .05) greater compared with the fermented dough and Hulu‐mur flakes  among sorghum landraces, processing and their possible interactions , TRP , and FRAP  were used to measure the in vitro antioxidant activity in grains of Sorghum. The antioxidant activity in grains of Sorghum measured by three in vitro assays revealed a significant difference  in FRAP contents between the Hulu‐mur flakes and fermented dough           Figure , while t) Figure  Also, TR) Figure  and betw) Figure . Once ag) Figure  A simila) Figure  and betw) Figure , whereas) Figure .3.4Hulu‐mur preparation stages ingredients from the two sorghum landraces Abjaro and Hegarii  biplot revealed an apparent clustering of the i Figure . For thei Figure . The comi Figure . While fi Figure . The PCAi Figure . AccordiHulu‐mur preparation stages ingredients (x variables) on the stated factors (y variables) of the two sorghum grain landraces Abjaro  were observed. However, the higher values were obtained from both landraces at the final products, Hulu‐mur flask. These changes might be associated with the traditional processing related to the Hulu‐mur such as germination, malting, fermentation, and hot‐plate cooking.Generally, the obtained results revealed that both Abjaro and Hegarii landraces contain high amounts of phenolic compounds with high antioxidant activity. During The germination process of grains might lead to activating enzymes that are not active in raw seeds, resulting in structural modification and the construction of new compounds, thus improving grains' palatability and nutritional value . Dewanto et al.  observedHulu‐mur flakes improved the accumulation of health‐promoting phytochemicals and antioxidant activity of Sorghum, whereas malted flour improved only the TFC for both sorghum landraces. Furthermore, the step of Hulu‐mur flakes of Abjaro and Hejarii's landraces (Figure Hulu‐mur, the Sudanese traditional nonalcoholic beverage from these landraces, might significantly improve the health‐promoting metabolites of Sorghum‐based food.Observations in the PCA Figure  declareds Figure  show theHulu‐mur flasks prepared from both Abjaro and Hegarii landraces exhibited high content of the secondary metabolites and antioxidant activities. Therefore, they might be considered functional sorghum‐based foods and associated with substantial health‐promoting metabolites that contribute to the health benefits. On the contrary, the making of Hulu‐mur as a local nonalcoholic beverage from different Sudanese durra types, rather than Sorghum variety Feterita, should let the industry to produce traditional sorghum‐based foods and drinks rich with secondary metabolism and antioxidants.In general, based on the obtained results, 5Hulu‐mur flask, the Sudanese traditional nonalcoholic beverage, differently affected the contents of Secondary metabolites and antioxidant activity values. The phytochemical compound and the antioxidant capacity were enhanced during malting and fermentation of sorghum flour. However, the highest values were found significantly higher in Hulu‐mur flask obtained from Abjaro and Hegarii landraces. Moreover, regarding the PLS, the final Hulu‐mur product from both landraces is revealed as the greatest valid, which represents an excellent way to increase the secondary metabolites and antioxidant activities. Hence, Hulu‐mur initially could be considered for the food industry as traditional sorghum‐based foods and drinks rich in some secondary metabolism and antioxidants.The traditional process of producing The authors declare that there are no conflicts of interest.Ethics approval was not required for this research.


Balaenoptera physalus) 20 Hz acoustic presence in Eastern Antarctic waters. Passive acoustic recordings were collected at four sites in Eastern Antarctica from 2013 to 2019. A generalized linear model fitted by a generalized estimating equation was used to test the hypothesis that fin whale 20 Hz acoustic presence shows significant variation between light regimes dawn, day, dusk and night. In the Indian sector of Antarctica, at the Prydz and Southern Kerguelen Plateau sites, fin whale acoustic presence was significantly more common during the night and dawn before declining during the day and dusk periods. A different diel pattern was observed in the Pacific sector, at the Dumont d'Urville site: fin whale acoustic presence was significantly more common during the day than dusk and night periods. No diel pattern was identified at the Casey site. The identified diel patterns in the Indian sector of Eastern Antarctica correlate with previously identified diel patterns of the fin whales' prey. We suggest an indirect association between fin whale acoustic presence and foraging, with the animals more likely to produce the 20 Hz pulse during the night when not foraging and less likely to vocalize when foraging during the day.This study presents evidence of diel patterns in fin whale ( Th. Th25]. In the Pacific sector of Antarctica, at Dumont d'Urville, acoustic presence also differed with light regime; however, the pattern was different to that of the Indian sector sites. Fin whale acoustic presence was more common during the dawn and day than dusk periods . At the p ≥ 0.05). At the Southern Kerguelen Plateau, noise level was lowest during the night; however, hours with acoustic presence were similarly high to those during dawn (p ≥ 0.05). Ambient noise level at Casey significantly affected hours of fin whale acoustic presence during the day and night (p ≤ 0.01 and p ≤ 0.01), with hours with acoustic presence more common when noise level was low and acoustic presence less common when noise level was high. However, no diel pattern in ambient noise level was observed at this site (p ≤ 0.01), with hours with acoustic presence less common when noise level was high. Noise level at this site was lowest during the night and highest during the day, which also had the highest acoustic presence hours , aggregating at depth during the day and rising in the water column at night [Aggregation of fin whales in regions of Antarctica is thought to be driven by high-density areas of prey ,37. Both superba , which i superba –41. In Aat night . This DVat night ,44, howeat night . The purat night ,44.Off California, fin whales exhibit strong diel patterns in their dive behaviour, diving consistently throughout the day and spending prolonged periods in shallow water during the night . This coIt is possible that the diel patterns in acoustic presence reported here in the Indian sector of Antarctica at Prydz and the Southern Kerguelen Plateau were indirectly associated with feeding behaviour of fin whales. The animals may be less likely to produce the 20 Hz pulse when diving for prey during the day and may be more likely to produce the 20 Hz pulse during the night when feeding is less efficient. Similar suggestions have been made for fin and blue whale populations exhibiting this diel pattern in the Northern Hemisphere ,20.Euphausia superba, where they cease their DVM behaviour in spring and summer months [E. superba may occur later in the year at this site, therefore affecting fin whale 20 Hz calling behaviour. The low sample-size and intermittent acoustic presence observed later in the season at Dumont d'Urville may also account for this difference in diel patterns between the Indian and Pacific sectors of Antarctica.While the Dumont d'Urville site largely followed this pattern of greater acoustic presence at night than at dusk, fin whale acoustic presence was most common during the day rather than declining as at the other two sites. This contrast in diel patterns between the Indian and Pacific sectors of Antarctica may reflect differences in prey type and/or availability. This location may not be a consistent feeding zone for the animals, thereby affecting the night and day rhythms. The variability in fin whale diel patterns at Dumont d'Urville may also be a result of variability in the DVM of r months . The DVMWhile the acoustic presence of the 20 Hz pulse was significantly affected by light regime at these sites, diel variation was only minimal. Other studies reporting statistically significant variation in fin whale 20 Hz diel presence have observed similar minimal variation between light regimes ,20. Our The identified diel patterns in fin whale 20 Hz acoustic presence across these sites may be influenced by detectability of fin whale pulses by the automatic detection algorithm. Factors affecting the sound propagation environment can impede the detection range of the receivers and thereby total detected fin whale 20 Hz pulses. A range of factors affect propagation, including the bathymetry, water temperature, salinity and ambient noise . AmbientThe Casey site was the only location in the Indian sector of Antarctica to not record a diel pattern in fin whale 20 Hz acoustic presence. The lack of a diel pattern at this site was probably due to the long-term pattern of intermittent and inconsistent acoustic presence of fin whales in this region . Fewer aet al. [Our study highlights variability in diel occurrence and patterns of fin whale 20 Hz acoustic presence across Eastern Antarctic waters. Further, the diel pattern identified in the Indian sector is inconsistent with the diel pattern identified at Maude Rise in Western Antarctic waters . Shabanget al.  hypothesThis study has identified the first to date evidence of diel patterns in fin whale 20 Hz acoustic occurrence in Eastern Antarctic waters. The diel pattern of greater acoustic presence during the night and dawn observed in the Indian sector may indicate an indirect association with foraging behaviour: the animals are more likely to call when feeding is less efficient. The Pacific sector site, Dumont d'Urville observed a contrasting pattern with greater acoustic presence during the day and the Casey site observed no diel pattern. This variability in diel patterns observed in regions of Eastern Antarctica, combined with previous Western Antarctic studies, outlines the lack of a consistent diel pattern of fin whale 20 Hz acoustic presence in Antarctic waters.


The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a new class of cholesterol-lowering medications that provide significant reductions in lipids but at a large cost relative to statins. With 2 such drugs now on the market, alirocumab and evolocumab, comparing the evidence base for these drugs is necessary for informed decision making.To compare the benefits and harms of the PCSK9 inhibitors alirocumab and evolocumab.ClinicalTrials.gov were used to search for randomized controlled trials of alirocumab or evolocumab with any relevant comparator reporting health outcomes, lipid outcomes, or harms through September 2015, and information was requested from manufacturers. Results were reviewed according to standard review methods.The databases Ovid MEDLINE, Cochrane Library, SCOPUS, and The database searches revealed 17 fair- and good-quality trials; however, none had primary health outcomes or directly compared PCSK9 inhibitors. Alirocumab (75 mg to 150 mg subcutaneously every 2 weeks) resulted in significantly greater reductions in low-density lipoprotein cholesterol  at 12-24 weeks in patients with (a) heterozygous familial hypercholesterolemia and (b) patients at high or varied cardiovascular (CV) risk who were not at LDL-C goals with statin therapy. The highest strength evidence was for patients with high CV risk not at LDL-C goals. Alirocumab also resulted in high-density lipoprotein cholesterol (HDL-C) increases of 6%-12%. Low- and moderate-strength evidence for adjudicated CV events at 52-78 weeks for a priori analyses indicated no benefit. Low- and moderate-strength evidence also found no differences in harms except possibly slightly more injection-site reactions. Evolocumab (120 mg subcutaneously every 2 weeks to 420 mg every 4 weeks) resulted in significantly greater reductions in LDL-C (-32% to -71%) at 12-52 weeks in patients with heterozygous or homozygous familial hypercholesterolemia, patients intolerant of statins, and patients with varied CV risk not at LDL-C goal with statin therapy. The highest strength evidence was for heterozygous familial hypercholesterolemia and patients not at LDL-C goals. Moderate-strength evidence showed HDL-C increases in the range of 4.5%-6.8%. Harms were not different between groups, except possibly slightly greater overall adverse event reporting. Evidence on adjudicated CV outcomes was insufficient to draw conclusions because of sparseness of events, study limitations, and inability to assess consistency of findings.Alirocumab and evolocumab have evidence of large improvements in lipid levels. The strength of the evidence is greater for alirocumab than evolocumab in patients with high CV risk who were not at LDL-C target goals, while evidence for evolocumab is stronger in patients with heterogeneous familial hypercholesterolemia and patients with varied CV risk who were not at LDL-C target goals. Evidence on adjudicated CV outcomes for a priori analyses is unable to show benefit for alirocumab and is insufficient to draw conclusions for evolocumab. Important questions remain about the comparative effects on long-term health outcomes. What is already known about this subjectThe proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab produce large reductions in low-density lipoprotein cholesterol (LDL-C) when given in addition to statins in a variety of populations with hypercholesterolemia or alone or in combination with ezetimibe in patients intolerant to statins.Cardiovascular benefits are as yet not clearly established, with some analyses of incidentally reported or secondary outcomes indicating benefit.Concerns raised about the evidence include the methodology behind cardiovascular endpoint analyses, long-term effects of large reductions in lipids, whether comparison groups were optimal, and cost of the drugs in light of these concerns.What this study addsThis study compared the strength of the evidence base for each of the PCSK9 inhibitors alirocumab and evolocumab.The evidence base for alirocumab is stronger than evolocumab for patients at high cardiovascular risk who have not reached LDL-C targets with statin therapy. Although there is strong evidence that alirocumab lowers lipids significantly, there is currently no evidence of a benefit in cardiovascular outcomes when limiting to adjudicated cardiovascular events and a priori analyses.Evidence for evolocumab is stronger than alirocumab for patients with heterogeneous familial hypercholesterolemia and patients with varied cardiovascular risk not at LDL-C target, but evidence on cardiovascular events is insufficient or absent. Evolocumab also has evidence in these other populations: homozygous familial hypercholesterolemia, populations of patients with varied cardiovascular risk, and follow-up studies of varied populations.2 However, there are patients for whom statins alone or in combination with other lipid-low-ering therapies are not always adequate to reduce cardiovascular risk, even at maximally tolerated doses. There are also patients who are intolerant of statin therapy, in whom treatment with drugs such as ezetimibe alone are also inadequate. Monoclonal antibodies that inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9) have been under development as novel therapies, potentially filling these gaps in current standard therapies for hypercholesterolemia. The first 2 drugs in this new class of antihyperlipidemic treatments received U.S. Food and Drug Administration (FDA) approval in mid-2015. In combination with other treatments—typically maximally tolerated statins— alirocumab was approved for use in heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease who required additional low-density lipoprotein cholesterol (LDL-C) lowering, and evolocumab was approved for patients with clinical atherosclerotic cardiovascular disease or heterozygous and homozygous familial hypercholesterolemia who required additional LDL-C lowering.HMG-CoA reductase inhibitors, or statins, have been the primary therapeutic intervention for hypercholesterolemia for decades. They have been successful in reducing the risk of major cardiovascular events and mortality in a wide range of at-risk individuals.5 In this cost-conscious era of health care, clinicians, payers, and the public are already questioning how to best manage this costly new drug class.6 While there have been reviews of the evidence published,8 there has been concerning criticism of the analysis of the evidence, as well as the evidence itself. These concerns center around long-term health outcomes 10 and comparison groups in trials .14Alirocumab  and evolocumab (Repatha) have shown striking LDL-C reductions over 10 to 78 weeks (26%-67%). But, as with many novel specialty drugs, the promise of better results with PCSK9 inhibitors comes with a high price tag—in this case, the cost is estimated at more than $14,000 per patient per year.18 In the meantime, Navarese et al. (2015) pooled data from the 24 available smaller studies with follow-up ranging from 2 months to 2 years and reported that PCSK9 inhibitors as a group reduce all-cause mortality  and rates of myocardial infarction .7 However, these findings have been questioned based on concerns that the statistical approach used by Navarese et al. is biased in how study arms with zero events were handled.10 Critics demonstrated that use of a few different less-biased conventional methods produced results of consistently smaller magnitude and in 1 case lost statistical significance. Because of the instability and imprecision of these findings, critics urge us to wait for the results of the adequately designed cardiovascular endpoint trials now underway before promoting use of these drugs. Given the increased demand by payers such as Medicare for definitive evidence that interventions improve health outcomes, and not merely intermediate endpoints,19 this debate has important implications for coverage policy determinations as well.To date, no clinical trial of a PCSK9 inhibitor designed a priori, with adequate size and duration, to assess cardiovascular outcomes as the primary outcomes has yet been completed. However, 4 such trials are underway and are expected to be completed in 2018.12 In the largest PCSK9 inhibitor trial to date, the ODYSSEY LONG-TERM trial of alirocumab,20 which alone accounts for 45% of mortality events in the Navarese 2015 meta-analysis,7 only 47% of patients were receiving high-dose statins, despite the trial's focus on high-risk patients. In their published response to this criticism, the ODYSSEY LONG-TERM authors agreed with this limitation and promised that the ongoing ODYSSEY Outcomes study (NCT01663402) will address this uncertainty.21Additionally, there has been criticism that even the LDL-C benefits of PCSK9 inhibitors may have been overestimated because of underutilization of high-intensity statin therapy.22 The purpose of this review was to evaluate the body of evidence for each drug based on the population and comparators studied to better stratify the evidence for decision making with regard for their place in therapy and for selecting a specific PCSK9 inhibitor.To support the work of the participating organizations of the Drug Effectiveness Review Project, the Pacific Northwest Evidence-based Practice Center conducted a systematic review of the comparative effectiveness of alirocumab and evolocumab versus each another, other lipid-lowering regimens, or placebo.For this systematic review, randomized controlled trials (RCTs) of alirocumab or evolocumab were included that reported 1 or more health outcomes , lipid outcomes , or harms . For cardiovascular events, only those that were adjudicated through a formal process were included; those events that were reported as incidental findings were excluded.ClinicalTrials.gov, and requested information from drug manufacturers. Two reviewers, using consensus to resolve disagreements, assessed studies for eligibility. Study characteristics, including baseline patient characteristics, and study results were abstracted by 1 reviewer and checked by a second reviewer for accuracy.To identify relevant studies, Ovid MEDLINE , the Cochrane Library databases (2009 through 2015), and Scopus (2010 through 2015) were searched, using drug names as search terms. Additional studies were located by hand searching reference lists of included studies, 23 Individual studies were assigned ratings of good, fair, or poor. Studies with major flaws were rated as poor; those with essentially no flaws were rated as good; and the remainder were rated as fair. Data in studies that were clinically and methodologically similar were pooled using random effects models, and statistical heterogeneity was explored using the I-squared statistic.24The internal validity  of individual studies were assessed based on predefined criteria developed for the Drug Effectiveness Review Project .25 This grading assessed the limitations, directness, consistency, and precision of the body of evidence for each outcome and resulted in evidence rating of high strength (★★★★), moderate strength (★★★), low strength (★★), or insufficient (★) to draw conclusions. In the tables presented in this review, these ratings are shown as stars. Individual study quality and the strength of evidence ratings were dually reviewed with disagreements resolved using consensus.For studies with multiple arms of differing doses, the doses within the FDA-approved dosing range were analyzed. Body of evidence strength was graded for a given key outcome based on the guidance established for the Evidence-based Practice Center Program of the Agency for Healthcare Research and Quality.43 There are no completed or ongoing studies that directly compared different PCSK9 inhibitors. Study details are summarized in For this review, 17 trials were included in 19 publications .20,26-4338 Evidence for alirocumab compared with placebo in patients with heterozygous familial hypercholesterolemia who took a low- to moderate-intensity statin was insufficient .39 There were no studies of alirocumab in patients with homozygous familial hypercholesterolemia.Compared with placebo, there was low-strength evidence that alirocumab achieved a higher LDL-C reduction in patients with heterozygous familial hypercholesterolemia who took a maximum statin dose plus ezetimibe, based on 1 fair-quality trial (N = 77). Similar effects were shown for high-density lipoprotein cholesterol (HDL-C), but there was insufficient evidence to draw conclusions about harms.34 In patients with homozygous familial hypercholesterolemia who took a maximum statin dose and ezetimibe  that evolocumab (140 mg every 2 weeks to 420 mg every 4 weeks) achieved a greater LDL-C reduction in patients with heterozygous familial hypercholesterolemia who were largely taking a high-intensity statin plus ezetimibe, with a greater improvement in HDL-C and no differences in harms (moderate-strength evidence).zetimibe , low-str41 There is also low-strength evidence from the GAUSS study (N = 62) that the combination of evolocumab (420 mg every 4 weeks) plus ezetimibe (10 mg) led to a greater percentage of LDL-C reduction than ezetimibe (10 mg) alone, but there was insufficient evidence to draw conclusions on other outcomes.41There was no evidence for alirocumab in patients who were intolerant to statins. In statin-intolerant patients, there was low-strength evidence based on 2 fair-quality, 12-week RCTs  that evolocumab (280 mg every 4 weeks or 140 mg every 2 weeks) led to a greater reduction in LDL-C than placebo, with similar effects in HDL-C and harms.27 Similarly, the difference in the percentage of change in LDL-C and HDL-C at 24 weeks was greater with alirocumab . Moderate-strength evidence found that there was no difference in overall adverse event reporting between alirocumab and ezetimibe and that the rate for reporting any adverse event was high (69%). Low-strength evidence found that withdrawal because of adverse events and serious adverse events were not different between the groups. Low-strength evidence suggested a higher rate of injection-site reactions with alirocumab than with placebo injection plus ezetimibe, but this estimate was imprecise . Neurocognitive events were rare.Several studies evaluated a PCSK9 inhibitor in patients with varying levels of cardiovascular risk, who had not achieved an LDL-C of < 100 mg/dL or < 70 or 75 mg/dL using mainly statin-based therapy before randomization. Very few patients had familial forms of hypercholesterolemia in these studies. In high-risk patients, moderate-strength evidence based on a good-quality trial  demonstrated that alirocumab (75 mg to 150 mg given every 2 weeks) resulted in a higher proportion of patients with high cardiovascular risk reaching the study goal of LDL-C < 70 mg/dL at 24 weeks  than ezetimibe (10 mg).30 The difference in the percentage of reduction in LDL-C and HDL-C was also greater. High-strength evidence found no statistical difference in overall adverse event reporting and that the rate for reporting any adverse event was high (75%). Moderate-strength evidence found that withdrawal because of adverse events and serious adverse events were also not different between groups. Low-strength evidence suggested that the risk of injection-site reactions  or neurocognitive events were not increased, although the estimates were imprecise because of few events.Based on 2 trials , there was high-strength evidence that alirocumab (75 mg to 150 mg given every 2 weeks) resulted in a higher proportion of patients with high cardiovascular risk reaching the study goal of LDL-C < 70 mg/dL at 24 weeks than placebo .35 This study provided insufficient evidence to draw conclusions about HDL-C, serious adverse events, or withdrawal because of adverse events because of the small magnitude of change or event rates. In patients with high cardiovascular risk, a small 12-week (N = 104 for placebo comparison) study provided low-strength evidence that evolocumab (420 mg monthly) resulted in higher rates of meeting LDL-C targets of < 100 mg/dL and < 70 mg/dL when added to statins in Japanese patients, compared with placebo.29 There was greater mean change in LDL-C but insufficient evidence to draw conclusions about other outcomes.In a comparison of evolocumab and ezetimibe (both with statin therapy) in patients with high cardiovascular risk, the LAPLACE-2 study (N = 329 for this comparison) provided low-strength evidence that when added to either atorvastatin (10 mg or 80 mg), compared with ezetimibe (10 mg), evolocumab (420 mg monthly) resulted in higher rates of meeting an LDL-C target of < 70 mg/dL at 12 weeks, with similar rates of patients with overall adverse events.30 For evolocumab, adjudicated cardiovascular events were reported as secondary or post hoc outcomes, but evidence was insufficient to draw conclusions because of too few events (imprecise estimates), study limitations, and lack of ability to verify findings across multiple studies  fair-quality RCTs indicated that in patients stabilized on statins who have not achieved an LDL-C of < 100 mg/dL, alirocumab (150 mg subcutaneously every 2 weeks for 8-10 weeks) resulted in significantly more patients achieving study goal (LDL-C < 100 mg/dL) and a greater percentage of reductions (49%-67% more) than statins alone.35 There is also moderate-strength evidence of modest HDL-C increases with evolocumab (420 mg monthly) and moderate- to high-strength evidence of no differences in adverse events. Based on 1 good-quality longer-term trial , there is moderate-strength evidence that evolocumab (420 mg given every 4 weeks) also results in significantly more patients achieving a goal of LDL-C < 70 mg/dL, compared with placebo; low-strength evidence of a modest increase in HDL-C; and evidence of no difference in harms (low- and moderate-strength evidence depending on outcome).In short-term comparisons of evolocumab and placebo, LAPLACE-TIMI 57 and LAPLACE-2 (N = 996 for placebo comparison) provided high-strength evidence that, at 12 weeks in patients with varying risk levels and not meeting LDL targets, significantly more patients taking evolocumab (420 mg monthly) than taking placebo (both with statin therapy) achieved an LDL-C of < 70 mg/dL and had a greater percentage of reduction in LDL-C.37 This reduction was largely sustained at 48 weeks . This analysis of the 2 studies also provided low-strength evidence of a greater proportion of patients meeting an LDL-C goal of < 100 mg/dL or < 70 mg/dL and a greater increase in HDL-C at 12 weeks than with standard therapy alone.There is moderate-strength evidence, based on a pooled analysis of 2 open-label extension studies (OSLER 1 and 2), of patients completing 1 of 12 previous trials , that evolocumab (420 mg monthly or 140 mg every 2 weeks plus standard care - primarily statins) reduced LDL-C by 61% more than standard care alone at 12 weeks.There is low-strength evidence that slightly more patients on evolocumab experienced any adverse event at 12 weeks, compared with statins alone, without differences in serious adverse events but insufficient evidence to draw conclusions about other adverse event outcomes.This systematic review of PCSK9 inhibitor drugs finds low- to high-strength evidence of moderate-to-large magnitude reduction in LDL-C when added to statin therapy in patients with familial forms of hypercholesterolemia and alone or added to ezetimibe in those who are intolerant of statins. Although there are no direct comparison studies, and the lipid outcomes are fairly similar across the trials, the strength of this evidence varies by population and by drug. In patients with heterozygous hypercholesterolemia, the trials of evolocumab were larger (499 vs. 98), and the strength of the evidence was consistently stronger than for alirocumab  was $681,000 for those with familial hypercholesterolemia (either type) and $557,000 for patients with established cardiovascular disease and LDL-C > 70 mg/dL.44 Although these are estimates for comparison with continuing statins alone, they clearly exceed the typical threshold for cost-effectiveness of $50,000 to $100,000 per QALY.44 The analyses using this model suggest that in order for the drugs to be cost-effective, the price range should be closer to $3,600 per year than the current price range of approximately $14,000 per year.In addition to the uncertainty around long-term outcomes, and with an estimated price of almost $14,000 per year,Another important issue raised about this evidence is the comparison groups, including the concomitant antihyperlip-idemic therapy given. Clearly, in a step-therapy approach, the choices in the face of inadequate treatment include continuing to maximize the current therapy, add a second treatment, or even switch treatments. Pharmacologically, the PCSK9 inhibitors are likely to work better when used alongside a statin, and most of the studies continue statin therapy in PCSK9 inhibitor-treated patients. A fair comparison, then, would be maximization of the statin therapy  in the control group in particular. Most of these studies do not adhere to this standard (Tables 2 and 3); consequently, future studies are required to determine the true incremental benefits of PCSK9 inhibitors.45 and without good-quality evidence on cardiovascular outcomes for the PCSK9 inhibitors, it is less clear how to interpret and apply the findings of these studies. Using the percentage of reduction in LDL-C from baseline is not a better marker, since we do not yet understand the implications of 30%-60% above and beyond any initial reductions with a statin. Adding to this lack of clarity, are the several studies in varied- or average-risk populations. In a recent editorial, Shrank et al. (2015) discussed the challenges and implications of determining the best use of PCSK9 inhibitors in light of the recent changes in recommendations for treating hyperlipidemia but recommends a step-approach that promotes maximizing the use of low-cost statin medications rather than PCSK9 inhibitors.14The bulk of the evidence, then, is from patients currently receiving varying doses of statins who have not achieved study-specified target LDL-C levels. While this less than optimal use of statins is not an ideal comparator as an alternative strategy to PCSK9 inhibitors, it may reflect real-world statin use. When limited to populations of patients who are at high cardiovascular risk and whose baseline LDL-C on statin therapy are above targets of 70 mg/dL to 75 mg/dL or < 100 mg/dL, we find large absolute reductions in LDL-C and higher proportions of patients achieving these study goals. However, with recent guidelines suggesting that therapy be directed by risk level and not specific LDL-C targets,With 2 PCSK9 inhibitors approved and others in the pipeline, there will not only be questions about the role of this new class of drugs in the treatment of hypercholesterolemia, but also comparative questions about whether there are important differences among the drugs. Because these drugs will be taken for many years and are expensive, and because there are still questions regarding long-term benefit and harm, studies in the highest risk populations that are designed to assess cardiovascular and potential harm outcomes with appropriate comparison groups  are needed in order to shed light on these important questions.The main limitations of this review are those related to the evidence itself, as previously described . Additional potential limitations of this review include the search strategy and the exclusion of studies published in languages other than English. It was attempted to locate all studies relevant to the scope of this review, but it is possible that evidence was missed. There was limited ability to assess potential publication and reporting bias because of the few opportunities to pool studies and the lack of availability of study protocols. Finally, the scope of this review limited the inclusion of some studies included in other reviews  and within those incidentally reported cardiovascular outcomes.Alirocumab and evolocumab have evidence of large improvements in lipids and limited evidence on cardiovascular outcomes, but the strength of evidence differs between the drugs. The strength of evidence is greater for alirocumab than evolocumab in patients with high cardiovascular risk not at LDL-C target, while evidence for evolocumab is stronger in patients with heterogeneous familial hypercholesterolemia and patients with varied cardiovascular risk not at LDL-C target. Important questions remain about the comparative effects of either drug on long-term health outcomes.