Limited health literacy (LHL) is associated with multiple adverse health outcomes in chronic kidney disease (CKD). Interventions are needed to improve this situation, but evidence on intervention targets and strategies is lacking. This systematic review aims to identify potential targets and strategies by summarizing the evidence on: (i) patient- and system-level factors potentially mediating the relation between LHL and health outcomes; and (ii) the effectiveness of health literacy interventions customized to CKD patients. We performed a systematic review of peer-reviewed research articles in Medline, Embase and Web of Science, 2009–19. We assessed the quality of the studies and conducted a best-evidence synthesis.n = 26) and focused on dialysis and transplantation (n = 38). We found strong evidence for an association of LHL with smoking and having a suboptimal transplantation process. Evidence was weak for associations between LHL and a variety of factors related to self-care management (n = 25), utilization of care (n = 23), patient–provider interaction (n = 8) and social context (n = 5). Six interventions were aimed at improving knowledge, decision-making and health behaviours, but evidence for their effectiveness was weak.We identified 860 publications and included 48 studies. Most studies were of low quality (Study heterogeneity, low quality and focus on kidney failure largely impede the identification of intervention targets and strategies for LHL. More and higher quality studies in earlier CKD stages are needed to unravel how LHL leads to worse health outcomes, and to identify targets and strategies to prevent disease deterioration. Healthcare organizations need to develop and evaluate efforts to support LHL patients. What is already known about this topic?approximately 25% of chronic kidney disease (CKD) patients have low health literacy (LHL);CKD patients with LHL experience a faster disease progression and more comorbidities; andto improve health outcomes for CKD patients with LHL, interventions are needed, but an overview of promising intervention targets and strategies is currently lacking.What this study adds?this systematic review has identified a variety of factors, mostly related to self-care management and utilization of care, which potentially explain why LHL patients experience worse health outcomes. Evidence was strong for an association of LHL with smoking and having a suboptimal transplantation process;the few available HL-tailored interventions mainly used web-based strategies to inform and educate CKD patients. These interventions gave weak evidence that they improved knowledge, decision-making and health behaviours in CKD patients with LHL; andconsiderable research gaps remain. There are limited studies in earlier stages of CKD and thus on chances for prevention of progression towards severe kidney disease in patients with LHL. In addition, studies that unravel the role of the healthcare professionals in the support of LHL patients are lacking.What impact this may have on practice and policy?healthcare organizations should improve the support of patients with LHL to prevent worse health outcomes. Although the best intervention strategies remain underexplored, web-based education was promising for improving patients’ knowledge and behaviours. Organizations could best start by implementing strategies that target smoking and the transplantation process;especially in earlier stages of CKD, more research is needed to unravel the mechanisms by which LHL leads to worse health outcomes. Additionally, research needs to develop and assess the effectiveness of HL-tailored interventions to improve these outcomes; andthis should lead to further unravelling of LHL-associated mediating factors and enable targeting them with health literacy interventions, especially in earlier stages of CKD, to slow down and prevent the global rise of kidney disease.In the last few decades, the number of people suffering from chronic kidney disease (CKD) has steadily increased , 2. In tAbout 25% of CKD patients experience limited health literacy (LHL) , such asThe Pathway of Paasche-Orlow provides a theory of patient- and system-level mechanisms which contain multiple factors that might mediate the relation between LHL and health outcomes . TargetiThe first research agenda on CKD and HL  and the This systematic review therefore aims to identify potential targets and strategies by summarizing the evidence on: (i) patient- and system-level factors that potentially mediate the relation between LHL and health outcomes; and (ii) the effectiveness of HL interventions that are customized to CKD patients.We performed this systematic review in line with the principles of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) .Two reviewers (M.D.B. and E.M.F.) developed the search strategy and eligibility criteria with the support of two database search experts from the University Medical Center Groningen. After a pilot search to determine sensitivity and specificity, and discussion with a third reviewer (A.F.W.), the strategy was finalized. The search strategy aimed to retrieve original English, French or German peer-reviewed quantitative, qualitative and intervention studies related to HL and CKD. The final search strategy included a combination of CKD-specific terms, such as ‘chronic kidney’ or ‘dialysis’ and ‘renal transplant’ and HL related terms, such as ‘literacy’ and ‘numeracy’. Details on the search strategy are in Studies were eligible for inclusion if they: (i) included (a cohort of) any stage CKD patients aged ≥18 years and/or healthcare professionals; (ii) assessed HL using a validated screener or questionnaire; (iii) gave results on associations of LHL with potential mediating factors, derived from the Pathway of Paasche-Orlow; or (iv) provided information on the development and testing of interventions, customized to CKD and the needs of LHL patients. We excluded studies that: (i) used educational level as a measure of HL; (ii) focused solely on associations of HL with knowledge or health outcomes; or (iii) developed or validated HL screeners. Further information about the inclusion and exclusion criteria can be found in Two reviewers (M.D.B. and E.M.F.) performed a systematic database search in Medline, Embase and Web of Science. They used an Excel file with main author, year and title to guide study selection. Both reviewers read titles and abstracts of all identified unique records to include studies that met the inclusion criteria. Disagreements were solved by discussion. If there was still uncertain about eligibility, then the reviewers read the full-text publication and decided based on a new discussion.The two reviewers then performed a full-text review of the included publications and filled in a data extraction table in Excel. Extracted data regarded study characteristics, study aims, main results and conclusions. For each study, data on associations between LHL and mediating factors were sorted into different columns in the Excel file, based on the mechanisms in the Pathway of Paasche-Orlow: self-care management, P–P interaction and utilization of care. The extraction file also encompassed columns to extract data on LHL and the role of the social context or competences of the healthcare professional, which came from IROHLA Intervention model . ClinicaM.D.B. and E.M.F. rated the methodological quality of the included quantitative and intervention studies with the checklist of Downs and Black  and threTogether, the tools provided 16 criteria for quantitative studies, 30 for intervention studies and 18 for qualitative studies within four domains: (i) reporting; (ii) external validity; (iii) internal validity; and (iv) study participation. Each criterion could be rated with 0, 1 or 2 points. The total rating for all criteria and each independent domain was expressed as a percentage of the total maximum score possible. Domains could be of low (≤50%), moderate (>50% and ≤75%) or high (>75%) quality. Both the total and domain ratings were used to determine the final study quality. A high-quality study had a total score >75% and at least three domains with a high-quality rating. Details on the rating system are in Following the quality assessment, M.D.B. performed an evidence synthesis, which was checked by A.F.W. The synthesis aimed to determine the strength of evidence regarding an association of LHL with a specific mediating factor or, regarding the effectiveness of targeting a factor in interventions, based on number and quality of studies reporting results. This method of evidence synthesis is based on other publications , 32. Then = 33), were conducted in the USA (n = 35), and focused mainly on dialysis and transplant patients (n = 38). Only seven studies measured multiple HL domains, instead of just functional HL. Details on authors, year of publication, study population, sample size and used HL screener are in Nine quantitative studies and one qualitative study were of high quality. Nine quantitative studies, two qualitative studies and one intervention study were of moderate quality. The other 26 studies were of low quality. The risk for external validity bias was high: only two studies could fully ascertain the study population was a good representation of the total population. In 25 studies, participation bias was a risk: sample sizes were often not justified or participation rates were low. Within the domains reporting and internal validity, two criteria commonly caused risks of bias: (i) limited adjustment for confounders and (ii) not reporting actual probability values (e.g. 0.035 rather than 0.05). In qualitative studies, bias risks were often a consequence of inappropriate methodology: studies did for example not justify sampling procedure and data saturation. Most intervention studies used weak non-randomized control study designs, which led to low-quality ratings. Twenty-five studies gave generally weak evidence for an association of LHL with a variety of mediating factors related to self-care management. We found strong evidence for an association of LHL and current smoking , 34, 50.Twenty-three studies provided generally weak evidence for an association of LHL with factors related to utilization of care. We found strong evidence that LHL is associated with a suboptimal transplant process, illustrated by a lower likelihood of being wait-listed for , 58, 59,Eight studies gave weak evidence on factors related to P–P interaction. CKD patients did not perceive engaging with providers as their greatest HL problem , 42, 45.Five studies provided weak evidence on associations of LHL with the social context. For an association of LHL with reduced social support evidence was weak , 39, 44.The interventions mainly used digital, visual strategies , 76–78 aEvidence on patient- and system-level mediating factors and effectiveness of interventions is generally weak, which impairs the identification of promising intervention targets and strategies. We found strong evidence for an association of LHL with a suboptimal transplant process and smoking. We retrieved only weak evidence for a variety of other factors that potentially mediate the relation between LHL and health outcomes. Moreover, we found weak evidence that HL-tailored intervention strategies were effective in improving knowledge, decision-making and health behaviours.We retrieved strong evidence for an association of LHL with having a suboptimal transplant process , 59, 67 We found only weak evidence for a variety of factors that potentially mediate the relation between LHL and health outcomes. This impedes the drawing of strong conclusions on targets for interventions in CKD. Even though studies on HL in other diseases like diabetes and cardiovascular disease showed strong associations of LHL with mediating factors, such as knowledge, P–P communication, medication adherence and self-care behaviours , 93. A pIn agreement with HL interventions in other populations , 23, 94 We identified several important research gaps. Most studies focused on dialysis and transplant patients. There is very little evidence on the improvement of outcomes of LHL patients in earlier stages of CKD, and thus on the prevention of progression towards severe kidney disease. Moreover, most studies are from the USA. The results from these studies should be confirmed for other parts of the world, as findings may be influenced by culture and specific characteristics of the health system. Finally, interventions that target the capacities of healthcare professionals are totally lacking.Our review is, to our knowledge, the first to unravel associations of LHL in CKD with a specific intervention focus; previous reviews have instead focused on predictors and prevalence of LHL in CKD , 11 or oThis review also has limitations. The first is our use of two different quality assessment tools, possibly resulting in differences in quality rating between quantitative and qualitative studies. However, because we used a strict classification system to increase comparability, we expect no major biases. The second limitation is that we did not ask for grey literature and excluded several study types. We therefore might have missed information, but since we still provide an extensive overview, it is our opinion that such additional evidence would not greatly affect our conclusions. The third limitation is that we could not assess the effects of the way of measuring HL. Most studies measured functional HL, the ability to read and understand written and oral health information. Broader definitions and measures of HL, which include communication and critical literacy and contextual factors, have become more common only recently. The used measure may affect the associations found with mediating factors, for which we could not account.Our findings imply that healthcare organizations need to take action. Although the best intervention strategies remain underexplored, organizations could best start with targeting smoking behaviour and transplantation processes. The web-based strategies that we identified are promising for improving knowledge and decision-making, and need further implementation in healthcare settings. Additionally new strategies need to be developed. Policy makers should seek ways to simplify navigation in the health system to improve care access.We found high-quality studies to be scarce. This shows a need for larger cohort and intervention studies to unravel the mechanisms by which LHL leads to worse health outcomes and to assess the effectiveness of HL-tailored interventions to improve these outcomes. Such research should include studies on earlier stages of CKD in various parts of the world to find ways to prevent kidney deterioration among people with LHL. Additionally, research is needed to adapt the activities of healthcare organizations to the needs of patients with LHL, for example, by strengthening the communication capacities of professionals. This may help to better inform patients with LHL and improve communication between these patients and professionals .In conclusion, despite the call for urgency in the research agenda on CKD and HL in 2009 , effectiSupplementary data are available at ndt online.This research was conducted independently by the research team, but supported by funding from the Dutch Kidney Foundation. The research was funded by the Behavioural and Social Research Call, grant number: 17SWO06.M.D.B. and A.F.W. designed the study in line with PRISMA guidelines. The first search strategy was developed by E.M.F. and M.D.B. in close cooperation with the database search expert from the Department of Health Sciences and the database search expert from the Medical Library of the University Medical Center Groningen. M.D.B. and E.M.F. discussed the search strategy with A.F.W., and both E.M.F. and M.D.B. pilot-tested the strategy independently to determine specificity and sensitivity. After the first pilot-test, the search strategy was again discussed with A.F.W. and adapted, omitting terms related to ‘education’. After a second pilot-test, E.M.F., M.D.B. and A.F.W. decided that this would be the final search strategy. E.M.F. then developed a draft of an Excel file, which was checked and adapted by M.D.B. and then discussed with A.F.W. Using this Excel file, E.M.F. and M.D.B. independently screened title and abstract for all results. They discussed disagreements, and when still uncertain, consulted with A.F.W., E.M.F. and M.D.B. together developed a second Excel file for data extraction, which was discussed and adapted with A.F.W., E.M.F. and M.D.B. again performed an independent data extraction and discussed results to check for disagreements. M.D.B. performed the quality assessment and evidence synthesis, which were checked by E.M.F. or A.F.W. M.D.B. set up drafts of the article, which were discussed four times with A.F.W., S.A.R., G.N. and R.W. All authors added comments to the publication for each of the four discussion moments and did in-text suggestions for improvement. After consent from all authors above, the final publication was submitted by M.D.B. The results presented in this article have not been published previously in whole or part, except in abstract form.None declared.Nephrol Dial Transplant 2021; 36: 1155–1157)(See related article by Lameire and Vanholder. Health literacy problems of kidney patients. gfaa273_Supplementary_DataClick here for additional data file.


On this basis, we expressed the hypothesis that AN11127 might be a functional analogue of other Sec12 proteins. In no point in our article did we doubt that the product of AN11127 functions as Sec12-like guanine nucleotide exchange factor (GEF) specific for SAR1 in A. nidulans [Prof. Peñalva and co-workers provided evidence that AN11127 is related by sequence and function to Sec12 , we exprA. nidulans. The authors in Section 2.1 provide evidence showing that AN11127 is isofunctional to other Sec12 proteins. Yet, functional analogy is not evidence for orthology [Prof. Peñalva and co-workers provided several lines of evidence, including novel in silico searches, supporting that AN11127 is the Sec12 protein of rthology . Thus, trthology , and notIn the second part of the Results Section (Section 2.2), Prof. Peñalva and co-workers used NCBI tblastn in FungiDB to search for genomic sequences encoding AN11127 product homologues. Their new searches provided convincing evidence that AN11127 is present in possibly all Aspergilli and most ascomycetes. Their targeted search indeed “corrected” our inability to detect AN11127 homologues in several fungi using the standard blastp search and also highlighted the dangers of false annotation of genome databases. We welcome this new evidence that orthologues of AN11127 seem to exist in most ascomycetes. On the positive side, the discussion raised by our article highlights the evolutionary particularity of Sec12-like proteins in fungi, plants and Metazoa, as they are exceptionally divergent in sequence in different species or genera, seemingly more divergent than any other of the main proteins involved in COPII formation and function . The hi


To date, BAs present either pro-viral or anti-viral effects for the replication of enteric viruses in vivo and in vitro. In this review, we summarized current information on biosynthesis, transportation and metabolism of BAs and the role of BAs in replication of enteric caliciviruses, rotaviruses, and coronaviruses. We also discussed the application of BAs for cell culture adaptation of fastidious enteric caliciviruses and control of virus infection, which may provide novel insights into the development of antivirals and/or disinfectants for enteric viruses.Bile acids (BAs) are evolutionally conserved molecules synthesized in the liver from cholesterol to facilitating the absorption of fat-soluble nutrients. In the intestines, where enteric viruses replicate, BAs also act as signaling molecules that modulate various biological functions  Bile acids (BAs) are a large family of molecules that have a steroidal structure and are synthesized from cholesterol in the liver and actively secreted along with cholesterol, bilirubin, and phospholipids into bile. Serving as important signaling molecules, BAs have important physiological functions, including elimination of cholesterol, absorption of fat and fat-soluble vitamins, and regulation of gut microbiome  mediated oxidation of cholesterol through 2 biosynthetic pathways, the classical and alternative pathways Fig.  Chiang . Primaryvia basolateral BA transporters, including organic solute transporter subunit α (OSTα)/OSTβ complex. BAs are then taken up into hepatocytes by sodium/taurocholate co-transporting polypeptide  and organic anion-transporting polypeptide 1  and MRP4  and lithocholic acid (LCA), respectively Fig. . The privia the portal vein, is termed enterohepatic circulation. In humans, a BA pool of about 3 g  is recycled between the gut and the liver approximately 8 times per day, with only 0.2–0.6 g of de novo synthesized BAs being produced per day to maintain a stable pool of BAs -expressing enteric bacteria  grows in mouse macrophage and dendritic cell lines. Its infection of mice has been used as a model to study the replication and pathogenesis of noroviruses due to the lack of an animal model for HuNoVs with the exception of germfree piglet model  and protruding (P) domains. P domains form dimers bind to the host receptors to initiate virus infection. There are 2 binding sites for GCDCA and LCA at P domain dimer interface of MuNoV. These BA binding sites are distinct from those for CD300lf receptor. GCDCA enhances intrinsic affinity of P domain of viral capsid protein for cellular receptor CD300lf and is necessary for cell attachment  than KD and AA (< 7 log10 TCID50/mL) strains in vitro after the 20th passage level. Interestingly, replication of 8aa was inhibited by trypsin. It replicated poorly and was fully attenuated in nursing piglets  via GPCRs in IPEC-J2 cells (paper submitted to Veterinary Microbiology). These results suggested that some BAs could affect enteric coronavirus replication. The interaction among BAs, microbiota and intestinal enzymes (e.g. proteases), BA effects and molecular mechanisms on coronavirus replication in vivo remain unclear. Such findings may also have implications for the human epidemic/pandemic CoVs  because all have been reported to infect the gastrointestinal tract  are positive sense, single-stranded RNA viruses that cause diseases in mammals and birds. They can cause respiratory, enteric, hepatic and neurological diseases, and peritonitis with highly variable severity (De Groot et al. in vitro replication of herpes simplex virus (Herold et al. in vitro replication of hepatitis B virus (Kim et al. In addition to the modulation of enteric virus replication, BAs can limit in vivo and in vitro. It would be interesting to determine if other viruses that preferentially replicate in liver or intestines, such as hepatitis A virus, hepatitis E virus and other enteric viruses, are also affected by BAs and have evolved mechanisms to survive or even benefit from BA signaling. To date, studies have reported that BAs activated several key innate signaling pathways to potentiate antiviral immunity (Fiorucci et al. BAs activate multiple signaling pathways and transcription factors to promote or inhibit virus replication In addition to facilitating the absorption of dietary fats, BAs act as signaling molecules through different cell receptors and signaling pathways to regulate lipid, glucose and energy metabolism. Research in the past two decades has contributed substantially to our understanding of the role of BAs in virus infections. In this review, we have discussed BA biosynthesis, transport and metabolism and the mechanistic links between BAs and enteric virus infections, with a focus on enteric caliciviruses, rotaviruses, and coronaviruses. We also summarized the roles of certain BAs on replication of enteric viruses in Table


An Informatics Consult has been proposed in which clinicians request novel evidence from large scale health data resources, tailored to the treatment of a specific patient. However, the availability of such consultations is lacking. We seek to provide an Informatics Consult for a situation where a treatment indication and contraindication coexist in the same patient, i.e., anti-coagulation use for stroke prevention in a patient with both atrial fibrillation (AF) and liver cirrhosis.We examined four sources of evidence for the effect of warfarin on stroke risk or all-cause mortality from: (1) randomised controlled trials (RCTs), (2) meta-analysis of prior observational studies, (3) trial emulation  and (4) genetic evidence (Mendelian randomisation). We developed prototype forms to request an Informatics Consult and return of results in electronic health record systems.We found 0 RCT reports and 0 trials recruiting for patients with AF and cirrhosis. We found broad concordance across the three new sources of evidence we generated. Meta-analysis of prior observational studies showed that warfarin use was associated with lower stroke risk . In a target trial emulation, warfarin was associated with lower all-cause mortality  and ischaemic stroke . Mendelian randomisation served as a drug target validation where we found that lower levels of vitamin K1 (warfarin is a vitamin K1 antagonist) are associated with lower stroke risk. A pilot survey with an independent sample of 34 clinicians revealed that 85% of clinicians found information on prognosis useful and that 79% thought that they should have access to the Informatics Consult as a service within their healthcare systems. We identified candidate steps for automation to scale evidence generation and to accelerate the return of results.We performed a proof-of-concept Informatics Consult for evidence generation, which may inform treatment decisions in situations where there is dearth of randomised trials. Patients are surprised to know that their clinicians are currently not able to learn in clinic from data on ‘patients like me’. We identify the key challenges in offering such an Informatics Consult as a service.The online version contains supplementary material available at 10.1186/s12911-021-01638-z. Evidence informing treatment decisions traditionally takes years to generate and leaves many clinical uncertainties unaddressed . EspeciaThe Informatics Consult concept has been proposed –11 to prOur objective was to demonstrate proof of concept of the Informatics Consult using the atrial fibrillation-cirrhosis-warfarin example. Specifically, we sought to 1) develop prototype electronic health record forms for requesting an Informatics Consult and return of results, (2) generate four sources of evidence for an Informatics Consult ,  for multiple novel sources of evidence. We developed prototypes for the request form and the report form in consultation with the Chief Clinical Research Informatics Officer and clinicians . We illustrate possible forms based on an EHR platform, but similar design principles are relevant in EHRs from other vendors, and in other settings, including primary care.We searched for previously reported and currently recruiting trials on anticoagulants in patients with atrial fibrillation, with stroke or mortality in the primary outcome using the ClinicalTrials.gov registry. We then used the 8-digit National Clinical Trial numbers to retrieve detailed information on inclusion and exclusion criteria for each trial to identify if any trials included patients with both atrial fibrillation and cirrhosis.Study identification We searched PubMed for peer-reviewed articles using the keywords “antithrombotic”, “anticoagulant”, “warfarin”, “cirrhosis” and “atrial fibrillation”. We considered eligible studies as those reporting the effects of anticoagulation therapy in patients with both liver cirrhosis and atrial fibrillation. We excluded reviews, single case reports, editorials and small case series (< 10 cases). Data extraction We extracted the following variables: author, setting, eligibility criteria, number of patients with atrial fibrillation and cirrhosis, number of patients in treated and untreated groups and summary measures. Analyses were performed following PRISMA guidelines. Outcomes of interest were mortality and ischaemic stroke. Statistical analysis A meta-analysis of associations was performed by pooling hazard ratios (HRs) or odds ratios (ORs) depending on data availability from observational studies using DerSimonian and Laird random-effects models. We also performed leave-one-out sensitivity analyses.https://caliberresearch.org/portal and have previously been validated [We used population-based EHRs to perform a target trial emulation, which is the application of design principles from RCTs to inform analyses on observational data , 15. We alidated , 17. PheWe developed a target trial protocol where eligibility criteria, treatment assignment, treatment strategy, follow-up period, causal contrast and statistical analyses were specified  is a central component in the production of blood coagulation factors. Warfarin (a vitamin K antagonist) inhibits the activity of vitamin K epoxide reductase to interfere with the recycling of vitamin K and to reduce blood clotting. We considered four single nucleotide polymorphisms (SNPs) that predict circulating phylloquinone (vitamin K1) selected from a genome-wide meta-analysis study on Europeans . Four SNWe tasked a review panel with expertise in health informatics, epidemiology, evidence synthesis and computer science (drawn from co-authors) with two questions: (1) What are the most time-consuming tasks for each of the 4 streams of evidence identification and generation? (2) What automation opportunities might be important for acceleration and scaling.After the initial development of the Consult, to gain insights into the acceptability and feasibility of the Informatics Consult, we conducted a pilot survey with an independent sample of 34 clinicians who had not taken part in the research.Clinicians wanted the request form Fig.  to incluWe provide an overall summary report based on new evidence on warfarin use  in patients with atrial fibrillation and cirrhosis Fig. . ThroughWe did not identify any previous reported RCTs on anticoagulants relevant to patients with cirrhosis. We identified four currently recruiting anticoagulant trials. All four trials reported exclusion criteria related to liver cirrhosis such as contraindication to anticoagulation, i.e., hepatic impairment and elevated liver function tests Fig. .Fig. 3Tr2 = 73%  comparing warfarin initiators with non-initiators  ; aged > 65: HR = 0.61 ; men: HR = 0.64 ; women: HR = 0.53  and normal INR of < 1.7: HR = 0.62 , where warfarin therapy is associated with lower mortality risk  Fig. B. The 10We found no GWAS summary data for vitamin K1 in patients with atrial fibrillation and cirrhosis, but we did find genetic evidence to indicate that warfarin use is associated with reduced stroke risk. For two-sample MR, we used four methods (inverse-variance weighted (IVW), MR-Egger, simple median and weighted median). The IVW analyses, which assumes no pleiotropy, revealed that higher genetically predicted levels of vitamin K1 were associated with a higher risk of any stroke with an odds ratio (OR) of 1.06 (95% CI 1.00–1.11) per Ln-nmol/L increase in vitamin K1 , responses were as follow: randomised trials: 82% useful (15% maybe useful); meta-analysis of prior observational evidence: 76% useful (18% maybe useful); target trial emulation: 62% useful (18% maybe useful) and genetic evidence: 26% useful (24% maybe useful). 74% of clinicians would discuss the Informatics Consult report with their patients (26% answered maybe). Clinicians offered 15 further clinical questions where the Informatics Consult might be of value and made additional comments including: “Ultimately, we practise defensive medicine—would my decision stand up in court based on available data—the Informatics Consult should help with that.” and “Regulators and guideline developers will require replication and quality assurance of evidence generated in clinical timescales”.We surveyed an independent sample of 34 clinicians from eight specialties with results shown in . This suggests that the prospect of ever mounting, or successfully recruiting to, an RCT in patients with AF and cirrhosis is low. Meta-analysis of observational studies and target trial emulation suggest evidence on the potential benefits of warfarin for stroke reduction, suggesting the significant impact on strokes and deaths averted if these patients are treated with anticoagulant therapy. Although we did not find any relevant GWAS summary data, evidence suggests that lower levels of vitamin K1 (target of warfarin) are associated with lower stroke risk which is corroborated by another study .Interestingly, the clinicians involved in this study recommended that information beyond efficacy and safety should be included as options for the clinician to request in the Informatics Consult. By providing information on the prevalence of cirrhosis and atrial fibrillation, we demonstrate that this pair of conditions is not highly prevalent . Knowing that the health system has data on diagnosis, treatment and outcomes in an estimated 35,000 individuals  with both conditions, highlights the importance of several areas. First, the importance of accessing and learning from nationwide data at scale; any one clinician may have clinical experience of only a handful of such cases, and it is not feasible or scalable to create registries. Second, the clinician likely has never had access before to population-based, contemporary prognostic information on such patients , nor the knowledge that in practice 43% of patients were started on warfarin. We anticipate that providing clinicians and patients with this information may stimulate further questions on generating new Consults on a wider range of prognostic outcomes, and predictors of prognosis.Nearly all clinicians are faced with treatment decisions where limited evidence exists where insights might be gained from analysis of large-scale data on ‘patients like me’. Previous studies have employed EHR data for diagnostic consultations , and othThe majority of clinicians in our survey thought that they should have access to the Informatics Consult as a service as their healthcare systems seek to learn from existing data . We haveTo the best of our knowledge, this is the first demonstration of Informatics Consult for a treatment decision, triangulation of evidence from meta-analyses of observational studies, target trial emulation using EHR data and MR. The breadth, depth and longevity (long follow-up period) of the EHR data, which links primary care, secondary care and the death registry is an advantage. Another significant strength is engagement with an independent sample of clinicians from multiple specialties to gauge the feasibility and acceptability of the Informatics Consult.Our study has important limitations. First, although we have prototyped EHR request and report forms based on feedback from clinicians, these have not yet been implemented in live clinical systems. Second, as initial proof of concept, we have not assessed bleeding outcomes and newer non-vitamin K oral anticoagulants due to current data access limitations. Third, it remains difficult to assess whether there unmeasured confounding despite employing causal inference methods. It is also possible that some prescription data is missing, which means that patients are incorrectly assigned to the control arms. Future analyses on a more recent and larger dataset involving both CPRD Gold and Aurum  would beWe proposed an Informatics Consult framework to summarize evidence from four sources and have developed a report prototype for answering a treatment question to enable new ways of data-informed decision making. The Informatics Consult may stimulate a conversation among public, professionals and policymakers about more rapidly realising the benefits of health system learning from ‘patients like me’.Additional file 1. Supplementary data 1 to 11.


Sjögren’s syndrome (SS) is an autoimmune sialadenitis with unknown aetiology. Although extensive research implicated an abnormal immune response associated with lymphocytes, an initiating event mediated by salivary gland epithelial cell (SGEC) abnormalities causing activation is poorly characterised. Transcriptome studies have suggested alternations in lysosomal function are associated with SS, but a cause and effect linkage has not been established. In this study, we demonstrated that altered lysosome activity in SGECs by expression of lysosome-associated membrane protein 3 (LAMP3) can initiate an autoimmune response with autoantibody production and salivary dysfunction similar to SS.Retroductal cannulation of the submandibular salivary glands with an adeno-associated virus serotype 2 vector encoding LAMP3 was used to establish a model system. Pilocarpine-stimulated salivary flow and the presence of autoantibodies were assessed at several time points post-cannulation. Salivary glands from the mice were evaluated using RNAseq and histologically.Following LAMP3 expression, saliva flow was significantly decreased and serum anti-Ro/SSA and La/SSB antibodies could be detected in the treated mice. Mechanistically, LAMP3 expression increased apoptosis in SGECs and decreased protein expression related to saliva secretion. Analysis of RNAseq data suggested altered lysosomal function in the transduced SGECs, and that the cellular changes can chemoattract immune cells into the salivary glands. Immune cells were activated via toll-like receptors by damage-associated molecular patterns released from LAMP3-expressing SGECs.These results show a critical role for lysosomal trafficking in the development of SS and establish a causal relationship between LAMP3 misexpression and the development of SS. Lysosome-associated membrane protein 3 (LAMP3) is ectopically expressed in salivary gland epithelial cells (SGECs) of patients with Sjögren’s syndrome (SS).LAMP3 overexpression promotes apoptosis and autoantigen release of SGECs in vitro.LAMP3 expression in SGECs is directly involved in the development of SS-like phenotype in vivo.The causal relationship between LAMP3 misexpression and SS provides us a novel target for interventions in the treatment of SS.IRF5 and STAT4 as susceptibility genes of SS. These genes are involved in IFN production and downstream signalling following stimulation of the IFN receptor.Sjögren’s syndrome (SS) is an autoimmune disease that primarily affects salivary and lacrimal glands. The disease is characterised by dry mouth and/or eye symptoms, lymphocytic infiltration of the affected glands, and the presence of autoantibodies, such as anti-Ro/SSA and anti-La/SSB antibodies. Although excessive immune activation by type I interferon (IFN) signalling pathway is thought to play an important role in pathogenesis of SS, the aetiology of the disease is unclear.LAMP3 is detected in the salivary glands of patients with SS compared with control glands.Many cellular proteins are reported to be regulated by IFN expression include those associated with lysosomal function. Lysosome-associated membrane protein 3 (LAMP3) is a membrane glycoprotein predominantly localised in lysosomes that is reported to be induced by IFN.The lysosome is a membrane-bound organelle that contains hydrolytic enzymes to degrade many kinds of biomolecules, and has various cellular functions, such as energy metabolism, plasma membrane repair and protein secretion, by ingesting and dissolving cell debris, other damaged organelles or foreign substances that have entered the cell.It is thought that excessive and inappropriate cell death may contribute to the initiation of autoimmunity through the release and ineffective clearance of intracellular antigens.To investigate the pathophysiological role of LAMP3 expression in SS, we established a mouse model with LAMP3 overexpressed locally in the submandibular glands following retroductal cannulation with an adeno-associated virus serotype 2 (AAV2) vector encoding LAMP3. The mice develop an SS-like phenotype with progressive salivary hypofunction and anti-Ro/SSA and La/SSB antibody production. Mechanistically, LAMP3 expression increased apoptosis in SGECs as monitored by transferase dUTP nick end labelling (TUNEL) assays and decreased protein expression related to saliva secretion. Activated immune cells were chemoattracted into the salivary glands through the cellular changes in SGECs induced by LAMP3. This study demonstrated a causal link between the development of SS and LAMP3 misexpression, incorrect expression associated with alteration of a phenotype.Detailed explanation of each procedure was described in 10.1136/annrheumdis-2020-219649.supp1Supplementary data11 particles/mouse in 100 µL) by retrograde ductal instillation. The same amount of AAV2 vector encoding green fluorescent protein (AAV2-GFP) was cannulated in control mice. Pilocarpine-stimulated salivary flow and the presence of serum autoantibodies were assessed at several time points post-cannulation. Submandibular glands were evaluated using RNAseq and histologically.Briefly, AAV2 vectors encoding LAMP3 (AAV2-LAMP3) were delivered into both submandibular glands of female 6–8-week-old C57BL/6 mice  mouse is a well characterised model of spontaneous onset of an SS-like phenotype in female mice at approximately 16 weeks of age independent of the occurrence of loss of glycaemic control.To establish a causal relationship between LAMP3 expression and the development of SS-associated pathology, LAMP3 expression was initiated in the salivary glands of healthy C57BL/6 mice by retroductal cannulation of the submandibular glands using AAV2 vectors to facilitate gene expression. AAV2 vectors were chosen because of their ability to direct long-term expression following localised delivery to the salivary glands of mice, with minimal host response to the vector.The effects of LAMP3 were assessed overtime between 1 and 6 months post-cannulation. Expression of LAMP3 in the salivary glands did not appear to have an overt effect on feeding by the mice as there was no significant differences in body weight between AAV2-LAMP3 treated mice (LAMP3 mice) and control mice . Pilocar2 vs 4.2/mm2, p<0.01, Previous work reported that transfection of LAMP3 expression plasmids into SGEC derived cells grown in culture induced apoptosis.To clarify the molecular mechanism associated with the development of an SS-like phenotype in the LAMP3 mice, RNA was collected from the submandibular glands of AAV2-LAMP3 cannulated mice at 2 months and 6 months post-cannulation and used for RNAseq and bioinformatics analysis. A total of 1063 differentially expressed genes were identified between the two groups . Analysis using DAVID Bioinformatics Resources 6.8 identified the differentially expressed genes were enriched in lysosome, endocytosis, phagocytosis, chemokine signalling, natural killer cell mediated cytotoxicity, antigen processing/presentation, leucocyte migration, adhesion and T/B-cell receptor signalling pathways. These enrichment pathways were related to innate and adaptive immunity .Tbx-21, Jak1, Stat3/4 and Ccr5/6 , T-cells and B-cell related genes were increased in the submandibular glands of LAMP3 mice at 6 months post-cannulation, reflecting cellular infiltration . Additiod Ccr5/6 . Taken t+ macrophages in the tissues (In agreement with the increase immune activation suggested by the analysis of the RNAseq data, H&E staining of slides identified clusters of lymphocytic infiltration in submandibular gland specimens from LAMP3 mice 6 months post-cannulation . The lym tissues . These p tissues . T-cellsTaken together, the bioinformatics analysis supports a hypothesis that LAMP3 expression in SGECs can be stimulatory to monocytes/macrophages as an initiator of autoimmunity. To test the hypothesis, THP-1 cells were treated in vitro with supernatant from LAMP3-transfected salivary gland acinar cells or ductal cells and stimulation was monitored by qRT-PCR for changes in cytokine production. Treatment of THP-1 cells with the supernatant stimulated a significant increase in the transcription of TNFα compared with control treated THP-1 cells. The increased expression of TNFα in THP-1 cells was independent of apoptosis in acinar or ductal cells as treatment with the pan-caspase inhibitor Z-VAD did not inhibit the increase in TNFα expression . In contScl12a2 (encoding NKCC1, Aqp5 (Despite the increase of apoptosis in the salivary glands of LAMP3 mice, overall atrophy or destruction of the gland structure was not seen at either 2 or 6 months post-cannulation . There wC1, Aqp5  genes meC1, Aqp5  and AQP5C1, Aqp5  when norC1, Aqp5 . Taken tIncreased IFN signalling is well established as a component of the pathogenesis associated with SS, but little is known regarding the effect of IFN on epithelial cells and its causal association with salivary gland hypofunction and the induction of autoimmunity. We recently identified by aggregated microarray analysis that LAMP3, an IFN inducible protein, is upregulated in patients with SS. Further analysis identified an association between LAMP3 expression levels and autoantibody positivity in patients. In vitro studies suggested that LAMP3 could induce apoptosis and the accumulation and release of SS-associated autoantigens via extracellular vesicles.A number of mouse models of SS have been reported.IRF5 and STAT4 polymorphisms,It is still unclear the mechanism that results in the increased LAMP3 expression in the SGECs of patients with SS. Considering that LAMP3 is an IFN-inducible gene, environmental factors like viral infectionIn conclusion, this study shows that LAMP3 expression in SGECs can induce an SS-like phenotype. The development of disease in this mouse model has distinct phases with the induction of apoptosis preceding salivary hypofunction, followed by progressive levels of immune activation, ultimately leading to the development of autoimmunity. Further investigations are needed to understand the context of the release of autoantigens from the cell and if additional cellular or lysosomal components are necessary for the induction of autoimmunity. Taken together, the present results demonstrate a critical role for salivary epithelial lysosomes in the development of SS and provide a new model for studies of targeted therapeutic interventions in SS.


In recent years, a significant number of investigations have discovered up to 200 000 unsubmitted sexual assault kits (SAKs) in the US. While the public outcry was largely directed towards DNA analysis, the SAKs also contained biological specimens specifically designated for toxicological analysis. Due to the sensitivity of analytes in potential drug facilitated sexual assaults, the preservation and maintenance of the specimens is crucial in providing accurate toxicological measurements. The investigations into the unsubmitted SAKs have identified subjective law enforcement officer (LEO) rationale for the unsubmitted kits, however the impact on toxicological specimens has not been examined. This brief review of policies and guidelines with respect to forensic specimens has identified potential sources of evidentiary degradation, despite the use of chemical preservatives. With respect to temperature-controlled environments, the variation in SAK submission policies established throughout the US are potentially detrimental to the preservation of toxicological evidence. Degradation as a result of time-delayed collection and poorly maintained storage temperatures plays a crucial role for/in the interpretation of qualitative and quantitative toxicological results. This review finds these delays can be addressed through modernisation of facilities; electronic tracking of unsubmitted SAKs; mandated transfer of biological evidence within 72 h; and documentation of temperature within the chain of custody or other records. Without identifying the range of temperatures in which the evidence was exposed, forensic toxicologists may unintentionally provide erroneous interpretations of toxicological analyses – potentially casting doubt on the survivor’s recall of events and negatively impacting future sexual assault investigations. Temperature-controlled conditions for biological evidence of sexual assault cases may be inadequate in the US.Biological specimens collected in drug-facilitated sexual assault (DFSA) casework must be immediately preserved in optimal temperature-controlled temperatures.If biological specimens are not stored at optimal temperatures, forensic toxicologists are likely to interpret values that do not reflect the specimen at time of collection.It would benefit DFSA investigations and toxicological interpretations if temperature-related information was included with the chain of custody or other included documentation.Expedient collection and analysis of toxicological evidence in forensic investigations is paramount. As a result, biological evidence collected from drug-facilitated sexual assaults (DFSAs) require temperature-controlled conditions or chemical additives to preserve potential drugs in the specimens. In the US, substantial delays in submission of DFSA evidence to forensic laboratories have been identified as a national issue . These rWhen a person survives a sexual assault incident, they may present to a hospital or rape treatment clinic for evaluation and/or examination. At this stage, they would be examined by trained professionals and interviewed by a sexual assault nurse examiner (SANE) and/or law enforcement officer (LEO). During the examination, potential evidence is collected and documented for further analysis. The SAK used by trained medical or forensic professionals provides all the tools necessary to safely collect and gather evidence following a sexual assault. Although the kit contents can vary between jurisdictions and municipalities , they typroactive DFSA” where a person is given drugs covertly or by force, and an “opportunistic DFSA” where a person is assaulted while they are incapacitated [Incidents involving DFSA may be described in two ways: a “acitated , 10. In acitated . In thesThe accurate interpretation of drug concentrations in human-performance casework is critical to the field of clinical and forensic toxicology . DegradaOver a 2-month period, articles for this review were mined and identified using the following online databases and resources: Nottingham Trent University Library One Search, Google Scholar, Web of Science, and US Department of Justice. Using those resources, the following terms were searched: DFSA, chemical submission, toxicology stability, SAKs, toxicology guidelines, and unsubmitted SAK. Content that did not provide evidentiary procedures, statistical analyses, and clinical or forensic case studies were not included in this review. The articles used in this review paper were largely based in the US, however, other jurisdictions and international protocols were considered as well.The detection and identification of drugs and alcohol in DFSA evidence is historically difficult. The reasons for this issue vary but are largely connected to the quick metabolism and degradation of drugs commonly used in assaults. According to previous reports , 12, theDue to the presence of drugs and alcohol in DFSA incidents, survivors may report a loss of memory and/or consciousness during the event . DependiIn Once the specimens are collected and submitted to LEO personnel, the biological evidence must be expediently transferred to the forensic laboratory for analysis. Over a 10-year period, surveys identified approximately 100 000–200 000 unsubmitted SAKs by LEO personnel, terminating any potential analysis by forensic laboratories , 7. In fAs seen in With the previous information in mind, it is important to acknowledge the unintentional delays during the transfer of evidence to the toxicological laboratory. In this review, there were several instances where the survivor requested their biological specimens to remain unsubmitted to forensic laboratories. A portion of surveyed survivors expressed a lack of desire to attend court where they may potentially see the suspect again or lose wages due to time constraints . SurvivoAccording to an investigation by Leder , a sexuaConsidering the intoxicating and incapacitating effects of drugs associated with DFSAs, the delays permitted in In an investigation by Muldoon et al. , DFSA caDue to the logistical difficulties presented from standardisation of analytical procedures, laboratories may consider taking a more judicious approach with respect to specimen handling and documentation. With respect to specimen temperature, the short- and long-term storage temperatures could be documented on the chain of custody, allowing the reviewing toxicologist to consider degradation as a result of suboptimal conditions. Though preserved with sodium fluoride and potassium oxalate, whole blood specimens require temperature-controlled environments. As shown in Shan et al. , blood eIn an investigation by Peters and Remane , limitedDue to the nature of the crime, prioritising the concerns and wellness of DFSA survivors is of the upmost importance. If the final toxicology results do not explain or reflect the survivors’ experience, they may experience self-doubt and shame for pursuing prosecution. Additionally, the survivors may question and doubt their own memories of the assault, causing further distress. This negative experience may be shared within the local community, resulting in a shared distrust of the clinical and toxicological evaluations. Another consequence of poorly maintained biological evidence could be the effect on legal processes. As described by Campbell et al. , prosecuAs the issue of unsubmitted SAKs became public, a collection of investigative reports have identified ways to address the backlog of casework . As statAnother area that impacts the detection of drugs is the application of chromatographic methods which employ large number of analytes. Forensic laboratories frequently have high caseloads which are managed through the employment of analytical techniques detecting multiple drugs of interest. Although this is desirable for processing large numbers of cases, limiting the numbers of analytes in a liquid-chromatography mass-spectrometry (LC-MS) method can reduce ion suppression and enhancement . This reReduced analyte stability as a result of exposure to uncontrolled temperatures is a common occurrence in the US and other parts of the world. While this situation is not uncommon, it is important for forensic toxicologists to acknowledge the potential impacts of these environments on the reliability of the analytical results. As stated by Peters , “Reliab


Background: Mild cognitive impairment (MCI) is an important stage between the normal cognitive decline of aging and dementia. The aim of this study was to compare and harmonize the recommendations for the diagnosis and treatment of MCI based on current clinical practice guidelines.Methods: We searched the PubMed, EMBASE, China National Knowledge Infrastructure, Wanfang Database, Chinese Science and Technology Periodical Database, and Chinese Biological Medicine Database from their inception date to April 24, 2021 to identify all published guidelines on MCI. The qualities of the eligible guidelines were appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation II instrument.Results: Thirteen guidance documents (four guidelines and nine consensus statements) with specific recommendations were included. Nine guidelines and consensus statements covered the screening and diagnosis of MCI. The evaluation of the documents showed that neuropsychological testing and biomarker assessments were the most common recommendations for the diagnosis of MCI. Nine of the 13 guidance documents covered the treatment and management of MCI. The recommendations for the treatment and management were classified into four categories, namely: intervention for risk reduction, pharmacologic interventions, non-pharmacologic interventions, and counseling. Regarding pharmacological interventions, three guidelines recommend no pharmacologic intervention. The use of cholinesterase inhibitors for MCI is contraindicated in three guidance documents, whereas one proposes that cholinesterase inhibitors and memantine should be deprescribed. EHb761®, Chinese herbal decoctions, and Chinese traditional patent medicine are recommended in two documents. A total of seven guidance documents recommend non-pharmacological interventions, including physical activity interventions, cognitive interventions, dietary and nutritional interventions, and acupuncture.Conclusion: An updated search for possible evidence on the diagnosis and treatment of MCI is needed. Potentially effective diagnoses and treatments, either conventional or complementary, and alternative therapies should be highly valued and addressed in correlation with the supporting evidence. Mild cognitive impairment (MCI) is regarded as the transitional period between the normal cognitive decline of healthy aging and dementia . It is cThe first Mayo diagnostic criteria for MCI proposed by Petersen et al.  was mainGuidance documents, such as clinical practice guidelines and consensus statements, are developed using a systematic method to provide guidance and recommendations for clinicians . GuidancClinical practice guidelines and expert consensus were included if they satisfied the following criteria:with specific recommendationsfocus on diagnosis and/or treatment of patients with MCInot intended for MCI general practice, education, training, certification, and researchnot protocols, abstracts, editorial comments, overview/review articles, and systematic reviews.The PubMed, EMBASE, China National Knowledge Infrastructure, Wanfang Database, Chinese Science and Technology Periodical Database, and Chinese Biological Medicine Database were systematically searched from their inception date to April 24, 2021. The keywords were Cognitive Dysfunction [MeSH] OR MCI [Title/Abstract] OR cognitive impairment [Title/Abstract] OR cognitive disorder* [Title/Abstract] OR cognitive dysfunction* [Title/Abstract] OR neurocognitive disorder* [Title/Abstract] OR cognitive decline* [Title/Abstract] OR mental deterioration* [Title/Abstract] AND Guideline [MeSH] OR expert consensus [Title/Abstract] OR recommendation statement [Title/Abstract]. The keywords mentioned above were adapted and searched in Chinese databases by using corresponding Chinese words; the search strategies are presented in The reviewers (NL and YC) extracted the basic characteristics and recommendation content of the included guidelines. The basic characteristics included guideline development information , guideline scope and content , evidence support (systematic search and number of references), grading systems of recommendations (level of evidence and strength of recommendations), and conflict of interest (type of funding).The included guidelines were reviewed, and the recommendations were extracted. Information on the level of evidence and strength of recommendations for diagnosis (or screening) and treatment (or management) were extracted separately. For guidelines with more than one version but which were developed by the same organization or group, the recommendations on the diagnosis and treatment of MCI were extracted from the most updated version.The qualities of the eligible guidelines were independently appraised by two reviewers (YC and XL) using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. The results of the assessment were checked by the third author (NL). The AGREE II instrument comprises 23 items organized in six quality domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each of the 23 items is rated on a seven-point scale. A score of 1 indicates “strongly disagree,” whereas a score of 7 represents “strongly agree.” The score of each domain is calculated based on the scores of its specific items , 16. BasA total of 13 guidance documents with specific recommendations were eligible, including four guidelines , 19, 20 Two documents , 24 wereThe scores for each domain of the AGREE II instrument are presented in Nine guidelines and consensus statements covered the screening and diagnosis of MCI , 26, 28.® can improve the symptoms of MCI   –37. In t1−42) , 24, 28.1−42) , 24, 28 1−42)  of these1−42) . Althoug1−42) . Only on1−42) . There a1−42) . About i1−42) , 23. FDG® is recommended in one consensus statement for the improvement of MCI symptoms  included in the present study were of sufficient and low quality. The domain with the lowest score was the “applicability” domain (domain 5). “Applicability” is a key measure of the implementation of a guideline in clinical practice . ApplicaTo the best of our knowledge, this is the first paper to summarize the published guideline recommendations for MCI. The main strength of this study is the comprehensive and systematic literature search that was conducted to identify guidance documents related to the diagnosis and treatment of MCI. The guidelines and consensus statements were independently appraised by two reviewers using AGREE II, and the finding on the methodological problems, mainly in the applicability domain, presented as lacking implementation strategies and related application resources, may help in the development of future MCI guidelines. The recommendations were summarized into key recommendations shown in tables, and the consistency of the recommendations and the difference between them were compared.The limitation of this study is that, although a systematic search strategy was implemented, certain guidelines may have been missed because of language limitations. Moreover, there were no accepted cutoff points for the domain scores of AGREE II. In addition, the fact that we referred to a previous article for the grading of the domain scores might be a matter of dispute , 18.An updated search of possible evidence for the diagnosis and treatment of MCI is needed. Potentially effective diagnoses and treatments, either conventional or complementary, and alternative therapies should be highly valued and addressed in correlation with the supporting evidence. The AGREE II and Reporting Items for Practice Guidelines in Healthcare tools can be referred to when developing guidelines.The original contributions presented in the study are included in the article/NL and Y-XC designed the study, developed the analysis plan, analyzed the data, and contributed to the writing of the article. X-LL and S-HY extracted the data and appraised the quality of eligible guidelines. Y-PW and N-NS revised the manuscript and polish the language. All authors contributed to the article and approved the submitted version.This work was supported by the National Key Research & Development Program of China .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.


There is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive.Building on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences? KQ4: What common ‘critical factors for success or failure’ can be identified across interventions that have been evaluated? We will search PubMed, PsycINFO, Web of Science, Universal Human Rights Index, HeinOnline, PAIS, HIV Legal Network, CDSR, Campbell Collaboration, PROSPERO and Open Science Framework. Critical appraisal will assess the source, processes and consensus finding for frameworks; COnsensus-based Standards for the selection of health Measurement Instruments criteria for measures; and risk of bias for interventions. Quality of evidence grading will apply. A gap analysis will provide targeted recommendations for future research. We will establish a compendium of frameworks, a comprehensive catalogue of available measures, and a synthesis of intervention characteristics to advance the science of HIV-related stigma.CRD42021249348. Extensive literature searches will summarise HIV stigma evidence.This review will establish a comprehensive compendium of frameworks, a user-friendly catalogue of existing measures, and a clear synthesis of the effects of interventions.The review is limited to internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level.et al who, bringing in the idea of the power dynamics that allow the distancing or othering so often associated with stigma, define stigma as ‘the co-occurrence of labelling, stereotyping, separation, status loss and discrimination in a context in which power is exercised’.et al define stigma as ‘a social phenomenon that occurs when a person is evaluated as having an undesirable trait, attribute or behaviour and is subsequently deemed imperfect by societal standards’.Stigma is derived from a Greek word meaning a mark or stain. Much work around HIV-related stigma uses as its starting point Goffman’s 1963 definition as ‘an attribute that is deeply discrediting’.The term stigma is often used in the literature to encompass both stigma and discrimination even as these are conceptually distinct. While stigma refers to an attitude or belief, discrimination is the behaviour or action that results from those attitudes or beliefs. Hence, when stigma is acted on, the result can be discrimination. Discrimination may refer to any form of arbitrary distinction, exclusion or restriction affecting a person, usually (but not only) because of an inherent personal characteristic or perceived membership of a particular group.HIV-related stigma has been defined by the Joint United Nations Programme on HIV/AIDS (UNAIDS) as negative beliefs, feelings and attitudes towards people living with HIV, groups associated with people living with HIV  and other key populations at higher risk of HIV infection, such as people who inject drugs, sex workers, men who have sex with men and transgender people.87 A 2015 UNAIDS report documented over 60 tools to assess and/or address stigma and discrimination within healthcare settings.There is strong global commitment to eliminate HIV-related stigma, starting with global political commitments and reflected in global and national strategies as well as the multitude of organisations and collaborations working to address stigma.Understanding the state of the research in relation to measurement of self-stigma, in accessing health services, and in laws and policies, is needed to help inform future efforts, at all levels, to better address stigma and support people’s health and well-being. This review will systematically identify and assess frameworks, measures and interventions of HIV-related individual internalised stigma; both stigma and discrimination within healthcare settings; and stigma and discrimination at the legal and policy level. The intersectionality of HIV-related stigma with other forms of stigma such as stigma relating to ‘key’ and ‘vulnerable’ populations that are disproportionately affected by HIV is critical. The review will focus on HIV-related stigma itself, acknowledging as possible where intersectionality is addressed and, specifically, if there appear to be particular gaps in attention to stigma with respect to specific population groups.The systematic review will be guided by four key questions.Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies?Which measures  of these different types of stigma and discrimination have been proposed and what are their descriptive properties?Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences of the interventions?What common ‘critical factors for success or failure’ can be identified across the interventions that have been evaluated that might inform future interventions?The reporting of the protocol and the review follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The systematic review is part of a larger project undertaken by the International AIDS Society (IAS). It is accompanied by four national initiatives to explore stigma and discrimination in the local contexts of Kenya, Malawi, South Africa and Zambia through key informant interviews and grey literature searches. The project started in November 2020 and is planned to be completed by March 2022.The systematic review will follow a transparent and rigorous procedure to minimise review selection and reporting bias. We will search multiple disciplinary and interdisciplinary sources to ensure all relevant studies are captured. Citations and full text publications will be screened by independent literature reviewers to reduce reviewer errors and bias. Eligibility decisions, including reasons for exclusions, will be tracked in citation management software. Data abstraction and critical appraisal will be conducted in online software designed for systematic reviews using detailed, pilot-tested forms with clear reviewer instructions to avoid ambiguity and ensure replicability of coding decisions. The collected data will be accessible in a review data repository.12Our systematic review will be embedded in the context of existing research syntheses. To date, a substantial number of systematic reviews has been published that address different aspects of HIV-related stigma and discrimination. These include associations of stigma ,We will identify and categorise existing systematic reviews to explore the research field further. Systematic reviews will be identified through PubMed  using the systematic review filter, through PsycINFO  and Web of science , as well as through the Cochrane Database of Systematic Reviews  and the Campbell Collaboration . Furthermore, we will search the review registries PROSPERO and Open Science Framework to ensure that all relevant registered systematic reviews have been identified.Given that there is no agreed nomenclature in this interdisciplinary field, we established working definitions of the concepts ‘stigma,’ ‘internalised stigma’ and ‘discrimination’ for the purpose of this systematic review:Stigma refers to beliefs and/or attitudes about HIV.Discrimination refers to the behaviours that result from attitudes or beliefs about HIV.Internalised stigma (self-stigma) refers to a person living with HIV internalising negative attitudes associated with HIV and accepting these as applicable to themselves.Stigma and discrimination in healthcare refers to negative beliefs and behaviours based on perceived or actual HIV status experienced in healthcare delivery settings.Stigma in laws and policies refers to distinctions, exclusion or restriction based on perceived HIV status or membership of a group that is vulnerable to HIV.The analytical framework depicted in The figure includes existing conceptual models for HIV-related stigma, including frameworks such as the global HIV stigma reduction framework,The systematic review is focused on people with living or perceived to be living with HIV and people who are disproportionately affected by HIV. For the purposes of this review and based on the UNAIDS definition, the latter group includes gay men and other men who have sex with men, sex workers, transgender people, people who inject drugs and prisoners and other incarcerated people.204To identify primary research studies, we will search the health-specific research database PubMed, in particular to identify research on stigma experienced in healthcare settings. We will search PsycINFO to identify psychological and social research on stigma and use the general scientific research database Web of Science, in particular to identify legal and policy analyses on stigma and discrimination. We will identify government and non-governmental organisation reports indexed in the Universal Human Rights Index, HeinOnline, PAIS and HIV Legal Network.Additional grey literature searches will target organisations relevant to key populations affected by HIV and funders of stigma research. Specifically, we will search the websites of the IAS, UNAIDS, United Nations Development Programme, STRIVE, Health Policy Plus and Sage (resource-sharing community for Canadian HIV and hepatitis C service providers).Targeted search strategies for each key question will combine free-text search terms with controlled vocabulary of the individual databases. Draft search strategies are shown in 10.1136/bmjopen-2021-053608.supp1Supplementary dataWe use a participant, independent variable, comparator or study design, outcome/measure, timing and setting framework to structure the eligibility criteria:People living with or perceived to be living with HIV and people from groups who are disproportionately affected by HIV infection. We will exclude studies of mixed populations and other participant targets unless the study provides HIV-relevant subgroup analyses.Frameworks will include models outlining and relating to multiple components of stigma and/or discrimination, including conceptual frameworks, logic models, taxonomies and analytic models for assessment, prevention, reduction or mitigation of stigma. Measures will include self and peer report measures used for formal assessment of stigma and discrimination. Studies using a published measure will be included if the psychometric properties of the measure are a central focus of the study . Eligible intervention evaluations may test strategies and policies aimed at preventing, reducing or mitigating HIV-related stigma and discrimination. Intervention evaluations aimed at self-stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level are eligible. We will exclude publications exclusively addressing community and cultural stigma.Publications introducing frameworks will be included regardless of the comparator or study design. Measure research needs to describe the tool in sufficient detail to be included but needs no comparator. Experimental evaluations of interventions have to report on a concurrent comparator  to be eligible. Observational evaluations of healthcare interventions not under the control of the investigator and influenced by secular trends, have to report on a historic or concurrent comparator  and be sufficiently large or encompassing to be eligible . For studies evaluating the impacts of laws, no comparator is required if the study author can demonstrate an alternative analysis of determining the effect of the law not compared with a prior period or different legislative environment. Systematic reviews will be retained for an umbrella review providing context and for reference-mining.Framework publications will be included regardless of any reported outcomes. Measure research needs to report a detailed description of the measure, the development process, or the evaluation or validation of the measure. Intervention research needs to provide a structured evaluation of an indicator of stigma or operationalisation of discrimination to be eligible.Frameworks will not be restricted by publication year. For measures and interventions, only those published from 2008 on will be included, building on the first People Living with HIV Stigma Index published in 2008, which transformed thinking around HIV-related stigma measurement.205The review is not restricted regarding setting but we will restrict to English language publications.For the frameworks, we will abstract the author group and publisher; publication year, scope, aim or purpose of the framework; subtype and definition of the constructs stigma and/or discrimination; addressed targets ; framework components; and a broad summary of the framework. The Draft Evidence Table Key Question 1 will summarise the identified frameworks see .For measures, we will document the author group; publication year; name of the tool; the stigma or discrimination subtype being assessed, the underlying framework (where applicable) and definitions of stigma and discrimination; the targeted population; the surveyed population used to develop or assess the measure; the scale structure of the tool, number of items, and answer mode; the documented reliability; and evidence of validity. Draft Evidence Table Key Question 2 outlines the evidence table documenting this information for each included publication see .For intervention evaluations (key question 3), we will document the study identification details, year of publication, country, study design, sample size, participant details, context or setting; intervention type, intervention description and intervention components, comparator type and comparator description, definition and measures of stigma and discrimination, and findings for the outcome measures. In order to document the effect of the intervention concisely, we will abstract data for the main effectiveness signal and adverse events or unintended consequences. In addition, we will record any information provided by the study authors on the appropriateness of the used measures, intervention or comparator. The draft evidence table is shown in For frameworks, we will assess the source  and processes used to develop the framework, including stakeholder involvement and formal consensus finding methods.206 207For measures, we will evaluate the demonstrated reliability  as well as evidence of the validity  applying COnsensus-based Standards for the selection of health Measurement Instruments criteria.208Intervention evaluations will be evaluated for potential selection, detection, performance, attrition, reporting and study-specific sources of bias, adapting RoB 2 and ROBINS-I criteria.209 210To determine the effects of the interventions, we will compute measure-independent effect estimates for all included studies, that is, standardised mean differences for continuous outcomes and relative risks for categorical outcomes, to facilitate comparisons across studies. Interpretation of the effect sizes will take the statistical significance of the difference compared with the control or preintervention status into account as well as the statistical power of the study to detect an effect. Where possible, results of studies across interventions will be summarised in random effects meta-analyses applying Hartung-Knapp corrections for small samples.211To explore which interventions are successful and to determine what characterises these interventions, we will first broadly categorise the type of intervention. The categorisation will be undertaken based on the abstracted intervention description and will be blind to the findings of the study. The categories will be used to identify subgroups of more homogeneous intervention types. In a second step, we will derive a set of common intervention components drawn from the identified literature and informed by existing intervention frameworks and taxonomies. The presence or absence of components will be documented for each successful and each unsuccessful intervention, together with context information such as the country of evaluation. The draft component tables for the successful and unsuccessful interventions are shown in Categorising the evaluations as successful or unsuccessful will follow a transparent algorithm and will be determined by two independent literature reviewers to reduce errors and bias. For all studies, the reduction of stigma will be determined. Assessments will be based on the results in the intervention group relative to a control group. In the absence of a concurrent control group, the change compared with the preintervention status will be used to determine intervention success. Categorising interventions as successful or unsuccessful will qualitatively stratify the identified research. We acknowledge that this step will lose the granularity of a continuous variable. However, we anticipate that a broad categorisation is necessary given the diversity of the approaches. We will use transparent methods to categorise studies and discrepancies in the effect classification between reviewer ratings will be resolved through discussion in the review team.Determining characteristics of successful interventions and success factors in often complex and multicomponent interventions, as well as reasons for failure, will require a careful analysis of the components or ‘active ingredients’ of the interventions. We will apply principles of qualitative comparative analysis and review the established component matrix across the successful interventions in seeking to determine which individual and figurations of factors appear to be associated with success.We will document transparent criteria to evaluate the certainty in the evidence across the included research. We will adapt the eight Grading of Recommendations, Assessment, Development and Evaluation criteria study limitation, inconsistency, imprecision, indirectness, reporting bias to upgrade, and the criteria large effect, dose–response relationship, and confounding would mask an effect, to downgrade the quality of evidence.The evaluation of the body of evidence will be used to arrive at internationally accepted certainty categories that communicate our confidence in the findings using the categories high, moderate, low and very low. High indicates confidence that the true effect is similar to the estimated effect, moderate indicates the true effect is probably close to the estimated effect, low suggests the true effect might be markedly different from the estimated effect, and very low signals that the true effect is probably markedly different from the estimated effect. We will review the appropriateness of the starting point of low quality of evidence for non-randomised studies before upgrading or downgrading of the evidence to avoid floor effects and ensure meaningful differentiation.The identified evidence will be documented in comprehensive tables and figures. The literature flow will be documented in a literature flow diagram and account for all identified research. Critical appraisal of frameworks and measures will be integrated into the evidence tables. The risk of bias across intervention studies will be documented in a risk of bias figure showing the distribution for each criterion. All included research will be documented in concise evidence tables providing details for each included framework, measure and intervention evaluation  and validity (evidence that the tool is measuring what it is supposed to measure). The third table will document the evidence for the interventions (key question 3), organised by context and modality  and within by outcome category , together with the quality of evidence assessment. The fourth summary of findings table will document commonalities of successful interventions and failed interventions (key question 4).Part of the systematic review will be a formal gap analysis. We will use a structured approach to document research gaps. Gaps will be documented in a Study design, Participants, Interventions, Framework, Outcomes, Context/Country framework, with attention to other relevant categories that may emerge during the evidence review. The gap analysis will document research needs and provide concrete recommendations for future research.The draft protocol was peer-reviewed by international content experts and a representative of the community of persons living with HIV to ensure that the review asks the right questions. Stakeholders will be asked to review the draft review to ensure that all relevant frameworks, measures and intervention evaluations have been captured and that the review contributes meaningfully to the knowledge base and to ensure that the evidence review is as impactful as possible.The systematic review conduct will be transparent and is designed to advance research to support people living with or suspected to be living with HIV and people disproportionally affected by HIV. The review is considered exempt as it does not involve human subjects and does not require review by the human subject protection committee.The review will be registered in PROSPERO, the results will be published in a journal manuscript and presented at research conferences. The data will be made available in the Systematic Review Data Repository.12


The Mood and Feelings Questionnaire (MFQ) is a widely used screening tool for child and adolescence depression but has not been validated with young people in Thailand. This study aimed to assess the reliability and validity and to determine the optimal clinical cut-off of the Thai MFQ.The Thai MFQ was evaluated in two parts. In part 1, The MFQ was translated and back translated into the Thai language and piloted on a small number of Thai adolescents. Then 1275 young people aged 12–18 years from three secondary schools in Thailand completed the MFQ and related measures of depression. In part 2, 138 students were invited to take part in a structured diagnostic interview (the Thai translation of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children -Present and Lifetime Version (the K-SADS-PL). Of those, 103 students were interviewed and completed the Thai MFQ a second time to assess test–retest reliability. Receiver Operating Characteristics (ROC) analyses were conducted to evaluate diagnosis accuracy and examine the optimal cut-off score of the Thai MFQ.The Thai MFQ had excellent internal consistency (α = 0.92) and good to moderate test–retest reliability in 2-week and 4-week intervals. The Thai MFQ also had good convergent validity with related measures of depression. The ROC analyses demonstrated that the Thai MFQ also had excellent accuracy distinguishing between depressed and non-depressed adolescents . A total score of 28 on the Thai MFQ was the optimal cut-off score (sensitivity was 0.97 and specificity was 0.83).The Thai MFQ demonstrated excellent psychometric properties and accurately distinguished between depressed and non-depressed adolescents. It is appropriate to use as a screening measure to identify adolescents with depression in community settings in Thailand.The online version contains supplementary material available at 10.1186/s13034-021-00372-8. Depression is a common mental health problem in adolescents worldwide . AdolescMany self-report measurement instruments are used to assess depression in adolescents in research and clinical practice . Most ofThere are over 87 million people with depression living in South-East Asia . Most ofThe Children’s Depression Inventory (CDI) , and theThe measures of adolescent depression that have been used in Thailand have some shortcomings in their ability to screen and measure the severity of depression. For example, in the CDI, each item includes three statements that describe symptoms of varying severity and which a young person is asked to endorse the one that best describes their symptoms. This requirement to select the “best” description is cognitively demanding, and some items have complex wording and may be confusing   is consiIn addition, to identify the diagnostic accuracy of the MFQ in Thailand it is necessary to compare the results of the MFQ with the gold standard diagnostic tool for depression. The Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children -Present and Lifetime Version (K-SADS-PL)  is consiThe present study had two aims. The first was to translate the MFQ into Thai and to assess its internal reliability, test–retest reliability, construct validity and criterion validity in a large community sample of young people. The second aim was to determine the optimal clinical cut-off of the Thai MFQ when compared against a structured diagnostic interview (the K-SADS-PL), which was also translated into the Thai language. These aims were addressed in two parts of our study.This study was approved by University of Reading Research Ethics Committee, the UK (SREC 2018/105) and Chiang Mai University Research Ethic Committee, Thailand (CMUREC 61/073). Informed written consent was obtained from all participants and from the parents of young people under 18 years of age based on standards prescribed by Chiang Mai University Research Ethic Committee.2(1) = 10.72, p = 0.001. The flow chart of participant recruitment is presented in Fig. Three public secondary schools in Thailand agreed to take part in the study; two from Phayao province and one from Chiang Mai province. A total of 1737 adolescents aged between 12 and 8 years old were invited to take part . Eighty percent (n = 1382) of those who were invited agreed to take part and provided written consent from their caregiver as well as written assent for themselves. Ninety-nine young people for whom consent was obtained were not included because they were absent from school on the day the research was conducted. Eight young people were excluded because more than 25% of their data were missing. Of the 1275 adolescents who took part 39% were male (n = 500) and 61% (n = 775) were female; significantly more females than males took part, χThe Mood and Feelings Questionnaire (MFQ)  and 4-week test–retest was moderately reliable; ICC = 0.57, p < 0.001), 95% CI   .ROC curve analysis was performed to assess the accuracy of the MFQ to discriminate between depressed and non-depressed adolescents. The diagnostic accuracy of the MFQ was high  . The MFQ, 0.99 . M = 37.68, SD = 7.32) than those who did not meet criteria , t(101) = − 10.82, p < 0.001, d = 2.4. Using the MFQ cut-off of 28 (the present study cut-off), the majority of participants were identified correctly as depressed or non-depressed  and 13 participants had a discrepant diagnostic status . The results indicate that the Thai MFQ is a reliable and valid instrument for assessing depression in Thai adolescents. The Thai MFQ had excellent internal consistency, comparable to the original English language version in the previous studies , 38 and The Thai MFQ had excellent accuracy distinguishing between depressed and non-depressed adolescents. The AUC was better than those reported found in the previous validation studies in the original English language version –38 and tThe psychometric qualities of the Thai MFQ were excellent. Furthermore, adolescents found the phrasing of the items and structure of the Thai MFQ easy to understand and to follow, whereas some young people, especially younger adolescents, had difficulty understanding some items of the CDI and asked for clarification, e.g. “I do not do what I am told most of the time”.One strength of this study is the large community sample with a high response rate. The results of this study are therefore likely to be representative of the Thai adolescent population. This study also examined a range of psychometric properties of the Thai MFQ and used the gold standard structured clinical interview, the K-SADS-PL to discriminate between participants with and without depression. This procedure provided unbiased estimate of the diagnostic accuracy of the Thai MFQ. However, some limitations mean that our findings should be considered cautiously. First, this study recruited young people from the community, therefore the results of our study may not generalise to young people recruited in other settings, e.g., primary care and mental health settings, where the prevalence of depression is expected to be higher. Future research should aim to validate a Thai MFQ with a clinical sample. In addition, the diagnostic interviews were administered and coded by one researcher, which could introduce bias. We mitigated this by randomly checking the coding of the K-SADS-PL interviews with as experienced K-SADS assessor and trainer (FO). Future validation of the Thai MFQ should include multiple diagnostic interviewers and a comprehensive assessment of inter-rater reliability. Further, despite good psychometric properties of the Thai MFQ, this is not sufficient to establish cross-cultural measurement invariance across cultures. This should also be incorporated into future studies.Despite these limitations the psychometric properties of the Thai MFQ, its coverage of all depression symptoms, and ease of administration and scoring, suggest that the Thai MFQ may be the most efficient measure of detecting adolescent depression in community settings. The Thai MFQ could also be used with individuals attending primary care or mental health services. In addition, the cut-off score indicated in this study could help identify young people who are most likely to have an episode of major depressive disorder. Using the Thai MFQ could therefore improve the efficiency of identifying adolescents with depression in Thailand. The Thai MFQ could also help mental health staff in community settings, such as school psychologists or guidance counsellors, to effectively screen young people for depression and to determine whether further assessment and referral are indicated. The Thai MFQ would potentially help save time and resources in a country where mental health resources for young people are limited .Our findings suggest that the Thai MFQ is reliable, valid, and easily understood by young people. We provide promising evidence that the Thai MFQ is an appropriate screening measure for depression in Thai adolescents and may also be suitable for use in primary care and mental health settings, but this should be established before widespread use. The Thai MFQ could fill a gap in the assessment tools available to researchers and clinicians for assessing depression in Thai young people. The findings also provide support to the existent literature for the MFQ validation across cultures. However, the equivalence of the Thai MFQ across different cultures has not yet been examined. Therefore, evaluating the measurement equivalence of the MFQ across cultures should be examined in future studies.Additional file 1. The Thai MFQ. The Thai Mood and Feelings Questionnaire (MFQ).