Aim: Our objective is to evaluate the presence or not of this numerous peaks, as well as, their latencies and intervals and extend to make a standardizing study. Way of study: Contemporary study of Coorte with transversal cut and the outline was quantitative, descriptive e non experimental. Material and method: Studying several peaks, positives and negatives, caused by the middle latency auditory potentials, in a population of young adults individuals, ranging from 18 to 30 years old, from both genders, with normal hearing. It was used a monoauricular resonant stimulation and a capitation, separately, in both cerebral hemispheres, with surface electrodes. Result: In this research was verified that the analyzed crossings did not present statistically significant results and it was stipulated a pattern from the obtained results. Based on the non-statistical difference found we can affirm that to the Po waves was obtained respectively an average and standard deviation of 12,09 and 1,84; for Na 17,91 and 2,60; for Pa 29,41 and 5,66; for Nb 41,43 and 8,89; to for 51,44 ms e 12,63 and finally to the interval Na-Pa 11,52 and 4,99. Conclusion: 1- The presence of the defluxions Po, Na, and Pa was verified in all the registers, whereas the defluxions Nb and Pb were absent in only 06 registers. 2- By having these registers, we evaluated that the inveiglement of these defluxions can be used as a reliable method to detect the average latency of the auditory potentials, by electrical generated activities, possibly in sites located in the thalamus-cortical area, evoked by sonorous stimulation. From that point, we establish a pattern of responses for young ones with normal hearing, helping us with future studies in patients with alterations in the hearing system.The presence of auditory middle latency evoked responses allows us to make an evaluation of the peripheral and central auditory system integrity, as well as the nucleus and auditory ways existing until the level of the thalamus-cortical region and primary auditory cortex.  It is highly important to capture auditory middle latency evoked potentials (AMLR) in trying to objectively enhance auditory function assessment in patients with hearing loss, both to determine auditory limits and to study the latency period and values of the amplitudes related to its various deflections.These potentials represent a series of deflections, positive and negative, which occur between 10 and 18 ms after the beginning of the auditory stimulus, which are located after brain stem evoked potentials, preceding late responses, related to cortical and cognitive functions.These responses were registered for the first time at the “Massachusetts Institute of Technology” by Geisler et al.Nevertheless, in 1963, these responses were considered generators purely of myogenic potentialsFrom 1967 on there have been studies demonstrating the clinical applicability of these responsesIn 1974, various waves were described, elicited by sound stimuli, among which, N18 (Na), P30 (Pa) and P50 (Pb), already trying to distinguish and separate them from the purely myogenic responses, such as the ones that occur by contraction of the post auricular and temporal musclesLater studiesVarious authors, from then on, have done studies related to the latency wave generating sites between 10 and 80 ms, both in animals, differentiating the contributions of the primary sensorial portions from those originated in the extraleminiscal pathways of the auditory system, for example, reticular substance, suggesting the importance of the thalamus corticalDespite of such evidences, the more systematized studies on these responses used to evaluate the afferent auditory pathways only started to gain importance at the late 80’s.In our field of study, we may mention one on the auditory electrical potentials of middle latency in normal female individuals, with the objective of determining latency times for positive deflections  and negative deflections  in relation to the stimulated side and the frequency in which each of these deflections are seenVarious authors consider that the capture of auditory middle latency potentials have great clinical applicability in various situations, such as the electrophysiological determination of the auditory limits in the low frequency range, in evaluating the functioning of cochlear implants, to evaluate how the auditory pathways are functioning, the location of lesions in the auditory pathways and some intraoperative applicationsThese evoked potentials may be utilized for the evaluation of information processing, as we have seen studies, when analyzing concomitantly the auditory middle latency potentials in the somatosensorial and auditory modalities, more specifically P50, in healthy male individuals. This study supports the theory of deficiency in the processing of information in squizofrenic individuals (defect in P50)Trying to explore other aspects of information processing, the habituation of evoked auditory responses was studied (P50) utilizing repetitive stimuli. We observed, then, that the amplitude of the P50 response to the second of two homologous stimuli was significantly less reduced in patients with migraine then in healthy volunteersIt was suggested that the ascending reticular activity seems to be affected in some patients when studying the auditory middle latency evoked potentials in patients with obstructive sleep apnea syndrome, before and after treatment. After the apnea treatment, there was a significant improvement in the nocturnal hypoxia and also an increase in middle latency P1 peak width and these potentials had a better distribution on its electric field on the scalpThe capture of auditory responses from the brain stem and the auditory responses of middle latency have also been used to study a group of patients with tinnitus, in comparison with registries obtained from normal and from older individuals. In the tinnitus and elderly individuals groups, when looking at brain stem potentials, changes in relation to the VII wave were observed, and in regards of the middle latency potentials, many wide waves occurring in some of the components of this group were observed, but not in all of them. There has been, also, the widening of these middle waves without the corresponding widening of brain stem potentials. This suggests, in the authors’ opinion, that there could be a selective middle latency wave generator in patients with tinnitus and distinct effects of age over cochlear physiologyComparative analysis, when capturing auditory middle latency evoked potentials through electroencephalic registers and through magnetoencephalic data suggest multiple supra temporal sources for the various deflection s observed. Are correlated, then, Pa (28ms) to the medial portion of Heschl’s gyrus; Nb (40 ms)/Pb1 (52 ms) to the lateral face of the supratemporal gyrus; and Pb2 (74 ms) to the anterolateral portion of the Heschl’s gyrusThe capture of these responses may be impacted by external agents, such as alcoholic beveragesWe may register them to study patients with hearing disabilityAlso studying the auditory short, middle and long latency evoked potentials, it was verified the reliance of the registry of these potentials, when doing the test-retest procedure, in a one year time frame, both in young adults and in elderly individuals (between 21 and 92 years old)When doing the simultaneous capture of intracerebral auditory evoked potentials directly from the auditory cortex and the median geniculated bodyOne may also infer that the capture of these potentials is extremely useful to evaluate patients with cochlear implantsThese potentials represent an important tool to evaluation brain function, not only from an auditory perspective, but also in patients with neurological involvement, as has been demonstrated in various studies with comatose patients or patients who suffered head traumaIn the last years many scientific studies have been done, showing that these potentials are related to the nuclei and the auditory pathways situated in the thalamus cortical region and the primary auditory cortex, mainly the thalamus-corticalNevertheless, in our country, little has been produced on this matter.We still lack a higher standardization for our population, as to the appearance of various positive  and negative  deflections, according to their order of appearance, its respective latencies and amplitudes and on what relates to the stimulation of only one ear or both, concomitantly. Taking these data as our basis, we can create a test protocol adapted to our reality, with the goal of studying the variables which would interfere in the capture of the middle latency potentials, using auditory stimuli, either with a click or with tone burst.1- Identify the positive and negative deflections on the traces of the auditory middle latency evoked responses (situated between 10 ms and 80 ms after the sound stimuli) in a population of young adults, with normal hearing.2- Analyze the characteristics of these responses  and do its standardization for the population studied.Based on these evidences, we propose to study a group of normal patients and evaluate the presence of various deflections corresponding to the auditory middle latency potentials, as well as its latencies and amplitudes, with the following objectives:The alignment was quantitative, descriptive, and non-experimental. It was a contemporary cross-sectional cohort study. The data were collected in the laboratory. The study was a comparison among individuals.The sample was a group of 50 individuals, young adults of both genders, being 34 male and 16 female subjects, living in Itajubá. The subject of the study was the individual. The sampling was a non-probabilistic one and by convenience. The exams took place in Odontomed Itajubá Hospital, in the department of otorhinolaryngology.As inclusion criteria, young adults were studied, with ages ranging between 18 and 30 years old, with normal hearing and without previous history of otological and/or neurological diseases.The history of the participating individuals was obtained, and they went through clinical otological inspection, acoustic immittance measurements, stapedian reflex study, conventional tonal audiometry (frequencies tested between 250 Hz and 8000 Hz) and logoaudiometry to assure auditory health.The capture of middle latency potentials was done with both the equipment and the individuals situated inside an acoustic sound proof booth, to avoid electrical interferences of any nature . With this, there would only remain the proper interferences of the individuals being tested or the examiner.We tried to avoid these specific interferences through additional care measures. The electrodes, as well as the earphones, were positioned by the examiner, after instructing the individual. The environmental conditions in the booth  were the most adequate to maintain the individual comfortable and relaxed, without, though, allowing the person to fall asleep. The electrodes were placed, after careful skin cleansing, with adequate electrolytic paste, allowing for a better capturing of the potentials being studied. The exam was only started when the base line of the electroencephalogram was stable, without interferences.The equipment used is the operational system CE - EP 25. The label CE indicates that “Interacoustics AS” meets the requirements of the VI annex of medical directions 93/42/EEC and the equipment was approved by TÜV, with identification nº 0123.•Electrodes: one as live, two as references and another as ground (indifferent) allowing for the individual analysis of each brain hemisphere.•Pre-amplifier: EPA 25, with two channels, obtaining a gain of up to 80 dB, which works within a range of frequency up to 8,000 Hz.•Impedance measurer: with information regarding each electrode individually.•Sound stimulator: the stimuli might be presented ranging from 1.1 to 80.1/sec, through earphones 3A ABR with insertion modes, calibrated in an IEC 126 coupler or earphones TDH 39. It produces “clicks” of 100 mms in three polarities  and tone burst in the frequencies 500; 1,000; 2,000; 3,000 and 4,000 Hz. Level of stimulation between 20 and 130 dB. Sound pressure level- “SPL” (-10 to 100 dB Hearing Level “HL”). White masking noise, calibrated in SPL, with a masking levels from 0 to 40 dB relative to the stimulus.•Recording: up to 900 ms, with a gain of 74 to 104 dB . Has low pass filters , high pass filters (none or ranging from 0.83 Hz up to 500 Hz) and analogue filters (from 0.5 Hz).•Operational system: Windows 98.The exam protocol used in our research, to capture middle latency potentials, was as follows:•Stimulus: “click”, of 100 ms duration, with alternate polarity, without the use of masking, in a frequency of 7 stimuli per second, up to a total of 1,000 stimuli.•Intensity of the stimulus: 70 dB SPL, presented through ear phones TDH 39.•Electrodes: the ground electrode placed on the glabellum, the live electrode placed on the superior portion of the scalp, halfway between the cranial top and the mastoid region, over each cerebral hemisphere, and two “reference” electrodes, each placed over each ear lobe.•Impedance: electrode impedance around 2W, being acceptable up to a maximum of 3W.•Registration period: from 0 to 80 ms.•Filters: 10 Hz high pass filters and 1,200 Hz low pass filters were used.•Reproducibility index: 95%•Mono-aural stimuli•Sequence of stages of the stimuli and capture of answers:1.Right Ear Right Brain Hemisphere (RERH)2.Left Ear Right Brain Hemisphere (LERH)3.Right Ear Left Brain Hemisphere (RELH)4.Left Ear Left Brain Hemisphere (LELH)Stimulation Capture (*placement of the live electrode)This equipment, additionally, consists of:This way, we made 4 isolated registries in each of the 50 individuals, to a total of 200 registries of auditory middle latency evoked potentials.Results obtained in each of the stages mentioned above were plotted separately, being compared to the results obtained from each of the stages.Study parameters of the auditory middle latency responses  were processed electronically, using MS Excel.We considered, for analysis, the positive and negative deflections which were shown within the time frame from 10 ms to 80 ms after the sound stimulus. The positive deflections were named Po, Pa and Pb, while the negatives were named Na and Nb, according to the order of appearance. The latencies and the intervals were measured in milliseconds (ms).The results obtained were subject to descriptive statistical analysis consisting of independent variables: percentages, frequencies, standard deviation, average and number of validated cases. The “Student t test” was used with acceptance of the significance level below 0.05.We established variables overlapping: Po, Na, Pa, Nb, Pb waves and Na-Pa interval latencies, respectively on the sequences RERH, LERH, RELH and LELH, to establish its significance levelThe relevance of the study is to establish a normality standard for different variables  in relation to various registered waves.All the participants were explained the procedures to which they would be submitted and research goals, having accepted to participate in the study.This study consisted of non-invasive evaluations which did not lead to any damage to the patient.The research, which involved the participation of human beings, followed strictly the ethical rules established according to resolution no 196/96, of October 10, 1996 by the National Health Council, of the Health Ministry.This study was approved by the ethics committee in research of the Wenceslau Braz Nursing School of Itajubá.The registry of the variables  were obtained almost totally from the individuals examined, and can be seen on On this table we show the values corresponding to the averages of each deflection latency, positive and negative, and that of the interval Na-Pa. Also are shown the minimum and maximum values, and the Standard deviation for each of these variables. It also shows the number of examinations valid for this analysis.The Standard deviation, for each of the variables, is presented on Four tests were made with each Individual, adding to a total of 200 tests in a whole. As seen on On We can detect the presence of various deflections, positive and negative, in a period from 10 ms to 80 ms after the sound stimulus, in the almost totality of the registries, within the parameters observed by other authorsWe have adopted, in our study, the nomenclature accepted by various authors considering the many deflections according to the latency period. Thus the positive waves were named Po, Pa and Pb, and the negative waves were named Na and PaThe Po, Na and Pa deflections were present in all 200 registries, while the Nb and Pb deflections were absent from 6 registries.Since no statistically significant difference was found, we may infer that the response found is similar in all the values studied. Based on this statement, all other values obtained from the captures, RERH, LERH, RELH and LELH, were added up establishing one only average and standard deviation value for each variable.For the Po wave, we obtained, respectively, the average of the latency period and the standard deviation corresponding to the values of 12.09ms and 1.84; for the Na wave, 17.91 ms and 2.60; for the Pa 29.41 ms and 5.66; for Nb 41.43 ms and 8.89 and for Pb 51.44 ms and 12.63.In relation to the Na-Pa interval, the average value was 11.52 ms and the standard deviation was 4.99.Despite not having done a research study over points of generation for the various waves, we may infer that based on their latency periods, these deflections are generated in sites located in the thalamus cortical region and primary auditory cortex and/or primary cortical regions, as we have widely seen in the literatureWe believe, then, that these various waves are generated from sound stimulation in afferent auditory pathways anterior to the brain cortex, as initially observed by Geissler et al. in 1958Based on these statements, we may consider the registries of the Po, Na and Pa deflections fundamental to verify the integrity of the auditory pathways, to a thalamus cortical and primary auditory cortex region levelThus, this study could be used still as a method of evaluation of patients with neurological problems (such as head trauma or coma)As referred to in the literature, these potentials tend to maintain the same registration standard through the test-retest research within a time frame of one yearWe have analyzed the registries obtained in relation to the location of the auditory potentials considering the positioning of the electrodes, over the specific region of each brain hemisphere. When these results obtained overlapped we could not notice any significant differences between one capture region and another.We have observed the possibility of capture at the same time of both the auditory middle latency evoked responses  and the auditory short latency evoked responses (nuclei and auditory ways of the brain stem). This makes the present this study a tool of extraordinary importance in daily clinical practice.After making this standardization, as seen previously, the capture of these middle latency potentials presents us with a great possibility for further studies, under both the auditory and neurological perspectives. It allows us to electrophysiologically evaluate the auditory level of the individual, and gives us the possibility of a broader way of establishing the lesion area, in case of retrocochlear diseases.The responses obtained after a stimulus on one ear and with ipsilateral capture, when overlapped with the responses obtained from the other ear under the same conditions, and also, when overlapped with the responses obtained counterlaterally, do not bear statistical significance.The analysis of the amplitudes for each isolated wave or in a composition of two of them (for example: Na-Pa) will be made in another study, for verification of its significance and importance, through specificity and sensitivity.We haven’t done research over these potentials under the use of drugs or on patients under anesthesia, although these situations might become topics for future studiesThe similarity of answers of the standard deviations presented in From this data we may infer that a retrocochlear disease might alter these values in a significant way, making it possible, in the future, to create clinical and/or laboratory standards of specific middle latency potential. This type of exam will, in clinical practice, establish a disorder in the auditory anatomy and physiology, allowing for a sensitive or even specific exam.1.The presence of Po, Na and Pa deflections in all registries was shown, with an average of the latency period of 12.09 ms for Po, 17.91 ms for Na and 29.41 ms for Pa; while Nb and Pb deflections were absent from only 6 registries, and the averages of their latency periods were 41.43 ms and 51.44 ms respectively. The average of the Na-Pa interval was 11.52ms.2.Through these registries, we conclude that the capture of these deflections give us a reliable method to detect auditory middle latency potentials, occurring from electric activity generated, possibly, in sites located in the thalamus-cortical region, evoked with the use of sound stimuli. Based on that, we established a response standard, among us, for young individuals, with normal hearing, allowing us to further study patients with alterations in the auditory system.We may conclude that:


Despite the promise of evidence-based management as a practice for improving decisions and their outcomes in organizations, little empirical study exists on the effects of evidence use in the workplace. The present research develops a scale to assess subordinate perceptions of managerial evidence use in decision making and provides empirical evidence of the relationships this measure has with established workplace and organizational phenomena. First, scale development studies in four samples, including a field site and MBA courses with students employed full time, show that perceived evidence use can be measured reliably and is distinct from other leadership measures. Second, a cross-sectional study of 308 employees in 18 aged care homes demonstrates a positive relationship between employee perceptions of managerial evidence use and commonly used measures of leader member exchange, trust in supervisor, work-based learning, and organizational performance ratings, and a negative relationship with employee distress. These results suggest implications for leadership and management practices in contemporary, information-rich environments and novel insights into how employees can be affected by managerial evidence use. Evidence-based management (EBM) is an emerging practice in which managers strive to make conscientious use of the best available evidence in decision-making , 2. The EBM is part of the broader evidence-based practice (EBP) movement, which promotes the use of the best available evidence from multiple sources. Although practiced in domains as diverse as education, criminal justice, and medicine –8, EBP iThere are several reasons why employee perceptions of evidence use by managers might matter. First, perceptions of managerial evidence use can build employee confidence in management, enhancing their good will and advocacy for the organization. Second, perceptions of managerial evidence use can facilitate the teaching role of managers, fostering workplace learning. Third, perceived use of evidence in managerial decisions can support trust-based relationships by reducing employee sense of vulnerability to the effects of decisions based on poor evidence or managerial self-interest, thereby promoting employee well-being. Last, employee ability to discriminate between evidence use in decision making and other management and leadership qualities can provide evidence of the distinct contributions EBM-related practices can make in organizational assessment, development, and research.This study is the first empirical investigation of the effect that leaders’ evidence use in decisions has on subordinates and subordinate perceptions of the organization. Our research addresses basic questions important at this formative stage in the development of EBM practice. First, are subordinates aware of how their managers use evidence? Second, how do the effects of perceived evidence use in decisions compare with those of established leadership constructs like leader–member exchange (LMX), trust in leadership, and transformational and transactional leadership? Third, what relationships do managerial evidence use have on organizational and employee-related outcomes?We examined the effects of perceived evidence use (PEU) on subordinate experiences including workplace learning and relationships with their managers. As per Hinkin , 15, we This research has substantive implications for the literatures of management, leadership, and human resources. First, we develop a reliable and valid measure for employee perceptions of leaders’ evidence use in decision-making to make promote research on managerial evidence use in these domains. Second, we provide evidence of a key mechanism through which perceived evidence use affects employees and organizations, that is, through workplace learning. Third, we find evidence of benefit from perceived evidence use in the form of reduced employee psychological distress. Fourth, we discuss ways employees can have higher regard and advocacy for the quality of their organizations in consequence of PEU.Managers and managerial work differ from the practitioners and work conditions characteristic of other EBP domains. Unlike physicians, nurses, psychologists, educators and other professionals, managers can influence their own incentives and often negotiate the performance criteria for which they are responsible . BecominThe effects of EBP have generally been conceptualized in terms of benefits derived from evidence use in decision-making. These benefits include the use of practices known to be effective and the avoidance of ineffective practices . EvidencSeveral sources of evidence are pertinent to the practice of management . ScientiTo date, the lack of empirical work on the consequences of evidence use raises critical questions about EBM’s role in organizations . One potThe opinions that subordinates develop regarding their managers are products of their working relationship and interactions, representing interpretations or attributions subordinates make about their manager’s behavior and its effectiveness . AttribuIndividual employees notice the consistency and distinctiveness of their manager’s behavior when making attributions . These aWith these factors in mind, it follows that what managers communicate regarding their evidence use can influence subordinate attributions regarding the managers’ qualities as people and as leaders. In this study, we tested two attributions subordinates are known to make about their leaders, trust in leaders and the quality of leader-member exchange (LMX).Trust has been conceptualized as the willingness to be vulnerable to the intentions of another . In suboHypothesis 1: PEU is positively related to subordinate trust in the manager.LMX theory asserts that managers have differentiated relationships with their subordinates based on the quality of interactions a manager has with each subordinate . These dHypothesis 2: PEU is positively related to LMX.Managerial evidence use in decision making is likely to impact an organization in multiple ways. In this study we investigate the implications of PEU for employee reports regarding both organizational and individual outcomes. The primary organizational outcome on which we focus is employee evaluation of the overall quality of client care provided by the organisation. The primary individual outcomes we address are employee reports regarding their workplace learning and their psychological well-being (manifest as low employee distress).Learning is the process of acquiring new or modifying existing knowledge, behavior, skills, values, and practices. Managerial evidence use in decisions is likely to enhance both the managers’ own learning and that of their employees. For example, the quality and degree of informal learning in the workplace can be promoted when managers discuss with subordinates the processes and information they use in decision-making . WorkplaAlthough learning as a general process often occurs in social contexts that permit both observation and direct instruction , learninTwo additional workplace learning domains involve specific learning processes that managers can model and support. The first, learning by reflecting on task outcomes, involves paying mindful attention to experience, and can be used to both link current experience to past learning and to generate new insights . This leHypothesis 3: PEU is positively related to perceptions of workplace learning.Workplace demands can place considerable strain on employees. This strain can cause psychological stress , a form Thus, we hypothesize:Hypothesis 4a: PEU is negatively related to employee psychological distress.Hypothesis 4b: The relationship between PEU and employee psychological distress is mediated by (i) trust in manager (ii) LMX and (iii) workplace learning.Perceptions of managerial evidence use can also contribute to judgments employees make regarding how well their organization performs. In healthcare, the quality of care provided is a key measure of performance, and evidence use has been found to be predictive of care quality . This efHypothesis 5a: PEU has a positive effect on employee assessments of care quality.Hypothesis 5b: The relationship between PEU and employee assessments of care quality is mediated by (i) trust in managers, (ii) LMX, and (iii) workplace learning.We operationalized PEU in the context of workplace decision-making and implementation of new workplace practices. Consistent with scale-development processes recommended by Hinkin , 15, we Item generation. To assess the role of evidence use in leadership and workplace perceptions, a measure of managerial evidence use is required. We used a deductive approach to item generation .We examined the structural path for the hypothesized model, with the PEU4 independent variable mediated by LMX, trust, and each of the four WBL variables . After removing non-significant hypothesized paths, resulting fit statistics were well within the acceptable range [χp < .01), supporting both hypotheses.Hypotheses 1 and 2 predicted PEU would be positively related to employee perceptions of both trust in their manager and LMX. The paths from PEU4 to both LMX (.34) and trust in supervisor (.40) were significant (p < .01), the path from PEU4 to work-based experimentation was not significant. With both WBL colleagues and experimentation dropped from the analysis, Hypothesis 3 was thus partially supported.Hypothesis 3 predicted PEU would be positively related to perceptions of WBL. While the regression path from PEU4 to WBL supervisor was strong (.60) and the path to WBL reflection (.23) both were significant (p < .01), supporting this hypothesis. Hypothesis 4b predicted that the relationship between PEU and psychological distress is mediated by trust in manager, LMX and workplace learning. The paths from PEU4 to trust in supervisor (.40), LMX (.34), WBL supervisor (.60) and WBL reflection (.25) were significant. However only the path from trust in supervisor was significantly related to psychological distress. The path from PEU to psychological distress was therefore both directly and indirectly significant via trust in supervisor (-.22), supporting Hypothesis 4b. As no significant paths were found between psychological distress and either LMX or workplace learning. Hypothesis 4b was partially supported.Hypothesis 4a predicted that PEU would be negatively related to psychological distress. The path was significant  supporting Hypothesis 5a. Hypothesis 5b predicted that trust in supervisor, LMX, and workplace learning would mediate this relationship. There were no significant paths from WBL supervisor or WBL reflection or trust in supervisor to quality of care. The path from PEU4 to quality of care was mediated by LMX both directly (.42) and indirectly via WBL supervisor (.17) and trust in supervisor (.48). Hypothesis 5b is thus partially supported. Hypothesis 5a predicted that PEU would be positively related to perceptions of quality of care. The path from PEU4 to quality of care was significant  by their managers and its implications for their work-related and organizational experiences. We found that employees are able to discriminate between PEU’s relationships with different types of workplace learning. Notably PEU was strongly associated with learning from the supervisor, and moderately associated with reflective learning. The magnitude of the relationship between PEU and workplace learning from the supervisor was high (.74), suggesting the evidence use by managers may contribute to their subordinates’ ability to learn from those managers. In terms of reflective learning, perceived evidence use may encourage subordinates to make sense of prior experiences in light of newly presented facts and information . PerceivAlthough we cannot determine the specific forms of evidence managers used or the communication processes managers employed to convey their evidence use to subordinates, these first findings suggest organizations that do not encourage evidence-based decision-making are missing out on opportunities to develop their workforce. Our findings suggest that by modeling the evidence use in making decisions, leaders can provide their subordinates with opportunities for workplace learning.As expected, PEU was substantially related to, yet distinct from both LMX and trust in supervisor. Our findings suggest that leaders may be able to build subordinate confidence in their leadership through careful attention to facts and relevant scientific evidence when making decisions, and through communicating the role that evidence plays in those decisions. Although decisions about what constitutes high-quality evidence are sometimes contested , a patteThese results show that managerial evidence use also may enhance employees’ perceptions of the quality of services the organization provides. In the aged care setting, perceptions of quality of care are likely to be an important aspects of organizational performance. Indeed, in other settings, we would expect similar results on other relevant organizational outcomes. In organizations where managers make decisions based on evidence, employees are likely to have increased respect for and commitment to their employer and their managers. In effect, we expect employees to become stronger advocates for their employers when they perceive that organizational decisions are made with attention to evidence. When organizations are seen to offer informal learning opportunities through the communication of decision-making processes, employees are likely to respond with more favorable perceptions of the employer and other indicators of workplace quality. Indeed, “evidence-based management culture” has been described as an important component in a positive learning environment; one that provides a new element in human resource management .We found perception of evidence use to be negatively related to psychological distress. Note, however, that perception of evidence use did not reduce psychological distress via the traditional mechanisms of trust, LMX, and workplace learning that we investigated. Instead, employee perceptions that their managers used evidence directly related to lower psychological distress. It is possible that awareness of one’s manager’s reliance on evidence can reduce employee distress through the psychological ease or confidence evidence use engenders. Alternatively, evidence use may play a role in creating psychological safety in the workplace .The relatively large contributions that evidence use made to both LMX and trust in managers offer an opportunity to rethink leadership theory, particularly regarding the nature of effective leadership and behaviors that good leaders manifest. Since the emergence of leadership research in the 20th century, models of leader effectiveness have shifted from focusing on discrete behaviors such as consideration and initiation of structure  to assesWhat is particularly important to leadership theory is that organizational environments have become information-rich both in terms of online access to scientific evidence  and the The broader construct of EBM introduces a new dimension to leadership research as well as to practice. As a mode of management practice with implications for organizational outcomes, workplace relationships and learning, evidence-based practice is suggested as an important dimension of leader behavior and a contributing factor in positive leader–member relationships. Its contribution derives from subordinate observations of managerial evidence use in making decisions.Research is needed into the dimensionality of evidence use. Many things can be done with evidence. It can be applied in decision-making, used to evaluate consequences of decisions, shared to explain the rationale for decisions, or reflected upon to promote learning. In the broad practice area of EBM, several forms of evidence play a role, including findings from scientific research, organizational data, practitioner judgment, and stakeholder concerns and perspectives . We recoPerspective is also important in that although we investigated subordinate perceptions of evidence use other pertinent perspectives include those of the individual managers themselves and their superiors. Further research could reveal the extent to which both executive and employee perceptions of managerial evidence use converge with managers’ self-reported evidence use and the implications of the observed degree of convergence. It would be useful to know how those executive and employee observers perceive the quality of the evidence used by managers, and the conditions under which managerial evidence use is salient or ignored. For example, under what conditions might managerial qualities like charisma, authority, and entrepreneurial leadership  overrideLast, while this study identified possible consequences of perceptions of managerial evidence use, research is needed into its antecedents. Individual ability, motivation, and opportunity to practice all play major roles in engaging in EBP . We knowManagers are likely to create real value for their organizations and benefits for their subordinates by using quality evidence in making decisions. Perceptions of evidence use and sharing reinforce the everyday teaching role managers can perform for their employees. We advise organizations to assess how their managers use evidence by employing the PEU4 scale as part of their larger organizational surveys.Evidence use by managers in their decisions is part and parcel of building trust-based relationships with subordinates and is likely to foster workplace learning. Managers who run experiments to learn what does and does not work provide employees with a model of openness to feedback and reinforce the value of quality evidence in making decisions and solving workplace problems.Evidence use is not easy. It can take a special effort to obtain useful scientific and organizational evidence in making organizational decisions. Gathering in-house data requires building supportive infrastructure including information technology capabilities and a willingness to share information. Such investments and efforts can pay off with improved decision quality, organizational learning, and quality relationships with employees. Further, encouraging managers to become more evidence savvy may pose a threat to those managers who fear an emphasis on evidence takes away from their autonomy and personal control. Courage and competence are both required to reduce reliance on intuition and instead make conscientious use of quality evidence.The cross-sectional design of much of the present research limits our ability to draw inferences regarding causality. Further, the nature of the training and work environment of the caring and nursing staff we studied may limit generalizability of our findings. Although perceptual measures are appropriate when assessing employee perspectives, future research should link employee perceptions with both direct observation and managerial self-reports regarding evidence use. While we considered variables such as trust in supervisor, LMX and workplace learning, we failed to identify potential mediators of the effect of PEU on psychological distress, suggesting more attention is needed into the psychological effects that managerial evidence use has on employees. We suggest psychological safety  as a likThis research demonstrates specific effects of perceptions of managerial evidence use. Using an assessment with robust psychometric properties, these findings advance our understanding of EBM by identifying ways that PEU by managers can enhance the employee workplace experience. These results highlight the potential game-changing role that managerial evidence use can play in relationships between leaders and their subordinates. In information-rich environments, how contemporary leaders make use of evidence can be a telling leadership quality itself.


Rarely, large B-cell lymphoma is located in the spleen, making the diagnosis difficult.Malignant lymphoma occurs in all the systemic organsHerein, we report a patient presenting with massive splenomegaly due to LBCL. Splenectomy was essential to assess the diagnosis and to guide postoperative therapeutics.A 47-year-old woman, with no comorbidities, complained of weight loss and abdominal pain. She had a palpable spleen that extended below the navel.CT scan revealed massive splenomegaly and lymph nodes in the spleen hilum. Splenectomy was performed.Histopathological examination confirmed the diagnosis of large B-cell lymphoma.The postoperative course was uneventful. Three courses of chemotherapy were given. The patient was in remission after a follow-up of 8 months.Massive splenomegaly can be one of the circumstances of the discovery of large B-cell lymphoma.Splenectomy was then essential to confirm the diagnosis and to guide postoperative therapeutics. It also permits reducing hypersplenism and preventing spleen rupture.In patients with high operative risk, splenic needle biopsy should be taken into consideration.Splenic artery embolization before surgery can also be performed in patients having massive splenomegaly to reduce the spleen volume.We highlight the importance of splenectomy to confirm the diagnosis and to relieve the symptoms. Postoperative chemotherapy is essential to prevent relapses.Splenectomy is essential in spleen localized large B-cell lymphoma. It permits to confirm the diagnosis, relieve symptoms, and treatment of underlying hematologic malignancies. Postoperative chemotherapy is essential to prevent relapses. •Spleen localized large B-cell lymphoma is a rare condition.•Massive splenomegaly is rarely a circumstance of discovery of the disease.•Splenectomy is essential to confirm the diagnosis and relieve symptoms. In comparison with Hodgkin Lymphoma, Non-Hodgkin's Lymphoma (NHL) has a greater predilection to touch extranodal sites, including the spleen Herein, we report a patient presenting with massive splenomegaly due to spleen localized LBCL. Splenectomy was essential to assess the diagnosis. This work has been reported in line with the SCARE 2020 criteria 2A 47-year-old woman, with no comorbidities, complained of weight loss and abdominal pain.On the physical examination, she had no palpable peripheral lymphadenopathy. She had a palpable spleen that extended below the navel. There were no ascites or hepatomegaly.Laboratory studies revealed haemoglobin of 9.3 g/dl, platelet count of 75,000/μl, white blood cells count of 5300/μl. Renal and hepatic functions were normal. LDH, uric acid, and serum Ca levels were normal.CT scan revealed massive splenomegaly and lymph nodes in the spleen hilum , Fig. 2.The two essential diagnoses evoked were: lymphoma and abdominal tuberculosis.We opted for laparotomy instead of laparoscopy because of the massive splenomegaly. A left subcostal incision was made. Intraoperative findings revealed lymph nodes in the splenic hilum. We performed splenectomy. It was performed by a surgeon with seven-year experience. The blood loss was estimated at 150 mL and the operation time was 150 min.The resected spleen weighed 3.5 kg and measured 22 × 20 × 10 cm.In the cut surface, there were grey-white homogenous tumors soft in consistency .Fig. 3ThMicroscopy showed the proliferation of large neoplastic lymphoid cells . ImmunohThe disease was classified low risk according to the international prognostic index for non-Hodgkin lymphoma The patient received antibiotic prophylaxis with Penicillin 1000 mg/12 h. This treatment will last two years.The postoperative course was uneventful. Three courses of standard CHOP  plus rituximab chemotherapy were given. The patient was in remission after 8 months without any complications related to disease and splenectomy.3Here, we reported a case of a spleen localized LBCL in a patient presenting massive splenomegaly and hypersplenism. Splenectomy was essential to relieve symptoms, confirm the diagnosis, and therefore guide postoperative therapeutics.The main weakness of our work is the short follow-up period and the non-performance of a positron emission tomography (PET) scan which is important in the disease staging.Large B-cell lymphoma is the most frequent non-Hodgkin's lymphoma representing 33% If the rigorous criteria given by Das Gupta et al. are followed Splenomegaly and hypersplenism can be one of the circumstances of the discovery of this pathology. Computed tomography (CT) scan is not performant to confirm the diagnosis Weight loss, the presence of lymph nodes in the spleen hilum were suggestive of lymphoma in our case. But tuberculosis, which is endemic in Tunisia, couldn't be ruled out Laparoscopy has become the most common approach for elective splenectomy. Its use for massive splenomegaly is controversial. Some authors recommend the use of laparoscopy regardless of the spleen size Splenectomy was then essential to confirm the diagnosis and to guide postoperative therapeutics. It also permits reducing hypersplenism and preventing spleen rupture Splenic artery embolization before surgery can also be performed in patients having massive splenomegaly to reduce the spleen volume. It reduces bleeding and makes spleen manipulation simpler It was reported that splenectomy for massive splenomegaly has a high rate of perioperative mortality, nearing 20% Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis. Prophylactic antibiotics along with the adoption of appropriate vaccination are necessary to prevent post-splenectomy infections Patients after splenectomy are at significant risk of infection by encapsulated bacteria such as Most cases of aggressive lymphoma such as large B-cell lymphoma show fast disease expansion and progression, requiring immediate adjuvant chemotherapy In summary, we reported a case of spleen localized lymphoma in a patient presenting massive splenomegaly and hypersplenism. We highlight the importance of splenectomy to confirm the diagnosis, relieve the symptoms, reduce hypersplenism, and avoid splenic rupture.4Splenectomy is essential in spleen localized large B-cell lymphoma. It permits to confirm the diagnosis, relieve symptoms, and treatment of underlying hematologic malignancies. Postoperative chemotherapy is essential to prevent relapses.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Not required.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Dr. Beji HazemDr. Mahdi BouassidaNot commissioned, externally peer reviewed.Hazem Beji and Mahdi Bouassida did the conception and design of the work, the data collection, and the data analysis and interpretation.Ghazi Laamiri and Emna Chelbi did the critical revision of the articleNo conflicts of interest.


Background: Traditionally, EB-CPGs have been believed to mainly improve the quality and consistency of health care, but this claim must be conclusively proven. We used the Donabedian three-dimensional model  to assess improvements in the quality of medical care derived from implementing EB-CPGs. This study corresponds to the second systematic review carried out as a series of studies on different clinical issues that aim to evaluate the effectiveness of the application of the EB-CPG for improving the quality of care.Methods: We followed the methods described by the Cochrane Handbook and presented a descriptive analysis because of the high heterogeneity found across the included studies. We searched the Cochrane Central Register of Controlled Trials, PubMed, and EBSCO Host databases, as well as the grey literature, between 1990 and April 2021. No language restrictions were applied. Only randomised clinical trials (RCTs) were selected.Results: Of the total of 364 interventions included in the eleven RCTs evaluated, 11 (3%) were related to healthcare structure, 51 (14%) to the healthcare delivery process and 302 (83%) to patient outcomes. Regarding the impact of using the EB-CPGs, in 303 interventions (83%), there were no significant differences between the control and experimental groups. In 4 interventions (1%), the result favoured the control and intervention groups in 57 of the interventions (16%).Conclusions: Our study showed that EB-CPGs slightly enhanced the quality of health care in the three dimensions described by Donabedian. Future RCTs should improve their design and methodological rigour by considering the certainty of the evidence supporting the EB-CPGs recommendations. In that context, broader analyses could be performed, having more concise hypotheses for further research. Registration: PROSPERO CRD42020205594 The emergence of the Evidence-Based Clinical Practice Guidelines (EB-CPGs) in the 1990s has improved decision-making for healthcare personnel and patients with different health conditions .The research question was translated into the PICO framework for guiding the study search and the criteria selection . We deveWe explored the following electronic databases for primary studies: Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Library, including the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register, Pubmed, Scopus, EBSCO, Academic Search Complete, CINAHL, Biomedical Reference Collection: Comprehensive, APA PsycInfo, Nursing & Allied Health Collection: Comprehensive, Alt HealthWatch, SPORTDiscus with Full Text, Psychology and Behavioral Sciences Collection, Health Source: Nursing/Academic Edition, Biomedical Reference Collection: Basic, AMED - The Allied and Complementary Medicine Database, Consumer Health Complete, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Rehabilitation & Sports Medicine Source, AgeLine, Global Health, International Pharmaceutical Abstracts, MasterFILE Premier, Rehabilitation & Sports Medicine Source, LILACS, and Health Technology Assessment Database. We also searched the Science Citation Index and Social Sciences Citation Index for papers that refer to studies included in the review.The PubMed search strategy was executed in the other databases using the appropriate controlled vocabulary. Searching for other resources included grey literature from different sources and hand searching of those high-yield journals and conference proceedings that have not already been hand searched on behalf of the Cochrane Collaboration.Appendix 1 , and discrepancies about study selection were resolved by a third reviewer (MT). Inclusion criteria were: 1. Randomised Clinical Trial (RCT) or cluster-type RCT measuring the impact of using any implementation model versus passive dissemination or no use of the EB-CPG. 2. The studies evaluated the impact on any of the three domains described in the Donabedian model  for using EB-GPC in treating breast cancer. 3. No language restriction. 4. Published studies from 1990 to 2021.Three authors  independently undertook data extraction. They used a modified version of the Cochrane Collaboration EPOC Group “Data Collection Checklist”, employing an electronic datasheet .To assess the bias risk, we used standard Cochrane methods described in chapters 8, 10 and 23 of the Cochrane Handbook for Systematic Reviews of Interventions , and discrepancies were resolved by discussion. A summary of the risk of bias assessment is presented as part of the characteristics of included studies table.We did not find cluster-type RCTs; then, we did not apply what is stated in chapter 23 of the Cochrane Handbook for Systematic Reviews of Interventions . Approximately 55% (6) were carried out in the United States of America. The clinical practice guidelines examined within the selected trials were follow-up  and treatment . When evaluating the outcome categories involving the clinical practice guidelines quoted, most referred to the quality of life . A summary of the characteristics of the included studies (n=11) is available . A broadTwo different studies  in domain 1: randomisation process. Some concerns occurred in domain 2: deviations from the intended interventions . A low risk of bias was found for domain 3: missing outcome data  and domain 4: measurement of the outcome . Finally, we found some concerns in domain 5: selecting the reported result .Overall, one study (9%) reported low risk , incomplete outcome data , and imprecision .We found for the study with the lowest risk of bias  corresponded to the health care structure dimension, 51 (14%) interventions to the dimension process and 302 (83%) interventions to the dimension of patient outcomes. A broader description of the main findings by the dimensions evaluated in the included studies is available as extended data,Regarding the impact of using EB-CPG, we found 303 (83%) interventions with no significant difference between the control and experimental groups. The outcome favoured the control group in 4 (1%). Three outcomes interfered with the patient’s adherence , as reported byFor more than two decades, governmental and non-governmental institutions have been making economic and methodological efforts to develop more and better quality EB-CPGs, seeking to deal with different issues most healthcare systems face. Such as the ageing population, rising costs motivated by increased demand for quality care, increasingly expensive emerging health technologies, variability in the provision of health by presuming that part of this disparity could cause inadequate care (either overuse or underuse of supplies), and the desire for clinicians and patients to provide and to receive, respectively, the best possible care with measurable clinical effect. However, it still appears that some of these EB-CPGs are far from contributing to an effective, standardised clinical practice based on the best available evidence  and the care provided (14%); both were the least explored. Surprisingly, patient outcomes were the most evaluated domain (83%), with significant results in 43 of 302 (14%), representing 75% of all significant results.This fact could lead us to suppose that researchers finally focused on the importance of evaluating the patient health, solely prioritising evaluating the adherence to the CPG (assess the process dimension). They are trying to glimpse more clearly what the use of the CPG represents for patients and not only for clinical staff. As this review considered breast cancer, we could not ignore that there is more social and economic pressure to know the patient outcome.Four studies (36%) reported a high risk of bias  as this could have a more significant impact on the results when the best available certainty of evidence recommendation is implemented. We keep in mind that explicit EB-CPG improves clinical practice when introduced within a context of rigorous evaluations .More research is necessary to define which factors related to the implementation of EB-CPG and its specific recommendations are essential to predict the application of EB-CPG and, therefore, achieve better patient results.This systematic review aimed to support the development of programs evaluating the effects of EB-CPG on the quality of health care. Also, to provide reliable evidence sustaining the decision-making process related to the production of EB-CPGs.Even when some of the results of this systematic review were statistically significant, supporting the use of EB-CPG as a tool to improve clinical practice and quality of care, the results of this review need to be interpreted with caution.The implementation of EB-CPGs must consider the differences in the measures of effect to define customised approaches and specific recommendations within the guideline to enhance health care.For the adequate implementation of EB-CPGs, it is necessary to consider the possible costs, risks, and benefits and the expected effects derived from EB-CPGs recommendations. The efforts to build EB-CPGs must be complemented with psychosocial strategies promoting health personnel to follow the recommendations of the EB-CPG and evaluate their impact.Greater methodological rigour in the development of CPGs is needed. It is also required to carry out this process within a standardised formal program in the health systems. Greater credibility could be achieved if recommendations are based on the best available evidence, improving the credibility of their positive effect among health personnel. It could also lead to a more willingness to implement the CPGs and to participate in evaluating their impact.This study corresponds to the second systematic review of a series of studies aiming to assess the effect of Evidence-Based Clinical Practice Guidelines (EB-CPGs) on improving health care quality. Our next and last project will investigate Covid-19 disease.Due to recent research in this field, and the results of this study were not conclusive, more research is necessary to evaluate how EB-CPGs could impact the quality of health care, especially emphasising fewer investigated areas, such as the structure of healthcare services and patient outcomes.Additionally, the design and methodological rigour applied to future RCTs should improve by considering the certainty of the evidence supporting the EB-CPGs recommendations. Besides, focusing on those with a greater level of evidence (high or moderate) which could lead to determining more clearly the effect that these recommendations have on the quality of health care.Underlying dataAll data underlying the results are available as part of the article, and no additional source data are required.Extended datahttps://osf.io/6h9pm/?view_only=  increases the ability to assess the implementation of the guidelines on the subject. The search method, selection (eligibility criteria), data extraction, risk of bias assessment, and quality of evidence are fully reproducible and adequate. There is a limitation in the expression of results due to the already expected heterogeneity between the randomized clinical trials included in the guidelines implementation environment (11 RCTs and more than 300 interventions involved). The analysis, fundamentally supported by the “outcomes” domain, discourages the use of guidelines, since, in the majority, the results are similarwhen using or not using a standardized conduct. However, this analysis is not specific about the interventions adopted and measured outcomes, which in addition to not allowing a quantitative expression, does not allow for analyzing the reasons for the absence of differences in the implementation of the recommendations. And the questions that remain are: is there still any doubt whether the homogenization of medical practice produces benefits and reduces harm to patients? Is this question still open to investigation?Are the rationale for, and objectives of, the Systematic Review clearly stated?YesIs the statistical analysis and its interpretation appropriate?Not applicableAre sufficient details of the methods and analysis provided to allow replication by others?YesAre the conclusions drawn adequately supported by the results presented in the review?YesReviewer Expertise:Evidence Based Medicine, Systematic Review and GuidelinesI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This is an original paper of substantial importance addressing CPG implementation effect. Mostly a very sensible, necessary and well-developed document. In general, the writing is clear and concise, however, needs some editing to avoid unnecessary repetition . The effect of the implementation of 11 guidelines identified after a rigorous and well-done literature search is presented, as detailed in Methods and Figure 1. The reviewer has some concerns and suggestions regarding Methods (GRADE use) and Discussion that need to be addressed to improve the manuscript. An article that is worthy of being indexed.Major CommentsMethods:Data extraction, page 4, last paragraph, “An analysis of the quality of the evidence…we assessed the certainty...”: It is unclear how this was done. GRADE is a very labour-intensive and specific methodology, and to perform a GRADE evaluation, the authors have two options: a) simply seek the strength of evidence from the original implemented guideline included in the review, or b) evaluate and critically assess original articles cited in the guidelines reviewed, when they did not use GRADE methodology. This needs clarification on what the authors mean. In addition, readers do not need the authors to explain what GRADE method is.Results:Quality of evidence assessment, page 7: This section should be clarified in accordance with previous comments on the use of GRADE.Discussion:The structure of this section does not agree with the established "norms" on how the "discussion" section should be drafted. The main findings of the study should first be highlighted in relation to the objective of the study, and in a second step explain the causes of such findings and contrast with similar studies in the available literature. Thus, the large first paragraph could be moved down (and shortened) in the text.et al. (2005)).The reviewer does not agree with the statements made in the current third paragraph, in the sense of contrasting the effect on the "process of care" with the effect on "patient outcomes". There are RCTs that relate the implementation of guidelines process of care with the appropriateness and necessity of care for patients' benefits  appears in the abstract and keywords.Introduction:In the sixth paragraph:“Although survival has improved…..”: There is a huge debate whether the improved survival depends on the early diagnosis or the improvement of knowledge of the natural history and new treatments of breast cancer , Elmoreet al. (2005)). Thus, some sentences should be complemented with “...of early detection programs and treatment improvement”.Discussion: The comments on the usefulness of EB-CPG could be shortened.Are the rationale for, and objectives of, the Systematic Review clearly stated?YesIs the statistical analysis and its interpretation appropriate?YesAre sufficient details of the methods and analysis provided to allow replication by others?PartlyAre the conclusions drawn adequately supported by the results presented in the review?YesReviewer Expertise:Clinical EpidemiologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Dear Dr. Ignacio Marin, We would like to thank you for agreeing to participate in the review of our research. We consider that your contributions are very valuable to improve our work. Regarding your comments, we describe as follows the research team's position on each of them:A. Concerning the analysis of the certainty of the evidence, you wrote:Methods: Data extraction, page 4, last paragraph, "An analysis of the quality of the evidence…we assessed the certainty...": It is unclear how this was done. GRADE is a very labour-intensive and specific methodology, and to perform a GRADE evaluation, the authors have two options: a) simply seek the strength of evidence from the original implemented guideline included in the review, or b) evaluate and critically assess original articles cited in the guidelines reviewed, when they did not use GRADE methodology. This needs clarification on what the authors mean. In addition, readers do not need the authors to explain what GRADE method is.Results: Quality of evidence assessment, page 7: This section should be clarified in accordance with previous comments on the use of GRADE.Answer to #A:  We agree with you about the options using the GRADE method to develop or adapt a Clinical Practice Guideline. However, we used the GRADE method to assess the certainty of the evidence only for the RCTs that met the inclusion criteria. Therefore, it does not comprise part of the objective and scope of this systematic review to evaluate the evidence included in the CPGs that these studies reviewed. We wrote as part of the Methods section: The studies showing the lowest risk of bias  and one resulting in the highest risk of bias  were chosen to be evaluated with the GRADE methodology and to build a summary of the findings. We decided to grade only four outcomes per study described, including two reporting statistically significant results and two not statistically significant results. Performing a GRADE table provided the rank of possible grades for the certainty of the evidence found in the 362 interventions from the 11 studies included. Hence, we do not consider it necessary to modify the text in the section "Quality of evidence assessment". Then, we want to clarify that it is part of the objective and scope of this systematic review to evaluate the certainty of the evidence of the RCTs included and not of the EB-CPGs that they evaluated.B. About the article's Discussion section, you wrote:B.1The structure of this section does not agree with the established "norms" on how the "discussion" section should be drafted. The main findings of the study should first be highlighted in relation to the objective of the study, and in a second step explain the causes of such findings and contrast with similar studies in the available literature. Thus, the large first paragraph could be moved down (and shortened) in the text.Answer to #B.1:  It is relevant to clarify that our article complies with F1000Research guidelines for preparing a Systematic Review article. The journal requests the main body section as follows: Main Body: The format of the main body of the article is flexible: it should be concise, making it easy to read and review, and presented in a format that is appropriate for the type of study presented. For most Systematic Reviews, the following standard format will be the most appropriate: Introduction, Methods, Results, Conclusions/Discussion. Also, we consider that the aim of the discussion was achieved because we highlighted our findings and contrasted them with similar research. We must add that we have also complied with the PRISMA 2020 statement checklist . About the discussion, our study meets with the following items: 23a Provide a general interpretation of the results in the context of other evidence. 23b Discuss any limitations of the evidence included in the review. 23c Discuss any limitations of the review processes used. 23d Discuss the implications of the results for practice, policy, and future research. Therefore, considering that neither of the indications describes an expected order of ideas as you have indicated, the authors alleged it convenient to include this first paragraph to provide a context about the world situation regarding the efforts to develop guidelines and the expectations placed by health caregivers on their effect. Also, to link this finding with the findings in our study. Consequently, as the first paragraph of this section is congruent with the aim of this systematic review, we consider it appropriate to keep the paragraph unchanged.B.2 Additionally, regarding your comment about the third paragraph of the discussion section:The reviewer does not agree with the statements made in the current third paragraph, in the sense of contrasting the effect on the "process of care" with the effect on "patient outcomes". There are RCTs that relate the implementation of guidelines process of care with the appropriateness and necessity of care for patients' benefits [2]). We would like to explain the following:Answer #B.2:  This statement refers to the findings we got from the first systematic review  that focused on the impact of CPGs in the cardiovascular approach; at that time, we included nine RCTs. Therefore, we decided to compare the results obtained in this second SR to our previous research regarding the number of interventions evaluated according to the dimensions described by Donabedian (1988)[4].[5] (7 January 1919 – 9 November 2000). Therefore, what has been understood by the implementation of clinical practice guidelines, as defined in the UK glossary published by NICE, adheres to the definition mentioned earlier: "implementation, The process of putting guideline recommendations into practice" (NICE 2014)[6]. Evaluation components of CPG use, such as clinical auditing, can be of great value. However, clinical auditing has not been disseminated to be available in other countries, predominantly low-income countries. This report corresponds to the result of a Systematic Review that includes only Randomized Controlled Clinical Trials (RCTs) whose objective was to measure the impact that Clinical Practice Guidelines have produced on the quality of health care. This review's authors analyzed the RCT measurements' results according to the framework proposed by Avedis Donabedian[7] using the quality of care model by Donabedian. This publication has been very inspiring for the authors of this series of systematic reviews. This review mainly includes RCT studies and some before and after studies done on CPG made in the Netherlands, a country with a long tradition in the design and use of CPG. Some of their results are encouraging, although other aspects were weak, such as the impact on patient's health, which should be considered a very relevant result. In 2008, Dutch authors Lugtenberg M, Burgers JS and Westert GP published an excellent systematic review Due to the nature of the data, it was impossible to have a quantitative synthesis, only qualitative. But it did not inhibit us from assessing the certainty of the evidence for the results of the included studies after searching and screening according to the inclusion criteria. To determine the confidence of the evidence, we have followed Cochrane's recommendations using the tools developed by GRADE. GRADE is a tool that requires knowledge of the essential elements of effective measurement and its potential biases. The authors of this SR are trained to complete this task with adequate competency.B.3Some comment on study weaknesses is missing.You also wrote:Answer #B.3:  We did not write within a specific section of our article what the research's weaknesses are. The weaknesses of the study are described throughout different statements, for example, when describing the risk of bias assessment for the included studies. We also identified many EB-CPGs developed in contrast to the few numbers evaluated through formal RCT-type investigations. We also wrote about the implications for research: Due to recent research in this field, and the results of this study were not conclusive, more research is necessary to evaluate how EB-CPGs could impact the quality of health care, especially emphasising fewer investigated areas, such as the structure of healthcare services and patient outcomes. Additionally, the design and methodological rigour applied to future RCTs should improve by considering the certainty of the evidence supporting the EB-CPGs recommendations. Besides, focusing on those with a greater level of evidence (high or moderate) which could lead to determining more clearly the effect that these recommendations have on the quality of health care.C. About your minor comments:C.1First, about the abstract section you wrote:Abstract: It is required that the clinical problem addressed in the study (breast cancer) appears in the abstract and keywords.Answer #C.1:  We agree to add "breast cancer" as a keyword.C.2Second, concerning the introduction section, you wrote:Introduction:and treatment improvement".In the sixth paragraph: "Although survival has improved…..": There is a huge debate whether the improved survival depends on the early diagnosis or the improvement of knowledge of the natural history and new treatments of breast cancer [8], Elmore et al. (2005)[9]). Thus, some sentences should be complemented with "...of early detection programs Answer #C.2:  We agree to add the suggested text.C.3Third, referring to the discussion section, you wrote:The comments on the usefulness of EB-CPG could be shortened.Answer #C.3:  The authors alleged it is convenient to describe the usefulness of EB-CPG because it is congruent with the aim of this systematic review. Therefore, we disagree with the modification suggested.C.4Fourth and last, you wrote that there are 'partly' details of the methods and analysis provided to allow replication by others.Answer #C.4:  Full details on methods and further analyses to allow replication by others can also be accessed through the research protocol, registered at PROSPERO: CRD42020205594.References [1] Page et al. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ , 372, p.n71. [Online]. Available at: doi:10.1136/bmj.n71.Revista Española de Cardiología (English Edition). 2005; 58 (6): 640-648  [2] Romero A, Alonso C, Marín I, Grimshaw J, et al.: Effectiveness of a Multifactorial Strategy for Implementing Clinical Guidelines on Unstable Angina: Cluster Randomized Trial. https://doi.org/10.12688/f1000research.18865.3 [3] Ramírez-Morera, A., Tristan, M. and Vazquez, J. C. (2019). Effects of evidence-based clinical practice guidelines in cardiovascular health care quality improvements: A systematic review . F1000Research 2019, 8:1041[Online]. Available at: [4] Donabedian, A. (1988). The quality of care. How can it be assessed? The Journal of the American Medical Association, 260 (12), pp.1743–1748. [Online]. Available at: doi:10.1001/jama.260.12.1743.Wikipedia.https://en.wikipedia.org/wiki/Donabedian_model [5] Donabedian model. . In  [6] Glossary | Developing NICE guidelines: the manual | Guidance | NICE [WWW Document], 2014 LAST UPDATED 18 January 2022. URL https://www.nice.org.uk/process/pmg20/chapter/glossary [7] Lugtenberg, M., Burgers, J.S., Westert, G.P., 2009. Effects of evidence-based clinical practice guidelines on quality of care: a systematic review. Qual. Saf. Health Care 18, 385–392. doi:10.1136/qshc.2008.028043Cochrane Database Syst Rev. 2013. CD001877  [8] Gøtzsche PC, Jørgensen KJ: Screening for breast cancer with mammography. JAMA. 2005; 293 (10): 1245-56 [9] Elmore JG, Armstrong K, Lehman CD, Fletcher SW: Screening for breast cancer.


Despite evidence that use of evidence-based communication tools (EBCT) with a universal precautions approach improves health outcomes, medical trainees report inadequate skills training.We developed, implemented, and evaluated a novel, interactive curriculum featuring a 30-minute, single-session didactic with video content, facilitated case-based discussions and preceptor modeling to improve use of EBCT among pediatric residents. A direct observation (DO) skills checklist was developed for preceptors to evaluate resident use of EBCT.Shortly after implementation of the curriculum, residents completed a survey assessing self-reported frequency of EBCT use both pre- and post-intervention. DOs were conducted 2 to 3 weeks after the didactic was completed and scores were compared among residents who participated in the curriculum and those who did not. A longitudinal 6-month follow-up survey was also distributed to assess changes over time.Forty-seven of 78 (60%) of residents completed the survey and 45 of 60 (75%) of the eligible residents participated in the DO. There was significant change in self-reported use of all but one EBCT after participation in the curriculum. Residents reported sustained increased frequency of use of all communication tools except for Teach Back, Show Back, and explanation of return precautions in the 6 months following the curriculum. Notably, there was no significant difference in resident scores in the DO among residents who participated in the didactic session and those who did not.HLRP: Health Literacy Research and Practice. 2022;6(2):e121–e127.]This novel interactive curriculum addresses ACGME  core competencies and fulfills a needed gap in resident curricula for health literacy-related skills training. Findings suggest a small, positive affect on frequency of self-reported use of health literacy EBCT. However, our findings demonstrate a lack of parallel improvement in resident performance during DO. Future curricula may require certain modifications, as well as reinforcement at regular intervals. [Use of evidence-based communication tools, such as presenting information in small chunks and avoiding complex medical terms among pediatric trainees, is limited. This study describes a new and interactive health literacy curriculum, with emphasis on preceptor modeling and DO to improve use of evidence-based communication tools among residents. After participation in the curriculum, residents report greater use of evidence-based communication tools. However, results from DO of residents did not demonstrate similar improvements. Nearly 30% of parents have below-basic/basic health literacy, with almost one-half unable to fully perform medication-related tasks . Due to Studies show that while pediatricians are familiar with tools for communication with patients with low health literacy, the extent to which they use them when assessed via direct observation (DO) is limited, owing to barriers such as time limitations and complexity of information . Most suWe describe an interactive health literacy curriculum with emphasis on a universal precautions approach to improve residents' use of EBCT. A DO instrument was created to evaluate curriculum impact on resident utilization of EBCT. The objective of this study was to determine whether curriculum implementation increased resident use of EBCT based on both self-report and a DO exercise. We hypothesized that a targeted curricular intervention would result in an increase in both reported and observed use of EBCT.All 78 pediatric residents have continuity clinic with patient panels and a primary preceptor at one of four New York Presbyterian community-based Ambulatory Care Network practices in Northern Manhattan. There are approximately 20,000 pediatric patients distributed across the four practice sites. The patient population served is predominantly Hispanic and publicly insured. In the community, 21.7% of households have limited English proficiency and 24.6% of households have less than a high school degree .often/always using Teach Back to assess patient/caregiver understanding. These findings were used to drive curriculum development.Kern's six-step curriculum development approach was used in the creation of the health literacy curriculum . A localThe conceptual framework of social cognitive theory served as the foundation for the curriculum, emphasizing the importance of observation and modeling to enact behavior change . An innoThe first component of the curriculum is an in-person, 30-minute interactive didactic with the following learning objectives: define health literacy, identify risk factors and signs of low health literacy, describe the universal precautions approach, counsel patients using EBCT, and identify health literacy resources for clinical practice. The universal precautions approach of assuming all patients have difficulty understanding health information was emphasized, as literature has shown that most people face some degree of health literacy challenges and that residents are not able to appropriately identify patients with poor literacy skills . The didThe second component of the curriculum consisted of preceptor modeling. Modeling is an effective teaching technique that improves learner skills and competencies and is associated with high rates of resident satisfaction . PreceptTable A). It was created, in part, to fulfill a new requirement by the Accreditation Council for Graduate Medical Education (ACGME) for completion of four evaluations in continuity clinics annually. Given the applicability to all patient care interactions and the gap in skills identified by needs assessment, a health literacy focused DO was chosen to meet this need. Skills observed in the DO were directly aligned with selected competencies, including communication skills, patient care, and professionalism, in accordance with best practices in DO . The 5-point Likert scale was used to assess resident satisfaction and self-reported changes. Recent evidence has demonstrated that retrospective pre-post surveys are as effective for program evaluation purposes among residents as traditional pre-post surveys  in the month that followed the in-person didactic  participated in the in-clinic didactic and 79% (n = 40) of respondents reported that their clinic preceptors modeled use of communication tools in the clinic. The proportion of first-, second-, and third-year residents who did not participate in the didactic was evenly distributed. Other demographic data were not collected from survey respondents.A total of 47 of 78 (60%) of pediatric residents completed the survey, of whom 25% were interns, 34% were second-year residents, and 40% were third-year residents, resulting in a similar distribution across the years of training. Seventy-five percent (Table 1). The 6-month post-survey was completed by a total of 20 of 78 residents, or approximately 25% of residents, with an even distribution between years. Residents continued to self-report significantly increased frequency of use of all communication tools except for Show Back, Teach Back, and explanation of return instructions in the 6 months after the implementation of the curriculum (Table 1).There was significant change in self-reported use of all EBCT after participation in the curriculum except for limitation of use of medical jargon , 1.5 (±0.5), 1.5 (±0.5), respectively .Of those residents who participated in the didactic session, 94% were overall n = 36, 80%) participated in the didactic session. There was no significant difference in mean scores in the DO among residents who participated in the didactic session and those who did not (Table 2).A total of 60 DOs were completed at the time of data collection, accounting for 77% of the residents. Forty-five resident observations were included in the analysis, accounting for 75% of total eligible DOs as 15 DOs were not included in the analysis as they were completed by study authors. A majority (We developed a novel, interactive curriculum on health literacy focused EBCT that addresses ACGME competencies. We assessed pediatric residents' use of health literacy EBCT after implementation of the curriculum through self-evaluations and DO. The curriculum addresses a clear need as most health literacy curricula are not focused on pediatric specific skills, do not incorporate preceptor modeling, and do not include an assessment of skill use with patients, but rather use of standardized patient encounters and role-playing .We have demonstrated that the in-person didactic portion of the curriculum was well-received and that resident's self-reported frequency of use of EBCT increased after its implementation. However, sustained use of all EBCT, particularly of Teach Back and Show Back was not achieved, perhaps reflecting previously identified challenges of incorporating communication tools into practice. Prior studies have also demonstrated limited long-term effects We developed a brief, health literacy-focused DO checklist both to fulfill the ACGME requirements for an additional DO in resident continuity clinic and serve as an evaluative tool for the health literacy curriculum. Literature has demonstrated that DOs play a critical role in formative feedback, and we are hopeful that the DO spurred discussion of use of EBCT among residents . This DOThere was no difference in directly observed skills for residents who participated in the didactic and those that did not. It is possible that residents may be using EBCT more often than realized, or alternatively, that residents are overestimating their skills using EBCT. This corroborates the literature that physicians are not reliable at assessing their own skills and underscores the need for objective assessments . This alThis study has several limitations worth noting. The curriculum was implemented at a single institution, potentially limiting generalizability. Although DOs were not limited to encounters with English-speaking patients, we do not have data on language or interpreter use, which could influence the use of certain EBCT. Additionally, the short-term improvement in self-reported use of EBCT is promising but may reflect the effects of social-desirability and/or response shift bias, as the study was appropriately powered. Further, the response rate of the 6-month follow-up survey was quite low and differed quite substantially from that administered immediately after implementation of the curriculum. The follow-up survey was administered in the spring, around the height of the coronavirus disease 2019 pandemic in New York City at a time when residents had been pulled from outpatient clinic to meet health system demands. It is possible that competing demands influenced resident participation.The DO tool was created locally by our team and lacks evidence of validity. Total number of DOs was also lower than we had hoped, with only 75% of eligible residents having DOs in MedHub. While we had hoped that this brief, focused DO would provide a sustainable approach for assessing residents in the ambulatory setting, it is clear there needs to be greater faculty development to improve completion rates of DOs. Despite these limitations, the aim of this project was to create a novel health literacy curriculum and this goal was achieved.Future work should focus on validating the use of the DO as well as addressing challenges in implementation of the curriculum. A longitudinal curriculum with reinforcement of health literacy focused EBCTs at regular intervals should be considered. The modeling component of the curriculum would also benefit from more careful tracking, as well as a standardized guide that preceptors could follow. Lastly, the videos used in our study can certainly be used in other pediatric outpatient clinics; however, if used in other settings, modifications should be made.Through the development of a novel, interactive health literacy curriculum based on ACGME competencies and preceptor modeling, we were able to improve residents' self-reported skills. However, our results from DO of residents did not match their self-reported improvements, highlighting the possibility that self-reported health literacy skills are unreliable. Given our curriculum did not result in significant observed behavior changes, future curricula may require additional modeling, reinforcement, and incentivization to achieve success.


Kawasaki disease (kDa) is a self-limiting acute vasculitis that affects small and medium-sized vessels, and is the most common cause of acquired heart disease in children. It is also an important reason for long-term cardiac disease into adulthood. Rapid diagnosis and management of kDa is challenging due to the heterogeneity of the disease, yet is vital for improving outcome. To date, there are no Egyptian nationally agreed, evidence-based guidelines concerning the diagnosis and management of kDa in children. Consequently, treatment regimens vary broadly.To develop a consensus, evidence-based recommendations for the diagnosis, evaluation and management of children living with kDa.This study was carried out to achieve an Egyptian expert consensus on a management strategy for kDa using Delphi technique. A multistep process strategy was adopted, which started by developing 16 key clinical questions by scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Time (PICOT) approach. The core leadership team identified clinicians and researchers with expertise in pediatric rheumatology all over Egypt. An evidence-based, systematic, literature review was conducted to compile evidence for the kDa management. Delphi process was implemented (3-rounds) to reach a consensus.Twenty-five expert panel participated in the 3 rounds with response rate 100%. A total of 21 recommendations, categorized into 9 domains , treatment (acute and after acute attack), management of resistant cases, management of complications , vaccination and long term follow up. The Agreement with the recommendations (rank 7–9) ranged from 83.6–95.7%. The Consensus was reached (i.e. ≥75% of respondents strongly agreed or agreed) on all the clinical standards. Algorithm for management has also been developed.This was an expert, consensus recommendations for the diagnosis and treatment of kDa, based on best available evidence and expert opinion. The recommendations provided a management approach based on easy-to-use algorithm and with the support of complementary tests.to provide updated recommendations for better management of kDa.