A fellow colleague in the emergency department consulted me for advice regarding a two-year-old child with a facial laceration. The child had had a simple fall against a wooden table and sustained a 3cm clean linear laceration in the intercanthal area. My colleague asked me whether glue would be a better idea than suturing. I replied that the cosmetic outcome with suturing was far superior and that one would avoid the risk of dehiscence. My reply was based on anecdotal evidence from other colleagues and senior surgeons. This doctor followed my advice and the child had her wound sutured under general anaesthesia with no complications.® search expecting a paucity of evidence; instead I was greeted with a Cochrane review and a number of prospective RCTs.I later thought to myself that there should be a body of evidence to support or refute my advice on this particular issue. I knew that strong evidence such as a randomised controlled trial (RCT) would answer this question. I performed a MEDLINEAs surgeons, we can only be effective if we question our practice daily. We should always endeavour to practise research to strive for the truth as this will improve patient care. Evidence-based practice can save our hospitals money and time, particularly in a period of such financial upheaval.


Increasingly high rates of obesity have heightened interest among researchers and practitioners in identifying evidence-based interventions to increase access to healthful foods and beverages. Because most food purchasing decisions are made in food stores, such settings are optimal for interventions aimed at influencing these decisions. The objective of this review was to synthesize the evidence on supermarket and grocery store interventions to promote healthful food choices.We searched PubMed through July 2012 to identify original research articles evaluating supermarket and grocery store interventions that promoted healthful food choices. We categorized each intervention by type of intervention strategy and extracted and summarized data on each intervention. We developed a scoring system for evaluating each intervention and assigned points for study design, effectiveness, reach, and availability of evidence. We averaged points for each intervention category and compared the strength of the evidence for each category.We identified 58 articles and characterized 33 interventions. We found 7 strategies used alone or in combination. The most frequently used strategy was the combination of point-of-purchase and promotion and advertising (15 interventions); evidence for this category was scored as sufficient. On average, of 3 points possible, the intervention categories scored 2.6 for study design, 1.1 for effectiveness, 0.3 for reach, and 2 for availability of evidence. Three categories showed sufficient evidence; 4 showed insufficient evidence; none showed strong evidence. More rigorous testing of interventions aimed at improving food and beverage choices in food stores, including their effect on diet and health outcomes, is needed. Obesity, overweight, and health outcomes associated with poor nutrition  represenSupermarkets play an important role in food purchasing ; consumeSeveral reviews on food store interventions have found strong evidence for feasibility but only modest evidence for effectiveness in changing eating behaviors ,9–11. A We searched all years of PubMed for original research articles and qualitative and quantitative reviews  describing supermarket and grocery interventions that promoted healthful food choices. We used a combination of keywords  and 1 MeSH term . An initial search yielded 140 citations dated from the late 1940s through July 2012.When we included only English-language articles, 134 remained. The first author (A.L.E.) read each title and abstract; if the article was relevant, she read the full text. She narrowed the search to include only original research articles that described community-  and store-based interventions (in which store involvement was described). She excluded clinical screening interventions and controlled marketing field experiments, articles that did not report the targeted outcomes, and other articles that were not within the scope of the review. She reviewed citations in the selected articles and included those articles if they met criteria. As a result, 58 articles published from 1978 through 2012 were included for further analysis; the 58 articles described 33 interventions.The first author (A.L.E.) categorized each article according to the intervention described and the strategy or combination of strategies used in the intervention . The 4 sPOP interventions typically entail the use of food demonstrations, taste testing, signs, labels, and other printed materials highlighting healthful food choices or describing recipes with the goal of influencing purchasing decisions toward more healthful options . InterveThe first author extracted the following data for each intervention: the theory on which the intervention was based , intervention setting, location, year in which an article was published; description of intervention activities and duration; study design ; and main outcomes measured. The main outcomes were awareness and use, sales data, customers’ knowledge and beliefs , prefereGuide to Community Preventive Services (Community Guide) (We created an assessment schema on the basis of accepted terminology in the y Guide)  and othey Guide)  and catey Guide) . For eacy Guide) ,22. GreaEffectiveness was scored as 0 to 3 points, according to effectiveness of the intervention’s main outcome measures . Studies reporting a 70% to 100% increase pre- to posttest or between comparison and intervention groups in outcomes  of the intervention were assigned 3 points. Studies reporting a 26% to 69% increase received 2 points. Studies reporting a 1% to 25% increase received 1 point. A score of 0 was assigned if no difference in outcomes was reported between study groups. Most studies reported effectiveness as awareness or use of their intervention . If awarReach was also scored as 0 to 3 points. According to the RE-AIM evaluation framework , reach iFor each intervention category , we calculated the average number of points for study design, effectiveness, and reach. We used this average as 1 of 2 subscores.For each intervention category, we assessed the availability of data using the following scoring system. We gave 3 points to categories that included 10 to 30 interventions, 2 points to categories that included 2 to 9 interventions, and 1 point to categories used by only 1 intervention. These points represented the second subscore and functioned as an indicator of the amount of evidence available.Community Guide designations  for each intervention category by multiplying the 2 subscores. We created 3 classes of evidence on the basis of the summary score: insufficient (0–9 points), sufficient (10–18 points), and strong (19–27 points). These classes were based on gnations . For allThe 33 interventions were implemented in the United States (n = 22), Canada (n = 4) –26, and Interventions were organized into the following categories : POP , effectiveness, 1.1 , and reach, 0.3  . The oveSix interventions used randomization; 2 of these used POP ,59; 1 usThe level of evidence for this category –57,62–74The level of evidence found for this category ,48,76,77The level of evidence for this category ,45,78–80Although this category had insufficient evidence ,31,42,75The level of evidence for this category ,52,58–61The level of evidence for this category ,43,81 waThe level of evidence for this category  was insuThe average level of evidence for the interventions summarized in this review nears a sufficient designation but was insufficient overall. Our review generated 4 main findings. First, demand-side interventions  represented most of the evidence for the study period. Second, evaluation of food store interventions in the early literature emphasized awareness of the interventions, use of the interventions, or both among target populations while excluding other important measures. Store-based strategies evolved to address the supply side, using such strategies as pricing ,43 and iWe found limited evidence on the effect of the interventions on customer purchasing behavior. Eight ,53,57,59Strengths of our study include the up-to-date systematic analysis of 58 articles identified through a comprehensive database and consideration of previous reviews ,9–11,82.Our study had several limitations. In an attempt to be comprehensive and include all evidence available to date, we included 7 studies from the late 1970s and the 1980s; data from older studies may not be relevant to today’s food environment. Findings for unsuccessful campaigns are less likely to be published in publications searchable in PubMed. We searched for published studies rather than nonpublished reports or gray literature because published articles tend to have more standardized information on setting, study design, evaluation methods, and results. We searched PubMed only. Highly controlled marketing experiments –87 may oThis review focused on supermarket and grocery store interventions. Food store interventions represent only 1 level of approach among many levels — from the individual to policy . Increaswww.getactivelacrosse.org/lacrosse/) complement larger environmental change, and policy initiatives , such as nutrition benefit interventions  to emphasize obesity prevention as well as nutrition education and are consistent with the socioecological model (Practitioners need access to up-to-date evidence when approaching grocery and supermarket owners or managers to implement interventions. Food stores want practical strategies that will change consumer behavior ; they alal model ,7, whichOur systematic review of supermarket and grocery store interventions to promote healthful eating suggests that interventions combining demand- as well as supply-side strategies have sufficient evidence to influence customers and management toward more healthful food purchases. The most effective strategies should be combined, and more rigorous evaluation designs should be used. Recent reports of the relationship between the food environment and health outcomes provide impetus for interventions to target food deserts –99 and r


We investigated  circuits


Multiport laparoscopic splenectomy (LS) is considered the “gold standard” for the management of surgical diseases in normal or slightly enlarged spleens. The concept of minimal-invasive surgical techniques has progressed since the early 1990s from standard multiport laparoscopy to natural orifice transluminal endoscopic surgery (NOTES) and, more recently, to single-port access (SPA). In this paper, we describe our technique for SPA splenectomy and provide a critical review of the current literature on SPA for splenic diseases.Preliminary results published to date indicate that the spleen can be safely removed using single-incision surgery and all the authors have unanimously endorsed the feasibility of this approach. However, available evidence is still scarce. It is based only on case reports and one small series, with a total of 17 patents and, therefore, firm conclusions cannot yet be drawn and more experience and comparative trials are needed to determine the exact role of this interesting new approach. Multiport laparoscopic splenectomy (LS) is considered the “gold standard” for the management of surgical diseases in normal or slightly enlarged spleens. Its effectiveness and low-complication rate, alongside patient comfort, decreased hospital stay and enhanced recovery make it the procedure of choice among doctors and patients.The concept of minimal-invasive surgical techniques has progressed since the early 1990s, from standard multiport laparoscopy to natural orifice transluminal endoscopic surgery (NOTES) and, more recently, to single-port access (SPA). Experience with SPA has been reported sporadically since minimal-invasive procedures  first appeared, but the number of papers on the subject has increased consistently since 2007, perhaps because surgeons view this technique as a bridge to the even lesser-invasive NOTES.2 In this Surgical technique has been published elsewere.5 The patThe technique used for splenic dissection is similar to that used in standard LS. After an explorative laparoscopy, the possible existence of accessory spleens ruled out and a 5-mm curved grasper is used for transanal endoscopic microsurgery (TEM)  is placed through the left port. The slightly curved end of this instrument fits into the flexible trocar or through a port of the mutichannel device, and it is suffciently curved to work intrabdominally without causing instruments to clash. A 5-mm harmonic scalpel  is then introduced through the right port. Using this approach, it is possible to mobilize the splenic colon flexure and to reach the lower pole of the spleen. The next step is to gain access to the retrogastric pouch and to section the short vessels at the upper pole of the spleen. With this view, and thanks to the flexible tip of the scope, it is possible, if desired, to ligate the splenic artery. The instruments are then moved to the posterior face of the spleen and the table is tilted to the left to take advantage of gravity and obtain exposure of the retrosplenic area. The posterior spleno-renal attachments are freed. Sometimes, especially if the umbilical approach is used and there are some difficulties with the more posterior and upper part of the upper splenic pole, a 3-mm instrument can be introduced through the left flank. This mininstrument can be used to retract or section (hook) retroperitoneal adhesions . Once thIn the case of fenestration of a splenic cyst Figures  and b, tWe reviewed all clinical reports published in PubMed and Google with the keywords: splenectomy, single-incision, single port, spleen and laparoscopy. We found eight papers, four of which were case reports.–13 TherePreliminary results published to date indicate that the spleen can be safely removed using single-incision surgery and all the authors have unanimously endorsed the feasibility of this approach. However, available evidence is still scarce. It is based only on case reports and one small series with a total of 17 patient and, therefore, firm conclusions cannot yet be drawn. Besides, experience to date has raised a number of technical and clinical questions.The surgical technique described is similar to the standard laparoscopic procedure, but some small variations have been suggested to solve the difficulties presented by SPA , with the surgeon handling the instruments and the assistant controlling the camera. Mallladi suggestsThere is clearly some controversy surrounding two key aspects: (1) the device used for SPA splenectomy and (2) the placement of the incision in the abdominal wall. In relation to the first topic, a number of different devices are currently available or are under investigation. We have used four types: a multi trocar (Curcillo), a Triport and a Quadriport (Olympus) and the Uno (Ethicon) system. All of them proved to be useful, but there is not yet sufficient experience to recommend one over another. In case of the spleen, however, devices that allow the introduction of 15-mm instruments (endobag) are recommended.The placement of the incision is a crucial question. Ideally, SPA offers less aggression and better cosmesis This latter advantage nevertheless only applies if the incision is made in the umbilicus However, depending on the patient’s body mass index and the shape and size of the spleen, some dissection manoeuvres can be specially difficult or even impossible due to the oblique dissection line between the umbilicus and the upper part of the spleen. In this situation, there are two solutions: first, the device can be placed in a subcostal access incision, in which case the aesthetic advantage would be lost or, second, a hybrid approach can be adopted to help the dissection, using additional mini or fine calibre instrumentation. In our experience, we have attempted the umbilicus approach in very thin patients only and, in two cases, we had to convert to conventional LS to achieve visibility of the dissecting area.There are a number of disposable and reusable flexing instruments specially designed for SPA. We have used the TEM instruments as good dissecting instruments as their slightly curved tip is suitable for intraabdominal coaxial movements. However, we await a new generation of specifically designed instrumentation that could facilitate the dissecting, grasping and retracting manoeuvres.To date, experience with SPA splenectomy is scarce and the level of evidence is low. Preliminary results are encouraging, as we have said, but a number of questions remain to be answered, namely patient selection and surgical technique standardization. To address this important question, findings from experience so far indicate that SPA offers better cosmesis, greater pain control, fewer postoperative complications and enhanced patient recovery. However, clinical trials comparing standard LS, mininstruments LS and SPA


Aziz Sheikh and colleagues report the findings of their systematic overview that assessed the impact of eHealth solutions on the quality and safety of health care. There is considerable international interest in exploiting the potential of digital solutions to enhance the quality and safety of health care. Implementations of transformative eHealth technologies are underway globally, often at very considerable cost. In order to assess the impact of eHealth solutions on the quality and safety of health care, and to inform policy decisions on eHealth deployments, we undertook a systematic review of systematic reviews assessing the effectiveness and consequences of various eHealth technologies on the quality and safety of care.We developed novel search strategies, conceptual maps of health care quality, safety, and eHealth interventions, and then systematically identified, scrutinised, and synthesised the systematic review literature. Major biomedical databases were searched to identify systematic reviews published between 1997 and 2010. Related theoretical, methodological, and technical material was also reviewed. We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. This systematic review literature was found to be generally of substandard quality with regards to methodology, reporting, and utility. We thematically categorised eHealth technologies into three main areas: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies. Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and “techno-enthusiasts” as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption.Please see later in the article for the Editors' Summary There is considerable international interest in exploiting the potential of digital health care solutions, often referred to as eHealth—the use of information and communication technologies—to enhance the quality and safety of health care. Often accompanied by large costs, any large-scale expenditure on eHealth—such as electronic health records, picture archiving and communication systems, ePrescribing, associated computerized provider order entry systems, and computerized decision support systems—has tended to be justified on the grounds that these are efficient and cost-effective means for improving health care. In 2005, the World Health Assembly passed an eHealth resolution (WHA 58.28) that acknowledged, “eHealth is the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research,” and urged member states to develop and implement eHealth technologies. Since then, implementing eHealth technologies has become a main priority for many countries. For example, England has invested at least £12.8 billion in a National Programme for Information Technology for the National Health Service, and the Obama administration in the United States has committed to a US$38 billion eHealth investment in health care.Despite the wide endorsement of and support for eHealth, the scientific basis of its benefits—which are repeatedly made and often uncritically accepted—remains to be firmly established. A robust evidence-based perspective on the advantages on eHealth could help to suggest priority areas that have the greatest potential for benefit to patients and also to inform international eHealth deliberations on costs. Therefore, in order to better inform the international community, the authors systematically reviewed the published systematic review literature on eHealth technologies and evaluated the impact of these technologies on the quality and safety of health care delivery.The researchers divided eHealth technologies into three main categories: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. Then, implementing methods based on those developed by the Cochrane Collaboration and the NHS Service Delivery and Organisation Programme, the researchers used detailed search strategies and maps of health care quality, safety, and eHealth interventions to identify relevant systematic reviews  published between 1997 and 2010. Using these techniques, the researchers retrieved a total of 46,349 references from which they identified 108 reviews. The 53 reviews that the researchers finally selected  provided the main evidence base for assessing the impact of eHealth technologies in the three categories selected.In their systematic review of systematic reviews, the researchers included electronic health records and picture archiving communications systems in their evaluation of category 1, computerized provider (or physician) order entry and e-prescribing in category 2, and all clinical information systems that, when used in the context of eHealth technologies, integrate clinical and demographic patient information to support clinician decision making in category 3.The researchers found that many of the clinical claims made about the most commonly used eHealth technologies were not substantiated by empirical evidence. The evidence base in support of eHealth technologies was weak and inconsistent and importantly, there was insubstantial evidence to support the cost-effectiveness of these technologies. For example, the researchers only found limited evidence that some of the many presumed benefits could be realized; importantly, they also found some evidence that introducing these new technologies may on occasions also generate new risks such as prescribers becoming over-reliant on clinical decision support for e-prescribing, or overestimate its functionality, resulting in decreased practitioner performance.The researchers found that despite the wide support for eHealth technologies and the frequently made claims by policy makers when constructing business cases to raise funds for large-scale eHealth projects, there is as yet relatively little empirical evidence to substantiate many of the claims made about eHealth technologies. In addition, even for the eHealth technology tools that have proven to be successful, there is little evidence to show that such tools would continue to be successful beyond the contexts in which they were originally developed. Therefore, in light of the lack of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, the authors say that future eHealth technologies should be evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle, and include socio-technical factors to maximize the likelihood of successful implementation and adoption in a given context. Furthermore, it is equally important that eHealth projects that have already been commissioned are subject to rigorous, multidisciplinary, and independent evaluation.http://dx.doi.org/10.1371/journal.pmed.1000387.Please access these websites via the online version of this summary at http://www.haps.bham.ac.uk/publichealth/cfhep/001.shtmlThe authors' broader study is: Car J, Black A, Anandan C, Cresswell K, Pagliari C, McKinstry B, et al. (2008) The Impact of eHealth on the Quality and Safety of Healthcare. Available at: eHealth resolutionMore information is available on the World Health Assembly the Global Observatory on eHealth, as well as a global insight into eHealth developmentsThe World Health Organization provides information at eHealth in Europe and some examples of good eHealth practiceThe European Commission provides Information on NHS Connecting for HealthMore information is provided on  Implementations of potentially transformative eHealth technologies are currently underway internationally, often with significant impact on national expenditure. England has, for example, invested at least £12.8 billion in a National Programme for Information Technology (NPfIT) for the National Health Service, and the Obama administration in the United States (US) has similarly committed to a US$38 billion eHealth investment in health care Moving this agenda forward thus requires a scientifically informed perspective. However, there remains a disparity between the evidence-based principles that underpin health care generally and the political, pragmatic, and commercial drivers of decision making in the commissioning of eHealth tools and services. Obtaining an evidence-informed perspective on the current situation may serve to ground unrealistic expectations that might hinder longer-term progress within the field, help to suggest priorities by identifying areas with greatest potential for benefit, and also inform ongoing deliberations on eHealth implementations that are being considered internationally.To inform these global deliberations, we systematically reviewed the preexisting systematic review literature on eHealth technologies and their impact on the quality and safety of health care delivery. We synthesised and contextualised our findings with the broader theoretical and methodological literature with a view to producing a comprehensive and accessible overview of the field. We present here a synopsis and updated version of a much larger recently published report covering the period 1997–2010 Systematic reviews of reviews have been particularly advocated to inform policy, clinical, and research deliberations by providing an evidence-based summary of inter-related technologies Inherent difficulties associated with systematic reviews of health care organisation and delivery intervention include the considerable effort required at the outset to facilitate their conduct For quality and safety considerations, we identified existing taxonomies and frameworks to facilitate this conceptual mapping exercise, which helped to delineate the scope of our work. For the field of eHealth, we drew from existing team members' conceptual and empirical work to aid our construction of a conceptual map for eHealth technologies We drew on established Cochrane-based systematic review principles to search for relevant systematic reviews. An inclusive string of MeSH and free terms  was deveOn the basis of the areas identified for prioritisation, we developed a detailed list of interventions that were to be included/excluded . End useAll systematic reviews having been identified as potentially suitable were assessed for inclusion by two independent reviewers, with arbitration by a third reviewer if necessary. Data from systematic reviews meeting the above criteria, henceforth referred to as “reviews,” were independently critically reviewed by two reviewers, and relevant data were abstracted. Systematic reviews not primarily concerned with assessing impact on patients, professionals, or the organisation, but nonetheless intervention focused, were drawn on to provide additional contextual information. These supplementary systematic reviews (henceforth referred to as “supplementary reviews”) were not subjected to formal critical appraisal.Critical appraisal was undertaken using an adapted version of the Critical Appraisal Skills Programme (CASP) tool for systematic reviews A standard approach was taken for each of the eHealth technologies of interest. Definitions were first clarified and then the individual use and broader scope for deployment conceptualised. Juxtaposing this with the aforementioned conceptual maps of the fields of eHealth, quality and safety provided a literature-based framework for delineating the principal theorised benefits and risks associated with each intervention. We used this framework to guide synthesis of the empirically demonstrated benefits and risks of implementing eHealth technologies.The body of literature identified was too diverse to allow quantitative synthesis of empirical evidence and we therefore undertook a narrative synthesis. This synthesis involved initially describing the technologies and outcomes studies using the above-described framework for each of the included reviews, which was followed by developing a summary of our assessment of and the key findings from each review . We thenOur searches retrieved a total of 46,349 references from which we selected a total of 108 reviews for inclusion . Our finThe EHR is a complex construct encompassing digitised health care records and the information systems into which these are embedded The theorised benefits and risks associated with EHRs are largely related to data storage and management functionality. These functions include increased accessibility, legibility, “searchability,” manipulation, transportation, sharing, and preservation of electronic data. Consequently, improved organisational efficiency and secondary uses of data are typically amongst the most commonly expected benefits. However, digitising health records can also introduce new risks. Paper persistence can result in threats to patient safety, unsecured networks can lead to illegitimate access, and increased time needed to document and retrieve patient data can result in organisational inefficiency. Moreover, the dynamic of the patient-provider interaction could become less personal with the intrusion by the computer as a “third person” in the consultation. If anticipated benefits are not realised, this may therefore mean that ultimately the EHR may be rendered cost-ineffective.Although a number of reviews purporting to assess the impact of EHRs were found, many of these in fact investigated auxiliary systems such as CDSS, CPOE, and ePrescribing. As a result, most of the impacts assessed were more relevant to these other systems. We found only anecdotal evidence of the fundamental expected benefits and risks relating to the organisational efficiency resulting from the storage and management facilities within the EHR and thus the potential for secondary uses . We did PACS are clinical information systems used for the acquisition, archival, and post-processing distribution of digital images. An image must either be directly acquired using digital radiography or be digitised from a paper-based format. It can be stored using an electronic, magnetic, or optical storage device. PACS can be integrated or interface with EHRs and CDSSs, or be stand-alone systems.Much like the digitisation of health records, certain benefits – i.e., accessibility, image (rather than data) quality, searchability, transportation, sharing, and preservation – can be expected from the digitisation of medical images, which were previously film based. Again, certain improvements to organisational efficiency should in theory follow on from this digitisation, including time-savings, continuity of care, and ability to remotely view images. Conversely, digitising medical images can lead to decreased organisational efficiency if increased time is needed for retrieval owing to the difficulties associated with navigating a new or cumbersome system or in the event of system downtime. If the potential benefits of a PACS implementation are not realised, high expenditure might render the application cost-inefficient.Although only three reviews on PACS were located, in contrast to the reviews on EHRs the impacts assessed in reviews of PACS were more congruent with the theoretically derived benefits . This asCPOE systems are typically used by clinicians to enter, modify, review, and communicate orders; and return results for laboratory tests, radiological images, and referrals (for pharmacy see ePrescribing) We found relatively few reviews on CPOE that were not focused primarily on the ordering of medications, rather than the ordering of laboratory tests and medical images. Within the reviews, we found that what had been empirically evaluated generally mirrored the theorised impacts  and 7. TePrescribing refers to clinical information systems that are used by clinicians to enter, modify, review, and output or communicate medication prescriptions. This term thus includes stand-alone CDSSs for prescribing purposes ePrescribing was the most commonly studied intervention amongst the included reviews. Consequently, we found multiple papers covering most of the theorised impacts  and 9. MCDSSs are, when used in the context of eHealth technologies, clinical information systems that integrate clinical and demographic patient information to provide support for decision making by clinicians In principle, the fundamental impact of CDSSs should be improved clinical decision making. This improvement should, in turn, lead to improved practitioner performance in a variety of care activities  and ways in which these care activities are delivered . These systems should also be able to help address disparities in care by facilitating standardisation, especially when part of an EHR, PACS, CPOE, or ePrescribing system. Improved practitioner performance should result in a variety of beneficial impacts depending on the care activity targeted  or better disease control. In addition, if practitioner's performance is directly related to patient outcomes, then these too should improve. The main theorised risks relating to the use of CDSSs include a potential decline in practitioner performance due to deskilling or flawed system design, and related threats to patient safety.Actual improved practitioner performance rather than just behaviour change in general was supported by only weak evidence  and 11. Our systematic review of systematic reviews on the impact of eHealth has demonstrated that many of the clinical claims made about the most commonly deployed eHealth technologies cannot be substantiated by the empirical evidence. Overall, the evidence base in support of these technologies is weak and inconsistent, which highlights the need for more considered claims, particularly in relation to the patient-level benefits, associated with these technologies. Also of note is that we found virtually no evidence in support of the cost-effectiveness claims  that areThis work is characterised by a number of strengths and limitations, which need to be considered when interpreting this work. Strengths include the multifaceted approach to the identification of systematic reviews and the synthesis of this body of evidence. Juxtaposing the conceptual maps of the fields of quality, safety, and eHealth permitted us to produce a comprehensive framework for assessing the impact of these technologies in an otherwise poorly ordered discipline. In addition, reflecting on methodological considerations and socio-technical factors enabled us to produce an overview that is sensitive to the intricacies of the discipline.Given the poor indexing of this literature and the fact that our searches were centred on English-language databases, there is the possibility that we may have missed some systematic reviews. Our use of a novel, multimethod approach may be criticised as being less rigorous than a conventional systematic review in that we were not in a position to appraise individual primary studies. These more novel methods of synthesis are less well developed and employed, and therefore less evaluated At the most elementary level, the literature that constitutes the evidence base is poorly referenced within bibliographic databases reflecting the nonstandard usage of terminology and lack of consensus on a taxonomy relating to eHealth technologies Our greatest cause for concern was the weakness of the evidence base itself. A strong evidence base is characterised by quantity, quality, and consistency. Unfortunately, we found that the eHealth evidence base falls short in all of these respects. In addition, relative to the number of eHealth implementations that have taken place, the number of evaluations is comparatively small. Apart from several barriers and challenges that impede the evaluation of eHealth interventions per se Another commonly criticised element of the existing evidence base is its utility A handful of high-profile primary studies demonstrating the greatest evidence of benefit often serve as exemplars of the transformative power of clinical information systems Keeping in mind the above, the maturation of evaluation is vital to the success of eHealth We found an important literature pertaining to the design and deployment aspects of eHealth technologies. This literature is central to understanding why some interventions succeed and others fail (or being judged as such). At the individual level, “human factors” play an important role in the design of an intervention, determining usability and ultimately adoption It is clear that there is now a large volume of work studying the impact of eHealth on the quality and safety of health care. This might be seen as setting a firm foundation for realising the potential benefits of eHealth. However, although seminal reports on quality and safety of health care invariably point to eHealth as one of the main vehicles for driving forwards sweeping improvements Our major finding from reviewing the literature is that empirical evidence for the beneficial impact of most eHealth technologies is often absent or, at best, only modest. While absence of evidence does not equate with evidence of ineffectiveness, reports of negative consequences indicate that evaluation of risks – anticipated or otherwise – is essential. Clinical informatics should be no less concerned with safety and efficacy than the pharmaceutical industry. Given this, there is a pressing need for further evaluations before substantial sums of money are committed to large-scale national deployments under the auspices of improving health care quality and/or safety.Promising technologies, unless properly evaluated with results fed back into development, might not “mature” to the extent that is needed to realise their potential when deployed in everyday clinical settings. The paradox is that while the number of eHealth technologies in health care is growing, we still have insufficient understanding of how and why such interventions do or do not work Finally, it is equally important that deployments already commissioned are subject to rigorous, multidisciplinary, and independent evaluations. In particular, we should take every opportunity to learn from the largest eHealth commissioning and deployment project in health care in the world – the £12.8 billion NPfIT and the at least equally ambitious national programme that has recently begun in the US Table S1Critical appraisal form.(0.05 MB DOC)Click here for additional data file.Table S2Characteristics and main findings of “reviews.”(0.42 MB DOC)Click here for additional data file.Text S1Search strategy .(0.05 MB DOC)Click here for additional data file.Text S2Intervention inclusion and exclusion criteria.(0.03 MB DOC)Click here for additional data file.


Dirofilaria, which are transmitted by a plethora of mosquito species. The principal agent of canine dirofilariosis in the Americas is Dirofilaria immitis, which may also occasionally infest humans, resulting in pulmonary nodules that may be confounded with malignant lung tumours. Because human cases of dirofilariosis by D. immitis are relatively frequent in the Americas and rare in Europe and other eastern countries, where Dirofilaria repens is the main causative agent, the existence of a more virulent strain of D. immitis in the Americas has been speculated. Recently, a case of human ocular infestation by Dirofilaria sp. was diagnosed in Pará State, northern Brazil, where canine heartworm dirofilariosis is endemic. The nematode was shown to be morphologically and phylogenetically related to D. immitis but it was genetically distinct from reference sequences, including those of D. immitis infesting dogs in the same geographical area. This finding raised questions regarding the aetiology of human dirofilariosis in the Americas, since information on the genetic makeup of filarioids infesting dogs and humans is meagre. Further studies would be needed to better characterize filarioids infesting dogs, wild animals, and humans in the Americas and to assess the existence of a more virulent D. immitis strain in this continent. Finally, the competence of different culicid species/strains from Europe and the Americas as vectors of Dirofilaria species should be investigated. Such studies would help us to understand possible variations in transmission patterns and even to predict possible scenarios that may emerge in the future, with the introduction of non-endemic Dirofilaria species/strains in free areas through importation of infested animals, vectors, or both.Dirofilarioses are widespread diseases caused by filarioid nematodes (superfamily Filarioidea) of the genus  Dirofilaria of the family Onchocercidae. These nematodes may infest wild and domestic mammals of several orders, such as Artiodactyla, Carnivora, Edentata, Lagomorpha, Perissodactyla, Primates, and Rodentia [Dirofilaria immitis, also known as heartworm, can present with respiratory distress, epistaxis, haemoptysis, ascites, exercise intolerance, and anorexia [D. immitis can be expensive and often associated with life-threatening complications, particularly in patients with moderate to severe heartworm disease [Dirofilariosis is a worldwide-distributed disease caused by nematodes of the genus Rodentia ,2. Most anorexia ,4. Impor disease .Dirofilaria infestations in dogs are still of major veterinary and public health concern, considering that canine and human dirofilariosis continue to be diagnosed in several tropical, subtropical and temperate regions of the world [Even if canine dirofilariosis is still widespread and highly prevalent worldwide, the availability of preventatives, improved diagnostic tools and different treatment options ,4 have ghe world ,7.Dirofilaria repens, whereas in the New World pulmonary dirofilariosis by D. immitis predominates [D. immitis or to a species other than D. repens in the Old World put in doubt the pathogenic role of the former species in humans in this region [D. immitis in Europe has been ascertained [D. repens[D. immitis prevails [Dirofilaria species is well recognized, the control and prevention of Dirofilaria infestations in reservoir hosts is often neglected.Human cases of dirofilariosis have been reported worldwide. In the Old World, most cases refer to subcutaneous infestations by ominates ,4. Nonets region . Indeed,ertained ,10, the prevails . AlthougD. immitis but genetically distinct from reference sequences, including those of D. immitis infesting dogs in the same geographical area [Dirofilaria species infesting wild and domestic animals in South America, as well on the aetiology of human pulmonary and subcutaneous dirofilariosis in the same region. Within this context, the present review focuses on some aspects related to the dirofilariosis and Dirofilaria parasites in the Americas, with an emphasis on South America, and lists future research needs on this neglected field of human parasitology.Information on the aetiology and, thus, eco-epidemiology of animal and human dirofilariosis in the Americas is fragmentary, particularly in South America. For instance, a recent human case of dirofilariosis from northern Brazil was attributed to a nematode morphologically and phylogenetically close to cal area . These fDirofilaria consists of 27 apparently valid species (Table Dirofilaria have been replaced into other genera [Candidatus Dirofilaria hongkongensis”) [Dirofilaria based on robust morphological and genetic data would be needed before the description of any new species.Dirofilariae are spirurid nematodes, which localize, with a few exceptions, in subcutaneous tissues of mammalian hosts  and are transmitted predominately by mosquitoes ,2,13-25.gensis”) , but congensis”)  any descDirofilaria species have been reported from wild and domestic mammals. In Brazil alone, eight Dirofilaria species – i.e., D. acutiuscula, D. freitasi, D. incrassata, D. immitis, D. magalhaesi, D. repens, D. spectans, and D. striata – have been reported so far [D. magalhaesi) has been questioned [D. repens in this country, and in the Americas as a whole, remains doubtful [In the Americas, several d so far , even ifestioned . Moreovedoubtful .D. repens in the Americas has been first reported in a dog from São Paulo, south-eastern Brazil [D. repens were detected in dogs from a semi-rural district near Santiago (Chile), but these microfilariae were larger and genetically distinct from D. repens[Dirofilaria species in the Americas needs to be further investigated, also to determine whether cases of D. repens in dogs are being actually misdiagnosed as D. immitis based on the retrieval of blood circulating microfilariae.The presence of n Brazil . RecentlD. repens. In any Dirofilaria species infesting wild and domestic animals in the Americas as well as the scant number of surveys on the mosquito species acting as potential vectors, the diversity of culicids transmitting Dirofilaria species in this region is currently underestimated. Indeed, little is known regarding the mosquito vectors of wildlife-associated Dirofilaria species, even considering that some of them  are of zoonotic concern [D. immitis in naturally caught mosquitoes [Given the fragmentary data on  concern . On the squitoes -31 or insquitoes -36.Dirofilaria immitis can be transmitted by mosquitoes belonging to different genera, such as Aedes (Ae.), Anopheles (An.), Culex (Cx.), and Ochlerotatus (Oc.). For instance, a study conducted in Rio de Janeiro State, south-eastern Brazil, using canine, feline and human baits, reported Oc. taeniorhynchus, Cx. quinquefasciatus, Oc. scapularis, Cx. declarator, and Cx. nigripalpus as the most likely vectors of D. immitis in this region [D. immitis developmental stages were found in Oc. scapularis, Oc. taeniorhynchus, Cx. quinquefasciatus, Cx. declarator, Cx. saltanensis and Wyeomyia bourrouli, with L3 being found only in the first three species [Cx. quinquefasciatus[Cx. quinquefasciatus supports the development of D. immitis to the L3 [D. immitis were found in Cx. pipiens and Stegomyia aegypti and they have been regarded as putative vectors of this nematode in Argentina [St. aegypti to D. immitis[D. immitis, including St. aegypti, Stegomyia albopicta, Oc. canadensis, Jarnellius sierrensis, Oc. trivittatus, Aedimorphus vexans, An. punctipennis, An. quadrimaculatus, and Cx. quinquefasciatus[D. immitis throughout the American continent, as it occurs in the Old World [s region . Indeed, species . In anotfasciatus. Indeed,o the L3 . Similarrgentina . As a co. immitis. Meanwhifasciatus,39-41. Ald World .Dirofilaria transmission is D. ursi, which infests American black bears (Ursus americanus) and is vectored by black flies (Simuliidae) [Worth mentioning, an interesting exception regarding uliidae) .D. immitis and other filarial nematodes in the Americas remains fragmentary. Some mosquito species may present high specificity for city regions  and landscape elements within these regions  [St. aegypti with high-density housing in urban areas, of Cx. quinquefasciatus with low-density housing in suburbs, and of Gymnometopa mediovittata and other native mosquitoes  with less disturbed habitats  [D. immitis may vary according to city region and landscape type. Indeed, studies indicate that the prevalence of heartworm infestation in dogs is usually higher in some coastal regions [D. immitis are widespread and may be present throughout the entire year. For example, an entomological survey carried out in Rio de Janeiro, south-eastern Brazil revealed that St. aegypti and C. quinquefasciatus were present the year-round [D. immitis infestation at the individual and population level.The American continent is extremely variegated in terms of topography, hydrography and climate. As such, the transmission patterns of different vector-borne pathogens may vary widely throughout this vast land territory. Still, the knowledge on the transmission patterns of density) . For inshousing) . Therefo regions . Becausear-round . AccordiD. immitis vectors may be restricted to particular months of the year. For instance, mathematical models suggested that D. immitis transmission in Argentina is markedly seasonal (with peaks in January and February) and that no region of this country would support transmission throughout the year [D. immitis infestation in dogs, especially during high-risk months. The elaboration of optimized control strategies is particularly important in developing countries, where dog owners cannot always afford the costs of preventative chemoprophylactic measures.In temperate regions, the presence of the year . UndoubtD. acutiuscula, D. immitis, D. repens, and D. striata in dogs [D. immitis is the most important causative agent of canine dirofilariosis [In the Americas, there are reports of infestation by  in dogs ,45,48,49lariosis ,45, beinlariosis . In Centlariosis ,45,51,52D. acutiuscula in a dog from Argentina [, D. striata in a dog from the United States [D. repens in a dog from Brazil [D. repens European sequence (GenBank accession number: AM779775), suggesting that the parasite found in Chile [D. repens. Another study conducted in Marajó Island, northern Brazil, revealed some level of intra-specific difference in 5.8S and ITS2 regions [The reports of rgentina , D. strid States , and D. m Brazil  and in dm Brazil  are doubin Chile  may not  regions . In geneD. immitis in cats may vary regardless of the prevalence of infestation in dogs from the same area.In the Americas, feline dirofilariosis has been reported in the United States, Canada, Brazil, and Venezuela . In a stD. immitis, other species may also infest and cause disease in humans in this region  has been reported once in the orbit of a 6-year-old boy living in North Carolina [Dirofilaria have been reported only once in humans, these case reports suggest that the number of potentially zoonotic dirofilariae in the American continent may be currently underestimated.While most cases of human pulmonary dirofilariosis in the Americas have been attributed to n Figure . For exa in Ref. ), which  in Ref. . Dirofil Janeiro . SimilarCarolina . Even coDirofilaria species  in humans is reputed to be higher in areas where there is a high incidence of these worms in their natural hosts [Dirofilaria species as a consequence of the fact that these nematodes may adapt to new animal hosts and arthropod vectors. At some specific occasions, such as in the case of hurricane Katrina in the United States, dogs infected by D. immitis were relocated from the areas stricken by the hurricane  to other states of North America, resulting in the introduction of this filarioid into previously non-endemic areas [Little is known regarding the epidemiology and risk factors of human dirofilariosis in the Americas. The risk of infestation by some al hosts . Importaal hosts , and thuic areas .D. repens[D. immitis and D. repens may co-infest the same reservoir hosts [D. immitis. For instance, over 100 cases have been detected in the United States, most of which coming from south-eastern regions where D. immitis infestation in dogs is highly prevalent [D. immitis in dogs in São Paulo is low [Most human cases of dirofilariosis reported in the international literature refer to subcutaneous/ocular dirofilariosis cases caused by D. repens. The greir hosts . In the revalent ,50,61. Crevalent ,62,63 anrevalent ,64-66. Rrevalent , one of o is low , the appo is low .D. tenuis, D. ursi and D. immitis (a single case) in North America [D. repens in dogs from Chile [Dirofilaria species in Chile and suggests a late introduction of this parasite in this country, which until recently was considered as a Dirofilaria-free area [D. immitis. However, high nucleotide differences  was found by comparing sequences from the nematode recovered from the patient’s eye with sequences obtained from dogs living in the same area and/or from other countries available in GenBank [Dirofilaria, which is close to D. immitis, might be circulating in Brazil and in the western hemisphere as a whole.Subcutaneous/ocular dirofilariosis in the Americas have been attributed to different species, such as  America ,61. In a America  and Braz America , respectom Chile . This reree area ,45,70. Free area . The parD. immitis in the Old World concluded that there is no proof demonstrating that Old World D. immitis plays a pathogenic role in humans [D. repens, even if D. immitis is more prevalent than D. repens in both dogs and vectors in some areas [D. immits genotypes in the New and Old Worlds, with varying infective capacities for dogs and humans. Alternatively, some unidentified factor, probably related to the vector, could modify the infective capacity of the parasite to humans in the Old World. Although both hypotheses are plausible and deserve to be investigated more in-depth, there is no evidence indicating the existence of a more virulent D. immitis strain in the Americas.A critical analysis of human dirofilariosis cases attributed to n humans . Indeed,me areas . Based ome areas . First, Even if some individuals can present with cough, chest pain, haemoptysis, and dyspnoea ,63,67,71D. immitis infestation in human hosts, most cases of pulmonary dirofilariosis will likely remain without a definitive diagnosis. As a consequence, the actual number of pulmonary dirofilariosis in the Americas is likely to be grossly underestimated at present. Nonetheless, the existence of a more virulent strain of D. immitis in the Americas remains uncertain. So far, available data do not support this hypothesis, mainly considering that most human patients present no apparent clinical signs.Considering the usually benign nature of bona fide information about the species of filarioids infesting dogs and humans in this region is meagre. Further studies are needed to better characterize filarioids circulating among different domestic and wild animals in the American continent. Certainly, the use of an integrated genetic  and morphological approach could be beneficial for the identification of filarioids [There are several lacunae in our knowledge regarding different aspects of animal and human dirofilarioses in the Americas. For example, larioids .Dirofilaria species is currently lacking. Similarly, scientific knowledge on the biology of Dirofilaria species infestation in humans is limited for obvious ethical reasons and several aspects of the host-parasite interactions  remain unknown. Certainly, studies on bacterial endosymbionts associated with Dirofilaria nematodes may provide further data on their biology and evolution [Wolbachia pipientis in Dirofilaria species has been associated with the immuno-pathology of dirofilariosis [Wolbachia surface protein and the participation of this bacterium in inflammatory processes occurring during dirofilariosis has been intensively investigated in recent years [Wolbachia endosymbionts of filariae were useful in damaging or even killing D. immitis adult worms [D. immitis, eventually reducing the risk of thromboembolism [D. repens[The high diversity of potential zoonotic dirofilariae in the Americas is undisputed, but information on the biology of most wildlife-associated volution , also colariosis ,74. In plt worms . Therefoembolism . A similD. repens,78.Dirofilaria species should be better investigated. Such studies would help us to understand possible variations in transmission patterns and even to predict possible scenarios that may emerge in the future, with the introduction of non-endemic species/strains in free areas through importation of infested animals, vectors, or both. In this context, mathematical models and distribution maps are extremely important for predicting the presence/absence and abundance of mosquito vectors in different regions.The competence of different culicid species/strains in the Americas as vectors of Finally, it is crucial to increase awareness among veterinary practitioners and medical physicians regarding the zoonotic significance of filarial nematodes of domestic and wild animals in the Americas. This is particularly important in remote areas, such as the Amazon region, where a different range of zoonotic, yet unknown filariae  is likelThe authors declare there are no conflicts of interest.FD-T wrote the manuscript and DO reviewed critically it. Both authors approved the final version of the manuscript.


Lateral epicondylalgia (LE) defines a condition of varying degrees of pain near the lateral epicondyle. Studies on the management of LE indicated unexplained variations in the use of pharmacologic, non-pharmacological and surgical treatments.The main aim of this paper was to develop and evaluate clinical quality measures (QMs) or quality indicators, which may be used to assess the quality of the processes of examination, education and treatment of patients with LE.Different QMs were developed by a multidisciplinary group of experts in Quality Management of Health Services during a period of one year. The process was based following a 3-step model: i) review and proportion of existing evidence-based recommendations; ii) review and development of quality measures; iii) pilot testing of feasibility and reliability of the indicators leading to a final consensus by the whole panel.Kappa > 0.8).Overall, a set of 12 potential indicators related to medical and physical therapy assessment and treatment were developed to measure the performance of LE care. Different systematic reviews and randomized control trials supported each of the indicators judged to be valid during the expert panel process. Application of the new indicator set was found to be feasible; only the measurement of two quality measures had light barriers. Reliability was mostly excellent (A set of good practice indicators has been built and pilot tested as feasible and reliable. The chosen 3-step standardized evidence-based process ensures maximum clarity, acceptance and sustainability of the developed indicators. Lateral epicondylalgia (LE), also known as tennis elbow or lateral epicondylitis, defines a condition of varying degrees of pain or point tenderness on or near the lateral epicondyle. Functional use of the involved upper extremity, especially during gripping activities usually exacerbates pain symptoms ,2. AlthoIn the past, studies on the management of LE indicated substantial and unexplained variations in the use of pharmacologic, non-pharmacological and surgical treatments ,8. CurreQMs, or quality indicators, enable the user to quantify the quality of a selected aspect of care by comparing it to an evidence-based criterion that specifies quality . Thus, QThe objective of this paper was to develop a set of valid and understandable clinical QMs that may be used to assess the degree of implementation of the best processes of examination, education and treatment of patients with LE, and to pilot test their feasibility and reliability.For the development of these evidence-based quality indicators, we assembled a multidisciplinary panel of recognized experts from the disciplines of traumatology, nursing, physical therapy and psychopedagogy. The study design and methods were reviewed and approved by the Academic Review Committee of Quality Management Program at the Faculty of Medicine of University of Murcia .Research into quality of care, together with epidemiological expertise, helped ensure methodological integrity of the clinical indicators and the ensuing sound approach to data collection and data analysis. The 6-member panel included people from geographically diverse regions including rural and urban areas.We used a 3-step process to define the QMs Figure . First, A working group of panel members performed a comprehensive literature search to identify basic systematic reviews (SRs) and clinical practice guidelines (CPG) that pertained to LE care. Literature searches of both reviews and guidelines were conducted in the following databases over the 10 previous years 2001–2011): Medline, Cochrane Library and Ovid, PEDro and ENFISPO. Additionally, searches of clinical guidelines were performed using the following specific guidelines databases: National Guideline Clearinghouse of AHRQ : Medline, the NewA  or B , with strength of recommendations categorized as strong or weak according to specific classifications, also taking into account a positive balance between the desirable and undesirable consequences and the lower costs of the alternative management strategies [The working group retained recommendations which had supporting evidence level rategies . To faciInitially, the working group performed a comprehensive search of quality indicators in the United States’ National Quality Measures Clearinghouse of the AHRQ and in articles indexed in the following databases for the 10 previous years (2001–2011): Medline, Scopus and Psycinfo. For each of the existing indicators, the working group provided an objective and a summary of the available evidence, in order to assess whether to support or refute them.The working group elaborated new clinical indicators or adapted existing ones when valid indicators were lacking for some of the recommendations selected during the first phase. Standardized reports of potential indicators were suggested by the working group to facilitate discussion within the whole panel before selection.Following a proposal of the Agency for Healthcare Research and Quality (AHRQ) on measure attributes of the National Quality Measures Clearinghouse , the repThe panel discussed the validity of each of the proposed measures and retained those with adequate evidence of the good practice measured and achievable or with the indicator compliance under control of providers.The set of quality measures was them pilot tested by two members of the panel to check whether the measurement of performance of healthcare providers by the QMs was feasible and reliable on a routine basis. This study was conducted in three hospitals located in Barcelona, Vigo  and Madrid. Each measure had its own eligibility criteria, depending on the type of patients it was aimed at. We selected only a randomized sample of 80 patients with LE who had received treatment during the 12 month time period before the testing date as we assumed that all QMs could have the minimal sample size of 15 patients . The datTo test for feasibility of the QMs the two examiners reviewed databases and selected medical records, reporting when it was not possible to assess some QMs and related reasons. Predictable reasons encountered were: difficulty to identify cases or misreported information in medical records.Intra-rater and inter-rater designs were used to examine the reliability of QMs. To test for intra-rater reliability, an examiner assessed each QM in two occasions spaced out over a period of 7 days. To test inter-rater reliability, an additional examiner carried out assessments using the same subjects’ medical records. Reliability indexes were determined through the calculation of the Kappa index using SPSS v.15. Alternatively, we used the general agreement percentage when occurrence or absence of evaluated processes of care was higher than 85%, because Kappa index could be biased. We interpreted Kappa levels using established conventions: values ranging from 0.40 to 0.59 may be considered moderate, 0.60 to 0.79 substantial, and ≥ 80 excellent . When thTable In the pilot testing, items with feasibility problems were evidenced for 2 QMs, due to a lack of specific information in medical records. They are indicated in Table All indexes indicated substantial to excellent agreement.Brief descriptions of the literature that supports the criterion of quality for each of the indicators are provided below.Patients with cervical radiculopathy, proximal neurovascular entrapment and radial tunnel syndrome  may compThe literature review failed to identify clinical studies that evaluated relations between outcomes and assessment of pain or functional limitations. However, because improvement of pain and function are two primary goals in the treatment of LE , it seemA variety of factors, such as force, repetition, posture -26 and sThe literature search identified 3 published studies for the effectiveness of patient education on pain and disability among individuals with LE -30, all Non-steroidal anti-inflammatory drugs (NSAIDs) via oral administration have been used extensively for many years to treat pain associated with LE. There is some evidence for a short term benefit of NSAIDs (2 weeks) with a decrease of pain and function, but this benefit was not sustained ,32. HoweNumerous RCTs and meta-analyses have demonstrated that NSAIDs are associated with a greater risk of GI bleedings. Exposure to NSAIDs has been associated with a 2.2 to 5.4 greater risk of various adverse GI events . A varieTherapeutic exercises Numerous RCTs have evaluated the effects of exercise on LE. Four SRs [Four SRs ,25,36-38The most recent RCT evaluated the short-term effects of daily eccentric exercises on functional pain-free hand strength in subjects with long-term LE . The exeManual therapy One SR [y One SR  showed ty One SR  studied Laser therapy The most recent meta-analysis [2.analysis  assessedNSAIDs are usually prescribed for 2 weeks ,32, and A RCT  supporteThere is a growing body of supporting evidence for this conservative approach, mainly for patients with LE with refractory symptoms after physical therapy management. Four SRs ,44-46 haFour SRs ,47-49 haThis paper summarizes the development of evidence-based QMs for measuring degree of implementation of best practices recommendations for patients with LE. Over a period of one year, 12 QMs were developed and evaluated by a panel according to methodological requirements based on recommendations from the literature ,14.In our literature review we appreciated a considerable availability of systematic reviews including patients with LE ,44-46,49Although we were able to find solid evidence to support a link between the processes of care described in some QMs and meaningful patient outcomes, no such evidence exists for others, for example, for QMs related to pain and functional assessment. A possible explanation for this lack of evidence could be because these processes were traditionally assumed to be so essential to care that clinical trials assessing their importance have not been performed . TherefoMost of the QMs must be measured only for some individuals with LE. For this reason, we constructed many QMs including in the denominator and numerator only individuals with LE who should receive the indicated care. For example, not all patients with LE and NSAIDs should receive prophylaxis of GI bleedings by gastroprotective strategies, only those who are of an older age (age ≥75), with a history of adverse GI events, and concomitant therapy with anticoagulants or corticosteroids. In a similar way, not all patients with NSAIDs should receive a multimodal program of physical therapy within 14 days, only those who received a corticosteroid injection.The set of QMs we present here involves multidisciplinary interventions. All QMs are under control of the professionals whose performance is evaluated, so that it is possible for them to improve that performance. When using these measures for quality improvement purposes within an institution or facility, a baseline assessment of current practice is recommended to better understand the quality problem and to provide motivation for change. Baseline results should also be used to establish a basis for comparison across institutional units or over time ,54.Our study had its strengths and limitations. The main strengths are related to the development process. We decided to develop potential QMs using a standardized, rigorous, approved, evidence-based approach following previously defined recommendations to ensure high methodological quality and maximal clearness of our outcomes ,14,55. FThis is the first study to develop and evaluate QMs for patients with LE.The QMs we present were developed to assess quality and not to represent guidelines of optimal care. However, as there is no published CPG in the literature to-date, the evidence-based recommendations identified in our review could also be useful for developing a CPG to describe a range of diagnostic and therapeutic processes that might be considered best practices.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.The authors declare no competing interests in relation to the content of this article.FMi, designed the study; participated in literature search, literature review, carried out intra-rater reliability and wrote the paper. FMe, contributed to the initial study idea, study design, data interpretation, and read and approved the final draft. FV, contributed to initial study idea, study design, coordinated the working group, and carried out inter-rate reliability. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/310/prepub


Schum “… contains a collection of thoughts …” (p. 1) on issues related to evidence and to inference tasks based on evidence. The study of such issues is best summarized by an expression introduced in chapter 1: “Science of Evidence.” The Science of Evidence tries “… to treat the study of evidence as having a life of its own …” (p. 8). This perspective of examining evidence and inference with an interdisciplinary, generalist approach, is also reflected by the author David Schum himself: he is a professor of law and information technology and engineering at George Mason University. The fundamental insights he shares in this book are—unfortunately—all too often overlooked and unknown in forensic and judicial practice and research.An important feature of evidential inference is its involvement with uncertainty, and consequently its probabilistic nature. This view is held also by Schum. He acknowledges that uncertainty is a prevalent feature of reasoning tasks based on evidence, and that it attends situations of daily life but also and most prominently, legal applications: “… in any inference task our evidence is always incomplete, rarely conclusive, and often imprecise or vague; it comes from sources having any gradation of credibility. As a result, conclusions reached from evidence […] can only be probabilistic in nature.” (p. xiii) Unfortunately, forensic practice regularly distrusts the notion of probability because people focus on precise numbers (derived from a generous data pool). However, assigning numbers for probabilistic evidence evaluation is neither a prerequisite nor an end for analyses of evidential inference. Schum's work is directly relevant to this aspect by demonstrating that (1) purely structural considerations on evidence and (2) adopting probabilities as numerically variable ingredients of inferences, enable us to approach numerous problems, and to explore evidential subtleties or complexities. Let us first consider (1) and then (2).relevance and credibility. A relevance relationship between an event  and a hypothesis (“suspect is the assailant”) can involve a multistage reasoning (chain of reasoning). A given linkage pattern between elements of a chain of reasoning is called “argument.” Elements regarding the credibility of evidence  are located upstream in such a chain of reasoning. Depending on the type of evidence and the desired level of detail, it may also involve a multistage reasoning process and produce an argument. Thus, a probabilistic assessment of evidence requires an argument structured in terms of relevance and credibility. The argument structure becomes even more complex when multiple items of evidence are involved. In spite of this fact, basic configurations of evidence combination can be identified and analyzed probabilistically. Schum shows in his studies that such basic configurations of evidence combination result in specific inference structures and well defined inferential mechanisms.Every item of evidence fans out into two primary dimensions: inferential force. It expresses if and to what extent evidence supports a hypothesis. Its quantity depends on the argument structure we choose for the evidence and on the probabilistic assessment we attach to the argument. The likelihood ratio is commonly used in Bayesian analysis to measure the inferential force of evidence. The study of likelihood ratios under varying probabilities is an important aspect of Schum's work: “[m]y essential research strategy was to perform sensitivity analyses on the likelihood ratios I identified.” (Schum, Every item of evidence is characterized by an ” Schum, , p. 576.Now, how is such knowledge useful in practice? First, it does not matter from which domain the evidence comes from, nor do we need to be familiar with its domain-specific methods and techniques to enhance our reasoning with these insights. Second, by identifying generic inference structures we know which inferential mechanisms we are exposed to and which we are not. Hence, we are less likely to be subjected to flawed reasoning leading to over- and understatements when assessing the inferential force of evidence. Imagine, for example, a DNA trace is analyzed by two laboratories. Now we have two results, but is our evidence also twice as strong? Third, knowledge on basic inference structures creates gateways to contextualized evidence interpretation, and even more so when we deal with masses of evidence [see for the analysis of a judicial case (Kadane and Schum, The book discusses a vast array of evidence related subjects from different standpoints and across different disciplines. It demands time due to its broad scope; careful reading, and mental flexibility due to its interdisciplinary character. Sometimes it might even ask for the reader to be patient as some subjects are developed incrementally making a few passages appear repetitive. In turn, many topics and problems that have appeared opaque and uneasy before may become clear and intellectually palpable afterwards. For readers who are interested in better understanding the properties of evidence and how to embrace evidence by systematic and logic reasoning, this a book that deserves serious consideration.