Arabidopsis arenosa complex is closely related to the model plant Arabidopsis thaliana. Species and subspecies in the complex are mainly biennial, predominantly outcrossing, herbaceous, and with a distribution range covering most parts of latitudes and the eastern reaches of Europe. In this study we present the first comprehensive evolutionary history of the A. arenosa species complex, covering its natural range, by using chromosome counts, nuclear AFLP data, and a maternally inherited marker from the chloroplast genome . We unravel the broad-scale cytogeographic and phylogeographic patterns of diploids and tetraploids. Diploid cytotypes were exclusively found on the Balkan Peninsula and in the Carpathians while tetraploid cytotypes were found throughout the remaining distribution range of the A. arenosa complex. Three centers of genetic diversity were identified: the Balkan Peninsula, the Carpathians, and the unglaciated Eastern and Southeastern Alps. All three could have served as long-term refugia during Pleistocene climate oscillations. We hypothesize that the Western Carpathians were and still are the cradle of speciation within the A. arenosa complex due to the high species number and genetic diversity and the concurrence of both cytotypes there.The  ArabidopsisArabidopsis thaliana (L.) Heynh. with various taxa and cytotypes to investigate the hypothesis that past and ongoing gene flow between taxa and ploidal levels contributes to the ability of populations to adapt and survive in rapidly changing environments, particularly during the Pleistocene Pleistocene climatic fluctuations strongly shape the evolutionary history of new species  O'Kane & Al-Shehbaz and A. halleri (L.) O'Kane & Al-Shehbaz Arabidopsis species and show a remarkable broad spectrum of ecological adaptations from high alpine regions in the High Tatras to sand dune vegetation in Scandinavia A. arenosa species complex, including ploidal level and geographic distribution, is provided in Arabidopsis arenosa is a colline, montane, and subalpine species complex with a mainly Central European distribution range including parts of the Alps and Carpathians. Only a few studies have been attempted to unravel the evolutionary history of the A. arenosa complex A. suecica (Fr.) Norrl., which is of allopolyploid origin with the maternal parent A. thaliana and a paternal parent from the A. arenosa species complex A. arenosa complex A. arenosa and A. lyrata complexes The Arabidopsis arenosa complex comprises several taxa at various taxonomic levels. The complex has been treated as one species [A. arenosa (L.) Lawalrée] with two subspecies of partly overlapping distribution ranges in Central Europe arenosa (2n = 16/32), also occurring in northern Europe, growing mainly on siliceous bedrock and sandy soil, and the tetraploid subsp. borbasii (Zapał.) O'Kane & Al-Shehbaz (2n = 32), growing predominantly on calcareous bedrock and additionally found in the Carpathians. Diploid A. neglecta (Schult.) O'Kane & Al-Shehbaz (2n = 16) was described mainly from the Carpathians and rarely from the Alps, but its occurrence in the Alps is doubtful, since in the Alps this taxon has been introduced as Cardaminopsis arenosa var. intermedia (Kovats) Hayek CardaminopsisArabidopsis carpatica, nom. prov. (2n = 16), A. nitida, nom. prov. (2n = 16), A. petrogena (A. Kern) V.I. Dorof. subsp. petrogena (2n = 16), and A. petrogena subsp. exoleta, nom. prov. (2n = 32). In general, taxonomic concepts in the A. arenosa species complex are strongly debated According to different authors, the A. arenosa as a model system for adaptation to calcareous versus siliceous bedrocks , or character trait research such as shade-tolerance . Additionally, A. arenosa is interesting in terms of hybrid speciation, as it is the paternal parent of the natural allopolyploid A. suecica. Studies on the genomic consequences of hybridization are underway, and a first assembly of the A. arenosa genome is available (wiki.bioinformatics.ucdavis.edu/index.php/Arabidopsis_arenosa_whole_genome_assembly). Working with A. arenosa as a model system needs careful consideration of the evolutionary history of the taxa one is investigating, particularly the distribution of natural genetic variation within and among taxa.There is an increasing interest in Arabidopsis arenosa is distributed both in regions that remained largely unglaciated during Pleistocene climate oscillations and in areas formerly covered by glaciers, making it well-suited for comparative studies of evolution in changing environments.The following two aspects are the focus of our research: Unravelling the broad-scale cytogeographic and phylogeographic patterns of diploids and tetraploids: We are particularly interested in contact zones of populations with different or mixed ploidal levels, as they can indicate ongoing species differentiation. The second is detecting centers of genetic diversity: In the northern hemisphere late Quaternary climate oscillations, especially the last glacial maximum (LGM), about 26,500 to 19,000–20,000 years ago, had the most severe influence on present-day distribution and diversity of plant taxa. trnL/F sequence data from 365 accessions  (The accession list is provided in ls each) .Ploidy was determined both in this and a previous publication Total DNA was obtained from dried leaf material and extracted according to a CTAB protocol 2, 0.8 mM dNTP mix, 0.2 µM EcoRI-A primer (A-3′5′-GAC TGC GTA CCA ATT CA-), 0.2 µM MseI-C primer (C-3′5′-GAT GAG TCC TGA GTA AC-), and 0.25 U AmpliTaq polymerase (ABI). The reactions were held at 72°C for 2 min followed by 20 cycles of 94°C for 20 s, 56°C for 30 s, and 72°C for 2 min with a final 30 s extension at 60°C. The pre-selective PCR product was visualized on a 1.5% agarose gel and diluted tenfold. For selective PCR we used 2.5 µl of the diluted pre-selective PCR product as template in a total reaction volume of 12.5 µl. The PCR mix contained 1× GoldTaq buffer (ABI), 2.5 mM MgCl2, 0.8 mM dNTP mix, 0.08 µM EcoRI fluorescence labelled primer, 0.2 µM Mse primer , and 0.5 U AmpliTaq Gold (ABI). The reactions were held at 95°C for 5 min followed by 13 cycles of 94°C for 30 s, 65°C→56°C (−0.7°C per cycle) for 1 min, and 72°C for 1 min, followed by 23 cycles of 94°C for 30 s, 56°C for 1 min, and 72°C for 1.5 min with a final 8 min extension at 72°C.AFLP analysis was performed using a standard protocol Three differentially fluorescence labelled PCR products of the same sample were multiplexed and diluted, and the fragments were electrophoretically separated on a MegaBase 500 sequencer together with an ET-ROX 550 size standard . For each run a total of 48 samples were analyzed, including one standard sample, one negative control, one repeat within the runs, and several other replicates , as recommended by Bonin et al. trnL intron and trnL/F intergenic spacer (trnL/F-IGS), primers, PCR cycling scheme, purification of the amplified fragment, cycle sequencing, and sequencing on a MegaBace 500 sequencer followed the protocol of Schmickl et al. trnL/F-IGS included the complete trnL/F-IGS and the first 18 bases of the trnF gene.For the cpDNA markers EHA. arenosa subsp. arenosa, A. arenosa subsp. borbasii, A. carpatica, A. neglecta, A nitida, and A. petrogena. In order to analyze and display the similarity among the AFLP genotypes, a Principal Component Analysis (PCA) was performed using MVSP version 3.1 . Pairwise Euclidean distance was applied as distance measure and, alternatively, both Jaccard and simple match coefficient Several statistical parameters were computed using the R script AFLPdat trnL/F sequences were defined as i) haplotypes and ii) suprahaplotypes following our previous studies  share the same base order throughout the whole sequence except for the pseudogene-rich region, where they vary in both length and base content. Mutation rate within the pseudogene-rich region is about 10 to 20 times higher than within the non-coding spacer and intron regions trnL/F suprahaplotypes only. Suprahaplotypes differ from each other by single point mutations and/or indels. Newly defined trnL/F haplotypes were assigned to GenBank numbers  (aV) π and Nei's unbiased gene diversity EH.Plastid es e.g., . HaplotyJ477716] . The netIn order to visualize the geographical data, ArcView version 8.2  was used. The maximum extent of the ice sheets during the LGM was taken from Ehlers and Gibbard n = 28) and the Western Carpathians (n = 9) were analyzed with more than one individual per population.Two ploidal levels, diploid and tetraploid, were observed within our sampling . DiploidA. arenosa species complex (EH = 0.133 (GlaNEur) to EH = 0.159 (UnglaESEAlps). The proportion of variable markers differed more strongly between geographic regions, ranging from FP = 0.411  to FP = 0.906 (UnglaESEAlps). However, the proportion of variable markers is biased with respect to sample size  and, therefore, not a valid measurement of genetic diversity. Genetic diversity patterns in the A. arenosa complex need additional consideration in terms of taxonomy, as for certain regions, e.g., Carp, numerous taxa are described, and in other regions, e.g., GlaNEur, only one taxon is found. Gene diversity of the different taxa ranged from EH = 0.157 (A. arenosa subsp. arenosa) and EH = 0.155 (A. arenosa subsp. borbasii) to EH = 0.138 (A. carpatica and A. petrogena) and EH = 0.125 (A. neglecta). The proportion of variable markers is, again, highly correlated with sample size  and so should be treated with caution.Diversity statistics, based on AFLP data, showed similar values for gene diversity throughout the whole distribution range of the  complex , rangingA. arenosa subsp. arenosa but also subsp. borbasii formed large groups of AFLP genotypes in comparison to A. carpatica, A. neglecta, and A. petrogena . This finding underlines the high genetic plasticity of the tetraploids (A. arenosa subsp. arenosa and subsp. borbasii) in contrast to the mainly diploids . PCA according to ploidal levels , highest nucleotide diversity (π = 0.483%), and highest Nei's gene diversity (EH = 0.764) within the whole dataset. The Balkan Peninsula was detected as the second center of genetic diversity . The third center of genetic diversity, the Carpathians, was characterized by gene diversity values similar to those of the Balkan Peninsula . In contrast to these three genetically highly diverse regions, which remained largely unglaciated during Pleistocene climate oscillations, formerly glaciated regions showed reduced values of effective genetic diversity according to Gregorius, nucleotide and Nei's gene diversity: The part of the Eastern Alps formerly covered by glaciers was characterized by aV = 2.23, π = 0.310%, and EH = 0.561. The formerly glaciated Western Alps showed strongly reduced values . Glaciated northern Europe was characterized by aV = 1.81, π = 0.315%, and EH = 0.491. Although Central Europe remained largely unglaciated during Pleistocene climate oscillations, genetic diversity was also reduced . In contrast to AFLP data, effective genetic diversity according to Gregorius, nucleotide and Nei's gene diversity of diploid A. carpatica  exceeded that of tetraploid A. arenosa subsp. arenosa .Based on  complex . The ungIn all geographic regions, except GlaWAlps, unique suprahaplotypes were found, which occurred in one region only , 3A. TheA. arenosa complex two ploidal levels, diploid and tetraploid, were observed. Contact zones of these two cytotypes were localized in the northwestern part of the Balkan Peninsula and in the Western Carpathians, and, consequently, at least one independent polyploidisation event can be assumed for each of these regions. Regarding the Western Carpathians, we observed a mosaic pattern of diploids and tetraploids, which is in congruence with Měsíček Melampodium L., in particular the white-rayed species complex with mainly diploids and tetraploids, is an example for postglacial formation of polyploids via autopolyploidisation. Intrapopulational cytotype mixture was reported, but emphasized as rare Knautia arvensis agg. A. arenosa complex excludes recent polyploidisation events as well as secondary contact zones. We assume ancient polyploidisation, probably dated several glacial cycles ago. Slightly different ecological adaptations of diploids and tetraploids might have favored such a distinct pattern of diploid and tetraploid populations. Diploid A. neglecta subsp. neglecta, for example, is found on siliceous substrates, mostly in high alpine habitats above the tree line, where it grows along mountain streams. The tetraploid subspecies robusta  and one tetraploid (subsp. robusta) Arabidopsis petrogena is exclusively described from the Carpathians as diploid (subsp. petrogena) and as tetraploid  were found on the Balkan Peninsula. Diploid A. arenosa could have migrated northwards and experienced multiple polyploidisation events, especially in the Carpathians, where taxa of both diploid and tetraploid cytotype are described. The Alps were probably colonised by (a) tetraploid cytotype(s) of A. arenosa, which could have originated in the Julian Alps, where only tetraploids were found. The Balkan Peninsula as the ancient refuge area for the A. arenosa species complex is additionally supported by the occurrence of an Arabidopsis species endemic to the Balkan Peninsula, Arabidopsis croatica. This endemic is closely related to the A. arenosa complex, based on ITS sequence data  However, an alternative explanation for genetic differentiation between A. neglecta grows on siliceous bedrock along mountain streams in alpine habitats of the High Tatras (Slovakia), a similar ecological niche in the Eastern Alps  is occupied by a tetraploid taxon corresponding to Cardaminopsis arenosa var. intermedia (Kovats) Hayek A. arenosa complex. However, AFLP data did not confirm that the vicariant populations from the Eastern Alps and the High Tatras represent a single species (Cochlearia tatrae Borbás in the High Tatras (Slovakia) and diploid Cochlearia excelsa Zahlbr. ex Fritsch in the Eastern Alps . In parallel to A. neglecta and C. arenosa var. intermedia, these two Cochlearia species evolved independently and most likely within the last approximately 100,000 years Taxa in refuge areas like the Eastern Alps and the Western Carpathians probably underwent long-term adaptational processes, which could result in adaptation to the same ecological niche in the two mountain ranges in parallel. Indeed, we found one example for parallel evolution in the Eastern Alps and the Western Carpathians: Diploid  species . This neA. arenosa subsp. arenosa and subsp. borbasii were found. Local, periglacial survival could serve as one explanation for the high genetic diversity of especially A. arenosa subsp. arenosa. In Central Europe, numerous populations are restricted to relict habitats on exposed rocks in low mountain ranges, e.g., the Black Forest, the Eifel, the Elbe Sandstone Mountains, the Harz Mountains, and the Swabian Mountains, where they often co-occur with Pleistocene relict species such as Dianthus gratianopolitanus Vill. . A second explanation could be the lack of genetic bottlenecks and the maintenance of large effective population sizes during postglacial migration into formerly glaciated regions, probably enhanced by the plant's biennial life cycle. In a third alternative, gene flow between different taxa and/or ploidal levels could account for the high genetic diversity in especially tetraploid A. arenosa subsp. arenosa, probably before this taxon migrated from the Eastern Alps and Western Carpathians, its putative refuge areas, to Central Europe. Gene flow between different taxa of the A. arenosa species complex is documented by numerous hybrids, including triploid ones, reported from the Western Carpathians A. lyrataA. arenosa, which could have resulted in its ability to be a successful coloniser on various different substrate types  in various different habitat types .Based on both AFLP and chloroplast sequence data, genetic diversity was not strongly reduced in regions formerly covered by glaciers  in comparison to formerly unglaciated regions (UnglaCentrEur). In all these four regions, exclusively tetraploid Table S1trnL intron type, trnL intron GenBank no., trnL/F-IGS type, trnL/F-IGS GenBank no., trnL intron+trnL/F-IGS type, trnL intron+trnL/F-IGS suprahaplotype. Accessions, for which AFLP data were obtained, are marked (see AFLPs).Information about accession details and experimental results: taxonomic unit, taxon name on herbarium voucher, herbarium/herbarium voucher no., accession no., geographic region, latitude/longitude, locality, collector/date of collection, ploidal level/publication or other source, AFLPs, (XLS)Click here for additional data file.


Evidence-based medicine may have many deficiencies . But in A 49 year old male with ischemic heart disease attended our free medical camp conducted on the World Heart Day 2008. He was on metoprolol 50 mg bid, aspirin-clopidogrel 75-75 mg, ramipril 5 mg, simvastatin 20 mg and isosorbide mononitrate 20 mg bid prescribed by a private practitioner. This was an excellent evidence-based treatment for this patient [Like two sides of a coin, all evidences have two sides - obverse and reverse. We tend to follow the obverse side and call it the "evidence" whereas the reverse is also evidence and true. To check the reverse evidence, the raw data of a clinical trial is taken and a commonsense appraisal of the number of patients in the placebo or existing treatment arm is done. If the majority in the comparator arm has favorable outcomes, this will constitute the reverse evidence. This is done without complicated statistical analyses. While the evidence would support the new treatment, the reverse evidence will examine if the placebo or existing treatment has reasonably favorable outcomes. This will be useful in making ethical decisions on the face of the higher costs of the newer treatments.Thus the majority in the placebo arm had a favorable outcome and the treatment arm was not devoid of adverse outcomes. In the landmark 4S study [Here the three expensive medications were ramipril, clopidogrel and simvastatin. We reviewed the evidences for these drugs in the following well-designed randomized controlled trials. In the HOPE study  there we4S study  also didNow, he is happy and doing well on metoprolol, aspirin and isosorbide dinitrate at a cost of rupees 5 a day! Besides, it has improved his self respect - being empowered to make out-of-pocket purchase of the medicines rather than depend on insurance or doles.Reverse evidence-based medicine practice needs detailed patient counseling and patient acceptance. In the present case it was easy because the situation was that of a free medical camp where the patient requested a cheaper treatment. We do not deny the statistical benefits of the evidence based treatments. And every patient deserves the best evidence-based treatments. However when cost is a concern, it is worthwhile to consider the reverse evidence of an intervention if it is relatively inexpensive and reasonably acceptable. In this age of increasing healthcare costs, it would also be advisable for guidelines writers to mention the acceptable reverse evidence as an option in cases where the evidence favors an expensive treatment.


Reducing the burden of disease relies on availability of evidence-based clinical practice guidelines (CPGs). There is limited data on availability, quality and content of guidelines within the Southern African Development Community (SADC). This evaluation aims to address this gap in knowledge and provide recommendations for regional guideline development.We prioritised five diseases: HIV in adults, malaria in children and adults, pre-eclampsia, diarrhoea in children and hypertension in primary care. A comprehensive electronic search to locate guidelines was conducted between June and October 2010 and augmented with email contact with SADC Ministries of Health. Independent reviewers used the AGREE II tool to score six quality domains reporting the guideline development process. Alignment of the evidence-base of the guidelines was evaluated by comparing their content with key recommendations from accepted reference guidelines, identified with a content expert, and percentage scores were calculated.scope and purpose' and 'clarity and presentation' domains of the AGREE II instrument scored highest, median 58%(range 19-92) and 83%(range 17-100) respectively. 'Stakeholder involvement' followed with median 39%(range 6-75). 'Applicability', 'rigour of development' and 'editorial independence' scored poorly, all below 25%. Alignment with evidence was variable across member states, the lowest scores occurring in older guidelines or where the guideline being evaluated was part of broader primary healthcare CPG rather than a disease-specific guideline.We identified 30 guidelines from 13 countries, publication dates ranging from 2003-2010. Overall the 'This review identified quality gaps and variable alignment with best evidence in available guidelines within SADC for five priority diseases. Future guideline development processes within SADC should better adhere to global reporting norms requiring broader consultation of stakeholders and transparency of process. A regional guideline support committee could harness local capacity to support context appropriate guideline development. Clinical practice guidelines bridge the gap between policy and practice and should be based on up-to-date, high quality research findings ,2. ReducSeveral guideline appraisal tools have been developed to assess the quality of guidelines . Of thesOur project aimed to evaluate clinical practice guidelines (CPGs) from the Southern African Development Community (SADC) member states, for priority diseases, with respect to availability, quality and alignment with current reference guidelines. This study formed part of a larger programme, the Southern African Regional Programme on Access to Medicines (SARPAM) for harmonising CPGs and essential medicine lists for reforming regional procurement.We considered two issues: firstly, priority diseases should be representative of the following key components: adult & paediatric conditions; communicable & non-communicable diseases; chronic and acute onset diseases; maternal health; hospital-based & primary health care conditions. Secondly, time and feasibility limited our selection to five diseases. The following conditions were prioritised by the SARPAM study team: HIV in adults; malaria in children and adults; essential hypertension in primary care; pre-eclampsia; and diarrhoea in children.A public health clinician used an electronic search and e-mail enquiry strategy to obtain the CPGs for each SADC country: Angola, Botswana, the Democratic Republic of Congo (DRC), Lesotho, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Swaziland, United Republic of Tanzania, Zambia and Zimbabwe. The search strategy incorporated possible document and disease terms which were added to the country names Table . MedlineTwo reviewers  independently evaluated the global quality of the five CPGs for each of the SADC states and the reference guidelines using AGREE II. This tool is a recently revised and validated version of the AGREE instrument -18. AGREWe invited one South Africa-based content expert for each of the five priority areas to give input on this project. The current gold standard reference guideline for each topic was identified in consultation with the content expert -26. The The search was conducted between June and October 2010, including feedback from a SADC secretariat meeting in September 2010. The MEDLINE search yielded no results. Using Google™ and personal contacts the search yielded 30 guidelines from 13 SADC states  and 88% (range 17-97), whereas the 'applicability' and 'editorial independence' scored poorly, median 15% (range 0-52) and 0% (range 0-25) respectively.Eight guidelines were evaluated, including the 2010 draft version of the Namibian CPG. The lowest score was seen for the 'editorial independence' domain, median 0% (range 0-25) and the highest score was seen in the 'clarity and presentation' domain median 75% (range 36-89).Domains 'scope and purpose', 'stakeholder involvement' and 'clarity and presentation' received highest scores; the lowest score was seen for editorial independence median 4% (range 0-25).The median score for the domain on 'clarity and presentation' was 81% (range 53-97), and the 'scope and purpose' median score was 75% (range 39-92), however the other domains scored largely below 50% with 'editorial independence' scoring lowest, median 4% (range 0-50).Key recommendations from the reference guidelines were identified with input from experts in the respective fields.The Zimbabwe 2010) and Lesotho (2010) guidelines, both in draft form, were best aligned with current evidence-based guidelines and expert opinion, achieving > 80% alignment  was most recently published and was current in its recommendations and scored above 50% Figure .Diarrhoea management has not changed significantly in the recent years and as such, most CPGs produced after the WHO publication in 2005  had fair concordance with recommendations, including the use of zinc in all guidelines. Zimbabwe (2006), South Africa (2008) and Malawi (2009) scored 80% alignment Figure .Two countries with dedicated hypertension guidelines, South Africa (2006) and Mauritius (unknown date), scored best in their alignment with current best evidence  Figure . The remTo our knowledge this is the first study to report on the availability and appraisal of quality and content of clinical guidelines for five priority diseases within the SADC region. Of the available guidelines overall scores were poor using the AGREE II assessment-particularly with respect to rigour of development, applicability and editorial independence. Alignment with best evidence was highly variable, with better scores for guidelines that were more recently published and those that were disease-specific rather than sections within larger primary health care CPGs.HIV and malaria were most likely to have disease-specific guidelines which may reflect the global funding streams and political impetus targeting these conditions. The other priority diseases occupied sections within larger primary care CPGs. Our review found that the sections within other manuals that we evaluated were not comprehensive and provided incomplete guidance and were less likely to be up-to-date. Overall, the 'scope and purpose' and 'clarity and presentation' domains of the AGREE II tool were reported most comprehensively. However, the purpose, health question and target users were not explicitly described. Rather, the information was incorporated within the introduction and foreword sections and required extraction in order to identify the scope and objectives.Most documents employed clear and consistent methods for identifying key recommendations, such as flow diagrams, tables and highlighted text, making the documents accessible for end-users and resulting in good scores in 'clarity and presentation'. The value of the clarity and presentation has been questioned as it does not strictly reflect the internal and external validity of a guideline document . HoweverThe remaining four domains scored poorly across all diseases. The guidelines described the 'stakeholder involvement' of multidisciplinary professional groups; however, little was reported about the contribution of primary-care doctors and target patients. This is increasingly recognised as important for assuring that guidelines represent the needs of both the target users and patients. Involving these groups in the guideline development process, for example by pre-testing the guideline, or evaluating and incorporating preferences and values, may aid in securing the successful implementation of the guideline ,31.In our study, as in previous studies, 'rigour of development' scored poorly . A minorThe methods necessary to successfully implement the guidelines, were not clearly delineated, hence the low scoring 'applicability domain'. Facilitators and barriers to applying the guidelines should be described to support implementation. The process of defining facilitators and barriers to application should be integrated early in the guideline development process and include professionals proficient in implementation strategies .The low score in the 'editorial independence' domain reflects the poor reporting of potential conflicts of interest of stakeholders and the potential influence of funders in the guideline development process. Although the absence of these declarations does not necessarily imply that inappropriate influences guided the final recommendations, the presence of such declarations ensures that a guideline can be considered trustworthy ,13,32.Higher alignment scores were attained when guidelines were dedicated to a specific illness as seen with the malaria, HIV and hypertension guidelines. Gaps in the key recommendations occurred when the guidelines were out-of-date, occurring more frequently in the primary care CPGs. Pre-eclampsia scored poorly for alignment-indicating that the primary care CPGs we evaluated did not reflect current evidence. This condition requires hospital-based care and we did not identify any secondary or tertiary hospital guidelines during this review. Good alignment was achieved in guidelines despite poor scores in the 'rigour of development' domain-indicating a possible mismatch of the tool with the local practice of basing guidelines on WHO or equivalent high quality guidelines.A systematic review evaluating 42 guideline appraisal studies, including 626 guidelines, between 1988 and 2007 using the AGREE tool found similar distributions of low and high scores, supporting the notion that the domains within the guidelines that require improvement are similar despite disease or region . Our scoWe were mandated by the SADC Secretariat Pharmaceuticals Programme and therefore received cooperation from the ministries within the member states to assist with locating the relevant guidelines. We have attempted to address the research-knowledge gap by communicating a technical summary of the results to the SADC secretariat with specific recommendations for improving the availability, content and quality of CPGs within SADC. Although the AGREE II tool has been adopted widely as the reference tool to be used to evaluate guideline quality, this is the first time, to our knowledge, that it has been systematically applied across several diseases in a number of resource-constrained countries in Africa. This study can therefore contribute to a validation of the AGREE II tool and support uptake in our setting. The assessment of the alignment of the contents of the CPGs in this review was conducted with both published normative standard guidelines, such as WHO guidelines, and the input from experts in the respective fields.We did not locate all relevant documents given the absence of a central or country-level repository. The outstanding documents would be required to provide a representative baseline analysis for SADC. The guidelines we evaluated included a combination of disease-specific guidelines and sections within larger primary care manuals. These guidelines may not lend themselves to be pooled in analysis, but do provide a true reflection of current guidance of the management of the included diseases. AGREE collaborators recommend that increasing the number of reviewers increases validity ,19. CostIt is important that gaps in the availability of CPGs be identified and addressed. A repository of all guidelines in an accessible database will facilitate access for all SADC member states. It will facilitate cataloguing of guidelines and enable identification of those that may be relevant but missing or out-of-date. This could be done in collaboration with organisations such as the Guideline International Network .There may be value in creating a SADC guideline support committee, through the SADC Pharmaceutical Programme, to assist all member states to adapt, maintain and update in-country guidelines of high standard . This wiThe value of this review has been to identify specific gaps in the quality and content of the guidelines within SADC. There is increasing awareness that the transfer of research evidence into policy and practice is a complex issue, sensitive to the context of each country. In order to inspire confidence in the quality and evidence-base of guideline recommendations and in the transparency of the development process, each newly developed or updated guideline should adhere to the recommended reporting norms currently in use globally.CPG: clinical practice guideline; AGREE: Appraisal of Guidelines for Research and Evaluation.The authors declare that they have no competing interests.TK, NS, SC and JvH designed the protocol. AG, TK scored the guidelines using AGREE, NS provided input during process. TK evaluated alignment with key evidence-based recommendations from reference guidelines and content experts. TK drafted the manuscript, NS, JvH, AG and SC contributed to the final report. All authors have read and approved the final manuscript.


Hypersplenism is a common complication in cirrhotic patients, and liver transplantation would be one of the effective treatments. However, detailed dynamics, especially over a long term, are not fully understood. We investigated the long-term dynamics of hematological data and spleen volumes, as well as their correlation in cirrhotic patients who underwent liver transplantation.We studied 53 cirrhotic patients who underwent liver transplantation at our institute and followed for more than 1 year. Hematological data were collected from medical records, while spleen volumes were determined by CT volumetry at 0, 1, 3, 6, 12, 24, 36, 48, 60 postoperative months (POM).(1) Platelet (Plt) and hemoglobin (Hb) levels were gradually increased up to 18 and 10 POM, respectively, in contrast with white blood cells (WBC), which remained mostly unchanged from pretransplantation levels. (2) Spleen volume was sharply decreased in the first POM, then showed a slower but steady decline up to 48 POM. (3) Spleen volume was significantly correlated with hematological data, though the levels were generally weak . (4) Spleen volume was strongly correlated with all hematological parameters in HBV patients , in contrast with that in other etiologies, which had generally weak correlations though some were statistically significant.We investigated the long-term dynamics of hematological data and spleen volume in cirrhotic patients after liver transplantation. Unique dynamics and correlations between them were found among the different etiologies investigated. Hypersplenism and pancytopenia are common complications in patients with liver cirrhosis, which occasionally induce life-threatening complications or loss of quality of life (QOL) from bleeding, infection, or anemic symptoms. The incidence of hypersplenism among cirrhotic patients varies from 15–70% , and data for long-term dynamics are scarce. Moreover, finding regarding white blood cells (WBC) and red blood cells (RBC) in cirrhotic patients are particularly lacking and found only in older studies  counts, hemoglobin (Hb) levels, and platelet (Plt) counts were picked up from medical records in preoperatively, every postoperative month until 12 postoperative months (POM), and then every 3 months until 60 POM. Finally, data at 1253 time points were collected from 53 patients.Spleen volume was determined based on digital data of follow-up computed tomography (CT) in preoperatively, 1, 3, 6, 12 POM and then annually until 60 POM and collected retrospectively. They were approximated as the sum of truncated polygonal pyramids from 5-mm thin slices using Aquilion multislice CT system . Thus, CT data at 278 time points were collected from 40 patients.For comparisons of data that consisted of continuous numbers among the groups, Student’s t-test was applied. To analyze correlations between spleen volume and hematological data, linear regression analysis was applied. p < 0.05 in each analysis was considered as statistically significance. For linear regression analysis, correlation coefficients were used to evaluate the impact of the correlations. All analyses were done with SPSS 16.0 J software .The short-term dynamics of WBC were shown in Figure Figure These data showed that dynamics of each hematological parameter varied among the different etiologies of liver cirrhosis after liver transplantation.After liver transplantation, theoretically hypersplenism is expected to be cured because of resigning from liver fibrosis. We next analyzed the dynamics of spleen volume after liver transplantation in all patients and among the different etiologies.Spleen volumes showed a slow, but steady and significant decrease at least until 48 POM (Figure These findings show that spleen volumes generally had a steady and significant decrease in our cirrhotic patients after liver transplantation except in those with NBNC.Figure Analysis in each etiology, relatively strong correlations were seen in HBV patients, with the correlations between platelets and spleen volumes the strongest (Plt: r = 0.617, p < 0.001; Figure These results suggest that changes in spleen volume were significantly correlated with those of hematological data, though the correlations were generally weak. Therefore, there may be some independent and undefined mechanisms other than hypersplenism related to the changes in hematological data during the progression of cirrhosis and recovery after liver transplantation (Peck-Radosavljevic et al. The reduction in number of hematological cells in cirrhotic patients has already been shown to recover after liver transplantation in the previous studies by others (Yanaga et al. In the present study, we studied the dynamics of hematological data and spleen volume in 53 patients with cirrhosis who underwent liver transplantation without a splenectomy. Each hematological parameter showed different dynamics with platelet and WBC showing faster increases with peak levels reached at 1, and 2 POM, respectively (Figures Over the long term dynamics, spleen volume showed a slow, but steady and statistically significant decrease until at least 48 POM Figure c and 3c.Regarding platelets, relatively large numbers of candidates have been investigated in the previous studies. The most studied factor is thrombopoietin, a cytokine produced by the liver that regulates megakaryocyte maturation and platelet production (Pradella et al. In addition to the platelet production, decreased platelet survival time may be a mechanism related to thrombocytopenia in cirrhotic patients (Pradella et al. In contrast to the other etiologies investigated, the correlation between spleen volume and platelet count in HBV patients was strong (p = 0.617, Figure As for WBC and Hb levels in cirrhotic patients, information was much more scant. Sequestration of RBC in the spleen was shown to occur according to portal pressure and spleen size in an old study. Jiao et al. reported that erythrocyte creatine, which is considered to be a marker of destruction of erythrocytes, showed good correlations with spleen size and reticulocytes (Jiao et al. In our study, Hb was shown to increase slower than the other hematological parameters, thus the impact of spleen volume, which showed a steady decrease, might be supposed to affect the erythrocyte count to a larger degree than other parameters. On the other hand, an unknown mechanism might also exist because Hb level reached a plateau at 10 POM Figure a and 2c,In summary, we investigated the long-term dynamics of hematological parameters and spleen volume in cirrhotic patients after liver transplantation. Each hematological parameter increased in the early postoperative period, and thereafter, though each generally reached a plateau in the later phase. In contrast in spleen volume, a steady reduction was found up to 48 POM. Hematological data and spleen volume were significantly correlated with each other, though their correlations were generally weak. Furthermore, these dynamics were very different among the etiologies for cirrhosis investigated. To the best of our knowledge, this is the first report to investigate long-term dynamics after liver transplantation. From these findings, we intend to further investigate the detailed mechanisms of these differences among etiologies, as well as discrepancies between hematological data and spleen volume.Written informed consent was obtained from the patient for the publication of this report and any accompanying images and this study has done according to the guidance of Helsinki Declaration.


There is increasing evidence that outcomes of health care differ by patient characteristics, such as gender and ethnicity. If evidence-based medicine is to improve quality of care for all patients, it is essential to take this diversity into account when designing clinical studies. So far, this notion has mainly been translated into recommendations for including minority populations in trials. We argue that a more comprehensive view of the production of diversity-sensitive clinical evidence is needed, one that takes heterogeneity as a starting point in research. We call for a mix of methodological approaches aimed at identifying diversity issues that matter and analysing the impact of these diversities on clinical outcomes. Institutional changes are necessary to support this methodological reform. Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients . The maiRegulatory reforms in the mid-1990s, particularly those in the USA, drew attention to this issue . These ret al. [However, only some of these studies have the potential for subgroup analysis, which is a prerequisite for assessing differences in treatment outcomes between groups. For example, after looking at 86 original articles in medical journals that reported on clinical trials funded by the National Institutes of Health (NIH), Geller et al.  concludeThe challenges are great. A multidisciplinary project commissioned by the Netherlands Organisation for Health Research and Development (ZonMw) - involving clinicians, epidemiologists, ethicists, sociologists, and anthropologists - examined factors that both facilitate and constrain a focus on diversity in clinical research. The project included a number of literature reviews, and a conference in which the conclusions of these reviews were discussed . Based oFrom an epistemological view, homogeneity is the dominant paradigm in clinical research. This is apparent from the methodology of clinical trials: strict inclusion and exclusion criteria are set for clinical trials to minimize the chance of side effects, comorbidity, and early dropout . HomogenConsequently, diversity issues are frequently framed as deviations from the homogeneous population. Given the under-representation of ethnic minorities, women, and older people, this generally means that these are deviations from the white male population. But this does not mean that diverse groups  are always different from each other with respect to health or medical care. On the contrary, the literature contains many examples of studies showing that the effects of clinical interventions do not differ between subgroups. Well-known examples include the use of aspirin to prevent coronary heart disease, which is now thought to be as effective in women as in men, despite the results of previous trials pointing to its ineffectiveness in women ,15.However, deliberating about populations that may or may not differ from the standard population will in itself not be enough to ensure a thorough understanding of inequalities between populations. The limitations of this approach are twofold. First, it looks at diversity issues from the perspective of the standard only . For example, this has led to an emphasis on the specific health risks faced by women . In this perspective, the specific health risks faced by men are likely to be neglected. If we take gender sensitivity rather than deviations from the male norm as a starting point for analysis, this might draw our attention to characteristics such as the attitudes and values that underlie differences between genders, including masculinity and caring capacities ,17. SecoIf we are to take the principle of diversity-sensitive clinical knowledge seriously, it needs to be made the core perspective in study design, starting with the conceptualization of the problem to be studied. This requires that the hypotheses underlying studies based on a nuanced understanding of possible differences between groups should be studied in a population that represents groups that differ on the aspects considered to be relevant. This will help to produce clinical knowledge that can be applied to the entire population, as it allows for a detailed understanding of why a specific intervention works and for whom. As such, producing diversity-sensitive clinical knowledge is also likely to benefit the standard population to which trials are usually restricted.What are the implications for clinical research methodology if we take heterogeneity as the guiding principle?RCTs can, of course, be used to study heterogeneity. If the effect of the intervention under study is hypothesized to differ between subgroups, such as the hypothesis that the preventive effect of aspirin differs between men and women, there are two options. First, new RCTs can be designed that specifically test treatment effects in relevant subgroups, as was done in the Women’s Health Initiative, which critically examined the existing evidence on the preventive effects of hormone replacement therapy on cardiovascular disease . A seconWhen aiming to include subgroups that are traditionally under-represented in clinical trials, many problems might be encountered in terms of adequate trial enrolment, the validity of measurements (including self-reported measurements) in different groups, and compliance and retention  . In viewHowever, this does not imply that all clinical trials should automatically include subgroups. Ensuring the inclusion of subgroups large enough to allow for subgroup analysis has an enormous impact on costs. In view of limited resources, the choice for a heterogeneous study population should at least be weighed against the strength of the indications for the presence of diversity in health outcomes. This implies that confronting diversity in clinical research starts with formulating hypotheses as to why diversity does or does not matter in a specific case.To identify the diversity issues that matter for health outcomes, a mix of different methodologies is needed. An increasing number of complementary research methods are available as shown below.et al. [Reanalysis of past trials: researchers can critically review past trials, exploring unexpected phenomena in RCTs and identifying variance in effects, such as outliers. Meta-analysis at an individual level can be used to explore differences in treatment outcomes by subgroup. A meta-analysis on the effects of chemoradiotherapy for cervical cancer in subgroups of women by patient variables could serve as an example . Of couret al. .Observational studies: researchers can review the increasing number of biomedical and pharmacodynamic studies that reveal how aetiology, prognosis, disease perception, and/or effects of interventions are affected by age, sex and/or ethnicity and by other factors ,29, or tDatabases of routine health care: researchers can consult databases of patients registered with, for example, a general practitioner for routine health care, to explore effect modification in treatment outcomes. Databases of adverse drug reaction reports may also be relevant. An analysis of a population-based birth defect registry in The Netherlands  might serve as an example . In geneQualitative studies: these can also help identify diversity issues that matter for health outcomes. First, qualitative evidence might arise from observations by patients and professionals, as they are the first to observe differences in treatment outcomes. What differences are observed? What causes these differences? Are there puzzling phenomena, unexpected side effects, or unidentified variances in treatment effects? Physicians sometimes publish these valuable experiences as case reports. The experiential knowledge of patients and the clinical experience of health professionals have been shown to complement those of researchers . Second,Once the diversity hypotheses have been identified, further analysis and testing is needed. This could lead directly to the recommendation to include subgroups in RCTs, but also to aetiological studies to investigate possible underlying causes of the differences if these are unknown. The development of diversity hypotheses as we propose here might help to compensate for the above-mentioned weakness of the subgroup analysis strategy, that of drawing misleading conclusions: the more precisely the hypotheses as to why groups might differ with regard to the intervention effect are formulated before the data collection, the more likely the study will result in valid estimates of differential effects of the intervention. The subgroups to be involved in the analyses can then be defined so that they have aetiological consequences. For example, in the field of hypertension, if ethnicity has been related to differences in plasma renin levels as an effect modifier, future trials could consider this as the relevant variable rather than ethnicity.The production of diversity-sensitive clinical knowledge also requires institutional mechanisms and arrangements that facilitate the methodological reform described above. Although the role of funding agencies seems to be crucial in this respect, we would like to point out the responsibilities of other organizations as well.The NIH in the USA seems to have been most successful in implementing specific diversity-relevant programmes. Within the organizational structure of the NIH, offices can be established to increase research on specific subjects. To stimulate research on women’s health issues, the NIH established the Office of Research on Women’s Health (ORWH) in 1990. Other examples include the National Institute on Minority Health and Health Disparities (NIMHD) at the NIH . In EuroIf diversity-relevant research is mainstreamed, funding organizations should facilitate attention for this issue throughout all working processes. This includes the processes by which relevant committees review funding proposals. At this stage, attention for diversity issues can be facilitated by ensuring that all proposals include a concise and systematic review of the relevant evidence on diversity, that they specify how diversity in disease aetiology, progression and manifestations, and treatment outcomes has informed the study design, and that they specify which of the other diversity issues that matter will be analysed in the study.The way diversity is conceptualized is crucial in this respect. Both the NIH and the EU have chosen to focus on broad subgroups, such as women or older people. In line with our methodological recommendations, additional dimensions of diversity require such mainstreaming. In addition, there is a need for calls for proposals that allow for multidisciplinary and multi-stakeholder programmes aimed at producing a broader range of diversity-sensitive clinical evidence, which is still lacking at present. These programmes should include funding for innovative studies that use a mix of qualitative and quantitative methods, and which aim at generating and analysing diversity-relevant hypotheses. The funding programmes should be committed to further analyses and testing once relevant diversity issues have been identified, with the overall aim of producing better evidence on diversity to guide medical practice.Funding agencies in several countries have also developed guidance documents for researchers to enhance the quality of research among subgroups, such as minority populations. The effectiveness of this kind of guidance, which contains methodological and practical recommendations, has not been studied widely. Recent experiences from a major funder of social science research in the UK suggest that this guidance has little impact on practice. The authors conclude that in order to have an impact, this guidance needs to be promoted more vigorously .Apart from funding agencies, other stakeholders also seem to be vitally important. These include (but are not limited to) researchers, professional organizations, patient organizations, and medical ethics committees.Researchers should design studies more carefully to allow for the analysis of diversity issues that matter, as described in the first part of this paper. In determining endpoints for their studies, they need to more systematically consider diversity in aetiology as well as manifestation and progression of disease. In defining diversity issues that matter, they should in fact consider all relevant factors that may influence the efficacy of health care.The professional organizations of general practitioners and specialists tend to identify gaps in diversity-sensitive evidence when developing treatment guidelines. The gaps can guide research programmes. They can also help to identify the underlying philosophical assumptions of the observations of current research, as well as generate hypotheses on diversity issues that matter from clinical observations.Patient organizations can also play a key role in identifying diversity issues. Funding agencies increasingly have patient representatives on their committees, which often raises issues about representation. Who can be considered to represent a specific patient population or community? The position developed by INVOLVE, a British advisory board that supports greater public involvement in health research, is that involvement of patients or consumers should not aim to represent users, but to seek different perspectives: involving a range of people introduces a range of perspectives . AlthougMedical ethics committees can play a key role as well . HistoriThe importance of producing diversity-sensitive evidence for the development of guidelines for clinical care has been acknowledged for decades. Solutions have focused mainly on including under-represented groups in trials. Although this issue is still of the utmost importance, the production of diversity-sensitive clinical evidence requires more than just this. We argue that heterogeneity should be the starting point of clinical trials, implying an exploration of diversity issues that matter for the outcome of health care services. To produce the evidence that justifies clinical trials that take diversity issues into account, a mix of hypothesis-generating and hypothesis-testing research is needed, involving studies that use a mixed-methods approach. Confronting diversity in clinical research thus demands a programmatic and iterative approach that ensures an ongoing interest in relevant variance. Stakeholder participation is key. Doctors and patients can alert the researchers to diversity issues that matter in routine health care, thus contributing to a more relevant evidence base for practice. In addition, a broad conceptualization of diversity is crucial in this respect. In analysing diversity in treatment outcomes, the design of RCTs needs to be based on a nuanced understanding of the interplay of the factors underlying patients’ background characteristics, including genetic, environmental, sociocultural, economic, and behavioural factors. This methodological reform can only be achieved if it is supported by institutional changes. Diversity issues need to be mainstreamed into all phases of funding programmes for health research, from commissioning to implementation. In addition, many other actors, including professional organizations and medical ethics committees, should incorporate diversity as a core value in the way they operate.We hope our reflections will inspire others who take diversity in the production of clinical evidence seriously. This trajectory is essential, so that the further development of EBM will benefit all patients.EBM: Evidence-based medicine; EDICT: Eliminating Disparities in Clinical Trials; EU: European Union; FP5: Fifth Framework Programme; NIH: National Institutes of Health; NIMHD: National Institute on Minority Health and Health Disparities; ORWH: Office of Research on Women’s Health; RCT: Randomized controlled trial; ZonMw: Netherlands Organisation for Health Research and Development.The authors declare that they have no competing interests.All authors conceived the study, participated in the manuscript design, and performed parts of the literature search. KS and AH drafted the manuscript. NFW critically read and helped to revise the draft. All authors read and approved the final manuscript.


David Sinclair and colleagues discuss their experience at the Ghana National Drugs Programme reviewing the international evidence base for five priority pediatric medicines and report that applying the global recommendations to Ghana was not straightforward for any of the five medicines.Please see later in the article for the Editors' Summary This paper reports the experience of the Ghana National Drugs Programme as they reviewed the international evidence base for five priority paediatric medicines.Applying the global recommendations to Ghana was not straightforward for any of the five medicines, regardless of the presence of high quality evidence of important clinical benefits.Four main factors generated debate and uncertainty in the committee: (1) effect unproven in African settings; (2) control group in trials not consistent with current practice; (3) little evidence on cost and cost effectiveness; and (4) limited supply chain.This project demonstrates why global recommendations should be presented alongside transparent descriptions of the evidence base, allowing policy groups to identify where, when, and how the interventions have been evaluated, and any factors limiting applicability.As many policy questions are relevant across sub-Saharan Africa, and policy makers are likely to encounter similar problems, we encourage regional collaboration on health technology assessment, and sharing of information and resources.In 2011, the World Health Organization (WHO) Essential Medicines Programme published a list of “priority medicines” they considered essential for countries to achieve the Millennium Development Goals in child and maternal health The WHO model EML is adapted for use in Ghana by the Ghana National Drugs Programme of the Ministry of Health (MOH), and access to essential medicines is now largely financed through the National Health Insurance Scheme (NHIS). This scheme was established by the government of Ghana in 2003, and covers over 60% of the population Following publication of the 2011 model EML it was noted that five of the priority paediatric medicines were not included in the 2010 Ghana EML: oral zinc sulphate for acute diarrhoea, injectable artesunate for severe malaria, topical chlorhexidine for preventing neonatal cord sepsis, dispersible oral amoxicillin for community acquired pneumonia, and oral and injectable caffeine citrate for neonatal apnoea Before adopting these medicines, the Ghana National Drugs Programme (GNDP) wanted to review the evidence base and how it applied to Ghana, using a transparent and evidence-informed approach, which further considered the local priorities, feasibility, and resource implications. In this paper we report on how the GNDP did this, and the difficulties experienced when interpreting and applying global recommendations to a national context.The National Drugs Programme first prepared concise evidence summaries for each of the five WHO “priority” medicines. These five summaries were then used by the Ghana “Standard Treatment Guidelines” expert review committee in November 2011 (with representation from the NHIS and GNDP), to facilitate an open and informed discussion.Training in the retrieval, appraisal, and interpretation of systematic reviews was provided for a selected team of Ministry of Health staff by specialists from the Liverpool School of Tropical Medicine. These staff then wrote the summaries, following a structure based on the work of the SUPPORT collaboration, summarising existing systematic reviews, rather than conducting new reviews What are the benefits and harms of [drug name]?What would be the public health impact of introducing [drug name] in Ghana?What are the resource implications to the country of introducing it?Is introduction currently feasible and acceptable in Ghana?For evidence of benefits and harms participants searched the Cochrane Library and PubMed for existing systematic reviews. When more than one systematic review was found, the most reliable review was chosen on the basis of an evaluation of the search strategy and methods. When the most recent review was more than 2 years old an additional PubMed search was conducted for recently published randomized controlled trials. Confidence in the methods of systematic reviews was appraised using the AMSTAR checklist The potential public health impact of introducing each medicine was estimated by applying the relative mortality reductions from trial data to the best available national statistics for disease burden. A commentary on the costs and feasibility of introduction was prepared by reviewing international price guides for potential suppliers A brief summary of the findings of each evidence summary is presented in Applying global recommendations to Ghana was not straightforward for any of the five medicines, regardless of the presence of high quality evidence of important clinical benefits . We haveThe applicability of the evidence base for both zinc sulphate (for diarrhoea) and chlorhexidine 4% solution (for cord care) to Ghana was limited, as the majority of available data came from Asian countries, where the effects could reasonably be expected to be different.Zinc sulphate is recommended by the WHO as an adjunct to oral rehydration therapy for children with acute diarrhoea The applicability of the global evidence base for chlorhexidine, and artesunate , was limited because the control groups used in the primary research were different to current practice in Ghana.Chlorhexidine was included on the WHO list of priority medicines for application to the umbilical stump to prevent neonatal sepsis Similarly, most trials evaluating artesunate have compared it to quinine, but in Ghana, as in many sub-Saharan countries, injectable artemether has become widely popular due to the ease of intra-muscular administration. Only a single trial in adults from Asia has directly compared artesunate with artemether and the result did not reach statistical significance The cost of introducing each medicine was important for the committee, but none of the WHO documents recommending these five medicines included advice or guidance on costs Searches of the NHS Economics Evaluations Database found two economic evaluations of artesunate versus quinine Only one further cost-effectiveness evaluation was available, for zinc sulphate, which had limited applicability to Ghana The committee was concerned about the harmful effects of changing national policy before a reliable supply of a new drug was assured.Artesunate was recommended as the first-line antimalarial for severe malaria in Africa in a 2011 update to the WHO Malaria Treatment Guidelines Reliable international or national suppliers were also limited for dispersible zinc tablets, dispersible amoxicillin tablets, and caffeine citrate Four of the five priority medicines were approved by the expert committee for addition to the Ghana EML: zinc sulphate, artesunate, dispersible amoxicillin, and caffeine citrate. The fifth, chlorhexidine, will be re-considered once the ongoing African effectiveness studies have been published.Confident national decisions require understanding and debate of the evidence-base underlying global recommendations, plus additional consideration of national conditions and resources.To facilitate this, global recommendations should be presented alongside transparent descriptions of the evidence base, allowing policy groups to identify where, when, and how the interventions have been evaluated, and any factors limiting wider applicability.In addition, for interventions where feasibility and affordability are likely to vary from setting to setting, the WHO could further assist national decision-makers by providing implementation guidance on the assessment of health system implications, training and education requirements, and country level cost analyses.As many policy questions are relevant across sub-Saharan Africa, and national policy makers are likely to encounter similar problems, we strongly encourage regional collaboration on evidence evaluation, and sharing of information and resources. We hope this paper will encourage further capacity building initiatives, which facilitate and empower countries to make more informed decisions, choosing the interventions that are right for their context, and not implementing unproven interventions.Text S1Artesunate evidence summary.(PDF)Click here for additional data file.Text S2Artemether evidence summary.(PDF)Click here for additional data file.Text S3Zinc evidence summary.(PDF)Click here for additional data file.Text S4Chlorhexidine evidence summary.(PDF)Click here for additional data file.Text S5Amoxicillin evidence summary.(PDF)Click here for additional data file.Text S6Caffeine evidence summary.(PDF)Click here for additional data file.