O tempo pessoal ele aproveita com a sua acolhedora família, que está semprepor perto e o apoia: sua gentil e querida esposa, Janet; suas duas filhas, Jeniffer eClaire; seu filho, Jonathan; e seus adoráveis netos, Roury e Lois. Além da família, Kevinadora futebol , gosta de cozinhar (faz pizzas deliciosas), cuidar do seu belo jardim e pedalarpor Manchester. Meus sinceros agradecimentos aos Profs. José Augusto Mendes Miguel,Jonathan Sandler e Ki Beom Kim, que colaboraram na elaboração dessa entrevista.Recebi com grande satisfação o convite para coordenar a entrevista com o Prof. KevinO’Brien. Meu primeiro contato com o trabalho dele ocorreu em 2009, quando me deparei comdois artigosKlaus Barretto Lopes - coordenador da entrevista Could you tell us what you consider the ten most important clinical trials in the lastten years that have influenced clinical practice the most? Jonathan SandlerCochrane CollaborationI think that the individual trials are not the important factor in changing practice.The best evidence is derived from systematic reviews, and the really important andhigh-quality ones are published by the Randomized clinical trials (RCTs) are known to provide the best evidence on a specificquestion, but its high cost, time needed and other difficulties make this method quiteselective. What are the criteria to indicate this type of study and in which situationother methods should be suggested? José Augusto Mendes MiguelA trial is indicated whenever we want to evaluate the effect of interventions. It isalso important to remember that a good properly planned trial will include outcomes thatare relevant to patients - for example, self-esteem and the perceptions of treatment.This information cannot be obtained by retrospective studies. As an alternative, theanalysis of data that we have already collected on our patients may be helpful, but weneed to carefully assess any bias in this information.Systematic reviews have been published in large scale in the main orthodontic journals.A great part of these papers did not bring significant contributions either becausestudies published on the topic were of low quality or of very diverse methods, notallowing for comparisons. What criteria should be adopted for systematic reviews andmeta-analyses to really contribute for a high level of evidence? José Augusto MendesMiguelA good systematic review should only include randomized trials. This will ensure thatthe review is based on high levels of evidence.Historically, orthodontic researchers have used surrogate outcomes, such as Angleclassification, cephalometric measurements or other factors, that did not bringobjective answers about the treatment benefits for the patient. At this time and age,shouldn’t the researchers change their focus to patient-centered questions regardingpersonal satisfaction, self-esteem or quality of life? José Augusto Mendes MiguelYes, we have spent many years collecting and analyzing data that is only relevant toorthodontists. We need to consider patients relevant outcomes in all studies. This wouldbe a major step and add substantially to our knowledge.We already have several RCTs and systematic reviews in the main topics of orthodontics.Why are clinical practice guidelines still not used in Orthodontics as they are inMedicine? Klaus Barretto LopesThis is a difficult question. My only suggestion is that perhaps we have not beeninterested enough in making this step change.How might social media both positively and negatively affect the practice ofOrthodontics in the 21st Century? How would you advise young orthodontists to get themost from social media to enhance their clinical practice? Jonathan SandlerThe development of social media has been remarkable and it should be very useful to usall. However, the dangers are that it is not controlled and people are making extremeclaims about treatment and philosophies. This is a clear negative effect. The positiveside is that it is great for sharing information, and we need to make sure that peopleare sufficiently trained and informed to evaluate the quality of this information.Your blog is one of the most popular orthodontic blogs in the world. This brings you agreat exposition resulting in a great number of “likes” and “dislikes”. How do youmanage the positive and negative feedback that you receive? Klaus Barretto LopesI am very surprised at the success of my blog. At the end of each day, I look at thecomments and approve or not accept them. I do my best to answer the most relevant. I tryto accept them all, but sometimes they are so extreme that I cannot publish them. It isa side of the blog that is popular and so it is essential that I try to make it as goodas possible.Dental professionals are increasingly using social media with the sole purpose ofself-marketing. On the other hand, your blog shows that the internet can be used as animportant tool for discussing ideas and providing information. Tell us about thisexperience and its reach. José Augusto Mendes MiguelAs I said before, I am surprised at the success of the blog. I initially started it as“something to do”, but now it is a major part of my work. When I started, the firstposts were read by about 40 people. Now a post is read by 3-7 thousand readers. In Junethis year, the posts were read by 48,000 people and this is steadily increasing.How should we prepare to embrace the technological advancement including big data andartificial intelligence? Ki Beom KimThis is going to be a great opportunity. But we know very little about the possibilitiesof this new technology. My real concern is that we will use big data in the same waythat we used readily available data to run retrospective studies, that we now recogniseare biased. So my advice would be that if we are going to collect data we need to makesure that we collect information on every patient. This includes those who terminatetreatment early and whose treatment did not “work out so well”.Are there still things to be discovered about the treatment of Class II cases or in yourview, do we now have all the answers? Jonathan SandlerWhile there is a large amount of evidence-based information, I am not sure if we haveall the answers. Orthodontic treatment is always going to be a rapidly moving specialityand there are many new developments that need to be tested. For example, there are manyquestions about the use of fixed functional appliances and even the use of Class IIcorrectors that are based around aligners.Class II malocclusion can be successfully treated in different ways. As a result,several orthodontic training programs teach orthodontists to treat Class II malocclusionbased on personal experience rather than on the best evidence available. Do you thinkthat it is time to evidence-based orthodontic training? Klaus Barretto LopesYes, all training should be evidence-based, if the evidence is there. In the absence ofevidence, we have to rely on clinical experience. However, this approach is somewhatflawed.How would you suggest to improve the perception of evidence-based orthodontics who don’tbelieve it? Ki Beom KimWe simply need to educate people to understand how to interpret the literaturecritically. This should be done in all training programmes. I have come acrossprogrammes that do not cover this aspect of training and it is somewhatdisappointing.What do you think is the most urgent issue in orthodontics and how would you expect thefuture of Orthodontics? Ki Beom KimThis is difficult, I think that one of the most interesting research areas now is toinvestigate methods of making teeth move faster. While there has been some work done onthis, it has not been of high quality and we still do not have the answer about theeffectiveness of this new treatment. The other work that needs to be done is to moveorthodontic research away from measuring the morphological effects of treatment to theanalysis of patient values. I am sure that we will find much more useful information ifwe can make this considerable change.


Dirofilaria immitis is a mosquito-borne pathogen that is spreading worldwide, and the associated infection (i.e. dirofilariosis) is becoming a threat to animals and humans living in endemic areas. Little is known about the occurrence and risk of infection of D. immitis in pinnipeds. Here we report dirofilariosis by D. immitis in several pinniped species kept in captivity in Portugal.D. immitis, blood was collected from the park’s resident pinniped population, which consisted of 16 animals . Dirofilaria immitis nematodes were detected by real-time PCR and by the presence of circulating antigens. In addition, modified Knott’s technique was performed to detect circulating microfilariae. Necropsies and histopathological examination of two animals which died during the study were also conducted.Animals were housed in an oceanographic park located in Algarve, southern Portugal, a geographical area endemic for canine dirofilariosis. To assess the occurrence of D. immitis by real-time PCR , two of which (P. vitulina) were also positive for the nematode’s antigen. Additionally, D. immitis microfilariae were detected in one A. p. pusillus. Furthermore, several D. immitis specimens were retrieved from the right ventricle and pulmonary arteries at the necropsy of one P. vitulina and one A. p. pusillus.Out of the 16 pinnipeds housed at the park, seven (43.8%) were positive for D. immitis infection in pinnipeds diagnosed through clinical, molecular and pathological findings. Additionally, the South African fur seal is herein reported as a new host for this zoonotic filarioid. The situation herein described could also occur in other parks located in areas where canine dirofilariosis is endemic. Active surveillance and preventive measures of dirofilariosis in pinnipeds on a local and global scale are therefore vital to improve the early diagnosis and control of dirofilariosis.This study provides new epidemiological data on  Dirofilaria immitis (Spirurida: Onchocercidae) is a mosquito-borne pathogen spreading worldwide, and the associated infection (i.e. dirofilariosis) is becoming a threat to animals and humans living in endemic areas [Dirofilaria immitis shows low vertebrate host specificity, infecting several mammalian species . In humans, this parasite may cause a severe clinical condition of increasing concern, with adult stages located mostly in the patient’s lungs, eyes or other anatomical districts [D. immitis in pinnipeds. Only a few cases of infection in captive pinnipeds have been described so far [D. immitis have only been found in one hooded seal (Cystophora cristata) [Phoca vitulina) [Zalophus californianus) kept in zoological parks in Florida [Arctocephalus pusillus pusillus, as a new host for D. immitis.ic areas . Althougistricts . Howeverd so far –7. Accord so far  and adulristata) , one comitulina) , and in  Florida , Louisia Florida  and Japa Florida . In the  Florida –6. Clini Florida , 5. Inde Florida –6. Here A. p. pusillus) housed at the Zoomarine park in Albufeira , D. immitis nematodes were accidentally found in the pulmonary arteries and right ventricle of two animals . These cases prompted an epidemiological survey to assess the occurrence of D. immitis in the park’s resident pinniped population (n = 16). In 2015, 5 common seals (Phoca vitulina), 2 grey seals , 3 California sea lions  and 6 South African fur seals (A. p. pusillus) were surveyed for D. immitis infection. All animals were housed in facilities with pools and dry areas and no ecto- or endoparasitic treatments were administered. The animals originated from either Europe or Canada, and remained in Portugal for at least 10 years.In 2013 and 2014, during the necropsy examinations of two adult South African fur seals (P. vitulina and H. grypus) and from the interdigital vein of the hind flippers or caudal gluteal vein in the otariids , as previously described [® HW Heartworm Antigen Test Kit  was used to assess the presence of D. immitis circulating antigens and a modified Knott’s technique was performed to detect circulating microfilariae in the pinnipeds’ blood. In one of the animals, it was possible to perform an ultrasound to assess the presence of heartworm infection and evaluate cardiac function.Physical examination was performed to check for the presence of abnormal clinical signs in individual animals. Blood was collected from the epidural intervertebral vein in the phocids , coupled with melting-curve analysis for the detection and discrimination of Dirofilaria spp. [Genomic DNA was extracted from segments (about 10 mm) of the adult worms collected from the necropsies and from the 16 blood samples, using a commercial kit  and tested by real-time PCR (qPCR), based on SsoFast™ EvaGreenria spp. . The rearia spp. .P. vitulina were antigen positive (12.5%) and one A. p. pusillus scored positive for D. immitis microfilariae (6.3%) , with melting peaks (mean Tm = 75 °C) corresponding to the species-specific range of D. immitis positive control (mean ± SD: 75.7 ± 0.3 °C) , showing 100% nucleotide identity to a D. immitis sequence in GenBank (KF553638).One us Table . Data frus Table . Macroscges Fig. , pulmonages Fig. , Fig. 4.D. immitis in pinnipeds, diagnosed through clinical, molecular and pathological findings. The South African fur seal is herein described as a new host of D. immitis. All animals were housed in a tourist attraction (i.e. an oceanographic park) in the Algarve region, southern Portugal, an area that records the highest number of days/year with suitable conditions for Dirofilaria transmission [This study provides new epidemiological data of dirofilariosis by smission , and thesmission .D. immitis infection in pinnipeds. Indeed, qPCR detected seven infected animals, of which two P. vitulina and one A. p. pusillus which were also positive for circulating antigen and microfilariae, respectively. qPCR was highly sensitive in diagnosing D. immitis in pinnipeds, since it was able to detect one animal that was only antigen-positive (no. 5) and another that was only-microfilaremic (no. 12), although both presented several nematodes  during the necropsy. In addition, it detected also another case  only positive for the antigen, but in which transthoracic echocardiography revealed linear hyperechoic structures consistent with heartworms within the right ventricle and main pulmonary arteries. Furthermore, qPCR was also able to detect four other animals that were negative in all other diagnostic tests used , two cases of pulmonary nodules by D. immitis [Dirofilaria repens [Although pinnipeds are aquatic mammals, they spend large periods of their life in terrestrial environments, and are therefore exposed to mosquito bites. As in the present survey,  immitis  and two a repens , 18 haveD. immitis herein reported in a confined area where pinnipeds are kept, may represent a risk interface for zoonotic pathogen transmission. Therefore, a One Health approach applied on a local and global scale [This study emphasizes the need for active surveillance of dirofilariosis in facilities where animals and humans are in close contact, and strengthens the need for routine heartworm preventive measures  and vectal scale  is vital


The concept of physical literacy has received increased research and international attention recently. Where intervention programs and empirical research are gaining momentum, their operationalizations differ significantly.The objective of this study was to inform practice in the measure/assessment of physical literacy via a systematic review of research that has assessed physical literacy .Five databases were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols guidelines, with 32 published articles meeting the inclusion criteria. English-language, peer-reviewed published papers containing empirical studies of physical literacy were analyzed using inductive thematic analysis.Qualitative methods included: (1) interviews; (2) open-ended questionnaires; (3) reflective diaries; (4) focus groups; (5) participant observations; and (6) visual methods. Quantitative methods included: (1) monitoring devices ; (2) observations ; (3) psychometrics ; (4) performance measures ; (5) anthropometric measurements; and (6) one compound measure. Of the measures that made an explicit distinction: 22 (61%) examined the physical domain, eight (22%) the affective domain; five (14%) the cognitive domain; and one (3%) combined three domains  of physical literacy. Researchers tended to declare their philosophical standpoint significantly more in qualitative research compared with quantitative research.Current research adopts diverse often incompatible methodologies in measuring/assessing physical literacy. Our analysis revealed that by adopting simplistic and linear methods, physical literacy cannot be measured/assessed in a traditional/conventional sense. Therefore, we recommend that researchers are more creative in developing integrated philosophically aligned approaches to measuring/assessing physical literacy. Future research should consider the most recent developments in the field of physical literacy for policy formation.The online version of this article (10.1007/s40279-017-0817-9) contains supplementary material, which is available to authorized users. In recent years, the concept of physical literacy has gained increasing international political attention and has been integrated into several educational and sport policies , 2. It iA recent systematic review outlined the challenges of many definitions of physical literacy and related constructs currently under debate such as different misinterpretations and lack of consistency with operationalization . Some ofIn an effort to summarize and synthesize this literature, Edwards et al.  conducteDebates acknowledging these philosophical standpoints have questioned whether physical literacy can be measured/assessed in any conventional sense, or at least what might constitute an appropriate method of collecting empirical data for the study of physical literacy , which aIn this context, it is important to acknowledge what is meant by measurement/assessment. According to Huitt et al. , measureAs noted by Dennett : “There positivism, which asserts that observations made by scientists can and should be completely unbiased and neutral, and that—if sufficient unbiased observations are made—then the underlying mechanisms and explanations will ‘emerge’ and become obvious, leading to theoretical understanding. That understanding can be used to generate specific refined hypotheses, which are then tested in further observations. Implicitly or explicitly, this is the core assumption underlying many scientific studies, even though many of its core assumptions have been disproved [Of course, the decision regarding whether this area of research is ‘in crisis’ is entirely subjective, but in proposing the very concept of physical literacy, Whitehead , 25 had isproved –31. It iNevertheless, it is important to ask whether these assumptions are applicable to the concept of physical literacy. Like positivism, several ‘sets’ of assumptions have been proposed arguing that the reality of physical literacy is not the same everywhere, for everyone, and thus cannot be measured in an unbiased, neutral, or consistent way. Broadly classified under the banner of ‘interpretivism’, these approaches rule out both the prospect of objective measurement, and the ‘reduction’ of a complex phenomenon to its component parts for ease of measurement . Fundameidealist and pragmatic perspectives, and have previously been referred to as ‘academic’ and ‘practical’ approaches [As a broad summary, two approaches have emerged in relation to how one understands the concept of physical literacy . These aproaches . An ideaproaches . As suchOther scholars have adopted a more pragmatic perspective when seeking to measure the concept of physical literacy , 42. A pA range of initiatives and programs have emerged from the pragmatic approach towards operationalizing physical literacy . Kiwi SpFurther, the importance of physical literacy has been acknowledged by the United Nations Educational, Scientific and Cultural Organisation to generate healthy, able, and active citizens as an outcome of high-quality PE . While iOverall, the tension appears to be between the desire to develop consistent, reliable, and valid measures of physical literacy, vs. the viewpoint that physical literacy is inherently complex and dynamic and thus not readily measured using such instruments. We do not currently know what measures/assessments are most appropriate for different age groups and environments. To help resolve this tension at the heart of physical literacy research, a systematic review of current empirical research—including methods of measuring/assessing the concept of physical literacy—was conducted to facilitate new insight and clarify key considerations. Previous narrative reviews on physical literacy outlined the importance of assessing participants’ knowledge within the concept of physical literacy , and empTwo systematic reviews concerning physical literacy and its related constructs have been conducted; specifically, one that investigated the effectiveness of school-based physical activity interventions on students’ health-related fitness knowledge  and anotTo systematically review the empirical research and measurement/assessment attempts in relation to the concept of physical literacy and its related constructs ; andTo critically characterize, evaluate, and compare existing measures/assessments of physical literacy and its related constructs in relation to age group, environment, and philosophy.The purpose of this systematic review was to collate and analyze empirical studies conducted on physical literacy and its related constructs, and to synthesize, and reflect on, current  empirical measurement practice regarding physical literacy. Consequently, the aim will be met through the following two objectives:The methodology of this article was adapted from that of Edwards et al.’s  systematAn electronic search strategy was deployed, using the following databases: (1) SPORTDiscus; (2) MEDLINE (via PubMed); (3) Scopus; (4) ScienceDirect; and (5) Education Research Complete, last searched on 14 June, 2017. The above databases report on areas including education, sport, and health, which are relevant to the concept of physical literacy and therefore increased the likelihood that all relevant studies were located , 62. A BThe inclusion criteria in this systematic review were as follows: 1) papers with a peer-reviewed published status; and (2) publications in the English language up until the date last searched: 14 June, 2017. To address the aims and objectives of the study, the following exclusion criteria were adopted: (1) papers not attempting to measure/assess attempts and/or empirical studies; (2) conference reports and readings; and, (3) editors’ letters, forewords, and comments. The authors used the PRISMA-P evidence-based checklist during the planning, conduct analysis, and reporting of this process . The PRI papers wA total of 671 papers were identified through database searches and an additional 50 records were retrieved from the reference lists in these 671 papers. In line with the PRISMA-P procedures, a total of 515 duplicated papers were removed during the search process, leaving 206 papers for the screening process. Non-duplicated papers were read thoroughly by two analysts and evaluated against the inclusion/exclusion criteria: in each case, mutual agreement was required between analysts . To ensuInitially, inductive thematic analysis was employed to extract, label, and evaluate data from each paper. Characteristics including the author(s), definition of physical literacy used, philosophy adopted, outcome assessed, strengths and limitations of measures/assessment in relation to physical literacy and related constructs, age group, and environment were extracted from the 32 papers in the analysis  physical domain; (2) affective domain; (3) cognitive domain; and (4) physical, affective, and cognitive domains  as opposed to not declaring their philosophical assumptions (n = 15). In this review, the adoption/declaration of a holistic philosophical standpoint was dependent on the individual studies as opposed to the specific qualitative methodology. To achieve alignment between the definition, philosophy, and outcome measure/assessment, researchers working within physical literacy should be explicit about the definition and philosophy they adopt.Overall, interviews, focus groups, participant observation, and video recordings were predominantly holistic in their philosophy, whereas open-ended questionnaires and portfolios did not declare a philosophy. More qualitative papers adopted a holistic philosophy, purportedly drawing from phenomenology, monism, and existentialism . A likely reason for more measures/assessments in children aged under 12 years may be the opportunistic research strategies, as children aged under 12 years are readily accessible in a school environment. The results of the analysis suggest that interviews, reflective diaries, photo elicitation, and participant observation were highly suitable for children aged under 12 years  [The analysis revealed that the dominant environment to qualitatively assess physical literacy was during PE lessons ( papers) –84, 94.  papers)  and five papers) , 79, 85.In contrast to qualitative measures/assessments, the definition of physical literacy adopted by quantitative measures/assessments varied: 29% of measures/assessments used Whitehead’s definition , 80, 92;n = 1) [n = 7) [Under the physical domain, two quantitative measures/assessments adopted a holistic philosophy , whereasn = 1)  compared [n = 7) , 87, 90. [n = 7) , 86, 90  [n = 7) . Overall [n = 7) , 90, 92  [n = 7) .Further, quality of movement was often not measured/assessed in the quantitative studies that captured the physical domain; tests were usually timed, which was problematic for the following two reasons. First, solely timing a test as the main measure omits the opportunity for quality of movement to be captured. Second, these types of times tests have the potential to create a comparative environment if administered in the incorrect manner , 90–92. n = 4) compared with adolescents (n = 1) and adults (n = 0) [Similar to the findings in the qualitative measures/assessments subsection, children aged under 12 years were the leading age group studied most often under the physical domain with a total of nine quantitative measures/assessments , 88–91.  (n = 0) , 87, 89. (n = 0) , 80, 90  (n = 0) , 79, 80  (n = 0) , 86.Though there are limitations with recall in self-report measures with children, many quantitative measures/assessments across physical, affective, and cognitive domains were judged to be reliable –90, 93. Many quantitative measures/assessments are cost/time effective and easy to administer; therefore, they would be accessible in a variety of different environments (PE/community/other) , 85, 93.The results and discussion clearly demonstrate a scarcity of measures/assessments that attempt to capture the entire range of domains within physical literacy, and/or treat it as an integrated construct across these domains. To date, only one measure/assessment  has attempted to collectively measure/assess three domains of physical literacy . Three potential reasons for the limited measures/assessments of physical literacy include: (1) researchers are yet to discover measures/assessments that align with their definition and philosophy of physical literacy; (2) researchers are yet to discover the appropriate physical literacy measures/assessments for the age and/or environment; and, (3) the complex and multifaceted physical literacy concept poses challenges to researchers on how it is best operationalized. Adding to this complexity, the results of the present systematic review indicate that researchers are yet to consider the social domain within measures/assessments of physical literacy. As such, our analysis revealed that by adopting simplistic and linear methods, physical literacy cannot be measured/assessed in a traditional/conventional sense. In this context, there is a need for more creative approaches to measure/assess physical literacy through non-conventional methods. Future research should therefore consider the more recent developments by Dudley et al.  in the fPapers in the English language were solely considered for this systematic review; thus, the papers were primarily derived from the UK and Canada, which may be considered as a limitation. Owing to the limited empirical research on the concept of physical literacy, the 32 papers included in the present study encompassed both physical literacy and its related constructs, such as physical activity. Caution should be exercised when assessing the papers that measure/assess the related constructs of physical literacy. These papers should not be considered as the sole method to measure/assess physical literacy, but used in conjunction with explicit physical literacy assessments. Nevertheless, future empirical research and attempts to measure/assess physical literacy will significantly contribute to the field of physical literacy.This paper is the first to provide a systematic review of empirical research efforts to measure or assessment physical literacy, and is the first to systematically reveal that the concept cannot be measured/assessed in a traditional and conventional sense using simplistic and linear methods. This systematic review has identified the strengths and limitations of both qualitative and quantitative approaches to measuring/assessing physical literacy in relation to age group, environment, and philosophy adopted . QuantitAn implication for theory development within physical literacy is the need for researchers to declare their definition and philosophical standpoint whilst undertaking empirical research, to ensure alignment between the definition, philosophy, and measure/assessment adopted. Identifying a philosophical standpoint would enable researchers to “operationalize the related construct of physical literacy and establish meaningful, measureable differences” . WithoutSimilarly, to apply high-quality pedagogy to foster physical literacy, practitioners should also consider creating a caring climate , empowerRecommendations for future research include a need for more empirical research on the concept of physical literacy; essentially, there is a need for more research that is open about the definition and philosophical approach used and theories tested. Future research should measure/assess beyond the constructs of physical proficiencies, and aim to measure/assess physical literacy from a more holistic perspective. Further, research across all ages and different environments is required; current research is predominantly constrained to children and youth in PE lesson settings with a minority measuring/assessing physical literacy in young adults, adults, and the elderly.Supplementary material 1 (DOCX 649 kb)Supplementary material 2 (DOCX 28 kb)Below is the link to the electronic supplementary material.


Since the introduction of minimally invasive gynecologic surgery, the percentage of advanced laparoscopic procedures has greatly increased worldwide. It seems therefore, timely to standardize laparoscopic gynecologic care according to the principles of evidence-based medicine. With this goal in mind—the Dutch Society of Gynecological Endoscopic Surgery initiated in The Netherlands the development of a national guideline for laparoscopic hysterectomy (LH). This present article provides a summary of the main recommendations of the guideline.This guideline was developed following the Dutch guideline of medical specialists and in accordance with the AGREE II tool. Clinically important issues were firstly defined and translated into research questions. A literature search per topic was then conducted to identify relevant articles. The quality of the evidence of these articles was rated following the GRADE systematic. An expert panel consisting of 18 selected gynecologists was consulted to formulate best practice recommendations for each topic.Ten topics were considered in this guideline, including amongst others, the different approaches for hysterectomy, advice regarding tissue extraction, pre-operative medical treatment and prevention of ureter injury. This work resulted in the development of a clinical practical guideline of LH with evidence- and expert-based recommendations. The guideline is currently being implemented in The Netherlands.A guideline for LH was developed. It gives an overview of best clinical practice recommendations. It serves to standardize care, provides guidance for daily practice and aims to guarantee the quality of LH at an (inter)national level. Since the introduction of laparoscopic hysterectomy (LH) more than 2 decades ago, a rapid implementation of this procedure has been observed in many countries , 2. For With this goal in mind, the Dutch Society of Gynecological Endoscopic Surgery (WGE) initiated the development of a guideline for LH. This guideline aims to provide gynecologists with an overview of best practices, directly applicable for daily practice. The guideline should also ensure a minimum quality of care and enhance patient safety. This article provides a summary of the main recommendations of the guideline.The WGE, a working group of the Dutch Society of Obstetrics and Gynecology (NVOG), initiated the development of the guideline. A guideline working group was assembled and consisted of three gynecologists and one resident . The guideline was developed in accordance with the Dutch guideline of medical specialists . This doA brainstorming session was organized by the WGE with 40 gynecologists, all performing advanced laparoscopic procedures. During that meeting, key topics for this guideline were determined and transformed into appropriate clinical research questions.st of March 2016. Each research question had its own inclusion and exclusion criteria. Overall, we first searched for systematic reviews. If none were available, we focused on randomized controlled trials (RCTs) and, if necessary, added cohort studies as well. Studies from the eligible systematic reviews were reviewed to avoid duplicate inclusions. Only LH for benign indications and/or low-grade malignancy were considered and will hereinafter be referred to as ‘laparoscopic hysterectomy’ (LH). Studies focusing on endometriosis sanitation with concomitant LH as well as high-grade malignancy were not included. Study reports, letters, non-published manuscripts and articles that were not published in English were also excluded. After selecting the eligible studies, these studies were summarized in evidence tables and when possible, extracted for meta-analysis using Review Manager . The quality of evidence was rated for the different outcomes following the GRADE method . Standard stent placement could also result in unnecessary complications. Stents are, however, easy to insert and improve the identification of the ureters. In the Delphi study by Janssen et al., the experts did not reach consensus regarding the additional value of ureter stents during LH [.29]. StaRecommendationsCystoscopy appears to be safe and results in limited extension of the operative time . When the overall risk of bladder and/or ureter injuries is below 2%, a standard cystoscopy is not cost-effective for LH . The AmeRecommendationsRecommendationsBased on the available evidence, we concluded that the incidence of unexpected sarcoma varies between 1:350 and 1:2000  and incrRecommendationsUsing a urinary catheter during LH is recommended  but the RecommendationsSufficient evidence is available to state that LH is associated with a shorter hospital stay and a quicker recovery than AH . HoweverRecommendationsThis guideline serves as a summary of best practices of LH, and it should provide clinicians with relevant and evidence-based information for daily practice. In other countries such as Germany, guidelines on hysterectomy have been developed as well with similar recommendations . BesidesRegarding the methodology of this guideline, we focused on systematic reviews and RCTs. If insufficient evidence was available from the RCTs, we added cohort studies to our analysis. A limitation of this approach is that it increases the methodological and clinical heterogeneity. For instance, by including cohort studies, differences in baseline characteristics might exist, which could have influenced the outcomes. On the other hand, this method can also been seen as a strength because for rare events RCTs are often not the best study design as they are often underpowered. During the development of this guideline, we realized that, although GRADE is currently a well-established instrument to assess the quality of evidence , it has The guideline for LH serves as guidance for gynecologists performing LHs. The recommendations in this best practice review should enhance quality of care, minimize (unfavorable) practice variations at the (inter)national level and thereby increase patient safety.


Clinical Practice Guidelines are developed to improve clinical standards, encourage use of evidence-based treatments, and provide a foundation for audits, service evaluation, and research. This presentation by the expert writing group responsible for the updated RANZCP Clinical Practice Guidelines for Schizophrenia and Related Disorders describes the process, the challenges and the barriers in writing these new clinical guidelines. Once published, dissemination, discussion and utilisation of new clinical practice guidelines is crucial.https://www.ranzcp.org/Publications/Guidelines-and-resources-for-practice.aspx.The RANZCP Clinical Practice Guidelines (CPG) for Schizophrenia and Related Disorders were developed using the existing RANZCP and international guidelines, research evidence, and in the absence of clear evidence, expert consensus. The NHMRC levels of evidence for intervention studies were used as a benchmark for each recommendation. A clinical staging model was proposed. There was an increased emphasis on physical health comorbidities, psychological treatments, and vocational recovery. The draft document was subjected to extensive review and revision involving independent psychiatrists, other clinicians and stakeholders, consumer groups, RANZCP committees and reviewers for the ANZJP. The Guidelines are available for open access on the RANZCP website at The Guidelines have been widely cited. The RANZCP has developed a Consumer Guide and Clinical Audit Tools based on the CPG recommendations. The recommendations made in the guidelines have resulted in some controversy – most notably about the use of depot antipsychotics, and antipsychotic medication discontinuation after recovery from first episode psychosis. As with most CPGs, there is no mechanism for ongoing updating of treatment recommendations in response to new evidence, so regular revisions of CPGs will be needed.The Guidelines provide a comprehensive summary of the evidence for interventions to treat schizophrenia and related disorders, set out a recommended standard of care to be adopted by clinicians in Australia and New Zealand, and create a benchmark against which individual practice and services can be compared. The debate generated by the publication of the guidelines has highlighted the gap between the recommended standard of care and existing practice, especially as it relates to the physical care and psycho-social interventions offered to people with these conditions.


The multi-sensor data fusion technique plays a significant role in fault diagnosis and in a variety of such applications, and the Dempster–Shafer evidence theory is employed to improve the system performance; whereas, it may generate a counter-intuitive result when the pieces of evidence highly conflict with each other. To handle this problem, a novel multi-sensor data fusion approach on the basis of the distance of evidence, belief entropy and fuzzy preference relation analysis is proposed. A function of evidence distance is first leveraged to measure the conflict degree among the pieces of evidence; thus, the support degree can be obtained to represent the reliability of the evidence. Next, the uncertainty of each piece of evidence is measured by means of the belief entropy. Based on the quantitative uncertainty measured above, the fuzzy preference relations are applied to represent the relative credibility preference of the evidence. Afterwards, the support degree of each piece of evidence is adjusted by taking advantage of the relative credibility preference of the evidence that can be utilized to generate an appropriate weight with respect to each piece of evidence. Finally, the modified weights of the evidence are adopted to adjust the bodies of the evidence in the advance of utilizing Dempster’s combination rule. A numerical example and a practical application in fault diagnosis are used as illustrations to demonstrate that the proposal is reasonable and efficient in the management of conflict and fault diagnosis. The multi-sensor data fusion technique plays a significant role in fault diagnosis. Due to the complexity of the targets, the report collected from a single sensor is insufficient in decision making processes. Additionally, because of the impact of the environment, the data gathered from multiple sensors may be unreliable or even wrong so that it can cause erroneous results in fault diagnosis. Hence, multi-sensor data fusion technologies are required in various fields of practical applications ,6,7,8,9,Dempster–Shafer evidence theory, which is an uncertainty reasoning tool, was firstly proposed by Dempster ; then, iIn this paper, therefore, a novel multi-sensor data fusion method is proposed, which is a hybrid methodology in terms of the distance of evidence, belief entropy and fuzzy preference relation analysis. The proposal considers the support degree among the pieces of evidence, the uncertainty measure of the evidence and the effect of the relative credibility of the evidence on the weight, so that it can obtain more appropriately weighted average evidence before using Dempster’s combination rule. Specifically, the proposed method consists of the following procedures. First, in order to measure the support degree between the pieces of evidence, the function of evidence distance is leveraged, where the support degree represents the reliability of the evidence. After that, the relative credibility preference of the evidence is indicated by taking advantage of the fuzzy preference relation analysis on the foundation of the uncertainty of each piece of evidence measured by the belief entropy. Based on that, the support degrees of the evidence are adjusted, which can be utilized to generate the appropriate weights with regard to the evidence. Finally, the weighted average evidence can be obtained on the basis of the modified weights of the evidence before using Dempster’s combination rule. A numerical example and a practical application in fault diagnosis are used as illustrations to demonstrate that the proposed method outperforms the related methods with respect to the conflict management and fault diagnosis.The remaining content of this paper is arranged below. Dempster–Shafer evidence theory ,24 is exDefinition 1 (Frame of discernment).Let Θ be a nonempty set of events that are mutually-exclusive and collectively-exhaustive, defined by:in which the set Θ denotes a frame of discernment.The power set of Θ is represented as and ∅ is an empty set.When A is an element of the power set of Θ, i.e., Definition 2 (Mass function).In the frame of discernment Θ, a mass function m is represented as a mapping from which meets the conditions below:m in the Dempster–Shafer evidence theory can also be called a basic probability assignment (BPA). When A as the element of A.The mass function Definition 3 (Belief function).Let A be a proposition where The plausibility function where A, and the plausibility function A.Apparently, the plausibility function Definition 4 (Dempster’s rule of combination).Let two basic probability assignments (BPAs) be  Θ where the BPAs with:where B and C are also the elements of Notice that Dempster’s combination rule is only practicable for the BPAs Jousselme et al.  presenteDefinition 5 (Distance between two BPAs).Let two basic probability assignments (BPAs)  Θ, which contains N number of mutually-exclusive and collectively-exhaustive propositions. The distance between the BPAs where The elements of where A and B, which means that the element A highly conflicts with the element B so that the degree of similarity between the elements A and B is zero. Therefore, the smaller the A and B there is; whereas, A is identical to the element B.It can be stated that A belief entropy, called the Deng entropy, was first proposed by Deng  and has A be a proposition of the basic probability assignment (BPA) m on the frame of discernment m is defined as follows: A.Let When the belief is only allocated to the single object, which means that The larger the cardinality of the proposition is, the larger the Deng entropy of evidence is, so that the evidence contains more information. When a piece of evidence has a big Deng entropy, it is supposed to be better supported by other evidence, which represents that this evidence plays an important part in the final combination.Fuzzy preference relations play a fundamental part in many decision-making processes, and they were first presented by Tanino  in 1984.Definition 6.Let P be a fuzzy preference relation and where .Let P∗(1)(2)(3)(4)The consistency matrix Let In this paper, by considering not only the conflicts between pieces of evidence, but also the impact of the evidence’s uncertainty itself, a novel multi-sensor data fusion approach is presented and applied in fault diagnosis. The proposed method is a hybrid methodology that integrates the distance of evidence, belief entropy and fuzzy preference relation analysis, which consists of the following parts.The function of evidence distance is first leveraged for measuring the conflict degree among the pieces of evidence, then the support degree resulting from the distance of the evidence is obtained to denote the evidence’s reliability. When the evidence is well supported by other pieces of evidence, it is supposed to have less conflict with other pieces of evidence, so that a big weight should be allocated to this piece of evidence. Instead, when the evidence is poorly supported by other pieces of evidence, it is regarded to highly conflict with other pieces of evidence so that a small weight should be allocated to this evidence. Next, the information volume of the evidence is calculated by making use of the belief entropy. Based on the calculated quantitative information volume, the fuzzy preference relations analysis is applied to indicate the relative credibility preference in terms of the pieces of evidence. Whereafter, the support degree of the evidence is adjusted by taking advantage of the relative credibility preference of the pieces of evidence. Thanks to introducing the fuzzy preference relations analysis based on the belief entropy, it can automatically construct the fuzzy preference relation matrix, rather than being determined by experts, which decreases the epistemic non-determinacy in the decision-making process. Finally, the adjusted weights of the pieces of evidence are applied to modify the body of the pieces of evidence before utilizing Dempster’s combination rule. The flowchart of the proposal is shown in Step 1:The distance measure quations  and 10)dij betweStep 2:The similarity measure Then, the similarity measure matrix Step 3:The support degree of the BPA Step 4:The support degree of the BPA Step 1:The belief entropy of the BPA Equation .Because the belief entropy of the evidence may be zero in a certain case, in order to avoid allocating zero weight to such kinds of evidence, we utilize the information volume Step 2:The information volume of the BPA Step 3:Step 3-1:According to Definition 6, the diagonal element Step 3-2:If there are only two pieces of evidence, all of the off-diagonal elements Step 3-3:If there are more than two pieces of evidence, the variance of entropy for the BPA Step 3-4:The smaller the value duced in .(27)pijThe fuzzy preference relation matrix Step 4:Based on the obtained fuzzy preference relation matrix Equation .Step 5:With the consistency matrix Equation :(29)CrdWe can notice that In the course of information fusion, it is important to identify the relatively credible evidence in terms of the obtained pieces of evidence. Due to the increase of the uncertainty in the collection of information, the degree of anarchy involved in the systems rises, which violates the necessary condition to use Dempster’s rule of combination. Utilizing the ordered information can make the technologies based on the Dempster–Shafer evidence theory more robust. Therefore, we take advantage of the fuzzy preference relations analysis  based onStep 1:Based on the credibility degree Step 2:The Step 3:k denotes the number of BPAs and i-th BPA, which are modeled from the sensor reports.On the basis of the final weight Step 4:k number of pieces of evidence. Then, the final combination result of multiple pieces of evidence can be obtained.The weighted average evidence Equation , by k−1 In this section, to demonstrate the effectiveness of the proposal, a numerical example is illustrated.Example 1.Consider a target recognition problem based on multiple sensors associated with the sensor reports that are collected from five different types of sensors. These sensor reports that are modeled as the BPAs are given in  Θ that consists of three potential objects is given by Step 1:Construct the distance measure matrix Step 2:Construct the similarity measure matrix Step 3:Calculate the support degree of the BPA Step 4:Normalize the support degree of the BPA Step 5:Measure the information volume of the BPA Step 6:Normalize the information volume of the BPA Step 7:Construct the fuzzy preference relation matrix Step 8:Construct the consistency matrix Step 9:Calculate the credibility value of the BPA Step 10:Adjust the normalized support degree of the BPA Step 11:Normalize the adjusted support degree of the BPA Step 12:Compute the weighted average evidence as below:Step 13:Combine the weighted average evidence by utilizing Dempster’s rule of combination four times. The results of the combination for the first time are shown below:For the combination for the second time, the results are listed as follows:Next, the results of the third combination are calculated as:Then, the combination results of the fourth time, namely the final fusing results, are produced as follows:From Example 1, we can notice that the evidence A by different combination rules are shown in The fusing results that are generated by different combination methods are shown in A. As the number of pieces of evidence increases from 3–5, Murphy’s method [As shown in s method , Deng ets method , Zhang es method  and the In this section, the proposal is applied to the fault diagnosis of a motor rotor, where the practical data in  are usedS = Supposing that the frame of discernment According to the proposed method in After that, the weighted average evidence in terms of motor rotor fault diagnosis at Then, the results of the combination for the second time, namely the final fusing results for motor rotor fault diagnosis at On the basis of the proposed method in Next, by leveraging Dempster’s rule of combination, the weighted average evidence with respect to motor rotor fault diagnosis at Afterwards, for the combination for the second time, the final fusion results with respect to motor rotor fault diagnosis at By applying the proposed method in Therewith, the weighted average evidence with regard to motor rotor fault diagnosis at Then, the final combination results for the second time for motor rotor fault diagnosis at According to the results as shown in s method . Even faFurthermore, the proposed method outperforms Jiang et al.’s method  in termsg et al.  are 88.6On the other hand, the uncertainty In this paper, on account of the support degree among the pieces of evidence, the uncertainty measure of the evidence and the effect of the relative credibility of evidence on the weight, a novel method for multi-sensor data fusion was proposed. The proposed method was a hybrid methodology by integrating the distance of evidence, belief entropy and fuzzy preference relation analysis. It consisted of three main procedures. Firstly, the support degree of the evidence was calculated to represent the reliability of the evidence. Secondly, the credibility value of the evidence was generated to indicate the relative credibility preference of the evidence. Thirdly, based on the first two procedures, the weighted average evidence was obtained; thus, it could be fused by applying Dempster’s combination rule. As described above, the proposed method was a kind of approach to pre-process the bodies of evidence. Through a numerical example, it was illustrated that the proposal was more effective and feasible than other related methods to handle the conflicting evidence combination problem under a multi-sensor environment with better convergence. On the other hand, a practical application in fault diagnosis was presented to demonstrate that the proposed method could diagnose the faults more accurately.In future work, I intend to consider further fault diagnosis of complicated equipment/systems that involves certain faults, such as cracks and misalignment. On the other hand, multiple faults, like bearing faults, rotor-related faults, etc., will be taken into account in future work to improve the robustness of the technique.References


Over 25 years, emergency medicine in the United States has amassed a large evidence base that has been systematically assessed and interpreted through ACEP Clinical Policies. While not previously studied in emergency medicine, prior work has shown that nearly half of all recommendations in medical specialty practice guidelines may be based on limited or inconclusive evidence. We sought to describe the proportion of clinical practice guideline recommendations in Emergency Medicine that are based upon expert opinion and low level evidence.Systematic review of clinical practice guidelines  published by the American College of Emergency Physicians from January 1990 to January 2016. Standardized data were abstracted from each Clinical Policy including the number and level of recommendations as well as the reported class of evidence. Primary outcomes were the proportion of Level C equivalent recommendations and Class III equivalent evidence. The primary analysis was limited to current Clinical Policies, while secondary analysis included all Clinical Policies.A total of 54 Clinical Policies including 421 recommendations and 2801 cited references, with an average of 7.8 recommendations and 52 references per guideline were included. Of 19 current Clinical Policies, 13 of 141 (9.2%) recommendations were Level A, 57 (40.4%) Level B, and 71 (50.4%) Level C. Of 845 references in current Clinical Policies, 67 (7.9%) were Class I, 272 (32.3%) Class II, and 506 (59.9%) Class III equivalent. Among all Clinical Policies, 200 (47.5%) recommendations were Level C equivalent, and 1371 (48.9%) of references were Class III equivalent.Emergency medicine clinical practice guidelines are largely based on lower classes of evidence and a majority of recommendations are expert opinion based. Emergency medicine appears to suffer from an evidence gap that should be prioritized in the national research agenda and considered by policymakers prior to developing future quality standards. Over the last fifty years medicine has increasingly moved away from anecdotal replication of practice patterns taught during training and embraced evidence-based medicine. This transition is most strongly embodied by the widespread publication and dissemination of clinical practice guidelines by medical specialty societies, health care institutions, and governmental bodies. Such guiThe first Emergency medicine clinical practice guidelines were developed by the American College of Emergency Physicians (ACEP) in 1990 for the management of patients with chest pain. While emWhile the development process used for clinical practice guideline development is designed to reflect the highest quality of available evidence for clinical scenarios, prior evaluations of clinical guidelines in cardiology, obstetrics and gynecology and infectious disease found that many recommendations are based on lower-classes of evidence quality with the majority of recommendations based on expert opinion and low level evidence–8. ACEP Accordingly, we sought to describe the proportion of Clinical Policy recommendations that are based upon expert opinion and low level evidence, and to describe the classes of evidence supporting these ACEP Clinical Policies. We also sought to examine trends in the emergency care evidence base by describing trends in both recommendations and evidence classification.Systematic review of American College of Emergency Physicians clinical policies using PRISMA guidelines .http://www.acep.org/clinicalpolicies/. ACEP Clinical Policies are the only regularly published, medical specialty society sponsored clinical practice guidelines specific to emergency care in the United States. Each Clinical Policy is published as a peer-reviewed manuscript containing evidence-based recommendations designed to guide clinical practice. A Clinical Policy was defined as “current” if it was listed as such and available for download on the ACEP Clinical & Practice Management website as of October 20, 2015. A Clinical Policy was defined as “non-current” if it was listed as “past” on the ACEP Clinical & Practice Management website. We did not include clinical guidelines published by other professional organizations in emergency medicine, as they have neither a regular process nor a group charged with regular clinical guideline development and maintenance. We also did not include clinical guidelines published primarily by other organizations and co-signed or endorsed by ACEP as they followed a different review and writing process : bibliographic; evidence-based; and recommendation-based data elements.The bibliographic data collected included date published, the clinical category focus of the guideline , current or non-current Clinical Policy status, whether it is a revision of the prior Clinical Policy, and whether other clinical societies (e.g. the American College of Cardiology) were involved in authorship. Each Clinical Policy includes a compendium of references in a single evidentiary table, so evidence grading can only be abstracted at the Clinical Policy level and not specific to each recommendation. References in the bibliography or evidentiary table that were not assigned a class of evidence were excluded. This was particularly applicable to the oldest Clinical Policies because evidence was not always explicitly documented between 1990 to 1995 with the first comprehensive classification of evidence appearing in Clinical Policies after 1996 [The evidence-based data elements were abstracted from the bibliography of each Clinical Policy in which each reference is graded as Class I, II, or III  from the first ACEP Clinical Policy in 1990 until 2009 with perfect inter-rater reliability for the extracted data, except for the levels of recommendation for one Clinical Policy , which iThe primary outcomes were the proportion of all current recommendations reported as level C equivalent and the proportion of all current evidence reported as class III equivalent.We report descriptive statistics including the mean number of recommendations and mean number of references included within each Clinical Policy. We also report each outcome by year and use the Cochrane Armitage test for trend to evaluate the change in the proportion of Level C Recommendations and Class III Equivalent evidence over time. We also use chi-square tests to describe differences in the primary outcome between current and non-current Clinical Policies.Because many Clinical Policies provide recommendations for unique clinical indications are available in the literature or secondary clinical knowledge tools despite no longer being listed as “current” by ACEP, and because several earlier versions of Clinical Policies contain unique recommendations not included in future Clinical Policies, we also conducted a secondary analysis of all Clinical Policies in the dataset. For example, “Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures” has been revised four times—2014, 20041818, 1997[Between January 1990 and January 2016 ACEP published 54 Clinical Policies at a mean rate of 2.3 Clinical Policies per year . These Clinical Policies cover 27 unique topics of which 9 have no published revision or are first version Clinical Policies and 45 are updates or expansions upon prior Clinical Policies. A total of 25 Clinical Policies are clinically focused on a chief complaint (e.g. headache), 21 on a specific disease (e.g. appendicitis), and 8 on a procedure or intervention .Of all Clinical Policies, 19 (35%) were classified as current Clinical Policies, the oldest of which was published in 2003. PoliciesAmong the 19 current ACEP Clinical Policies, 14 were updates or revisions of prior guidelines and 5 represented the first version on a given topic. These current Clinical Policies contain 141 recommendations , of which 13 were Level A equivalent recommendations (9.2%), 57 Level B equivalent recommendations (40.4%), and 71 Level C Equivalent Recommendations (50.4%). In total the current clinical policies contained 845 graded pieces of evidence . Sixty-seven pieces of evidence were Class I equivalent (7.9%), 272 were Class II equivalent (32.2%), and 506 were Class III Equivalent (59.9%).Among the 14 current Clinical Policies that are the most recent revisions of 23 prior Clinical Policies, the proportion of level C equivalent recommendations increased from 36.3% in prior iterations to 44.7% in the current 14 Clinical Policies. Similarly, the proportion of Class III equivalent evidence also increased from 42.3% to 60.0%.Of 421 total recommendations included in all 54 Clinical Policies in the dataset, 37 (8.8%) were Level A equivalent recommendations, 184 (43.7%) Level B equivalent recommendations, and 200 (47.5%) Level C equivalent recommendations. There was no statistically significant trend in the proportion of Level C recommendations in guidelines between 1996, the first year of structured grading of recommendations, and January 2016 (two-sided Cochrane Armitage trend test p = 0.30)   were Class I equivalent, 1154 (41.2%%) were Class II equivalent, and 1369 (48.9%) were Class III equivalent. The proportion of Class III Equivalent evidence contained in current clinical policies was significantly higher than non-current Clinical Policies . In addition, the proportion of Class III evidence in clinical practice guidelines significantly increased between 1996 and 2015 (two-sided Cochrane Armitage trend test: p<0.0001).The development of clinical practice guidelines has become widespread across medical specialties including emergency medicine. We found that, like other specialties, close to half of current recommendations in emergency medicine clinical practice guidelines are based on expert opinion or lower classes of evidence rather than high quality clinical trials. We also found that clinical policies are increasingly likely to proportionally contain Level C recommendations and Class III evidence, including the subset of clinical policies that reflect updates and revisions to prior clinical policies.These evidence gaps in current emergency care clinical practice guidelines reflect the design of the ACEP Clinical Policy development and reporting process as well as gaps in the emergency medicine evidence base. Some medical specialties develop clinical practice guidelines based on the existing evidence base in a manner consistent with several international consensus standards for clinical practice guideline development. ACEP CliA growing proportion of emergency care clinical practice guidelines are based on lower classes of evidence despite a growing body of emergency care research and publications. This evidence deficit may be permissible for recommendations that are unlikely to warrant the conduct of a randomized clinical trial such as the recommendation to obtain a blood glucose in seizure patients, which is consistent with good clinical practice but unlikely to ever meet the Level A threshold. On the other hand, clinical recommendations such as the use of both a parenteral benzodiazepine and haloperidol to produce more rapid sedation than monotherapy in the acutely agitated patient  or the pIn addition to research gaps, we also identified several opportunities to improve the quality of each Clinical Policy based on the recent recommendations of the IOM. While ouCritical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism, includes one Level B recommendation and two Level C recommendations that serve as the basis for the quality measure, “Appropriate Emergency Department Utilization of CT for Pulmonary Embolism”included in the new CMS approved Clinical Emergency Department Registry (CEDR) (25).[Clinical Policy: Critical Issues In The Evaluation And Management Of Adult Patients Presenting To The Emergency Department With Acute Headache was cited in an evaluation of the measure that subsequently led to the withdrawal of the measure due to lack of supporting evidence. [Our findings also carry several implications for policymakers. As formal criteria for the classes of evidence or requirements for clinical practice guidelines to support the endorsement or use of quality measures are adopted—the content and quality of Clinical Policies become of utmost importance for clinical standards used in new pay for performance programs–34 PolicDR) (25). In contrvidence.  A recentvidence. , particuvidence. Several limitations of our work warrant mention. First, our systematic review was limited to clinical practice guidelines promulgated by the major emergency medicine specialty society in the United States and did not include the many clinical practice guidelines and recommendations for emergency care that may be contained within guidelines published by other specialty societies or in other countries. Second, the current design of ACEP Clinical Policies that published a summary evidence table precludes any assessment of the strength of evidence supporting individual recommendations—as such our conclusions reflect a broad assessment of current Clinical Policies as opposed to a detailed evaluation of individual clinical questions. Finally, our review abstracted recommendations and strength of designations as reported in each Clinical Policy and did not re-assess the strength of each recommendation or guideline using an independent scoring tool, such as AGREE II. As such,Nearly half of current emergency medicine clinical practice guideline recommendations are based on expert opinion and low level evidence rather than clinical trial evidence. Despite a rapidly expanding body of published emergency care research, clinical practice guidelines increasingly contain consensus-based recommendations based on lower classes of evidence. These evidence gaps in clinical guidelines highlight priorities for the future emergency care research agenda. Policymakers should be aware of the low quality of evidence behind many guideline recommendations when developing future quality standards.S1 Appendix(DOC)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Thus, both gp120 and MVAgp140 can augment potential protection of a DNA/MVA vaccine by enhancing gp120 and V1/V2 antibody responses, whereas potential protection by gp120, but not MVAgp140 boosts, may be further impacted by increased CD4+ T cell responses.An important goal of human immunodeficiency virus (HIV) vaccine design is identification of strategies that elicit effective antiviral humoral immunity. One novel approach comprises priming with DNA and boosting with modified vaccinia virus Ankara (MVA) expressing HIV-1 Env on virus-like particles. In this study, we evaluated whether the addition of a gp120 protein in alum or MVA-expressed secreted gp140 (MVAgp140) could improve immunogenicity of a DNA prime-MVA boost vaccine. Five rhesus macaques per group received two DNA primes at weeks 0 and 8 followed by three MVA boosts  at weeks 18, 26, and 40. Both boost immunogens enhanced the breadth of HIV-1 gp120 and V1V2 responses, antibody-dependent cellular cytotoxicity (ADCC), and low-titer tier 1B and tier 2 neutralizing antibody responses. However, there were differences in antibody kinetics, linear epitope specificity, and CD4 T cell responses between the groups. The gp120 protein boost elicited earlier and higher peak responses, whereas the MVAgp140 boost resulted in improved antibody durability and comparable peak responses after the final immunization. Linear V3 specific IgG responses were particularly enhanced by the gp120 boost, whereas the MVAgp140 boost also enhanced responses to linear C5 and C2.2 epitopes. Interestingly, gp120, but not the MVAgp140 boost, increased peak CD4IMPORTANCE Prior immune correlate analyses with humans and nonhuman primates revealed the importance of antibody responses in preventing HIV-1 infection. A DNA prime-modified vaccinia virus Ankara (MVA) boost vaccine has proven to be potent in eliciting antibody responses. Here we explore the ability of boosts with recombinant gp120 protein or MVA-expressed gp140 to enhance antibody responses elicited by the GOVX-B11 DNA prime-MVA boost vaccine. We found that both types of immunogen boosts enhanced potentially protective antibody responses, whereas the gp120 protein boosts also increased CD4+ T cell responses. Our data provide important information for HIV vaccine designs that aim for effective and balanced humoral and T cell responses. GOVX-B11, a subtype B DNA prime-modified vaccinia virus Ankara (MVA) boost vaccine, elicits higher response rates and titers of antibodies to the gp41 transmembrane than the gp120 receptor binding subunit of Env , 4.The GOVX-B11 vaccine expresses the native ADA (clade B) gp160 Env, a clade B CCR-5-tropic Env from a chronic infection , 8 and pThe regimen for vaccination was based on the regimen used in RV144 and on our clinical experience with DNA priming and MVA boosting –11. The –+ T cells over the MVA-only group. Given the comparable levels of elicited antibodies, and the potential for vaccine-elicited CD4+ T cells both to protect from infection  and MN gp41 were measured using enzyme-linked immunosorbent assays (ELISAs) and longitudinal serum samples. gp120- and gp41-specific IgG responses developed 2 weeks after the first MVA boost (week 20), peaked after the second boost (week 28) declined with time, and were boosted again after the 3rd boost  and B. ANext, we measured IgG responses to the vaccine-matched B.63521 gp120 protein. The MVA+gp120 group showed significantly higher responses following the 2nd boost, postcontraction at the time of the 3rd boost, and after the 3rd boost than did both the MVA-only and MVA+MVAgp140 groups . The difP values that are not controlled for multiple comparison [raw_p] = 0.03 for each)   and 2 anor each)  and 2 thIn contrast to the gp120 and gp140 responses, levels of binding to the V1V2 panel were similar for sera from the MVA+gp120 and MVA+MVAgp140 groups after both the 2nd and 3rd boosts, with both being approximately 2-fold higher than that for the MVA-only group .The durability and boostability of binding antibody responses were evaluated as the fold decline of the antibody response over the 12 weeks following the 2nd boost (week 28/week 40) and the fold increase of the antibody response following the 3rd boost over that following the 2nd boost (week 42/week 40) . The MVAIgG from the vaccinated animals targeted linear epitopes in the C1, V2, C2, V3, C4, and C5 regions of gp120 . In gp41The contribution of each epitope to the total Env linear epitope binding after the 2nd and 3rd boosts was evaluated by determining the percentage of the binding intensity for each epitope within the total Env linear epitope binding intensity. Among the 3 groups, the MVA+gp120 group was the most focused on V3, with 81.1% and 70.8% of total linear epitope binding (group median) targeting V3 at weeks 28 and 42, respectively, compared to 34.2% to 49.9% for other groups . The MVAP < 0.01) were found after the 3rd boost for C2.2 (MVA+MVAgp140 and MVA+gp120 > MVA only) and after the 2nd boost for C5.1 (MVA+MVAgp140 > MVA only and MVA+gp120) and C5.2 (MVA+MVAgp140 > MVA only)  were observed among groups for binding to epitopes in C2, C4, and C5 following either the 2nd (week 28) or 3rd (week 42) boost . Highly VA only) . Due to Binding responses to peptides representing different clades/strains were generally similar among vaccine groups and at the two tested time points (following the 2nd and 3rd boosts) . All groThe avidity of the antibody elicited for three linear epitopes—clade B V3, clade C V3, and gp41–ID—was measured by an avidity index assay , 15. For50) titers up to 5,274  and MW965.26 (clade C) viruses, with 50% inhibitory dose  against tier 2 viruses after the 2nd boost, with positivity rates ranging from 40% to 100% for 2 clade C tier 2 viruses (25710-2.43 and Ce1176_A3) and being 20% for the clade B tier 2 virus TRO.11   . Group m50 neutralizing titers for tier 1A and tier 1B clade B viruses were associated with binding magnitudes to peptides in the C1, V3, and the gp41_ID regions, with Spearman r values of >0.6 and raw_p values of <0.05 . Interestingly, the highly conserved gp41_ID was among epitopes with the most scores above a Spearman r of 0.5 (raw_p < 0.05) for tier 1B and tier 2 viruses. The ADCC titers measured with B.63521Δ11 gp120-coated cells associated most strongly with two C1 epitopes . Further examination of scatter plots revealed that correlations between binding magnitudes and neutralization titers for most pairs with r values of >0.6 were driven by data from all three groups, with the exception of MW965, for which correlations were driven by higher neutralization titers for the MVA+gp120 group  than in lymph nodes but more similar levels of elicited CD40L-expressing cells in these two compartments   . No sign in PBMC .+ T cell responses. Below we discuss these results and how they might relate to protective vaccine responses.The current study compared the magnitude, durability, specificity, breadth, and functional activity of antibodies elicited by MVA+gp120 protein boosts, MVA+MVAgp140 boosts, or MVA-only boosts of a DNA-primed response. Our results reveal that the addition of either gp120 protein or MVA-expressed secreted gp140 to boosts elicits higher, broader, and more functional antibody responses than the MVA-only boosts. They also reveal that protein, but not MVAgp140, boosts enhanced CD4The goal for adding boosts to the DNA/MVA vaccine was to enhance antibody responses to gp120, especially those that target the V1V2 region of gp120. Both B.63521 gp120 and MVAgp140 boosts enhanced these antibody responses. Following the 3rd and last boost, mean magnitudes of binding to the gp120 antigen panel and the V1V2 panel were 4.3- and 3.0-fold higher and 2.1- and 2.5-fold higher for the MVA+gp120 and MVA+MVAgp140 groups, respectively . The gp1In addition to the magnitude of binding antibody responses, the boost immunogens affected the durability of antibody responses and the performance of repeated boosts. The MVA+MVAgp140 group showed a trend for a slower decline and a more effective 3rd boost of responses than for the MVA+gp120 group. This lower contraction and higher boost with MVAgp140 suggest that MVAgp140 may elicit more durable and replenishable responses than the gp120 protein boost. Although lower levels of preboost antibody responses likely contributed to the efficiency of the 3rd MVAgp140 boost, there is precedent for late boosts, with MVA being highly effective in both preclinical and clinical settings –18.–+ T cell response over those elicited by the MVA-only boost vaccine. The MVA-specific T cell response was not measured. However, we consider it unlikely that adding 1 × 108 50% tissue culture infective doses (TCID50) of MVA gp140 to the 1 × 108 TCID50 of MVA62B in the MVA gp140 group significantly enhanced CD4+ responses because of the very shallow dose-response curve for MVA boosts of a constant DNA prime . These correlations were strongest and most frequent for the two tested tier 1 viruses. The finding of correlations with the gp41_ID region, albeit modest, are of interest because these correlations, with a highly conserved region in Env, included 4 of 9 tested tier 1B and tier 2 viruses. Monoclonal antibodies (MAbs) to the gp41_IDR capture virions  blocked ADCC activity in over 90% of subjects . A32 did+ T cell responses. These data demonstrate that both recombinant gp120 protein and MVA-expressed secreted gp140 are effective strategies for enhancing potential protective nonneutralizing antibody responses to HIV.In conclusion, gp120 protein and MVAgp140 were similar in their abilities to increase levels of antibody responses for gp120 and the V1V2 region of gp120 over the MVA-only boosts in the GOVX-B11 DNA/MVA vaccine regimen but differed in their abilities to enhance CD4+ T cell response may allow identification of conditions under which protein boosts of DNA/MVA vaccines enhance both Ab and preclinical protective responses.The study has had a direct impact on the protein boost protocol being advanced for the clade B DNA/MVA vaccine GOVX-B11. This study clearly demonstrated that under the conditions tested, B.63521Δ11 only modestly enhanced V1V2 responses. Because of this finding, both higher doses of B.63521Δ11 and a gp120 that is more effective at enhancing V1V2 responses are being tested in nonhuman primates and advanced to phase 1 clinical trials. Also, protein boosts have enhanced antibody responses but not protective responses in preclinical trials for DNA/MVA vaccines (see above). Understanding the nature of the enhanced CD48 TCID50 per ml in a proprietary buffer for storage and inoculation. MVA encodes a secreted ADA gp140 Env that was inserted into deletion II of MVA by plasmid insertion vector pLAS-2. It coexpresses the same HXB2/BH10 gag-pol as MVA62B. MVAgp140 was produced in CEF at the Laboratory for Viral Diseases, NIAID, NIH, purified by sucrose pad centrifugation, and suspended at 1 × 108 TCID50 for storage and inoculation. B.63521Δ11mutC gp120 was produced by transient transfection at the Duke Human Vaccine Institute, Duke University. To prevent proteolytic clipping, mutations were introduced into the B.63521Δ11 gp120 V3 (SIR-GPGQT) region. Antigenicity analysis with a panel of MAbs showed similar affinities of binding of soluble CD4 (sCD4) and CD4 binding site broadly neutralizing antibodies (bnAbs) (VRC01 and CH103 MAbs) and for bnAbs for the V3 loop ASN332-centered oligomannose patch  as well as the V3 loop MAb 19b, for B63521Δ11 with and without the mutC mutation .The GOVX-B11 vaccine consists of the pGA2/JS7 DNA and MVA/HIV62B (MVA62B) immunogens. The DNA prime expresses VLPs displaying the ADA gp160 Env. The DNA used in this trial also coexpressed rhesus granulocyte-macrophage colony-stimulating factor (GM-CSF) , 28. The8 TCID50 of MVA62B into the upper left limb on weeks 18, 26, and 40. At the time of the MVA boosts, animals in group 2 also received 100 μg of B63521Δ11gp120 plus 500 μg of Alhydrogel  and animals in group 3 also received 1 × 108 TCID50 of MVAgp140, both delivered intramuscularly in 1 ml by needle and syringe to the upper right limb. Sera, PBMC, and rectal swabs were collected at regular intervals throughout the trial. Lymph nodes as well as an exsanguination bleed were collected at the end of the trial, 2 weeks following the last boost. The general health, weights, clinical blood counts (CBC), and clinical chemistries of animals were monitored throughout the trial.The animal study was conducted at Bioqual Inc., Rockville, MD, in accordance with all rules of the American Association for Laboratory Animal Care and under the supervision of the Institutional Animal Clinical Care and Use Committee. Three-year-old male rhesus macaques, prescreened for background for Env binding antibodies and activated T cells, were randomized into 3 study groups of 5 animals each by weight. For all groups, 3 mg of DNA was inoculated by needle and syringe into the upper left limb on weeks 0 and 8 and 1 × 10Binding antibody response was tested both in enzyme-linked-immunosorbent assays (ELISAs) and in binding antibody multiplex assays (BAMA). The ELISA uses Con6 gp120 produced in BHK cells (Duke) and gp41 produced in bacteria  as antigens for antibodies to gp120 and gp41, respectively. Assays were done using a standard curve of macaque IgG captured by a goat anti-rhesus antibody and results interpolated to estimate micrograms of specific IgG per ml as previously described . BAMA weSerum epitope mapping of heterologous strains was performed as previously described –34, with–The affinity maturation of the vaccine-elicited antibody responses to the immunodominant region of gp41 (gp41_ID) and V3 linear epitopes (V3.B and V3.C) was measured by an avidity index assay using the binding antibody multiplex assay. Avidity index was measured by inclusion of a denaturation step  . UntreatAntibody dependent cellular cytotoxic activity mediated by test animal plasma/serum was detected according to our modification of the previously described GranToxiLux cell-mediated cytotoxicity procedure . CEM.NKRhttp://www.hiv.lanl.gov/content/nab-reference-strains/html/home.htm.Neutralizing antibodies were measured as a function of reductions in luciferase (Luc) reporter gene expression after a single round of infection in TZM-bl cells , 40. TZMHIV-specific cellular immune responses were assessed by multiparameter intracellular cytokine staining (ICS) assays following stimulation with GOVX-B11 vaccine-specific HIV peptides (15-mers overlapping by 11) as previously described . Panel oP value of <0.05 were further tested using Wilcoxon rank sum exact test. Correlations between binding antibody responses and neutralization and ADCC responses were tested using the Spearman correlation test. P values from the Wilcoxon rank sum test and Spearman correlation test were corrected for false discovery rate (FDR) using the Benjamini-Hochberg (BH) method . Both raw_p and FDR-adjusted P values (FDR_p) are shown in Antibody and T cell response measurements were first screened in an omnibus test. Differences between pairs of groups in the levels of measurements that showed a ) method . Statist


In charitable foundations throughout the world, different approaches are used to allocate funding. As many projects with good will  actually fail to help those who really need it, it is argued that the evidence-based approach  represents the best strategy to support projects that can really help the needy. Using this approach, scientific research findings are systematically used to (1) understand the nature of the problem and/or social needs, (2) design appropriate intervention programs based on the best available evidence, and (3) systematically evaluate the outcomes of the developed program. Using the Project P.A.T.H.S. funded by the Hong Kong Jockey Club Charities Trust as an example, the characteristics underlying this approach are outlined. The systematic use of scientific evidence in the Project P.A.T.H.S. is exemplary in different Chinese societies. This project provides much insight for charitable foundations and funding bodies locally and globally.


Critical literacy is an important and highly relevant concept to hospital and health sciences librarians: the theory reflects the value our profession gives to informed, contextual, critical readings of the research literature; the importance of context in evidence-based practice; and the inclusion and consideration of the patient’s and family’s social or cultural needs, values, and preferences. To wit, “the approach taken in critical literacy is not to read texts in isolation, but to develop an understanding of the cultural, ideological and sociolinguistic contexts in which they are created and read” (p. xi).Sarah McNicol has gathered the work of twelve international authors from a variety of institutions—public libraries, school libraries, four-year college or university libraries, and a private college—to discuss various aspects of critical literacy as it relates to librarianship. Among the librarian-authors, only one is a health sciences librarian. The book has seven theoretical chapters and seven practical case studies, and each individual chapter is referenced. In the back of the book are an index and bibliographies for further reading on critical pedagogy, critical literacy, libraries and critical literacy, teaching resources, practical resources to support the teaching of critical literacy using comics, and new literacies and new literacy studies.The greatest value for medical librarians is likely McNicol’s introduction and some of the theoretical chapters. McNicol presents various definitions of critical literacy and makes clear that it is as much about power and position as about the functional cognitive ability to read critically. She admonishes readers in her first chapter to remember that “all texts are constructed and serve particular interests” (p. xi).It may feel, to some readers of this journal, that “critical literacy” is but an extension of “information literacy.” This is not entirely wrong, but it is a limited view. Jessica Critten’s theoretical chapter relates critical literacy to information literacy and delves deeper into the discipline of critical theory. Human reverence for the written word requires that we remind ourselves to critically consider the authority of the author against the life experience and perspective of the reader and, in medicine, to find the balance between well-designed, rigorous studies and the specific context of a particular patient.A theoretical chapter on “Reading Health-Education Comics Critically: Challenging Power Relationships” is one example of “new literacies,” reminding readers that the format or delivery of information can affect its reception and clarity, while pointing out that comics can represent both hemispheres of our brains, conveying emotions along with the information contained in the accompanying words. McNicol differentiates the common use of “health literacy” as a simple focus on delivery of information versus the more critical consideration that includes social determinants of health.The chapter then reports on a qualitative study about the use of comics and offers many quotes from participants. The chapter on “Using New Literacies to Discuss Disability in the Library” instructs readers to guard against an “abler…medical model” of disability limited to Americans with Disabilities Act (ADA) compliance and to aim for an “include” mindset with a universal design approach that works better for everyone (pp. 60–3). The author notes that not all disabilities are physical and that the ADA Amendments Act of 2008 (ADAAA) expanded consideration to conditions such as post-traumatic stress disorder (PTSD), autism, dementia, and other less visible disabilities. This author recommends various social broadcasting tools to gather and understand employee attitudes about accessibility as well as to gather patron expertise for improvements. This chapter, though, feels misplaced as a theoretical chapter: it should be in part 2 because its strength is in its practical examples and suggestions.The writing in this book is uneven. Some writers understand the topic deeply  and write incisively, while others slog through as if reproducing a dissertation: “here’s what I’ll tell you; I tell it; here’s what I told you.” There is definite value in the content—eventually, but an introductory paragraph should lead readers to why they should care, or the gap in what they know, or here is an exciting thing they can change, instead of defeating the intention with negativity before even beginning a topic. Then there are the run-on sentences that are difficult to follow. Some writers need editing, which unfortunately was not provided by the compilers of this anthology.Education studies programs, linguistics departments, and communication departments will be familiar with critical theory as the extension of the work of Paolo Freire  or Jean Chartered Institute of Library and Information Professionals (CILIP), based in London. Their laudable goal is to put information and library skills and professional values at the heart of a democratic, equal, and prosperous society.McNicol is a doctoral research associate at the Education and Social Research Institute of Manchester Metropolitan University. The book is published by the Critical Literacy for Information Professionals is useful and achieves what it sets out to do: offer a broad introduction to the theory of critical literacy, with practical examples that could be transferable to other settings. The practical chapters heavily emphasize primary and secondary school or undergraduate programs, but none specific to hospital or medical libraries as the two chapters directly related to health sciences are theoretical chapters. However, much of this work could still be adaptable, by any thoughtful librarian, to a medical or hospital context. Trudi Jacobson and Thomas Mackey’s books on meta-literacy [literacy , 4 might