Despite abundant bereavement care options, consensus is lacking regarding optimal care for bereaved persons.We conducted a systematic review, searching MEDLINE, PsychINFO, CINAHL, EBMR, and other databases using the terms (bereaved or bereavement) and (grief) combined with (intervention or support or counselling or therapy) and . We also searched citations in published reports for additional pertinent studies. Eligible studies had to evaluate whether the treatment of bereaved individuals reduced bereavement-related symptoms. Data from the studies was abstracted independently by two reviewers.74 eligible studies evaluated diverse treatments designed to ameliorate a variety of outcomes associated with bereavement. Among studies utilizing a structured therapeutic relationship, eight featured pharmacotherapy (4 included an untreated control group), 39 featured support groups or counselling (23 included a control group), and 25 studies featured cognitive-behavioural, psychodynamic, psychoanalytical, or interpersonal therapies (17 included a control group). Seven studies employed systems-oriented interventions . Other than efficacy for pharmacological treatment of bereavement-related depression, we could identify no consistent pattern of treatment benefit among the other forms of interventions.Due to a paucity of reports on controlled clinical trails, no rigorous evidence-based recommendation regarding the treatment of bereaved persons is currently possible except for the pharmacologic treatment of depression. We postulate the following five factors as impeding scientific progress regarding bereavement care interventions: 1) excessive theoretical heterogeneity, 2) stultifying between-study variation, 3) inadequate reporting of intervention procedures, 4) few published replication studies, and 5) methodological flaws of study design. Give sorrow words; the grief that does not speakWhispers the o'er fraught heart and bids it break.Macbeth IV, iii, 209Shakespeare, Grieving the death of a loved one has an ancient history: from time immemorial, cultures have provided the bereaved with advice and rituals to address – and express – the experience of grief . Over thGiven the abundance of care options, what is the best way to care for a bereaved person? Numerous studies measuring the impact of bereavement interventions have been published in diverse journals, yet no consensus has emerged in the medical, mental health, or social work communities regarding whether one form of treatment is preferable to another -5. We thbereaved or bereavement" and "grief", combined with secondary descriptors of "intervention or support or counselling or therapy" and "controlled or trial or design".To identify studies in the traditional medical literature as well as the complementary and alternative medicine literature, we searched the following databases: MEDLINE; PsychINFO; Cumulative Index to Nursing and Allied Health (CINAHL); BIOSIS Previews; ISI Science Citation Index Expanded and Social Sciences Index; Evidence Based Medicine Reviews (EBMR), including the Cochrane Database of Systematic Reviews (DSR), the Cochrane Controlled Trial Registry (CCTR), Database of Abstracts of Reviews of Effectiveness (DARE), and the American College of Physicians' (ACP) Journal Club Review; Sociological Abstracts; Alt HealthWatch; and Wilson Web from 1966 to 2003. We identified all relevant articles on bereavement care interventions by using the primary search terms of "Our inclusion criteria specified that each study: 1) addressed the treatment of bereaved individuals, and 2) included an evaluation of a selected method of therapy aimed at reducing the grief reaction due to bereavement. We considered only articles written in the English language. We then reviewed the titles and abstracts of all articles we retrieved through our initial database search, and obtained the full texts of all applicable studies. We also reviewed the references in all applicable studies for additional pertinent studies.The full articles of all studies that met inclusion criteria and passed subsequent title and abstract reviews were retrieved and examined independently by two of the authors. Each article was reviewed for measured outcomes, patient and decedent characteristics, and intervention characteristics. These measures included sample size, type of intervention, length of intervention, patient's relationship to the deceased, time since the bereaved death, and patient demographics. Data was extracted and any disagreements were resolved through discussion, clarification, and consensus within the research team.The initial literature search generated 737 citations. Elimination of duplicate citations yielded 340 references. 2 studies, written in Chinese and Spanish, were excluded. Reviewing the titles culled the sample to 243 citations, and a review of the abstracts found 87 of these to be potentially relevant. Of these, 9 were dissertations, 2 were irretrievable, 2 were duplicate publications of the same study, and 15 were ineligible because they did not meet our inclusion criteria. The resulting set of 74 articles was subject to review for data extraction. A list of all citations found, including those excluded from this analysis, is available see .Of the 74 studies that met inclusion criteria, almost 6,000 participants within these studies experienced a multitude of losses – of parents, spouses, children, and other loved ones who had died from a wide range of causes, both sudden and protracted. The therapies utilized and outcomes evaluated varied widely. Heterogeneity among both the outcomes and the measures used to assess similar outcomes precluded an effort to summarize data across studies, even in the form of generic effect-size measures. Furthermore, for a significant portion of the studies, concerns regarding the internal or external validity of the reported results cautioned against making quantitative summary statements regarding treatment effects.The 74 studies selected for detailed review evaluated diverse types of interventions designed to ameliorate the adverse physical and psychological outcomes associated with bereavement. These interventions can be classified according to various schemes, including their underlying theoretical framework , the format of the intervention , the timing of the intervention , the tasks assigned to the bereaved , or the population targeted for the intervention . We chose to organize this review on the basis of the social framework used to implement the intervention , as this attribute of the interventions emerged as the most verifiable and salient measure.pharmacotherapy, but only four compared active therapy to non-pharmacotherapy controls, and only one study clearly reported their random allocation method  report a bereavement intervention for Mexican-American widows . They foPsychotherapy-based treatments, another form of psychological interventions, can be done in different formats , and via different approaches. Of the 25 studies that use psychotherapy as an intervention, approaches included cognitive-behavioral, psychodynamic, psychoanalytical, and interpersonal approaches, as well as combinations of these and modality and social support  studied an intervention for parents bereaved by the violent death of their children .-79.73-79Ringdal and colleagues (2001) found no significant differences between those family members whose relative received palliative care and those who received traditional care . This inRobinson (1998) examined the psychological effect of witnessing resuscitation efforts of patients in the emergency room on bereaved relatives . They foper se, no consistent pattern of treatment benefit has been established across well-designed experimental studies.When reviewed systematically, the current bereavement intervention literature – notwithstanding the existence of many intriguing reports – yields few reliable conclusions to guide treatment. Good evidence supports the pharmacological treatment of depression occurring in the context of bereavement. For all other forms of intervention, however, and for all attempts to diminish grief Why – despite prevalence of bereavement, the intense dedication on the part of the bereavement research community, and the multitude of peer-reviewed published bereavement studies – does the field of bereavement care lack a formidable evidence base? In order to improve the effectiveness and quality of bereavement care, this question begs to be addressed. On the basis of our systematic review of the literature, we postulate the following five factors as hindering methodical scientific progress regarding bereavement care interventions.As the history of science and medicine suggests, successful scientific inquiry into a topic is typically a cumulative process undertaken by a community of investigators working within a shared scientific paradigm ,81. The Treatments featured in published studies vary almost as much as the authors who tested them. One can observe substantial variation across studies regarding the type of intervention generally or regarding the specific implementation of a specific type of intervention ; regarding characteristics of targeted patient populations; regarding outcome measurements and study design methodology. Scrutinizing the key outcome measures listed in the accompanying tables illustrates this remarkable heterogeneity. Although these differences have been due in part to diverse treatment-theory paradigms, even studies conducted within the same theoretical paradigm often differed markedly in terms of what potential benefit was being tested, and how it was being measured. Such substantial variation between studies stymies comparison or confirmation of treatment effects.Aside from the pharmacological studies, which reported the dosing of the intervention medication, very few reported studies describe the intervention procedures in sufficient detail for readers to envision clearly what tasks or activities intervention subjects were asked to perform. This under-specification prevents sensible analysis, within a class of treatments , of observed differences in treatment effects .Inadequate specification of intervention procedures, combined with other factors at work within the community of bereavement care investigators, may have resulted in the dearth of published replication studies. This lack of replication prevents the accumulation of a body of evidence that would confirm, refute, or refine prior estimates of treatment effects.ad hoc basis, and which may therefore have compromised measurement accuracy and inference validity. Lastly, studies that failed to demonstrate a statistically-significant difference for the main outcome measure often performed numerous post hoc subgroup analyses, a practice that negates the rigor of statistical hypothesis testing.A final factor inhibiting research progress in the realm of bereavement care interventions encompasses a number of recurring methodological flaws that greatly limit inferences regarding treatment effects. First and foremost is the omission of control groups. Control groups are essential for the valid evaluation of a bereavement intervention, particularly because of the typically self-limited course of grief: even absent any treatment, most bereaved people show "diminished pathological symptoms and fewer signs of disturbance within two years of the loss". PurportIf these five factors are indeed hampering progress towards improving bereavement care interventions and quality of care for bereaved individuals, then concrete actions could facilitate progress within the field of bereavement care, specifically: 1) Convening a consensus-building conference among key stakeholders and investigators to define a specific research agenda that would draw on a limited number of theoretical paradigms and delineate key elements of treatment theory ; 2) FocuNone declared.CG Control groupNT NortriptylineSSRI Selective serotonin reuptake inhibitorsTCA Tricyclic antidepressantsTRIG Texas Revised Inventory of GriefAF assisted in the design of the review, conducted data collection, data abstraction, and drafted the manuscript. MH assisted in the design of the review and critically reviewed several drafts of the manuscript. RP assisted in data collection and abstraction. CF conceived of and designed the review, assisted in drafting and revision of the manuscript, and provided support and mentorship through the process. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:All citations. This file contains citations to all of the studies identified by our literature search and screened for inclusion in this review, as well as other scholarly works consulted during the conduct of this review.Click here for file


This issue of CytoJournal contains an article on screening for anal intraepithelial neoplasia in high-risk male patients. This accompanying Editorial focuses on current understanding of this relatively new disease entity, with insights as to the potential role of screening cytopathology in the epidemiology, pathophysiology and clinical management of this HIV and HPV related anal lesion, which predominates in male patients living long-term with AIDS. Mention is made of techniques of obtaining samples, methods of preparation, and morphologic classification. Issues of anoscopic confirmation, as well as topical and surgical management are emphasized. The similarity of initial experiences in anal screening to problems encountered early in cervical cancer screening programs several decades ago, are highlighted. For corresponding research article please see Arian et al, 2005 The subject of anal screening cytology has entered the epidemiologic and cytopathologic literature as a topic of interest over the last decade, and is highlighted in this issue of CytoJournal in an article by Arain and colleagues. Until recently, anal cancer was not considered to be a neoplasm of major public health concern . It occuDuring the 1990s, in several European and North American cancer centers, an initially unaccountable increase in anal cancers was seen in younger people. It soon became apparent that HIV-positive homosexual males were affected in numbers greatly in excess of those expected. This was first noted in those urban areas in which large concentrations of homosexual men had been treated since the outbreak of the HIV epidemic. The term "males having sex with males" (MSM) was coined to cover these high-risk individuals. Preliminary information gleaned from screening programs in high HIV-positive incidence areas amongst MSM, showed detection rates of intraepithelial and early invasive neoplasia higher than any incidence ever recorded for cervical cancer screening. Further, HIV-negative homosexual MSMs, and HIV positive non-homosexual men (eg drug users) also exhibited an increased incidence of pre-malignant and invasive anal carcinomas. More recently, the syndrome of early onset anal cancer has been extended to include HIV-positive female patients, as well as females who are not HIV-positive, but who have genital HPV. All these groups show a higher incidence of abnormal anal cytopathology, though none quite as high as that found in HIV positive MSM. The unifying factor in most instances is ano-receptive intercourse, or extension of HPV infection from the genital tract to the anal mucosa, most obvious in the face of deficient immunity, or high viral load -6.Epidemiologic studies have indicated that a prolonged preclinical phase precedes the onset of anal cancer in these high-risk groups. Just as in the cervix, there is a transitional zone  in the anus. Rectal mucosa, with goblet cells, ends about one inch proximal to the external sphincter, giving way to a transitional epithelium, which in turn blends into a stratified squamous epithelium at the level of the anus.  Almost all anal cancers develop in the transitional zone, where atypical, dysplastic and in-situ lesions are identifiable histologically. The cytologic counterparts are those of atypical cells of uncertain significance (ASCUS), low grade squamous intraepithelial lesions (LSIL) and high grade squamous intraepithelial lesions (HSIL). Once this natural history had been demonstrated and confirmed, it seemed natural that exfoliative cytology could be investigated as an "anal Pap smear" ,8.As with the cervix, the technique of obtaining the anal sample is critical to the success of screening. Standard colonic preparation is not required, but the rectum should be emptied prior to obtaining the anal sample. Brushes, brooms and Dacron swabs have all been used, the type of spatula probably being less important than the skill of the operator. The instrument is inserted to a depth of one and a half inches beyond the external sphincter, and subsequently withdrawn in a firm downward spiral movement incorporating 10–12 rotations, to ensure the device has made contact with the full surface area of the transformation zone. Some have used direct smears onto glass slides with immediate wet fixation; most centers, however, employ immediate insertion of the scraping device into liquid fixative for thin layer preparation. This appears both to improve adequacy and preservation, and also to eliminate any fecal contamination; residual material in the vial can be used for HPV studies if required, or for the creation of a bank of teaching slides.There has been a relative dearth of literature on the cytomorphology of anal samples -11. ClasExperience over the last decade suggests that anal cancer may be as highly appropriate a target for screening as is the cervix, in selected populations. The neoplasm is frequently encountered in well-defined high-risk groups. It has a detectable pre-malignant phase, and is amenable to easy cytologic sampling. Cytodiagnosis is reasonably sensitive and highly specific, and histologic confirmation is relatively easily obtained by well-trained personnel. If there is a current area of deficiency in such programs, it may well be in the treatment of intraepithelial lesions, which, as yet, has not been adequately assessed in large numbers of patients. It is known that highly active anti-retroviral therapy (HAART) does not appear to alter the pathophysiology of anal lesions once initiated. A variety of topical agents such as podophyllotoxin and imiquimod have been tried, as has intralesional interferon; superficial ablative therapies including liquid nitrogen, electrocautery, laser and LEEP have been attempted with varying success rates. Circumferential surgical resection almost inevitably results in unacceptable loss of sphincter control and soiling, but anoscopy-directed limited excision may prove less morbid. The fact that so many options are available implies perhaps that no single modality is yet considered sufficiently effective, with minimal complication ,13. Thisineffective in these communities. The second feature dictating the institution of screening programs in developing countries relates to antiretroviral therapy. Anal intraepithelial neoplasia and cancer are not encountered early in the progression of HIV/AIDS. Rather, they are late complications of patients living long-term with AIDS, usually implying patients living long-term on HAART [An interesting consideration is whether or not anal cancer, and thereby anal cytopathology screening programs, would be of value in the developing world, particularly in Africa, India and China, where the bulk of the global incidence of HIV resides. This will depend on two very different factors. First is the nature of transmission. Unlike the situation in the developed world, AIDS in these regions is not essentially a disease of homosexual males; thus, without anal intercourse predominating, an upward trend in the incidence of anal cancer would seem unlikely. Anal screening programs would be unnecessary or cost-on HAART . Unless


Over 250 million years ago (mya), all the continents of Earth formed a single land mass called Pangaea. Some 50 million years later, this supercontinent began to split in two, forming Laurasia—now North America, Asia, and Europe—and Gondwana—present-day Antarctica, Australia, South America, Africa, and India. After another 50 million years, Gondwana, too, broke up. At the end of the Cretaceous period, New Zealand split off (about 80 mya), then South America and Australia separated from Antarctica (about 35 mya). Fairy-tale quality aside, the story of continental drift fits comfortably with the geological and fossil record and feeds our understanding of current distributions of plant biodiversity.Nothofagus—the southern beech tree, a plant whose 80-million-year-old fossil history goes back to the days of Gondwana—has polarized views on the nature of Southern Hemisphere biogeography.Although we know how and when Pangaea broke apart, the distribution of fossils of the same species on many different continents, separated by vast ocean waters, challenges us to explain how they got there. Plant life on New Zealand, for example, shares striking similarities to that on other Southern Hemisphere land masses, but scientists have yet to agree on how this came to pass. In particular, one genus, Nothofagus seeds are not considered ocean-worthy vessels, many believe vicariance is the only possible explanation.One theory suggests that geographic barriers  would have prevented species expansion after the break-up of the continents, so similar contemporary species must have already existed in both places before New Zealand broke away from Gondwana. In this scenario, called vicariance, ancestors of existing lineages drifted with the repositioned land masses. Another hypothesis, born of existing distributions and fossil data, suggests that long-range oceanic dispersal is more likely. But since Peter Lockhart and colleagues argue that a clear picture of the divergence dates of various southern beech species could help clarify the relative contributions of vicariance versus dispersal. But they would need significant lengths of DNA sequences to reliably characterize the evolutionary history of each species.Nothofagus subgenera—Lophozonia, Fuscospora, and Nothofagus—from South America, Australia, and New Zealand. Reconstructing the trees' evolutionary relationships (phylogeny) based on analyses of their chloroplast sequences, the authors discovered a nuanced evolutionary history that supports vicariance for some species and dispersal for others.Consequently, Lockhart and colleagues analyzed a 7.2-kilobase fragment of the chloroplast genome  for 11 species of three Assuming that beech was present throughout Gondwana (which fossil data support), the sequence of the Gondwana breakup should be reflected in the beech's phylogeny. New Zealand beeches should be more distantly related to both Australian and South American species, because of the greater period of separation—65 million years compared to 30 million years. Yet Australian and New Zealand beeches are more closely related to each other than to South American species, which reflects more recent relationships. Given that fossils of all beech subgenera extend back to the New Zealand Cretaceous period, the dating of splits and the nature of the relationships indicate extinction of beech lineages within current subgenera in New Zealand, and possibly in Australia and South America.Lophozonia and Fuscospora species are too recent to have roots in Gondwana, indicating a role for transoceanic dispersal. The evolutionary relationship between the Australasian and South American Fuscospora lineages, however, is consistent with vicariance. These divergence results, the authors conclude, indicate that current distributions of Nothofagus cannot be explained solely by continental drift (followed by extinction of some species) and that contemporary New Zealand Nothofagus species are not direct descendants of the beeches thought to have reached the island after the split from Antarctica.Lockhart and colleagues' analyses suggest that the relationships of the Australian and New Zealand Nothofagus seeds—and stresses the need to consider more complex hypotheses to explain something as dynamic and complex as the evolutionary history of biodiversity.Taken together, the results highlight the need for caution in evaluating fossil evidence. The fossil record doesn't necessarily capture when a species first appeared, and a continuous fossil presence can mask extinctions and reinvasions. The authors conclude that their molecular data make the case for investigating possible mechanisms of long-range dispersal—especially the dispersal properties of


Consisting of three lineages—cephalochordates (amphioxus), urochordates (tunicates) and vertebrates  , the monCiona and Halocynthia), offering a very narrow taxonomic range to tackle these two points. Although evolutionary developmental (evo-devo) studies soon attempted to increase the taxon sampling, these were impaired by the lack of accessible functional genomics techniques readily available for emerging model animals. Consequently, most of the early molecular genetics’ studies in the field of chordate evo-devo consisted of the analysis of a single or a limited number of genes in few species. Therefore, and despite their importance, the mechanisms underlying the origin and evolution of both ancestral traits and morphological novelties of chordates have remained largely elusive. The recent surge and exponential growth of genome assemblies available from a wider set of animal models, together with the availability of the most recent technological innovations in genome editing and whole genome scale high throughput expression and regulation analyses are starting to provide answers to some of the long-standing chordate evo-devo questions.Two processes are particularly relevant to chordate evolutionary success: the formation of the chordate body plan, and the origin of vertebrate traits. Traditionally, developmental biology and genetics have relied on the use of a handful of model animals  by taking into consideration lost or duplicated genes (and therefore non conserved), thus permitting to measure the degree of phenotypic evolution through more comprehensive comparative transcriptomics analyses. Tena and Santos-Pereira provide a review on how new technological advances on chromatin conformation studies have enabled us to better understand how the three-dimensional nature of genomes constrain the regulatory landscape of genes, and how changes in these 3D domains can lead to pathological situations, but at the same time provides opportunities for evolutionary innovation.Comparative genomics approaches are instrumental to decipher the genomic changes underpinning phenotypic evolution. While vertebrates have traditionally occupied the top position in terms of number and quality of genome sequencing projects, the recent burst of high-quality genome assemblies of less-studied chordate models have provided new opportunities to study genomic evolution at an unprecedented resolution. Carvalho et al., based on confocal imaging of embryological stages of the European amphioxus Branchiostoma lanceolatum, used as reference, propose a universal staging system for lancelet species, which they corroborate with comparisons with other amphioxus species. They also propose an unambiguous nomenclature of developmental stages, which will undoubtedly standardize the use of amphioxus embryos from different species across studies. A further extension of this universal staging system for lancelet development is put forward by Bertrand et al., who introduce the first ontology resource for an amphioxus species, termed AMPH, with ontology terms classified as developmental and anatomical specific entities, and hosted in open, public repositories. Importantly, these two amphioxus studies will further facilitate the use of amphioxus in large comparative analysis in evo-devo studies. Lacalli reviews very recent gene expression data on the most anterior region of the central nervous system of amphioxus and provides a thought-provoking article describing the role of heterochronic shifts in the origin of the telencephalon in the vertebrate brain, suggesting that the olfactory function is the driver of such shift. Somorjai et al. show, through careful pharmacological inhibition experiments, the roles that JNK  exerts during amphioxus development. Specifically, they find that JNK is particularly important in gastrulation, notochord formation and antero-posterior elongation of the embryo. Also on this Research Topic, Satoh et al. provide the first single-cell RNA-seq analysis in a cephalochordate, the Japanese lancelet Branchiostoma japonicum. They generated this preliminary resource from six different amphioxus stages and used it to better understand the expression divergence of the two Brachyury genes present in the amphioxus genome, Bra1 and Bra2. Two last articles focusing on amphioxus provide new methodologies that promise to significantly advance our knowledge of cephalochordates and their use in chordate evo-devo studies. First, Machacova et al. describe a method that combines tissue clearing and light sheet microscopy, which significantly improves the rapid observation of whole-mount post-metamorphic amphioxus, from 1 to 6 month-old stages. Last, Zou et al. provide a simple method for the early detection of mutant and transgenic founders of amphioxus carrying either desired mutations–introduced by genome editing techniques such as the CRISPR/Cas9 technology—or transgenes–introduced by the Tol2 transposase system—, respectively, demonstrating their suitability to be used in amphioxus. This method promises to significantly increase the use of these state-of-the-art technologies for functional genomics studies in amphioxus, enabling a better understanding of the mechanistic processes of chordate development.Cephalochordates, or amphioxus, share with tunicates and vertebrates the oldest common ancestor of chordates. This key phylogenetic position in the chordate tree , togetheOikopleura dioica, which represents a unique case to study evolutionary divergence in chordates due to its reduced genome size and large amount of gene losses. The first of these studies, from Calatayud et al., investigates metallothionein proteins, a family of modular proteins with a variable number of cysteine-rich domains. The different number of domains in different genes entail these proteins different binding capacities to transition metal ions. The authors also found that variants of these proteins with different numbers of repetitive domains exist in distinct populations of O. dioica. Their work offers a new model in which to study protein modular evolution. Then, Martí-Solans et al. highlight the importance of gene losses and their implications in evolution. These last authors analyzed the Wnt (wingless) gene family, their numbers and expression patterns, finding that few Wnt genes have been retained in O. dioica, which therefore contains the shortest, yet functional, Wnt repertoire described so far in chordates. Other three studies focus on the more traditional tunicate model, the ascidian Ciona spp.: Marotta et al. identified the gene members of the Activator Protein-1 transcription factor family (AP-1) and their expression patterns in Ciona robusta. Given that only single copies of these genes exist in Ciona, this enables Ciona as a helpful experimental organism to study the evolution of the AP-1 transcriptional complex in chordates; Oonuma et al. provide evidence of a common regulatory network involving hedgehog and FoxA genes in the origin of midline structures in tunicates and vertebrates, namely the floor plate of the neural tube, plus the hypochord in vertebrates and the endodermal strand in tunicates; last, Olivo et al. review the molecular bases of the pigment cells and the otolith of C. robusta in order to understand the evolution of sensory organs in chordates.Urochordates, or tunicates, are the sister group of vertebrates  and, as Sugahara et al. report a comparative analysis of gene expression patterns in the dorsal side of the rhombomere 1 in both the lamprey and in the less accessible hagfish. They provide an updated evolutionary scenario for the origin of the cerebellum, involving the presence of a Ptf1a-Atoh1 axis for the specification of inhibitory and excitatory neurons. Kusakabe et al. provide a review of the most recent data in lampreys and sharks concerning the evolution of a type of skeletal muscle, the hypaxial muscles, which are involved in the origin of key novel structures in vertebrates such as the fins and limbs. They propose a new evolutionary hypothesis in which the divergent expression of Lbx paralogs is behind the gradual elaboration of skeletal musculature during evolution. Then, Mayeur et al. present an innovative 3D atlas of expression data in the embryonic head of the catshark Scyliorhinus canicula. This important adaptation of RNA tomography in a non-model system will bring useful information to other researchers that aim to apply this technique to different chordate species. Continuing with the adaptation of state-of-the-art technologies to emerging experimental organisms, Stundl et al. describe a method for the use of the CRISPR/Cas9 system into a non-model, slow-growing, non-teleost fish: the sterlet sturgeon Acipenser ruthenus. Sturgeons belong to the chondrosteans, an important lineage in evolutionary studies of fishes due to its key phylogenetic position as the sister group to two major lineages of ray-finned fishes: holosteans and teleosts. In a proof-of-concept assay, the authors applied the method to successfully mutate the Tyrosinase and Sonic hedgehog genes. In another research article, Torres-Paz and Rétaux present a powerful tool for experimental embryology, describing a method to grow blastoderm explants (pescoids) and to produce chimeric embryos of the Mexican tetra, Astyanax mexicanus, an important evo-devo experimental organism to understand phenotypic evolution. Using these methods, they studied the impact of embryonic and extra-embryonic tissues on cell fate decisions and early developmental processes. To finish, this Research Topic also includes two original articles on the study of bat evolution: first, Ito et al. use advanced computed tomography, called diceCT (from diffusible iodine-based contrast-enhanced computed tomography), to study in detail the 3D prenatal development of various bat species, providing new insights into the evolution of nasal turbinals in bats; and lastly, López-Aguirre et al. studied the development of the humerus in bats, a very specialized bone, using a geometric morphometrics approach to find the presence of fluctuating asymmetry, both on the longitudinal and cross-sectional patterns of humeri, which might be under developmental control of independent mechanisms. They discuss the implications their results might have to understand the selective pressures behind this structure, which is crucial for the specific ecological adaptations of bats.Vertebrates represent the most diverse subphylum of chordates , both inIn conclusion, the collection of articles in this Research Topic introduces the most-updated current state of evo-devo research in chordates, presenting original studies in a wide taxonomic range of animals, and also providing novel methodologies that we hope will significantly improve studies in other evo-devo experimental systems.


Elastin-like Polypeptide (ELP) are widely applied in protein purification, drug delivery, tissue engineering, and even tumor therapy. Recent studies show that usage of ELP has made great progress in combination with peptide drugs or antibody drugs. The combination of ELP and photosensitizer in cancer therapy or imaging has made more progress and needs to be summarized. In this review, we summarize the specific application of ELP in cancer therapy, especially the latest developments in the combined use of ELP with photosensitizers. We seek to provide the most recent understanding of ELP and its new application in combination with Photosensitizer.Elastin-like polypeptides (ELPs) are stimulus-responsive artificially designed proteins synthesized from the core amino acid sequence of human tropoelastin. ELPs have good biocompatibility and biodegradability and do not systemically induce adverse immune responses, making them a suitable module for drug delivery. Design strategies can equip ELPs with the ability to respond to changes in temperature and pH or the capacity to self-assemble into nanoparticles. These unique tunable biophysicochemical properties make ELPs among the most widely studied biopolymers employed in protein purification, drug delivery, tissue engineering and even in tumor therapy. As a module for drug delivery and as a carrier to target tumor cells, the combination of ELPs with therapeutic drugs, antibodies and photo-oxidation molecules has been shown to result in improved pharmacokinetic properties  while restricting the cytotoxicity of the drug to a confined infected site. In this review, we summarize the latest developments in the application methods of ELP employed in tumor therapy, with a focus on its conjugation with peptide drugs, antibodies and photosensitizers. Several decades ago, Urry et al.  isolatedFollowing the discovery of its amino acid sequence and an understanding of its stimulus-responsiveness, the pentapeptide repeat units of ELPs were identified and modified to be composed of VPGXaaG (Xaa is a guest residue and can be substituted for any amino acid except for Pro); replacing the guest residue with a specific amino acid can change the physicochemical and biological properties of the ELP . If the Based on different application scenarios, ELPs can be endowed with specific suitable properties for targeted application. The biological and scientific significance of ELPs revolves around their stimulus-responsiveness to temperature, pH and light. With respect to temperature, ELPs exhibit lower critical solution temperature (LCST) behavior whereby the ELP either solubilizes or coacervates in aqueous solutions in response to changes in temperature below or above the critical transition limit ,19. ThroIn the field of tumor therapy, multiple strategies have been developed to manage or treat tumors depending on the severity of the case. Although more sophisticated strategies are available in the clinical phase, radiation therapy, chemotherapy (‘chemodrug’), surgical removal and immunotherapy are currently widely employed. Although chemotherapy often yields exciting results, its side effects consistently concern patient who may have to undergo the process. Whereas chemodrugs efficiently target cancer cells, normal cells are equally attacked and destroyed in the process ,32. To lProteins have increasingly been recognized as attractive natural therapeutic macromolecules for the treatment of a wide variety of diseases. Although targeted therapeutic proteins/peptides commonly referred to as peptide drugs (PDs) have high specificity and activity toward diseases, a major limitation hindering their clinical application is their short circulating half-life ,42. ProtPresent studies have indicated that upon fusion with ELPs, the circulating half-life of PDs, including single-chain antibodies  and therapeutic peptides (AP1 and p50), in the body increased significantly while inducing enhanced cytotoxic damage to the target tumor site or cell line ,54,55. AAside from enhancing the circulating half-life of PDs, the second significant effect of ELPs on PDs is their ability to increase the accumulation of targeted drugs at the tumor site in a temperature-dependent manner. The most classic application of this strategy is fusion of ELPs with cell-penetrating peptides (CPPs) or with a specific peptide that targets tumor antigens (TPs) in combination with antibiotics or small-molecule drugs . ELP-CPP or ELP-TP fusion protein complexes can improve cell penetration and drug targeting and prolong the half-life and reduce the toxicity of small-molecule drugs to normal cells and tissues. Compared to free drugs, ELP-CPP drug modules show significant cell penetration and improved cancer-cell-killing efficacy . MoreovePhotodynamic therapy (PDT) is a clinically recognized non-invasive treatment approach that can be used to treat series of cancers and non-malignant diseases by triggering a series of cell death mechanisms ,70,71. GTaking advantage of the phase-transition property of ELPs, their amino acid sequence, composition and molecular weight can be fine-tuned to either solubilize or coacervate according to the conditions of the tumor microenvironment. Because tumors are highly vascularized, ELPs can take advantage of this medium to be transported and deposited at target sites in order to achieve highly homogenous tissue infiltration while limiting their clearance rate. Thus, combining ELPs with PSs endows the PSs with enhanced tissue permeation and increased half-life without affecting their ability to respond to light and to generate ROS . For mor1O2), which induced the formation of disulfide bridges between the cysteine to form a stable hydrogel both in vitro and in vivo. The stable hydrogel formed by cysteine crosslinking served as a reliable therapeutic depot for a sustained release of ROS, resulting in significant tumor growth inhibition when compared with either Ce6 or cELP alone. (See For example, according to a report by Mukerji et al. , the phoSimilarly, Phill et al.  decorateAlthough the combination of surgery and chemotherapy remains a reliable go-to choice in many tumor management cases, the search for an improved therapeutic strategy with little to no life-threatening effect continues to be pursued. Hence, improving the therapeutic potency of polypeptide-mediated and ELP-based drug delivery systems could represent the next-generation advancement in healthcare in terms of improving the wellbeing of patients. Nonetheless, due to present limitations of such a therapeutic approach, prospective studies could consider addressing some identified issues to improve the efficacy of this polymer-based drug delivery system. Tumors are highly susceptible to extravasation, which accounts for most cases of metastasis and is also the cause of loss of inoculated drug conjugates. Although conjugation of ELPs with photosensitizers may induce crosslinking of ELPs to form a stable hydrogel, nanoparticles or micelles to improve their residence time, the pore size of the vasculature at the tumor site and the size of the ELP-transformed micelles, nanoparticles or hydrogel requires investigation to establish the formation of stable conjugates in tumors resistant to extravasation in the event of fluid leakage. Aside from leakage, it has been demonstrated by multiple studies, including those by Moktan and Raucher  and SaraIt is now established that ELP sequence, chain length, guest residue, protein concentration, salt type and concentration and solution pH are all important factors that affect the Tt of ELPs . Hence, Moreover, combination of ELPs and photosensitizers provides route to develop optically responsive ELPs. At present, light-responsive hydrogels prepared by the combination of ELPs and photosensitizers have the advantages of long-term structural stability and no adverse immune responses in animals . ReversiIn general, ELPs show low to no toxicity but improve the pharmacokinetic properties of the drug to which they are conjugated, indicating that ELPs as a biomaterial have merits and high potential as a module for drug delivery but require improvement to be accepted and utilized for the purposes of drug delivery without the fear of inducing inflammation or adverse immune responses. Combining drugs with ELPs could not only significantly improve the therapeutic effect of conventional drugs but also increase targeting specificity and reduce toxicity to normal cells or tissues.


A substantial proportion of individuals with low cardiovascular risk receive inappropriate statin prescription for primary prevention of cardiovascular disease (CVD) instead of the evidence-based recommendations to promote healthy lifestyle behaviors. This study reports on the structured process performed to design targeted de-implementation strategies to reduce inappropriate prescription of statins and to increase healthy lifestyle promotion in low cardiovascular risk patients in Primary Care (PC).A formative study was conducted based on the Theoretical Domains Framework and the Behavior Change Wheel (BCW). It comprised semi-structured interviews with PC professionals to define the problem in behavioral terms; focus groups with Family Physicians and patients to identify the determinants (barriers and facilitators) of inappropriate statin prescription and of healthy lifestyle promotion practice; mapping of behavioral change interventions operationalized as de-implementation strategies for addressing identified determinants; and consensus techniques for prioritization of strategies based on perceived effectiveness, feasibility and acceptability.Identified key determinants of statin prescription and healthy lifestyle promotion were: the lack of time and clinical inertia, external resources, patients' preferences and characteristics, limitation of available clinical tools and guidelines, social pressures, fears about negative consequences of not treating, and lack of skills and training of professionals. Fourteen potential de-implementation strategies were mapped to the identified determinants and the following were prioritized: 1) non-reflective decision assistance strategies based on reminders and decision support tools for helping clinical decision-making; 2) decision information strategies based on the principles of knowledge dissemination ; 3) reflective decision-making restructuring strategies .This study supports the usefulness of the BCW to guide the design and development of de-implementation strategies targeting the determinants of clinicians' decision-making processes to favor the abandonment of low-value practices and the uptake of those recommended for CVD primary prevention in low-risk patients. Further research to evaluate the feasibility and effectiveness of selected strategies is warranted.ClinicalTrials.gov, Identifier: NCT04022850. Registered July 17, 2019. In: ClinicalTrials.gov. Bethesda (MD): U.S. National Library of Medicine (NLM). Available from: https://www.clinicaltrials.gov/ct2/show/NCT04022850.Sanchez A. De-implementation of Low-value Pharmacological Prescriptions (De-imFAR).  De-implementation or abandonment of ineffective or low-value healthcare has gained great interest in recent decades, due, among other factors, to the growing empirical evidence of its high prevalence and its impact on patient safety, resource consumption and social inefficiency , 2. AccoIn light of current understanding of how to tackle targeted implementation and de-implementation endeavors, several fundamental aspects can be concluded. Firstly, factors driving the implementation of both evidence-based and inappropriate interventions in the clinical setting are multi-level, complex, and context specific . TherefoThe DE-imFAR  study aims to carry out a structured, evidence-based and theory-informed process involving the main stakeholders  for the design, deployment and evaluation of targeted de-implementation strategies for reducing low-value pharmacological prescribing . SpecifiDespite these recommendations, over the last years the consumption of statins in the Basque Country has increased substantially due, in part, to a CVD prevention approach excessively focused on the control of lipid levels and the use of medications. In this regard, the results from a descriptive observational study (as part of the DE-imFAR study) with data from electronic health records (EHR) on the inappropriate prescription rate of statins in patients aged 40–75 years with no history of CVD, with moderately cholesterol but with a CVR <5% (REGICOR) showed an incidence of new inappropriate prescriptions of 10.5 per 100,000 people/year . FurtherThis paper reports on Phase I of the DE-imFAR study. Its main aim is to conduct a formative research in the specific context of the Basque Health Service-Osakidetza to: i) understand the problem of low-value statin prescription in primary prevention of CVD and define it in behavioral terms; ii) identify the main determinants of this clinical practice  that must be addressed to change this behavior, and iii) map potential de-implementation strategies; and iv) prioritize mapped strategies based on their perceived effectiveness, feasibility and acceptability.ClinicalTrials.gov database .A Phase I formative study applying systematic, comprehensive and evidence-based frameworks, such as the Theoretical Domains Framework (TDF) , 24 and A working group, which was composed of experts in the design of implementation strategies, methodologists, pharmacists, qualitative researchers, clinicians and health service managers, used the TDF and BCW to identify, select, adapt and define possible behavioral change interventions operationalized as de-implementation strategies to address the prioritized determinants of inappropriate statin prescription in CVD primary prevention. This process involved eight steps grouped into the following three stages:n = 3) and Practice Nurses (n = 2) with recognized expertise and experience in CVD prevention in order to identify the overall behavioral scenario and break down the chain of behaviors and concomitant non-behavioral  factors (step 1). The interview script was centered on determining how physicians address and manage the clinical encounters related to CVD prevention, and what the main steps taken are. Three members of the working group independently reviewed the recordings of the interviews, and identified and proposed a set of possible target behaviors. Subsequently, using matrices and exercises proposed by the BCW (We conducted a set of five semi-structured interviews with a sample of Family Physicians (FPs)  of the selected target behaviors related to inappropriate statin prescription and healthy lifestyle promotion actions, a qualitative study comprising focus groups with FPs was performed (step 4).n = 83) and Barakaldo-Sestao (n = 123) IHOs with a brief explanation of the project and the invitation to participate. Out of the total number contacted, it was possible to recruit 21 FPs. Four focus groups of about 90 min of duration were conducted, two for each IHO, with between four to seven attendees in each group.Since the DE-imFAR study was carried out in two of the 13 Integrated Healthcare Organizations (IHO) of Osakidetza, a convenience sampling strategy for the recruitment of the healthcare professionals was used. In short, emails were sent to all the FPs from the Ezkerraldea-Enkarterri-Cruces , patient comfort with treatment, and so on.The goal at this stage was to identify the Behavior Change Techniques (BCTs) for each of the agreed determinants of selected target behaviors. Two researchers proceeded first to group each identified barriers and facilitators into their respective TDF domain. Subsequently, they described identified determinants in the form of “what needs to change” and linked them to the intervention functions guided by the BCW instructions and suggestions. Then, all potential policy categories were identified. Lastly, potential BCTs most likely to produce a change were selected for each determinant using the process established by the BCW .Final definition, packaging and selection of previously identified de-implementation strategies were carried out through a participatory consensus process in the form of round meetings involving the working group as representatives of the main stakeholders. In short, the working group first grouped and logically ordered all related mapped BCTs . Then and guided by examples of de-implementation interventions within the literature and by the experience of several team members in the design of implementation strategies, the working group decided upon a clear layout of the techniques to be applied  for each of the potential interventions identified through this structured mapping process.Finally, in order to prioritize the de-implementation strategies derived from the conducted mapping, a poll process using the LimeSurvey platform involving FPs who collaborated in the focus groups was carried out. Specifically, they assessed the potential effectiveness, acceptability and feasibility of each identified strategy. The prioritization analysis, taking into account the ordinal nature of the measurement scale, was carried out by counting the number (proportion) of observations in each value of the assessed variables. Those considered potentially effective while highly acceptable and feasible for enacting behavior change were prioritized as the final set of specific strategies, to be contained in at least one broad de-implementation strategy seeking to reduce low-value pharmacological prescribing in the primary prevention of CVD.Reduce the prescription of statins in the context of primary prevention of CVD in low-risk patients (REGICOR <5%) and favor the adoption and implementation of the recommended intervention, the promotion of healthy lifestyles  at any opportunistic or programmed health center visit for screening or addressing CVD risk factors” .”The FP Afterwards, in steps 2 and 3, this target behavior was broken down into the chain of behaviors involved and the concomitant precipitating factors Table S2Numerous determinants, facilitators of the inappropriate statin prescription and barriers toward healthy lifestyle promotion emerged from the focus groups with healthcare professionals. Determinants were identified from the quotes guided by a pre-specified coding. Though professionals' discourse tended to saturation, we do not have explicit confirmation of having reached saturation of data with the four groups. Participants felt that lack of awareness of the problem, doubts, clinical guidelines being out of date, and lack of consensus on or variability of recommendations, are main facilitators for an inappropriate prescription .The main determinant related to capabilities is the low perceived confidence in prescribing healthy lifestyles, a clinical practice considered difficult in itself as compared to prescribing a statin . This problem is augmented by the difficulties faced by professionals to tackle healthy lifestyle promotion actions as a means of preventing CVD in low-risk patients, who are not usually frequent attenders (Cap_Q3).The fear of negative consequences of not treating seemed to be a powerful driver of inappropriate prescribing (Con_Q1). This “defensive medicine” was also enhanced by the perceived effectiveness of statins in decreasing cholesterol levels (Con_Q2). Obtaining such a positive clinical result in the short term contrasted with the long term (and somewhat unperceived) benefits of healthy lifestyle promotion actions (Con_Q3). The adverse effects associated with statins seemed to be a potential barrier to statin prescription (Con_Q4).The abovementioned scarcity of positive expected results from healthy lifestyle promotion actions has derived in a low motivation of professionals (M_Q1). Actual intention in the form of action plans or goals, both for not prescribing statins and for providing healthy lifestyle promotion interventions, is seen as a necessary condition to endorse guideline-concordant CVD primary prevention efforts (M_Q2).A repeated theme in physicians' discourse is the influence of clinical inertia in decision-making favored by contextual factors such as lack of time and heavy workload . Pharmacological prescription is perceived to require less cognitive effort in a saturated clinical practice that leads to decisional fatigue. A defensive medicine mindset is always present when deciding upon treatments (MAD_Q3). Physicians also requested the removal of asterisks in patients' blood test results  as this visual stimulus induces patients' concerns regarding cholesterol levels . Such markers incite cholesterol-control-focused clinical actions.As previously commented, lack of time and the heavy workload experienced in Primary Care are the main obstacles for prevention efforts . Physicians also perceived that tools within the EHR are useful but somewhat limited for estimating cardiovascular risk, for reminding and fomenting guideline-concordant CVD primary prevention practice, and for restricting inappropriate statin prescribing . Teaming up with an involved Practice Nurse in order to share prevention efforts facilitated adequate healthy lifestyle promotion actions in primary prevention of CVD (E_Q5). Lack of external resources inside and outside the clinical setting  limits the reach of prevention efforts, especially in low-risk young adults, as a non-frequent-user population (E_Q6-Q8).Lack of coherence in prescription criteria among the different healthcare professionals  who attend the same patients dilutes responsible clinical practice . Uncertainties regarding limits in responsibility with respect to healthy lifestyle prescribing and fear of questioning each other's clinical decisions help to maintain inappropriate treatments (Rol_Q3).Patients' lack of awareness together with a perception of low susceptibility and vulnerability regarding cardiovascular risk hamper physicians' primary prevention efforts . In contrast, due to the importance given by the media and probably fueled by the pharmaceutical industry, cholesterol is “the bad guy” everybody is worried about and needs to be addressed (SI_Q3). Another ambivalence occurs with healthy lifestyles. On the one hand, the population seems to be more conscious about the overall benefits of healthy behavior. But on the other hand, patients seem to have become so used to the message about the need to change to healthy lifestyles that some prefer to take a “magic” drug in the belief that there is no need to change habits . In fact, neither the internal context in the health system which does not prioritize healthy lifestyle promotion practice, nor the external context at societal level influenced by media messages and the economic interests of the pharmaceutical industry targeting cholesterol reduction exclusively, are conducive to good CVD primary prevention practice (SI_Q6-Q8). Professionals also perceive that in certain sectors of the population, such as those with lower socio-economic status, the promotion of healthy lifestyle, although being the recommended practice, is very difficult to implement .Mixed emotions were reported by physicians who mainly favor inappropriate prescribing. Professionals must make decisions in an emotional climate marked by uncertainty due to the variability of recommendations and limitations of the Clinical Practice Guidelines (CPG) and fear of consequences of not treating (Em_Q1-Q3). The feeling of pleasing the patient coupled with peace of mind after prescribing statins and obtaining “positive” cholesterol results are factors that seem to weigh substantially on decision making . In contrast, positive emotions associated with successful healthy lifestyle changes seen in patients are the only emotional asset that favors continuing the work of promoting healthy lifestyles (Em_Q6).Professionals complained of a poor quality assessment culture in the healthcare system and of lack of standards and indicators established by the organization to anchor and guide clinical performance (BR_Q1). Data are needed to be able to reflect on performance and to be able to set goals, monitor progress and provide useful feedback, and the lack of access to such data prevents reflection and the establishment of objectives, both of which are seen as necessary to correct the problem of inadequacy in drug prescription (BR_Q2-Q4).In addition to the mentioned above in relation to objectives and performance indicators, the results of the evaluations of indicators carried out by the organization do not translate into incentives for professionals, which generates demotivation among those professionals willing to do things right .In addition, we conducted one focus group with six patients in order to triangulate professionals' discourse. We must highlight that the majority of the participants indicated a lack of explanation of the prescribed treatment and their desire to be more involved in the treatment decision. Moreover, they believed that family health history has a lot of weight in the decision and they are concerned about it. They reported that only some professionals recommended healthy lifestyles with or without prescription of statins. When we asked about their preferences for doing physical activity or taking a cholesterol-lowering drug in a context of low CVR, different points of view arose: some preferred physical activity while others preferred to combine exercise and pharmacological treatment. Overall, they were satisfied with taking statins although they preferred not to think about the adverse effects.Through various round meetings, the working group agreed and drew up a list of 14 potential de-implementation strategies with their respective format and techniques of delivery . The speLastly, the potential strategies were sent back to all the healthcare professionals involved in the discussion groups and two health managers for their evaluation regarding three dimensions: acceptability, feasibility and potential effectiveness. Thirteen complete evaluations (13/23) were received that allowed the prioritization of the de-implementation strategies see .This study aimed to report on the application of a systematic, comprehensive, theory-and evidence-informed framework to design potentially effective and feasible de-implementation strategies to favor the abandonment of low-value pharmacological prescribing in CVD primary prevention in low CVD risk patients . SpecifiAvoiding or substituting proven potentially harmful, ineffective or inefficient medical practices is important for improving the quality of healthcare while ensuring sustainability of healthcare systems, which is the reason why in recent years the interest in and the evidence base related to successful de-implementation strategies to favor the abandonment of low-value practices has grown quickly. Statins are among the most widely prescribed medications globally and are increasingly used to prevent CVD in people without CVD (“primary prevention”). However, statins have no or low value for the primary prevention of CVD in low-risk patients . On the From the growing scientific evidence in implementation research it is known that factors determining the implementation of both evidence-based and inappropriate interventions in the clinical setting are multi-level, complex, and context specific . ConsequThe identified determinants are in line with other determinants identified or reported in previous studies regarding determinants of low-value practice and of low-value pharmacological prescription. For example, uncertainty due to the variability and/or conflict of the guidelines with respect to the recommended practice, the pressures and demands on the part of the patients, the need for rapid and decisive action in response to the reasons for consultation and the desire to please the patients have been identified as interconnected motives that generally justify maintaining low-value practices . With reOne peculiar aspect in this point is that, due to the addressed clinical scenario , this project has attempted to simultaneously identify determinants of both clinical practices. Although it may seem obvious, in such clinical scenarios, stress must be placed on identifying the factors that facilitate or maintain the low-value practice, and on the other hand, the barriers that impede the recommended practice .With the main goal of designing and developing targeted strategies that address the specific determinants of CVD prevention practice in the Basque Health Service-Osakidetza, the present's study main action has been to carry out a mapping process of de-implementation and implementation strategies in order to reduce low-value practices (inappropriate statin prescribing) and promote the implementation of the recommended practice , based on the determinants of routine practice reported by FPs in the focus groups, following the procedure established by the BCW.The 14 strategies that have emerged from the mapping processes are all “old known” strategies and interventions. Nevertheless, previous studies targeting the reduction of low-value statin prescription have shown some effectiveness of certain dissemination strategies as informative web pages or the implementation of electronic CPGs when compared to routine practice especially when used as multi-component strategies –37. FurtHowever, the innovative contribution of having used the BCW is that, both actions, determinant identification and mapping of strategies, aim to target the specific clinical behavior most likely to enable the desired change prioritized by the research group and professionals involved: physicians' decision-making regarding the therapeutic option. Moreover, following a taxonomy of choice architecture techniques , all excThe present study has several limitations. First, the formative study has been performed in only two IHO of Basque Health Service-Osakidetza that are not representative of all Primary Care centers within our health service. Second, after having invited all professional within the two participating IHOs, only a reduced and auto-selected sample was obtained and we cannot guarantee that we have reached saturation of data regarding physicians discourse related to inappropriate statin prescription. And finally, this previous issue also extends to patients groups by limiting the planned triangulation of discourses to only one group of patients.The present study aims to contribute to the body of currently scarce literature available on practical de-implementation initiatives by providing detailed illustrations/explanations of our stepped, systematic approach to the design and development of targeted behavior change actions based on prominent available frameworks and theories, mostly from implementation science. Key research questions in implementation science also involve determining what implementation strategies should be provided, to whom, and when, to achieve optimal success in implementing evidence-based clinical practice. As the same paradigm must apply for de-implementation of low-value practices, we propose now to investigate the comparative effectiveness of some/different types or intensities of the prioritized strategies in Phase II of the DE-imFAR project. The future evaluative phase of our study will have the aim of increasing evidence on whether the specific strategies that address determinants of recommended practice in CVD prevention, some similar to those evaluated in the few studies conducted to date, are also effective in our context. If the strategies explored are successful, health planners and managers will have the evidence needed to support the introduction of such structured strategies, informed by the application of methods and procedures of the emerging science of implementation and de-implementation.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Basque Country Clinical Research Ethics Committee . The patients/participants provided their written informed consent to participate in this study.AS, JP, and GG conceived the idea, the study guarantors, primarily responsible for the study design and planning, as well as the funding obtained, and will be responsible for project coordination and supervision, analysis and interpretation of results, and manuscript preparation. SP, UE-A, SG-L, MM, IL, RS, ML, OL, and CH collaborated in the study design and were responsible for study coordination, interpretation of results, and manuscript preparation. AS, UE-A, and MM were responsible of the performed analysis. All authors critically reviewed the manuscript and approved this version submitted for publication.This project was supported by the Basque Government Department of Health (funded project 2018111085 and 2021111024) and by the Carlos III Institute of Health and co-funded by the European Union . The funding bodies had no role in the design of the study, collection, analysis, and interpretation of data or the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Despite mergers have increasingly affected hospitals in the recent decades, literature on the impact of hospitals mergers on healthcare quality measures (HQM) is still lacking. Our research aimed to systematically review evidence regarding the impact of hospital mergers on HQM focusing especially on process indicators and clinical outcomes.Population, Intervention, Comparison and Outcome model, querying electronic databases  and refining the search with hand search. Studies that assessed HQM of hospitals that have undergone a merger were included. HQMs were analyzed through a narrative synthesis and a strength of the evidence analysis based on the quality of the studies and the consistency of the findings.The search was carried out until January 2020 using the The 16 articles, included in the narrative synthesis, reported inconsistent findings and few statistically significant results. All indicators analyzed showed an insufficient strength of evidence to achieve conclusive results. However, a tendency in the decrease of the number of beds, hospital staff and inpatient admissions and an increase in both mortality and readmission rate for acute myocardial infarction and stroke emerged in our analysis.In our study, there is no strong evidence of improvement or worsening of HQM in hospital mergers. Since a limited amount of studies currently exists, additional studies are needed. In the meanwhile, hospital managers involved in mergers should adopt a clear evaluation framework with indicators that help to periodically and systematically assess HQM ascertaining that mergers ensure and primarily do not reduce the quality of care. Medicare Prospective Payment System and the growth of the managed care in the 1980s in the USA,,,Over the last three decades, a growing number of healthcare organizations of different countries, especially in the USA and in Europe, underwent mergers.,,Drivers for mergers are different and depend on countries and health system features: in Italy and in the UK, mergers were primarily driven by political decisions, while in USA, where federal or state government has less power to set the policy agenda, they were mainly entrepreneurial and market-driven.,Affecting the catchment area, the hospital organization and functioning and increasing the market concentration, hospital mergers could potentially impact healthcare quality measures (HQMs) affecting patients as well as employees and communities. In line with the volume–outcome relationship, service consolidation could improve the quality of care, for example with regards to surgical procedures. Nevertheless, some studies argued that less concentrated and high competitive markets report better clinical outcomes in hospitalized patients, i.e. in terms of mortality.Despite this, to date, literature on the impact of hospitals mergers appears to have mainly focused on economic aspects.Population, Intervention, Comparison, Outcome (PICO) model.A systematic research was conducted querying MEDLINE, Scopus, Web of Science from their commencement until January 2020. To gather evidence on the impact of hospital merger on HQM, a search string was elaborated using the Studies were considered eligible if they quantitatively assessed HQM of hospitals that have undergone a merger. In case of perception/satisfaction of employees qualitative studies were screened for inclusion as well. Exclusion criteria were represented by publications without original data  and with intervention represented by vertical merger or by non-homogeneous mergers such as those between hospital and non-hospital facilities. Regarding structure healthcare measures, financial indicators were not included because previously addressed in literature.From each study, the following data were extracted: first author's last name, year of publication, country, study design, period of observation (before and after merger), number of hospital involved in the merger, main investigated outcomes, main results in HQM classified in structure, process and outcome.,The risk of bias (RoB) and the methodological quality of the included studies were assessed using the National Institutes od Health (NIH) Study Quality Assessment tools for before–after and case–control studies, and The Joanna Briggs Institute Systematic Reviews Checklist for qualitative researches.Studies included showed methodological heterogeneity, particularly regarding study design and outcomes reporting. Few studies considered similar outcomes, and when they did, they had either different control group or different methodology of outcome assessment. A pooled analysis would have limited utility, therefore, a meta-analysis was deemed inappropriate. We preferred to synthesize data through a narrative synthesis of the study findings focusing on outcomes of interest reporting statistically significant results.,To further support the narrative synthesis and easier the identification of consistent results (i.e. increasing or decreasing of the same indicator in different studies), we performed a strength of evidence analysis according to literature.,The strength of the evidence was performed using a rating system based on the methodological quality of the studies and the consistency of results.strong evidence: provided by generally consistent findings in multiple high-quality studies;moderate evidence: provided by generally consistent findings, in one high-quality study and one or more moderate-quality studies or in multiple moderate-quality studies; andinsufficient evidence: inconsistent findings in multiple studies.P < 0.05).,promising, in presence of at least two significance in outcomes and >75% of consistent findings.Study findings were considered consistent if >75% of the studies reported the same conclusion with statistically significant results .,,,,Outcome measures were reported in five studies,,An overall judgement of the included studies is available online . The qua,,,,,t-test values for the indicators analyzed before and after the hospital merger. To facilitate the synthesis of significant findings, The included studies showed methodological heterogeneity in terms of statistical analysis: five adopted difference-in-differences analysis to compare changes in outcomes in merging hospitals to changes in a group of hospital controls not involved in a merger,t-value 0.35) were found.t-value 0.05), and the otherConcerning structure indicators, the change in number of beds after merger showed a decreasing trend: statistically significant decreases in two studies ,,t-value 0.07) while the otherP = 0.03) but probably not attributable to the merger since the improvement started before the acquisition.Regarding process indicators, three studiesRegarding personnel satisfaction, hospital executives considered mergers positively, especially for increased negotiation skills and costs reduction. Conversely, personnel expressed criticalities mainly regarding the different organization of merged hospitals, the inadequate communication of the merger process, the uncertainty of job positions and the lack of personnel involvement in the post-merger phase.,,,HQM that were mostly assessed in the studies included those related to AMI mortality, stroke mortality and hospital readmission. Only one study assessing AMI mortality showed a significant negative effect on the outcome,P.72).Regarding stroke mortality, one studyThe strength of the evidence rating system resulted as “insufficient” for all considered indicators. The sensitivity analysis did not show promising results with the exception of the decrease in the number of beds and in the inpatient admissions .In literature, the main potential benefits of mergers declared by hospital leaders usually refer to economic and financial availability, but also clinical quality improvements due to increased investments, higher volumes of specialized procedures and standardization of clinical protocols.Studies analyzed in our research show that, apart from some structural and process indicators, hospital mergers resulted in non-significant improvement in the HQM compared to the period before the merger itself.,Regarding structural and process indicators, the reduction in the number of beds and in inpatients admissions  could beRespect to the volume–clinical outcome relation, it is reported to widely vary across conditions and outcomes, with the largest benefits occurring among a small number of technically difficult surgical interventions.Lack of evidence of improved clinical quality after a merger is in line with a new researchOverall, the effects of the mergers could depend on some features—as the type of the organizations involved—and the merger between similar organizations, sharing the same culture and organizational attitude, appears to be more effective.This systematic review represents a first attempt to summarize evidence regarding the impact of hospital mergers on HQM with the purpose of providing a broader picture regarding research and practice on hospital merging processes.a priori methodology with an accurate search strategy involving different electronic databases supplemented by hand searching, forward citation searching, study identification, appraisal, data extraction and description. Furthermore, we sought to increase the value and the validity and reliability of findings performing strength of evidence analysis. Nonetheless, several limitations could be identified. First, our research has included only publicly available English-written articles; therefore, a language bias cannot be excluded. We cannot rule out that the wide variability in the terms used to define merger, as well as the national and governmental dimension of the topic, might have limited the inclusiveness of our research.The strengths of this review include an Most of the included studies provided only descriptive statistics and some outcomes (benefits or drawbacks) achieved after merging hospitals had been evaluated only in single studies consequently providing little inferential and generalizable information.High heterogeneity in the studies’ methodology was found, e.g. in measures used to evaluate results and in the follow-up duration (from months to years), hindering undertaking a formal meta-analysis and performing a rigorous strength of evidence analysis.Studies included in our analysis do not show strong evidence that hospital mergers impact HQM by bringing net improvements. At the moment, few studies indicate that the benefits related to mergers could be met counteracting the potential unintended consequences as decreased competition, higher prices for patients and reduced geographic coverage of services that mergers could cause.,Since a limited amount of studies currently exists, there is a need for additional studies providing concrete evidence that hospital mergers ensure and primarily do not reduce high-quality care that patients require. Researchers should work to produce high-quality, well-designed studies with adequate follow-up, in order to evaluate all healthcare quality dimensions (including cost-efficacy and equity) of hospital mergers. In particular, quasi-experimental studies with interrupted time series design can evaluate intervention effect estimating causal effects using observational approaches when, as in this case, randomized controlled trials  cannot be performed.EURPUB online.None.Conflicts of interest: None declared.Key pointsIn the last decades, an increasing number of hospitals have undergone a merger but literature on the impact of merger on hospitals Health Quality Measures (HQM) is still lacking.Studies included in our systematic review resulted to be heterogeneous in HQM analyzed and methodology adopted mainly providing only descriptive statistics and showing moderate to low risk of bias, few statistically significant results and inconsistent findings across them.Additional high-quality and well-designed studies with adequate follow-up are needed ascertaining mergers do not reduce the quality of care.Policymakers and hospital managers who are going to start a merger process must early adopt an evaluation framework that helps to perform an overall periodic assessment of HQM during the whole process.ckac002_Supplementary_DataClick here for additional data file.


Knee osteoarthritis is a common degenerative joint disease characterized by chronic knee pain and disability in daily living. The lesion can involve the cartilage as well as the synovium, bone, ligaments, and meniscus, indicating a complicated pathology for knee osteoarthritis. The association with the meniscus has recently attracted much attention. Meniscal tears can initiate and progress knee osteoarthritis, with deleterious effects on the important roles of the meniscus in load distribution, shock absorption, and stability of the knee joint. Degenerative meniscus lesions are commonly observed in elderly people, but they have less impact on the prognosis of osteoarthritis. However, they are often accompanied by meniscal extrusion, which substantially decreases the hoop function of the meniscus and increases the risk of knee osteoarthritis. When surgical treatment is necessary, meniscal tears should be repaired to the greatest extent possible to preserve meniscus function. Long-term studies show better clinical outcomes and less degenerative osteoarthritis changes following meniscal repair than following partial meniscectomy. For meniscal extrusion repair, centralization techniques have been proposed that involve suturing the meniscus-capsule complex to the edge of the tibial plateau. Advancements in orthobiologics, such as platelet-rich plasma or stem cell therapy, have the potential to prevent the initiation or progression of osteoarthritis.  Knee osteoarthritis (OA), one of the most prevalent degenerative musculoskeletal diseases, has several known risk factors, including old age, female sex, malalignment, obesity, genetic factors, and trauma ,2. The nMeniscectomy is used to treat meniscus tears, but it is well-known to decrease meniscal function and is often followed by the initiation and development of knee OA during long-term follow-up ,9. This In this review article, we present the critical pathologies of the meniscus involved in knee OA and treatments for the meniscus that can prevent the initiation/progression of knee OA. Although knee OA is recognized as a disease of the cartilage, we speculate that the meniscus is much more involved than initially thought.The meniscus is a fibrocartilage located between the femoral condyle and the tibial plateau and covers more than half of the tibial plateau . The rolThe cells of the meniscus differ according to their location; the outer zone cells are classified as fibroblasts, and the inner zone cells are similar to fibrochondrocytes . VasculaMeniscal tears can be caused by traumatic knee injury, or they can arise due to degenerative changes without traumatic episodes. The ESSKA  European meniscus consensus group has defined traumatic meniscus injury as a meniscal tear that is associated with sufficient knee injury and a sudden onset of knee pain . The natMorphological tear patterns of the meniscus can include longitudinal, radial, horizontal, and flap tears . MRI is Degenerative meniscus lesions (DMLs) are defined as meniscus lesions that occur without a history of knee trauma in patients older than 35 years . DMLs deMeniscal extrusion is a displacement of the meniscus body beyond the outermost margin of the tibial plateau  and is oMeniscal extrusion causes a decreased coverage of the tibial plateau, thereby leading to an increased load bearing of the cartilage. Therefore, meniscal extrusion is more strongly correlated with joint space narrowing when compared to meniscal tears and cartilage defects ,44, and MMPRT is a strong cause of MME and results in the loss of the meniscus hoop function, while also accelerating progression of the degenerative changes of knee OA . The bioThe widely accepted threshold of MME is a displacement of the meniscus body of more than 3 mm . HoweverUltrasound is also useful for detecting meniscal extrusion, and it can establish the effect of the weight bearing position in MME ,57. MME Meniscectomy is well-known to lead to radiographic and symptomatic OA in the long term . FairbanRandomized clinical trials that compared APM and PT for symptomatic DML showed no significant differences in patient objective outcomes at short-term or mid-term follow-up ,62. A muIn regard to traumatic meniscal tears, the prevalence rate of developing moderate to severe OA was 29% after ACL reconstruction in a minimum 20-year follow-up study, and the odds ratios for statistically significant factors for the presence of OA were 3.0 for medial meniscectomy . The eviWhen surgical treatment is necessary for meniscal tears, the first option should be meniscal repair to preserve the meniscus function . The ratIn the case of acute MMPRT, surgical repair should be considered more necessary than for other meniscus injuries due to the high risk of progression of cartilage degeneration. Therefore, accurate diagnosis by MRI and meeting the window of opportunity for treatment are quite crucial . MeniscuMeniscal centralization has recently been developed for the treatment of meniscal extrusion. Koga et al. first reported arthroscopic centralization of an extruded LM by suturing the capsule attached to the meniscus to the edge of the tibial plateau using suture anchors . SatisfaWhen malalignment of the lower leg is present as part of the meniscus pathology, preventing degenerative changes is difficult using only a meniscus preservation surgery . TherefoMeniscus replacement has been clinically performed for meniscus deficiency after meniscectomy. Acceptable short- or mid-term clinical results of meniscal allograft transplantation have been reported in painful knees that had previously been subjected to subtotal or total meniscectomy ,84. CollHowever, approval for use of these meniscal materials differs depending on the country. Autogenous tendon is also available as a potential for meniscus substitution and has strong tensile properties ,88. HoweRecently, orthobiologics have emerged as potential materials to improve the poor healing potential of the meniscus due to its inadequate blood supply, especially in the inner margin of the meniscus ,94. In aPlatelet-rich plasma (PRP), which contains growth factors, including transforming growth factor-β, platelet-derived growth factor, vascular endothelial growth factor, and basic fibroblast growth factor, is clinically used in meniscal repair. However, its efficacy is still a matter of controversy due to the differences in indications or PRP preparation techniques . SuccessStem cells are promising orthobiologics that can change the strategy of meniscus treatment. A single center, prospective, first-in-human safety study showed that implantation of autologous bone marrow-derived mesenchymal stem cells (MSCs) in a collagen scaffold into the avascular meniscal tear prior to meniscal repair resulted in 3 of 5 patients being asymptomatic at the 2-year follow-up and showing improved clinical scores and MRI findings . Synovial MSCs are a reasonable cell source for regenerative medicine of the meniscus due to their high proliferative and chondrogenic potential , and theThe meniscus has a critical role in OA initiation/progression, especially in middle-aged and elderly people. Preservation of the function of the meniscus is quite important for preventing the progression of OA. When surgical option is necessary for a meniscal tear, the recommended procedure is meniscal repair, rather than meniscectomy. However, PT can be applied to DML without any other pathology. When MMPRT or MME is present, a surgical procedure that preserves the meniscus function should be considered. In this field, longer-term follow-up and validated evidence are still necessary to accomplish the prevention of OA.