AbstractIUCN). “Data deficient” is a category that misrepresents the real risks of extinction of these species considering that (a) some of these species are known only from a handful of specimens collected in a single or a few localities long ago; (b) the Cerrado and the Caatinga have been sufficiently sampled to guarantee collection of additional specimens of these species if they were abundant; (c) natural habitats PageBreakof the Cerrado and the Caatinga have been substantially altered or lost in recent decades. Failures either in the design of the IUCN criteria or in their application to assign categories of extinction risks represent an additional important threat to these endemic faunas because their real risks of extinctions become hidden. It is imperative to correct this situation, particularly considering that these species are associated to habitats that are experiencing fast transformation into areas for agriculture, at an unbearable cost for biodiversity.We undertook a comprehensive, critical review of literature concerning the distribution, conservation status, and taxonomy of species of mammals endemic to the Cerrado and the Caatinga, the two largest biomes of the South American Dry-Diagonal. We present species accounts and lists of species, which we built with criteria that, in our opinion, yielded results with increased scientific rigor relative to previously published lists – e.g., excluding nominal taxa whose statuses as species have been claimed only on the basis of unpublished data, incomplete taxonomic work, or weak evidence. For various taxa, we provided arguments regarding species distributions, conservation and taxonomic statuses previously lacking in the literature. Two major findings are worth highlighting. First, we unveil the existence of a group of species endemic to both the Cerrado and the Caatinga . From the biogeographic point of view, this group, herein referred to as Caatinga-Cerrado endemics, deserves attention as a unit – just as in case of the Caatinga-only and the Cerrado-only endemics. We present preliminary hypotheses on the origin of these three endemic faunas . Secondly, we discovered that a substantial portion of the endemic mammalian faunas of the Caatinga and the Cerrado faces risks of extinction that are unrecognized in the highly influential Red List of Threatened Species published by the International Union for Conservation of Nature ( The latPageBreakTaxon classificationAnimaliaDidelphimorphiaDidelphidaeCryptonanusagricolai is endemic to the Cerrado and the Caatinga, and has also been collected in contact zones between these biomes and the Amazon in northern Mato Grosso and southwestern Piauí states Thylamyskarimii is endemic to the Cerrado and the Caatinga, and has been recorded in the Brazilian states of Bahia, Goiás, Mato Grosso, Minas Gerais, Pernambuco, Piauí, Rondônia, Sergipe, and Tocantins, and in the Distrito Federal Thylamysvelutinus is endemic to the Cerrado, and has been recorded in the Brazilian states of Bahia, Minas Gerais, São Paulo, and in the Distrito Federal Tolypeutestricinctus is endemic to the Cerrado and the Caatinga , and for the Brazilian states of Piauí (in the Cerrado-Caatinga ecotone) and Paraíba (in the Caatinga) (Lonchophylladekeyseri occurs in the Bolivian savannah and in the Cerrado–Caatinga ecotone in NE Brazil. One of the specimens supporting these records was examined a long time ago (DZSJRP 11459), and the other two  are distinct from other samples of Lonchophylladekeyseri as determined in a previous discriminant function analysis. These specimens are not included in this analysis because we were not able to compare them with samples from other localities.We are not convinced that ” We provisionally regard Lonchophylladekeyseri as endemic to the Brazilian Cerrado until further studies determine the taxonomic identity of specimens collected in Bolivia, the Cerrado-Caatinga ecotone, and the Caatinga.o contra , and haso contra . Additioaatinga) . HoweverIUCN ver. 3.1 assigned the category “Endangered” to Lonchophylladekeyseri  – and according to Micronycterisyatesi. No information about the morphology of the other specimen has been published Callithrixpenicillata is endemic to the Cerrado, and has been recorded in the Brazilian states of Bahia, Goiás, Maranhão, Minas Gerais, Piauí, São Paulo, and in the Distrito Federal . This estimate resulted from the analysis of sequence data from two mitochondrial genes. Subsequently, Sapajus at the genus level; ‘expert opinions’ have been invoked to promote this view  Elevating Sapajus and Cebus as an argument to elevate Sapajus at the genus level is flawed for two reasons. First, because the age of that split, as estimated by PageBreakphenomenon is provided by the recent proposal to validate the name Leontocebus as a genus, to contain the nigricollis group of Saguinus, using as an argument the fact that it is sympatric with other tamarin lineage  At least for now, using the age since the split between  lineage  – note tprimates should be fixed, and several proposed genera should be lumped into fewer ones. This process has already begun -species format  readily confers phylogenetic information. In this case, the genus name Cebus informs about the sister-taxon relationship between the subgenera Sapajus and Cebus – supported by a number of synapomorphies  might pose difficulties in scientific communication, for example for literature searches or for merging data from public repositories .(3) Continuing to recognize the long established, monophyletic genus hies see  – whereaprimates, whose generic and alpha-level taxonomy should be rectified in the upcoming decades.We take the opportunity to emphasize the importance of using the subgenus rank to preserve nomenclatural stability, similar to what have been recently done for other groups of mammals . This asIUCN ver. 3.1 assigned the category “Least Concern” to Cebus (Sapajus) libidinosus  into different genera are flawed for the same reasons we have already discussed under the account of Cebuslibidinosus (see above).We regard IUCN ver. 3.1 assigned the category “Critically Endangered” to Callicebusbarbarabrownae Lycalopexvetulus is endemic to the Cerrado and the Caatinga, and has been recorded in the Brazilian states of Bahia, Ceará, Goiás, Mato Grosso, Mato Grosso do Sul, Minas Gerais, Piauí, São Paulo, and in the Distrito Federal Galeaspixii is endemic to the Caatinga, and has been recorded in the Brazilian states of Alagoas, Bahia, Ceará, Minas Gerais, Pará, Pernambuco, São Paulo Kerodonrupestris is endemic to the Caatinga, and has been recorded in the Brazilian states of Alagoas, Bahia, Ceará, Minas Gerais, Paraiba, and Pernambuco Gyldenstolpiaplanaltensis is endemic to the Cerrado, and has been recorded in the Brazilian state of Mato Grosso, and in the Distrito Federal Cerradomysmarinhus is endemic to the Cerrado, and has been recorded in the Brazilian states of Bahia and Minas Gerais Euryoryzomyslamia is endemic to the Cerrado, and has been recorded in the Brazilian states of Minas Gerais and Goiás Calomysexpulsus is endemic to the Cerrado and the Caatinga . Specimens attributed to Calomysexpulsus have been recorded in the Brazilian states of Bahia, Goiás, Minas Gerais, Pernambuco, Piauí, Sergipe, and in the Distrito Federal  in a clade in which samples from the states of Ceará and Tocantins – for which we presume no karyotype were available – were also included.a contra . All but Federal . AccordiCalomysmattevii as a junior synonym of Calomysexpulsus. PageBreakity of Calomysexpulsus), Minas Gerais, with 2n=36/FN=66, correspond to Calomysexpulsus; however, Calomysexpulsus , which they described as Calomysmattevii. Although it is plausible that the specimens reported by Calomysexpulsus, this cannot be assumed as certain because multiple species of Calomys might occur in Lagoa Santa . In fact, Lagoa Santa is also the type locality of Calomystener , and using this material in comparative analyses that should include typical, or at least topotypical, material of other members of the large-size group of the genus  is a necessary step to evaluate the taxonomic status of Calomysmattevii. On the meantime, we consider that karyotype 2n=66/FN=68 corresponds to Calomysexpulsus, following Calomysexpulsus as reported by In summary, given the aforementioned uncertainties in the description of IUCN ver 3.1 assigned the category “Least Concern” to Calomysexpulsus Wiedomyspyrrhorhinos is endemic to the Caatinga, and has been recorded in the Brazilian states of Alagoas, Bahia, Minas Gerais, Paraíba, and Pernambuco PageBreak(rnambuco . BonviciWiedomys (Rodentia). Revista del Museo de La Plata, Zoología 18(172): 163R. .Souza ALG, Pessôa LM, Menezes AN, Bezerra AMR, Bonvicino CR (2011) O rio São Francisco como provável barreira geográfica para as duas espécies do gênero IUCN ver. 3.1 assigned the category “Least Concern” to Wiedomyspyrrhorhinos Carterodonsulcidens is endemic to the Cerrado, and has been recorded in the Brazilian states of Goiás, Mato Grosso, Mato Grosso do Sul, Minas Gerais, and in the Distrito Federal Thrichomysapereoides is endemic to the Cerrado . Subsequently, two other studies gave support to the polytypic nature of Thrichomys, one based on karyological data and morphometric analyses Thrichomysinermis is endemic to the Caatinga  baseados em identificação cariotípica. In: Fagundes V, Costa LP, Leite YLR, Mendes SL (Eds), Livros de resumos, III Congresso Brasileiro de Mastozoologia. Espírito Santo, Aracruz, p. 102.Carvalho AH, Fagundes V (2005) Área de ocorrência de três táxons do gênero Thrichomysinermis  do Tocantins. XXVII Congresso Brasileiro de Zoologia, Curitiba.Carvalho AH, Lopes MOG, Svartman M (2008) Cariótipo de IUCN ver. 3.1 assigned the category “Least Concern” to Thrichomysinermis Trinomysalbispinus is endemic to the Cerrado and the Caatinga . Reis and Pessôa (1995) did not discuss the biogeographic context they presumably considered to designate minor as a subspecies of Trinomysalbispinus  instead of a valid species. minor as a subspecies of Trinomysalbispinus due to the fact that karyotypes that they and albispinus and minor, respectively, shared the same diploid and autosomal fundamental numbers , morphology of the sex chromosomes, and size of the first and second pairs of autosomes. b sequences by minor were nested within a haplogroup formed by samples attributed to Trinomysalbispinussertonius  the two species occur in a geographic context in which no clear barrier to dispersal separate them  – even if they share the same karyotype and shallow genetic divergences. According to Trinomysminor as a species rather than as a subspecies of Trinomysalbispinus. A number of potential causes could explain the yet-to-be-confirmed topology described in the species account by Trinomysminor and Trinomysalbispinus.The recently published synopsis of the genus IUCN ver. 3.1 assigned the category “Least Concern” to Trinomysalbispinus Trinomysminor is endemic to the Cerrado and the Caatinga .See the Taxonomy section of IUCN ver. 3.1 has not yet attempted to evaluate the extinction risk of Trinomysminor, and although the IUCN acknowledged that the minor merited species-level recognition, it treated minor as a subspecies of Trinomysalbispinus Trinomysyonenagae is endemic to the Caatinga, and has been recorded in the Brazilian state of Bahia , other endemic to the Cerrado , and another endemic to the Caatinga and the Cerrado in combination . Altogether, these faunas encompass 43 species  that are only found in either the Caatinga, or the Cerrado, or both .h Tables  can be eSpecies richness was the highest in the Cerrado-only endemics, followed by the Caatinga-Cerrado endemics, and then by the Caatinga-only endemics. The order with highest species richness in all three faunas aforementioned was rodents; all other orders were represented by only one to three species Tables  and 2. PCryptonanusagricolai, Thylamyskarimii), one xenarthran (Tolypeutestricinctus), one bat (Micronycterissanborni), one primate (Cebuslibidinosus), one carnivore , and five rodents . Two genera are currently known to be endemic to the Caatinga-Cerrado unit . Among Caatinga-Cerrado endemics, only Trinomysalbispinus seems to be strictly associated to forest habitat, whereas Lycalopexvetulus, Oxymycterusdelator, and Trinomysminor seem strictly associated to open habitat. The remaining seven species are likely associated to both open and forest habitats  has been advocated is the existence of sexual dimorphism on pelage coloration in this form; however, there is a wide variation in color pelage within Alouattabelzebul, and some variation exists even among samples of “ululata”  and karyotypes , a status also considered by ululata” should test for an additionPageBreakal possibility, which is that population that have been referred to as corresponding to “ululata” could represent hybrids between Alouattabelzebul and Alouattacaraya (Garbino in litt.). With respect to the distribution of Alouattabelzebulululata, some authors regarded it as endemic to the Cerrado and the Caatinga  our criterion to deem a species as endemic is stricter than that used by other authors (see Methods); or (2) recently published information demonstrate that these species are present in biomes other than the Caatinga and the Cerrado; or because (3) we do not consider them valid species. Due to either of the former two criteria, we excluded the following species from our list of endemics: Calomystener, Cerradomyslangguthi, Cerradomysvivoi, Cerradomysmaracajuensis, Cerradomyssubflavus, Ctenomysbrasiliensis, Ctenomysnattereri, Clyomyslaticeps, Dasyproctaazarae, Guerlinguetuspoaiae, Kunsiatomentosus, Phyllomysblainvillii, Pseudoryzomyssimplex, Rhipidomysmacrurus, Thrichomyslaurentius , we adhere to recent synopses of mammal genera provided by various authors, and do not recognize the following names as corresponding to valid species: Guerlinguetuspoaiae, Urosciurusurucumus, Dasyproctanigriclunis, and Rhipidomyscearanus , the great PageBreakmajority of members of the endemic faunas of the Caatinga and the Cerrado are either of low concern, lack data for assessing their extinction risk, or have not been considered yet by the IUCN  conform 80% of the Caatinga-only endemics (8 out of 10 species), 68% of the Cerrado-only endemics (15 out of 22 species), 82% of the Caatinga-Cerrado endemics (9 out of 11 species), and 74% of all endemics (32 out of 43 species). We argue that this situation does not reflect the reality of these faunas. Our reasons are as follows:CN Table . Accordith century, surveys of mammals in both the Caatinga and the Cerrado covered numerous sites (GBIF) and the contribution by GBIF or that were not included in the publication by IUCN assigned the category “Data Deficient” are rather species with recognizable risks of extinction. The category “Data Deficient” implies the possibility that future efforts  might demonstrate that these species are sufficiently common to be of Low Concern; however, the sampling already conducted should have yielded enough distributional records if the species did not have very low population sizes, extremely restricted distributions, or both. The application of the IUCN criteria for assigning conservation statuses globally are clearly inadequate when applied to species that are known from few records and are endemic to regions that have been well sampled.For mammals, the Caatinga and the Cerrado have been relatively well sampled; yet several of their endemic species are known only from a handful of localities. Since the second half of the 20PageBreakPageBreakforests by open vegetation via charcoal production, timber and cattle ranching (Instituto Brasileiro de Geografia e Estatística (http://www.ibge.gov.br), we generated a map that shows extensive areas of the Cerrado and the Caatinga that have suffered of habitat transformation due to human activities  and two bats (Xeronycterisvieirai and Lonchophyllainexpectata). Both bat species have been recently described; hence, because future reexamination of museum specimens might reveal that these species are more common than currently thought, the category “Data Deficient”, which has been assigned to them, might be justifiable. All other cases are undoubtedly facing certain recognizable risk of extinction.The Red List published by the IUCN assessment, the Brazilian national assessment of the conservation statuses yielded categories that seem more congruent with the high risks of extinction these species face. Nevertheless, many of the species evaluated by the IUCN have not been considered in this national assessment, indicating the need for a larger and more expedite effort by Brazil’s Ministério do Meio Ambiente (When compared with the Ambiente  to assur


Within this research topic entitled “Recent Advances and Technologies in Algal Lipid Biology” is a collection of five papers which demonstrate the breadth and depth of current algal lipid research. Before highlighting the findings of these five papers, it is worth stepping back to define the terms “algae/algal” and “lipid” as they relate to these studies, especially because these terms are commonly used in the popular scientific press associated with the push to develop algae and their lipids as a source of renewable fuel.n-alkanes and alkenes), pigments , and toxins . As such, the papers within this research topic focus on fatty-acid containing lipids and sterols.A lipid is defined as any biological compound which is soluble in a non-polar organic solvent, such as chloroform, and generally insoluble in water. According to this definition, lipids represent arguably the most diverse macromolecule class because they can include such molecules as fatty acid-containing lipids , sterols , hydrocarbons  or as an energy storage molecule . More specifically, glycolipids such as monogalactosyldiacylglycerol (MGDG), digalactosyldiacylglycerol (DGDG), and sulfoquinovosyldiacylglycerol (SQDG) comprise the chloroplast membrane matrix within which photosynthetic pigments such as chlorophylls and carotenoids reside, whereas betaine lipids and phospholipids are thought to form other cellular membranes. Many of these lipids contain potentially economically valuable, long-chain, polyunsaturated fatty acids  as a means of producing more lipid. This highlights how a given algal species will probably need to be genetically augmented to make it a more efficient producer of lipid. Specifically, Gu et al. utilized a type III ketoacyl-ACP synthase from a halophilic diatom, Chaetoceros sp. isolated from Great Salt Lake, to replace an analogous enzyme in the cyanobacterium Synechococcus sp.; this led to improved production of medium-chain fatty acids . Medium- chain fatty acids are of particular interest as biofuels because they may be more suitable in colder temperatures than longer chain fatty acids.With regard to using algae to produce biofuel, the paper by Taipale et al. is a continuation in a long history of studies (see seminal paper by Volkman et al., Lastly, within the realm of algal lipids, there is a long history of using “unique” lipids as biomarkers for particular genera or classes of algae. The work of In summary, algae and lipids demonstrate a diversity of cell types and macromolecules, respectively. The set of papers in this research topic has given insight into how current experimental approaches can be used to both assess lipid functionality and improve their production in algae.All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.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.


I say it just begins to live that day”Emily DickinsonIn contemporary knowledge landscapes, interdisciplinary communication is crucial. In many cases, the interaction among experts of different fields is challenging, especially with regard to controversial definitions at the intersection of law, science, and bioethics. We analyze the legal definitions of the term “embryo” as the result of legal, ethical, as well as scientific implications, at the intertwining of social changes and scientific advancements. We show how embryo is a complex word, which may be interpreted in different ways. Taking into account the latest research advances on early stage embryo development, we focus on the delicate roles of law in balancing differing claims of scientific investigation and bio-ethic concerns. We conclude that sensitive ethical definitions are the synthesis of often competing interests among different disciplines. Moreover, human feelings toward controversial biology innovations should be taken into account.http://www.oxforddictionaries.com/definition/english/definition). Definitions, however, are based on words, and words are also tricky issues since, as poetically pointed out by Emily Dickinson , shifting the attention from a medical procedure to social relations, offer interesting cases for analyzing the science discourse and its implication in regulation of science innovations . The humin vitro embryos for longer than ever before, up to 12-13 days , ie, a question which biology is not deputed to solve. The further capability to generate in vitro embryos started a process of bio-objectification well analyzed by Beriain  was established to inquire into the ethical, scientific, and legal implications of ARTs.During the 1970s, when the Constitutional Courts of various countries, especially in the US and in Europe, had to face embryo’s legal status with regard to abortion legalization, embryo was obviously intended as the encounter of ovum and sperm occurring in the body of a woman. The focus, in those cases, was the balancing of embryo’s and mother’s conflicting rights. In the leading case on abortion in vitro embryos for research purposes (http://www.hfea.gov.uk/docs/Warnock_Report_of_the_Committee_of_Inquiry_into_Human_Fertilisation_and_Embryology_1984.pdf). Accordingly, “the meeting of egg and sperm at fertilization” was taken as a starting point and “the ensuing six weeks immediately following fertilization” were regarded as embryonic stage. Thus, the report, by fixing a start and by delimiting a time period, made clear that although no biological reasons claimed to set a limit to the development of the in vitro embryo, decisions were to be taken “in order to allay public anxiety” by ensuring that “embryos should not be kept alive for an undefined period.” The committee reported various proposals, determining at 17 days the deadline of in vitro embryo development, when “neural development begins,” or “at the end of implantation stage.” It finally took as reference point the formation of the primitive streak, ie, a well characterized histological structure formed at one end of the embryonic disc on the fourteenth or fifteenth day after fertilization, which marks the beginning of embryo’s head-to-tail axis , which used for this stage of embryo development various definitions like “early human embryo” or “preimplantation embryo” with reference to “the completion of implantation” of embryos into the uterus. The EAB concluded that: “… no embryos will be sustained in vitro beyond the stage normally associated with the completion of implantation (14 days after fertilization)”. The 14-day limit has been subsequently adopted in the reports of other ethical boards, in various countries, such as Australia and Canada  in 1979 (d Canada .Scientific American in 1979 (http://hansard.millbanksystems.com/commons/1986/oct/21/unborn-children-protection-no-2-bill), a “rethorical device”  has to be the intended in vitro embryo derived from the group of cells resulting from the progressive division of the oocyte until 14 days after fertilization. Again, the law established a 14-day limit for research on embryos  but, as well pointed out by scholars, in this phrasing, pre-embryo was defined first of all as an “embryo,” which is further characterized by its stage of development (preembrión” – besides other expressions like the fruit of conception (“fruto de la concepción”) – and stated that in vitro pre-embryos did not enjoy the same constitutional protection as the ones already transferred in utero. Other laws do not use the term pre-embryo, but clearly refer to it, as in the case of the Greek regulation statute , which, regulating the use of surplus “cryopreserved reproductive material” and of “non cryopreserved fertilized ova,” points out that they are to be destroyed after the completion of 14-day postfertilization.The need to use in bio-law a terminology to suitably define this stage of embryo development is documented by the various locutions used to define pre-embryo. An interesting example is the legal definition in the Spanish law regulating ARTs, adopted in 2006, whose article 1 stated that a preembryo (“elopment . In 1999embrione” tout court (law n. 40/2004 on ART) and in the Swiss law , which regulates the permission to undertake embryo stem cell research and adopts the term “embryo” in the German version and the corresponding terms “embryon” and “embrione” in the French and Italian versions respectively. This latter law, on the basis of biology and of applications, also details what has to be considered as an embryo, a spare embryo, embryo stem cells, and also a parthenote.Despite the above discussed attempt to apply proper definitions, in other laws, even in those regulating embryo research up to 14 days, no other terms but “embryo” are used. Worth stressing, this also occurs in laws prohibiting this research, such as in the Italian law, which uses the term “Oliver Brüstle v Greenpeace e.V., C-34/10, 18 October 2011), the Court included in the definition of embryo various results of egg manipulation, such as “any human ovum after fertilisation, any non-fertilised human ovum into which the cell nucleus from a mature human cell has been transplanted, and any non-fertilised human ovum whose division and further development have been stimulated by parthenogenesis” . In 2014, the Court of Justice gave a partially different definition, ruling that: “(…) an unfertilised human ovum whose division and further development have been stimulated by parthenogenesis does not constitute a ‘human embryo’ (…) if, in the light of current scientific knowledge, it does not, in itself, have the inherent capacity of developing into a human being (…)”. . The ECJ took as a starting point respectively the definition of the “concepts of ‘human embryo’ and ‘use for industrial or commercial purposes’” (Brüstle) and the “concepts of ‘human embryo’ and ‘organism capable of commencing the process of development of a human being’” . These two decisions are both relevant in the debate concerning the intellectual property field and once more they suggest, in embryology application, the recurrent need to establish the start of “being human.”Finally, in this analysis of terminology, it must be taken into account that the term “embryo” as defined by laws regulating ARTs might be intended differently as compared with the “embryo” as considered by Supreme Courts dealing with abortion, or with the embryo as defined by the European Court of Justice (ECJ), to the extent of patenting rights. Indeed, EU law excludes from patentability the use of “human embryos for industrial or commercial purposes.” Worth stressing, the interpretation of what should be intended as human embryo has been focused on a specific feature, such as the inherent potentiality to become a human being, rather than on the final product of its manipulation, ie, the embryo. In a first decision, in fact, (http://www.isscr.org/home/publications/2016-guidelines). This prohibition was based on 3 arguments, considering that these experiments “lack a compelling scientific rationale, raise substantial ethical concerns, and/or are illegal in many jurisdictions.” The same month (May 2016), on the other hand, Nature  published its revised and updated guidelines for stem cell research and clinical translation, adopting the 14-day limit to define prohibited research activities on human embryos  by the Belgian Advisory Committee on Bioethics . Accordingly, besides biology, human feelings intermingle into legal definitions with a dynamic and controversial process continuously negotiated between scientific evidence and human emotions and values.Finally, it should also be remembered that words are used not only to describe facts, but also to communicate perceptions. The definition of embryos to the extent of research regulation is a complicated issue, as previously well analyzed . Law neeIn science, new terms have been conceived following discoveries or to define novel products of innovations. Moreover, as well shown in ARTs, definitions seem to be fluid matters being subjected to continuous re-interpretation when facing demands of lay-society, needs of moral decision-making, and in different contexts. In law, the attempt to clearly identify bio-objects and develop proper regulations results in a variety of descriptions and interpretations according to socio-cultural landscapes and their evolutions/involutions. In the case of embryo, for instance, if its development is continuous from the biological perspective, law requires fixing specific features, which would fit regulation needs rather than strictly represent scientific facts. This is the case of legal interpretation of the term “pre-embryo,” for which the 14-day development period seems to have a strong symbolic and moral value. At the same time, however, such limit might result in an adaptable parameter since legal definitions are subjected to changes in the dialogue with science and ethics.Only through the understanding of this complexity, a truly interdisciplinary approach is possible. In this demanding exercise, different experts are claimed to cooperatively interchange their specific skills to build up a knowledge landscape where different visions blend to regulate social and personal needs, opportunities, and limits.


Children who live with a complex chronic or life-threatening illness face extraordinary challenges. Whether they are receiving disease-oriented treatment  or palliative treatment—or both concurrently—our challenge is to enhance their comfort and minimize their distress. Symptom management is thus a critical component of pediatric palliative care. Symptoms may be either physical or psychological in nature (or a confluence of both) and their effective management has a direct impact on the child’s quality of life. This article provides an integrative overview of children’s experience of selected physical and psychological symptoms, as expressed through their words and images. Understanding their perspectives is an essential component in the design and provision of optimal symptom management. Included, as well, are examples from siblings—a reminder of the profound impact of illness on these children who also “live” the experience, albeit in a different way. The symptoms that are described are pain, nausea and vomiting, fatigue, weakness, seizures, hair loss, depression, and anxiety. Although psychological symptoms are often inextricable from the physical, they may also present independently as part of the overall illness experience. Children who live with a complex chronic or life-threatening illness face extraordinary physical and psychological challenges. Many contend with hardship and terror as the illness wends its course into an uncertain future. Pediatric palliative care strives to optimize the quality of life of children living with serious illness, as well as to support the family. Whether children are receiving disease-oriented treatment  or palliative treatment—or both concurrently—our challenge is to enhance their comfort and minimize their distress.Too Scared to Cry: “‘Psychic trauma’ occurs when a sudden, unexpected, overwhelmingly intense emotional blow or a series of blows assaults the person from outside. Traumatic events are external, but they quickly become incorporated into the mind. A person probably will not become fully traumatized unless he or she feels utterly helpless during the event or events.”   “MA machine” (“MY machine”).  8]  in degenerative disorders.“A child with muscular dystrophy was tripping and falling constantly, but adamantly refused to use a wheelchair, protesting that he did not need it. His older brother with the same disease was already severely compromised. In a family drawing,  the chilplaying [author’s italics] falling down the hill.” Although she had been told that his weakness was actually a symptom of disease, she was still hopeful that it was not of any serious import.In a thematically-related drawing , a childSeizures ,14 are aAcceptance of the temporary hair loss secondary to chemotherapy is initially difficult for most children, regardless of age. Reactions of fear and sadness are common. Even young children recognize its significance, from the cosmetic surface through to the evidence of the gravity of the illness. A child stated that losing her hair been the hardest part of the illness for her  2] . Children’s drawings can be clues to identifying psychological symptoms.The following two images drawn by hospitalized children  to a generalized sense of foreboding. It is the latter that can be difficult to identify and address in children. A four-year-old child being cared for in home-hospice would not verbally acknowledge that he had any symptoms of any kind. However, he described a dark and threatening drawing as “a batman tunnel. It’s completely dark, but I wasn’t scared”  17] (p. (p.17]  [17] (p.Psychologist: What are your bad dreams about?Child: Monsters, a snake biting....Psychologist: When you have those bad dreams, what do you think you are worried about?Child: You dying. Everyone dying in the world and leaving me alone.... (p. 122–Nightmares are not uncommon manifestations of anxiety. Thus, this interchange:In a drawing by another child  2] (p.  (p. 2] (Many children are capable of describing symptoms vividly, whether in words or images, even at times offering an explanation or interpretation as to their significance. These selected narratives underscore the inextricable nature of the physical and psychological in the expression of many symptoms. Their complexity is testimony to the crucial need for an interdisciplinary treatment team and the paramount importance of ongoing communication among the children, families, and professionals who care for them.


Genetic testing for risk of hereditary cancer can help patients to make important decisions about prevention or early detection. US and UK studies show that people from ethnic minority groups are less likely to receive genetic testing. It is important to understand various groups’ awareness of genetic testing and its acceptability to avoid further disparities in health care. This review aims to identify and detail awareness, knowledge, perceptions, and attitudes towards genetic counselling/testing for cancer risk prediction in ethnic minority groups.A search was carried out in PsycInfo, CINAHL, Embase and MEDLINE. Search terms referred to ethnicity, genetic testing/counselling, cancer, awareness, knowledge, attitudes, and perceptions. Quantitative and qualitative studies, written in English, and published between 2000 and 2015, were included.Forty-one studies were selected for review: 39 from the US, and two from Australia. Results revealed low awareness and knowledge of genetic counselling/testing for cancer susceptibility amongst ethnic minority groups including African Americans, Asian Americans, and Hispanics. Attitudes towards genetic testing were generally positive; perceived benefits included positive implications for personal health and being able to inform family. However, negative attitudes were also evident, particularly the anticipated emotional impact of test results, and concerns about confidentiality, stigma, and discrimination. Chinese Australian groups were less studied, but of interest was a finding from qualitative research indicating that different views of who close family members are could impact on reported family history of cancer, which could in turn impact a risk assessment.Interventions are needed to increase awareness and knowledge of genetic testing for cancer risk and to reduce the perceived stigma and taboo surrounding the topic of cancer in ethnic minority groups. More detailed research is needed in countries other than the US and across a broader spectrum of ethnic minority groups to develop effective culturally sensitive approaches for cancer prevention.The online version of this article (doi:10.1186/s12889-017-4375-8) contains supplementary material, which is available to authorized users. BRCA1 and BRCA2 genes are known to be linked to breast, ovarian . They are so far away [from Western medicine]. The mammogram is coming out but this is the first time I heard about the gene test.”Asian American female, Glenn et al. “Black people aren’t into that yet. We need to know more about it so it will not seem so farfetched.”African American female, Matthews et al. Several studies including Chinese Australian, Hispanic, and African American samples reported that the majority of participants had low awareness and knowledge about the importance of genetics in cancer,  testing , 63–67.  testing , 65. Gen testing –64. Some testing , 64. The testing , 61, 65.“I have heard that if you hit your breasts, it could cause cancer—I saw a woman who got cancer after being hit with a bottle on her breast. My mother hit her stomach and then she got cancer in her uterus. The underwires in bras are not good and they harm your breast tissue and cause cancer. I take them out.”Hispanic female, Vadaparampil et al. Closely linked to participants’ low awareness and knowledge of cancer and genetic testing were the misconceptions held, including believing that genetic counselling prevents cancer , stress “… I think it will be harder for them to find out that they have a gene or a mutation that may cause...their body to develop cancer...in the future, and so I think for a lot of people just knowing that they have the mutation will be a lot more of anxiety source than actually helpful…”Hispanic, Kinney et al. Four studies found that African American and Hispanic participants had fatalistic views of cancer, which they perceived to be an illness that cannot be cured and is associated with death , 65, 66.“But now the word cancer is different from before…before people were ashamed, now they believe they will beat it, it was once a taboo.”Hispanic female, Sussner et al. However, within a Hispanic community, Sussner et al.  found th“the opportunity for early detection, instead of waiting until the cancer develops.”Benefits of genetic testing included African American female, Adams et al. Interest in and positive attitudes towards genetic testing for cancer susceptibility were identified , 63, 66.“I do believe that everything is in God’s hands, regardless. But, I don’t think that my spiritual beliefs would prevent me from going. If anything, they would motivate me to go…”African American female, Ford et al. Some African American and Hispanic participants discussed their spirituality and God, this was not presented as a barrier to genetic testing but as a way of seeking guidance and coping , 61, 67.“The stigma [would stop me from getting tested] because you always have a concern that somewhere this information is gonna reside on a computer somewhere; it may prevent you from getting employment, future insurance, or any number of things so that’s [my] concern. That is one thing that has stopped me from going ahead with testing.”African American female, Sheppard et al. Several negative attitudes and perceptions were held by participants in relation to cancer and genetic testing. Discussing illnesses such as cancer was described to be taboo by Chinese Australian, African American, and Hispanic participants , 64, 66.“…I felt in the past that doctors have sent me for tests just to get money. I feel that I was put through something…really bad, going you know, put fear in me for something…just so the doctor could put the claim in and I would never trust. It was terrible…”Hispanic female, Sussner et al. “One of my girlfriends who is so narrow-minded … would say ‘I wouldn’t let those people experiment [referring to genetic testing] on me’ …. Some of my other friends, who are not as narrowminded would think, ‘It’s best to find out all you can’… ‘Go for all the tests you can’ ”African American female, Glenn et al. Five of the eight qualitative studies conducted in the US reported that participants, particularly African Americans, discussed mistrust and disillusionment in the health care system , 63, 65.Only one study, involving Asian American participants, suggested that a cultural mismatch exists between genetic testing and their culture’s traditional medicine . However“The woman is meant to do everything, take care of the house, take care of this, take care of that, so health does go on the background…That’s how we were raised. You last, everybody else first”Hispanic female, Sussner et al. The theme of Family was raised in discussion by many participants and was described as both a motivator and a barrier to testing. Two studies reported that Hispanics identified a culture of prioritising family needs over their own, resulting in a lack of time to attend health appointments , 63 and “I was the first one diagnosed with breast cancer in my family, so I would be concerned about it for their sake to find out what was going on…so that’s what would motivate me, family.”African American female, Sheppard et al. However, helping others in society , 63 and “[Family] wouldn’t keep me from going. If I wanted to go, I would go”African American female, Ford et al. Only two studies referred to family support in relation to genetic testing , 65. ForA further issue specific to some Chinese Australians was their understanding or definition of ‘close relatives’ , 64. The“The doctor mentioned it during my last visit but he didn’t do anything about it so I didn’t do anything.”Hispanic female, Vadaparampil et al. Several practical issues were highlighted in relation to uptake of cancer genetic testing. Ease of access to services would motivate attendance for genetic testing . This co“I think if I had to incur the fees myself, I wouldn’t think of going…I can’t even imagine having to pay out of my pocket for tests.”African American female, Ford et al. As the majority of the qualitative studies took place in the US, cost and insurance were often discussed , 65–67. “But if you are let’s say Spanish and you don’t know the terminology or you don’t know, they (the doctors) think the person is ignorant. That’s not the case because just because you have a language barrier does not make you ignorant.”Hispanic female, Sussner et al. Language was identified as a barrier to using genetic services by Hispanics in two studies , 66. ParAll studies scored quite highly in the quality assessment, receiving scores of 0.75 or above  may not pursue genetic testing that is relevant to them. Low awareness and knowledge was also highlighted in qualitative research as a barrier to attending genetic counselling or undergoing genetic testing, and participants suggested a need for awareness and educational interventions especially emphasising the importance of family history of cancer. Qualitative studies also identified several misconceptions about cancer that could deter patients from attending cancer genetic services. However, it is difficult to make generalisations based on the results from qualitative research which may only represent the views of a few individuals. Furthermore, these misconceptions do not appear to be unique to those from ethnic minority groups. For example, Ford et al. [Ethnic minority groups’ knowledge of genetic risk of cancer also varied across the studies reviewed, indicating low to moderate levels of knowledge. Among samples of participants at high risk for cancer, often less than 50% of knowledge questions were answered correctly. Although knowledge about cancer genetics may not relate to intentions to test, individuals who lack understanding about the hereditary nature of cancer . Unlike a pathogenic high risk gene change, the association between a VUS and increased risk of cancer is unclear, leading to issues for providers   and patiS result , with a S result –82. DiffThe majority of the reviewed studies were conducted in the US which limits their generalisability to other countries, particularly in relation to levels of awareness and knowledge. Nevertheless, lack of awareness, the taboo of discussing cancer, and language difficulties, have also been reported in a UK genetics service evaluation  and a GeThe review has a number of limitations including the omission of intervention studies aiming to increase participant knowledge of cancer genetics from which we may have been able to extract baseline data. We did not include unpublished literature and our experience of using the quality assessment tool, specifically chosen for its ability to assess both qualitative and quantitative studies, indicated that it lacked a finer discriminatory capacity. The heterogeneous nature of the measures of awareness, knowledge, and attitudes used across various ethnic groups and different cancer types in the quantitative studies, made a meta-analysis impossible and interpretation of results difficult. Furthermore, the majority of included studies measuring knowledge and attitudes included only at risk patients or those already with a cancer diagnosis; therefore, results may not represent the knowledge or attitudes of the general population of ethnic minorities. Whilst still in the early stages of conception, due to an increasing understanding of cancer genetics and decreases in the cost of genetic testing, population based risk stratified interventions for cancer including genetic susceptibility testing are likely to be introduced in the future. Such interventions would provide people with information on their risk of cancer, and screening or treatment would be recommended based on their estimated level of risk. Before such interventions become a reality it is necessary to gain an understanding of the attitudes of the wider population, including those who are currently underserved such as ethnic minority groups. Meisel et al.  found poWidening public participation amongst ethnic minority groups in future cancer risk prediction programmes may be enabled by culturally sensitive knowledge and awareness raising interventions that decrease the stigma and taboo of cancer. For this, further international research is needed to provide clearer information of ethnic minorities’ attitudes, and information and support needs so that cancer risk prediction programmes are inclusive and effective in the prevention and early detection of cancer.Additional file 1:Review search terms. Full search terms for PsycInfo, CINAHL, Embase and MEDLINE used to find studies for the review. (DOCX 18 kb)Additional file 2:Study specific measures: Awareness, knowledge, and attitudes. The table presents descriptions of the main measures used to investigate awareness, knowledge and attitudes in relation to genetic counselling/testing. (DOCX 17 kb)Additional file 3:Rank order of included studies based on quality assessment. The table presents the quality assessments for each study and comments on why studies were marked down. (DOCX 19 kb)


This study aimed to identify barriers and enablers for dentists managing non-cavitated proximal caries lesions using non- or micro-invasive (NI/MI) approaches rather than invasive and restorative methods in New Zealand, Germany and the USA.Semi-structured interviews were conducted, focusing on non-cavitated proximal caries lesions . Twelve dentists from New Zealand, 12 from Germany and 20 from the state of Michigan (USA) were interviewed. Convenience and snowball sampling were used for participant recruitment. A diverse sample of dentists was recruited. Interviews were conducted by telephone, using an interview schedule based on the Theoretical Domains Framework (TDF).The following barriers to managing lesions non- or micro-invasively were identified: patients’ lacking adherence to oral hygiene instructions or high-caries risk, financial pressures and a lack of reimbursement for NI/MI, unsupportive colleagues and practice leaders, not undertaking professional development and basing treatment on what had been learned during training, and a sense of anticipated regret . The following enablers were identified: the professional belief that remineralisation can occur in early non-cavitated proximal lesions and that these lesions can be arrested, the understanding that placing restorations weakens the tooth and inflicts a cycle of re-restoration, having up-to-date information and supportive colleagues and work environments, working as part of a team of competent and skilled dental practitioners who perform NI/MI , having the necessary resources, undertaking ongoing professional development and continued education, maintaining membership of professional groups and a sense of professional and personal satisfaction from working in the patient’s best interest. Financial aspects were more commonly mentioned by the German and American participants, while continuing education was more of a focus for the New Zealand participants.Decisions on managing non-cavitated proximal lesions were influenced by numerous factors, some of which could be targeted by interventions for implementing evidence-based management strategies in practice.The online version of this article (10.1186/s13012-018-0744-7) contains supplementary material, which is available to authorized users. Dental caries is highly prevalent and costly to treat , 2. TradNI/MI control caries lesions without placing restorations , 7 and aHere, we used the Theoretical Domains Framework (TDF), which has been used previously to understand the motivations, cognitions and behaviours of health professionals when implementing evidence-based practice –19. Few Semi-structured interviews covered seven areas: 1) the dentist’s background (e.g. years of experience), (2) current clinical practice and decision-making for NI/MI/restoration, (3) knowledge and skills (e.g. awareness of guidelines), (4) professional role and identity (e.g. whose responsibility is NI/MI), (5) goals (e.g. changes to routine management in the future), (6) beliefs about consequences (e.g. benefits/disadvantages of NI/MI), (7) environmental context (e.g. factors that influence NI/MI), and (8) social influences (e.g. patient choice)  led the design of the interview schedule and data analysis. The clinical and dental research expertise was led by three researchers, one from each country . All researchers  acted as an expert panel to determine how to apply the TDF to oral healthcare . InterviProviding the underlying structure for data collection, analysis and interpretation, the TDF comprises 14 theoretical domains, each having a number of different constructs . Ten of NZ, the USA and Germany were chosen primarily for pragmatic reasons, including research team location and cost minimisation; they also represented three very different dental healthcare systems. In the USA, we sampled from only one state (Michigan) because it was felt that it would not be possible to use a USA-wide sample of dentists. We chose accordingly to sample from a state with many of the public and private healthcare systems available throughout the country. In each country, lists of registered dentists supplied names of general dentists who were then informed about the study by the research assistant or assistant research fellow in that country via email or telephone. Informal approaches and snowballing were also used.Although there is no specific requirement for the number of participants in qualitative research , we wantWe combined some TDF domains to reduce the time burden on participants Most dentists made comments regarding knowledge, with slightly more relating to procedural than construct knowledge. The former all centred on how the participants treated their patients using NI/MI, with most focusing on NI.At the enamel dentine junction, I have to think more about what this patient is like… how acidic is their mouth, how compliant are they going to be with the products. If they’re not interested in the products at all and they have terrible oral hygiene, then … we would need to do other things… non-invasive measures are not going to work. (NZ3)Comments grouped under knowledge of the task environment reflected knowledge of their patients’ dental/oral health history and how “compliant” they were perceived to be:If those new researches/findings remain out there for a few years, then yes. If they are only short-term studies, that have only been around for a year, then I would be very reluctant [to try them]. However, attending advanced courses and reading specialist journals helps to keep up to date. (G9)Knowledge construct comments generally linked with knowledge of the scientific literature, etc.I’d like to learn more about other modalities of treatment as well, more than I know. I don’t feel like I’ve had, because that’s not something that was taught when I was at dental school, so … I feel like I am a little short on knowledge or up-to-date with what the latest scientific recommendations are. (USA6)Interviewer: Are your recommendations supported by studies?I believe so because this is what I was told at university. (G2)A number also mentioned the importance of continuing education and reading dental journals. By contrast, a number said that they based their treatment on what they had learned at dental school. This was mainly the case with the Michigan and German dentists, who also reported that they did not undertake any ongoing education or professional development.I mean you don’t come out of Dental School having done lots…of things. You have done a few of many things, and so you, the real learning starts, I mean certainly from personal experience in that first year out, where you become exposed to techniques you know, modern and preventive techniques that you might not have even heard of. I came out of Dental School and really it was brush teeth, floss your teeth and we will paint fluoride stuff on, but we have come a long way since then. (NZ8)A lot of it is your experience you’ve built up over a period of time and sometimes I’m right and sometimes I could be wrong. So but I follow my best judgement. But it’s not a written list in essence. It is the 36 years of experience I have in dealing with the management of caries. (USA18)Few comments could be grouped under “skills”. Some listed fluoride application, but participants also commented on dietary advice, flossing and general oral hygiene. Comments falling under skills related primarily to experience, with many reporting that their clinical knowledge and professional judgement on using NI/MI increased with time in practice.Well that is the compliance. If he (patient) is willing to come in for regular recalls, do his homework, meaning proper tooth brushing at home and interdental hygiene. Also to brush his tongue, mucosa of the cheeks and to now and then use antibacterial mouthwash [and] if that isn’t the case and the patient does not think it is important to brush his/her teeth, then it can certainly be the case that we will directly do a filling. (G2)The only factor that would influence us to not offer treatment would be if somebody was really not interested and they didn’t show any signs of interest and we consider that it is going to be a waste of time. But you do get some patients or some children that they are not going to do what you ask them and I think that becomes a problem. (NZ10)All commented under this domain. Most comments fell under the social pressure construct, with patient “compliance” and oral hygiene as pressure factors influencing their decision to use NI/MI. There were 72 mentions of issues related to patient “compliance” (adherence to the dentist’s instructions).Well you know, unfortunately the financial advantage is kind of a negative because I'm financially advantaged to go in and do invasive care, I’m not saying that that’s a good thing. (USA8)Next was financial pressure, mostly from the German (23 mentions), followed by Michigan (18 mentions) and then NZ participants (2 mentions). All Germans mentioned the statutory German insurance and its lack of financial reimbursement for NI/MI. Many of the Michigan dentists mentioned the US public health insurance not covering NI/MI, with this causing them financial stress.Well if I do a filling then I will get paid. If I don’t do it, and tell the patient, we will observe , then I don’t get any money. At least a lot less and yes, that is why one or other colleagues tend to… do a filling, even though one may have easily been able to just observe it. (G2)Well I think I’m seeing, you know in slow economic times, I think unfortunately we see a lot of these restoration, these lesions restored when they otherwise could’ve been treated by other means, unfortunately that happens so that’s not really a benefit to the patient but more of a benefit to the provider. (USA12)Wider professional organisations and participants comparing their practice to that of other dentists were also commonly mentioned . More German (11 from 12) and Michigan participants (17 from 20) compared their practice to other dentists than NZ participants (six from 12).There are certain colleagues that go by how much they get paid off it, but would probably also do worse fillings. I am sure it is mixed. I don’t know this for sure. To be honest I don’t really like to talk about how much it costs. (G10)Most comments were grouped under the professional role construct, followed by professional identity, while fewer fell under social identity and none under identity. Professional identity comments centred on membership of professional bodies, and being knowledgeable about and adhering to evidence or guidelines. Group identity statements pertained to relationships with dental peers. Most comments categorised under professional boundaries centred on economic factors; that is, not engaging in specific treatments for financial profit.Comments grouped under professional role were varied, although most covered “educating” patients about good oral health or hygiene practices. Clearly, many participants viewed it as part of their professional role to raise patient awareness of good oral hygiene. It is interesting to note, however, that a few dentists made comments linking carrying out NI measures with hygienists, prophylaxis assistants or nurses.The advantage is the preservation of the tooth structure. We will preserve the tooth without a filling because even the best filling isn't the greatest compared to an untouched enamel layer. (G2)I think the biggest benefit is…my belief is that there is nothing better for the tooth than its own natural tooth structure with the filling in place once it is… we know that it has got a certain life expectancy that eventually that filling is going to break down and a bigger filling has to be placed and then a crown has to be placed and it is starting that process for more damage to the tooth. (USA1)The largest number of comments was grouped under beliefs, followed by outcome expectancies and characteristics of outcome expectancies. The overwhelming majority of comments related to the disadvantages of treating non-cavitated caries lesions with restorations. Almost all of the NZ and German participants and nearly half of the Michigan participants stated that restorations weakened the tooth structure, starting the cycle of restoration replacements. The following were typical.I have a lot of lesions that are in enamel only that I see that my colleagues would just treat immediately and I think that there’s potential for remineralisation with getting people better in their hygiene and their diet and trying to reduce the acid injury to the enamel there, and I think there’s a chance for natural remineralisation if the acid injury is arrested, slowed down anyway by different factors like fluoride and hygiene and dietary regulation. (G9)Many dentists saw NI/MI as a way of avoiding restoring non-cavitated proximal lesions. A number also reported that these methods could lead to remineralisation or lesion arrest.Sometimes you will see a cavity and it is small and you think, oh I should drill that and then you second guess yourself and say, you shouldn’t. Then two years later they are back again and you think, oh thank goodness, I didn’t drill that and other times there is a massive cavity there and you bitterly regret your decision. (NZ1)At the same time, however, a large number of comments were grouped under anticipated regret , that is, not being able to arrest lesions via NI/MI when still small and seeing them progress subsequently to requiring larger restorations. This was often associated with comments related to patients’ poor oral health attitudes and/or “non-compliance”.Because one will end up having more satisfied patients and a better bond with the patients. Patients are also a multiplication factor, [as] they recommend [me] to others and then I will have more satisfied patients in the practice… work is a lot more fun that way. (G5)I mean in terms of benefits I guess it’s fulfilling…as a career can be in that I honestly feel as though I’m helping people be truly healthy. I think and the staff feels that, so that would be the main benefit there in terms of being fulfilled in regards to our careers. (USA7)Most comments here were grouped under incentives, followed by rewards and reinforcement. Interestingly, very few  were grouped under sanctions, punishment and contingencies. As incentives, the benefits of non-invasive measures—such as remineralisation, not destroying tooth structure—were mentioned. As rewards, professional satisfaction and peace of mind were identified, along with enhanced dentist-patient relationships. Some Michigan dentists made comments that suggested they achieved professional satisfaction from treating patients with NI/MI. A few also listed having more patients as a benefit of using NI/MI, and four mentioned enhanced relationships with patients.Yes, definitely a priority for us in our practice. I do feel that, the less you do to the tooth the better chance that you have surviving longer, because as soon as you drill the tooth, really every couple of years you need to replace that filling. Every time you take a drill to a tooth, even if you try and be minimally invasive you will always make a bigger hole when you go back in. The best thing is not to start. (NZ6)Only a few comments were associated with intentions . These generally centred on the desire to use NI/MI whenever possible. Most stated that they would use NI in the outer half of the enamel, but fewer would if a caries lesion had reached the dentin-enamel junction. Most would alter their management strategy if patients had poor oral hygiene or if they felt patients would not follow their hygiene instructions.… the decision ultimately is the patient’s and what they’d like to do. I merely just give them information and recommendations, and you know more often than not they defer to the practitioner anyway. Ah but I do feel you know an obligation to help these patients be as healthy as they can and in my opinion being minimally invasive, or being conservative, you know preserving their natural tooth as long as possible without negative outcomes is important. (USA7)Approximately half of the NZ dentists made a comment that was grouped under one or more of the six constructs associated with goals, while fewer of the German and Michigan dentists made such statements. There was a marked overlap between the goals and intention domains, with an example of action planning being.There’s…a lot more advantages for the dentist to cut a filling ‘cos you, you get one…you get the fee for doing the filling and then two, eventually you get up to get the fee for replacing that filling at some time in the future. And then maybe 20 years down the track you end up having to do a larger restoration or a crown when the cusp cracks (NZ4)It isn’t paid. It requires more work that is not paid. Hence it isn’t really worth it for me. Maybe for the patient but sadly not for me. It just isn’t paid well. (G4)Environmental context and resources comprised one of the larger domains for responses. Most comments were grouped under resources and material resources, followed by environmental stressors and organisational culture/climate. Comments categorised under resources/material resources generally centred not only on the lack of financial reimbursement for NI/MI but also on regulatory restrictions.My hygienists are very preventive orientated you know and they’ve kind of encouraged the adoption of the fluoride varnish and… so I guess that was an enabler for me that my staff was gung ho. (USA5)Comments under organisational culture and climate pertained to colleagues supporting the use of NI/MI, or vice versa, with the organisational culture/climate being unsupportive.Digital x-rays and being able to show people x-rays that they can see without having to look through a magnifying glasses and things, that makes it very real for people. So having sharp clear x-rays um, that are life size or bigger than life size that patients can see clearly and you can demonstrate progress and show them also. That, is the biggest educational tool ‘cos we’re living in a digital age where seeing is believing. (NZ4)Comments under enablers mentioned specific technologies .Some Michigan participants also mentioned that instructing patients on NI was time-consuming, with patients reluctant to attend the required multiple appointments; in addition, NI/MI were good for patients with low pain thresholds or who were anxious.So in our practice … we’ve set about just recently on actually rewarding each other within the practice using a card reward system where if you see another member of our team not doing standard brush and floss-type stuff but actually tailoring the message to that individual patient um with something that’s much more achievable. (USA13)Behaviour regulation was the domain with fewest responses, possibly because most participants were already using NI/MI. One example, however, of how participants were motivating others was as follows.Six barriers were identified. One of the most commonly mentioned included a lack of (or less) remuneration for NI/MI under different dental health funding schemes.National health insurance does not pay for non- or micro-invasive measures. There is no real financial support for it and…that’s why, speaking from an economical perspective, support  will only happen once we start using the drill. (G3)Unfortunately the financial advantage is kind of negative because I'm financially advantaged to go in and do invasive… care, I’m not saying that that’s a good thing but when you look at it strictly like that. (USA7)The disadvantage is that minimal invasive treatments require more time, compared to those that are not minimal invasive. (G8)So I guess sometimes the barrier can be time if a patient needs extra time and educating. (USA4)Time pressure to perform NI/MI procedures was also mentioned as a common barrier, more likely to be mentioned by the German and US participants.I really can’t tell you. I haven’t looked at any studies for 20 years. (G1)The dental education when I was in Dental School. (USA11)Not undertaking continuing professional development and basing treatment on their initial dental training was a further barrier, but identified only in the German and US participants’ responses.A sense of anticipated regret  was another barrier.So [name] is in his late sixties now. I think it would be fair to say and think he’d probably agree that he can’t be bothered with [preventive measures] anymore. (NZ5)Dentists’ beliefs about whether patients were likely to adhere to oral hygiene instructions in the future and whether they were high-caries risk—as well as having unsupportive colleagues and/or practice leaders who were not interested in such methods—were two further barriers. Although most said their colleagues supported NI/MI management, there were exceptions. In some cases, these unsupportive colleagues were in a higher status position.It’s all about seeing evidence of arrested lesions, evidence of decalcification that has remineralised in people whether it’s radiographic or pictorial evidence, it might require both, but you’ve got a widely held and standard procedure dentistry for decades that a lesion that has not penetrated DEJ can remineralise and stay that way for 75 or 100 years if its properly cared for. (USA2)A similar number of enablers were identified; one was the belief that remineralisation can occur in non-cavitated proximal lesions and that those can be arrested.Directly to avoid having restorative work done on their teeth and preserving the natural tooth structure because it’s widely accepted that once a restoration is placed in the tooth…it’s going to lead to a lifetime of more restorations, they’re going to get larger and larger and maintaining… existing tooth structure should be of paramount priority. (G2)The understanding that restorations serve to weaken tooth structure was also a second identified enabler.The dentists that I meet up with at advanced training/education courses and attend advanced training/education courses together or that I meet there are all, working [on] the same concept [incorporating NI/MI] as myself. However, we are not representing all the dentists. Sadly this is how it is. (G5)Undertaking ongoing professional development and continuing education  was another enabler.What we normally do is, oral hygiene instruction with flossing keeping the area clean, this is usually reinforced by the hygienists as well and also a fluoride application. (NZ6)My hygienists are very preventive orientated you know and they’ve kind of encouraged the adoption of the fluoride varnish and… so I guess that was an enabler for me that my staff was gung ho. (USA5)Having supportive practice colleagues and skilled dental team members who work collaboratively to undertake non-invasive procedures  was another enabler. Some mentioned the significant role of dental hygienists, prophylaxis assistants or dental nurses in undertaking NI/MI methods, as well as alerting dentists and patients when they had non-cavitated lesions that needed monitoring.I think … digital x-rays and being able to show people x-rays that they can see without having to look through a magnifying glasses and things, that makes it very real for people. … and also just the immediacy of a digital x-ray, which pops up on the screen and having good, clear x-rays. Not sort of spotty, murky, fuzzy ones. So having sharp clear x-rays … that are life size or bigger than life size that patients can see clearly and you can demonstrate progress and show them also. That, is the biggest educational tool ‘cos we’re living in a digital age where seeing is believing. (NZ4)Having the necessary finances, equipment and staff resources was also identified as an enabler.There were similarities and differences across countries Table . The lacAnticipated regret was also a general theme, manifested in the fear of not having managed lesions early by placing a restoration. The hope of changing patients’ risk profile seems limited, especially among the German and US dentists. For many, placing restorations is the “safer” option.Relying on knowledge from dental school was more commonly found in Germany: nearly half of the German dentists mentioned that their treatment philosophy generally reflected what they learnt at university. By contrast, undertaking professional development or belonging to professional educational groups or having discussions with peers was more common with the NZ and US dentists, with only a few German dentists mentioning it. Having colleagues who supported NI/MI was another enabler, mainly among the NZ and US dentists.Having the goal or priority of performing NI/MI was also a relevant enabler, mentioned by most NZ dentists, but only a few German and US dentists. Those who mentioned it all intimated that they wanted to do the right thing for their patients and felt good when it succeeded.Two major groups of factors influenced dentists’ behaviour. The first was associated with knowledge, skills and the theoretical understanding of how to best manage dental caries and caries lesions. An awareness of the scientific literature—of the benefits of implementing NI/MI, and what these methods involve—was an enabler , 27. MorThe social aspects also shape behaviour, which may impact within the practice or the wider healthcare setting. For example, mandating guarantee times on restorations incentivised restorative overtreatment, shifting priorities towards restoration longevity, not patients’ health or tooth retention , 30, 31.We identified a number of aspects to be targeted by interventions to help close the implementation gap. First, dentists should be encouraged to regularly undertake continuous professional development (CPD), particularly in cariology . Second,This study has a number of strengths and limitations. A large and diverse range of dentists from different countries was interviewed, allowing exploration of “drivers to practice” among countries and understanding setting-specific factors. The TDF provided the underpinning theoretical structure; while such a framework is advantageous , its useThe decision on how to manage non-cavitated proximal lesions was influenced by numerous factors, and these differed to a certain extent among the three countries. As barriers to NI/MI, we identified lack of time or remuneration, basing treatment decisions on knowledge that is out of date, and a lack of patient “compliance” and involvement in decision-making. Enablers were undertaking ongoing professional development, being part of a professional group and working in a supportive environment. Financial reimbursement systems should fund NI/MI so that its clinical uptake is enhanced. Licencing bodies should insist on appropriate professional development in cariology or preventive dentistry as part of dentists’ ongoing registration. Undergraduate dental education programmes and CPD courses are the key to instilling shared decision-making principles as a cornerstone of the dental consultation.Additional file 1:Interview guides and examples of comments grouped under the different domains and constructs. (DOCX 46 kb)


As expected, two predictor variable vectors pointing in the exact opposite direction to each other would have a 180° angle between them, and would therefore calculate to a patient similarity metric of −1. Conversely, two perfectly overlapping vectors would have an angle of 0° between them, and would therefore calculate to a patient similarity metric of 1. Accordingly, before calculating the total patient similarity metric, the product for each predictor variable vector would be normalized to the range of −1 to 1 in the multidimensional feature space, if continuous , and data locality (Osman et al., Various patient similarity algorithms have been deployed and have been found beneficial by improving clinical efficiency (Wang et al., SB conceived, analyzed, designed, drafted, critically revised, approved, and agreed to be accountable for this submitted work.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.