Limnebius , measuring SSD and male genital size and complexity of ca. 80% of its 150 species and reconstructing its evolution in a molecular phylogeny with 71 species. We found strong support for a higher evolutionary lability of male body size, which had an overall positive allometry with respect to females and higher evolutionary rates measured over the individual branches of the phylogeny. Increases in SSD were associated to increases in body size, but there were some exceptions with an increase associated to changes in only one sex. Secondary sexual characters (SSC) in the external morphology of males appeared several times independently, generally on species that had already increased their size. There was an overall significant correlation between SSD, male body size and male genital size and complexity, although some lineages with complex genitalia had low SSD, and some small species with complex genitalia had no SSD. Our results suggest that the origin of the higher evolutionary variance of male body size may be due to lack of constraints rather than to sexual selection, that may start to act in species with already larger males due to random variation.Sexual size dimorphism (SSD) is widespread among animals, with larger females usually attributed to an optimization of resources in reproduction and larger males to sexual selection. A general pattern in the evolution of SSD is Rensch’s rule, which states that SSD increases with body size in species with larger males but decreases when females are larger. We studied the evolution of SSD in the genus  Sexual size dimorphism (SSD) is highly variable among animal species, from minuscule males with comparatively giant females to males much larger than females . In mostAlthough some species have reached this state of minimised males, in the absence of selection both sexes will tend to have the same size, given the strong genetic correlation between sexes for most traits . HoweverDespite the large body of work on sexual dimorphism, there is still a lack of understanding of its long-term evolution in diverse lineages, particularly among invertebrates . There ay-axis) vs. males (x-axis); while in others there was isometry  or only weak trends (butterflies and spiders). Rensch’s rule was mostly supported in groups with males larger than females, something unusual in ectotherms . Limnebius includes ca. 150 species with an almost cosmopolitan distribution, all of them aquatic, living in all types of continental waters with the only exception being the absence from saline habitats  the specimens that could be obtained differed in SSD from related species, raising the possibility of a sampling bias.We obtained morphological data of the males of 120 and the females of 86 of the ca. 150 described species of  species . Females species . In the  species . For somWe measured body length of adults  as the sum of the individual maximum lengths of pronotum and elytra, as the different position of the articulation between the two could alter the total length when measured together. Similarly, the head was not measured, as in many specimens it was partly concealed below the pronotum. Measures were obtained with stereoscope microscopes equipped with an ocular micrometer. In most analyses, we estimated SSD as the direct difference between male and female body sizes, measured in millimetres. In some analyses, we also used the ratio male body size/female body size (rSSD).Limnebius nitidus group, http://imagej.nih.gov/ij/)  .Perimeter of the aedeagus in ventral view, including the median lobe and the main appendages. We obtained an outline of the genitalia from digital images using ImageJ. The total perimeter was the sum of the values of the different parts of the genitalia . This software estimates the Minkowski fractal dimension of bidimensional images using the box-counting method ; (2) mitochondrial ribosomal genes (rrnL plus trnL); and (3) nuclear ribosomal genes (SSU plus LSU) (The phylogeny was constructed with Bayesian methods in BEAST 1.8  using a lus LSU) , with a Trees were calibrated with the rates estimated in We reconstructed the ancestral values of the morphological traits from the values of the terminals (extant species) in BEAST 1.8. We implemented a Brownian motion (BM) model of evolution, a null model of homogeneous evolution in which variation accumulates proportionally with time, with incremental changes drawn from a random distribution with zero mean and finite constant variance . The recLimnebius affect mostly the tibiae and the last abdominal sternites (Limnebius (but mostly in Limnebius s.str.), males have slightly curved and apically wider tibiae, especially in the anterior and medial legs, which also have suction setae  and in the individual branches, using phylogenetic ancestor–descendant comparisons . We measK metric , was lower than one, suggesting lack of phylogenetic signal . The K values for body size of males and females were, on the contrary, clearly larger than one, suggesting a strong phylogenetic signal .The phylogenetic signal Limnebius, rSSD was significantly correlated with male and female body size, but correlation values were much larger for male than for female body sizes , with males larger than females  SSD increased when the body size of males and females also increased, and decreased when body sizes decreased  and 4E. p < 0.005 of equal probabilities assuming a binomial distribution). For all studied species, the reconstructed average size change along the evolutionary path was larger for males than females.There were branches in which there was a significant change in SSD with an increase in body size of only one of the sexes. When males were the sex that changed, there was generally an increase in SSD  with that of females . When meLimnebius nitidus group, species in the Limnebius nitiduloides subgroup have a row of setae  and female (x-axis) body size had a slope larger than one . As a consequence, the ratio male/female body size (rSSD) was correlated mostly with male body size, while the correlation with female body size was lower and in some cases not significant, indicating that males drive the evolution of SSD. Also, when the evolution of SSD was reconstructed in the individual branches of the phylogeny evolutionary rates of male body size were generally higher than in females, and when females had higher rates there was a secondary reduction in SSD. When the change in SSD was measured in darwins (a compound measure including rate), it was also correlated to absolute changes in male, but not female body size, for which the correlations were negative but not significant. Results were very similar when regressions were obtained using raw data or phylogenetic independent contrasts, and for the later, when using the molecular phylogeny (with a subset of the species) or the estimated phylogeny with all species.Our results confirm the general validity of Rensch’s rule in the genus  females . There aBilimneus, the subgenus with females generally larger than males. Both cases contradict the association of SSD with an overall increase in the body size of both sexes resulting from the action of sexual selection on male body size, but still show larger changes in males than in females, in agreement with Rensch’s rule.The most commonly accepted cause for Rensch’s rule is the continued action of directional sexual selection on the body size of males . The incLimnebius phylogeny occurred in lineages with small species with low SSD. The second case is an increase in SSD due only to an increase in male body size, with no change (or a change lower than 5%) in the females. This situation was more frequent in the phylogeny, suggesting that in some circumstances there may be a decoupling of the evolution of the male and female body size. It has been suggested that when body size is subjected to other selective forces females should approach their optimal size independently of the size of males, which may be mostly driven by sexual selection . The reconstructed branches with isometric change in the election . The caselection .Limnebius seems to conform to a standard model with sexual selection favouring an increase in male body size with female body size also increasing due to genetic correlation, there was considerable variation, with deviating patterns in some lineages. The high evolutionary lability of SSD was confirmed by its low phylogenetic signal as measured with the K statistic, lower than for male and—especially—female body size.In general, although the overall evolution of SSD in Limnebius. Although the most complex genitalia are always present in the larger species, small species may also have complex genitalia. The size of the male genitalia was also evolutionary very labile, with no clear trends and a large variance, especially in Limnebius s.str., with the larger species and the more complex genitalia  occurred in a lineage that also secondarily reduced the SSD and the complexity of the male genitalia in some of the species, although other still have relatively complex aedeagus  or if it acquired the character independently, although the different conformation  suggest the later possibility  could be ancestral and not secondary (Secondary sexual characters of the external morphology appeared several times independently in election , which waedeagus . Due to subgroup , it is nsibility . This woecondary .Limnebius nitiduloides group, which has a strong variation in SSD despite having uniformly complex genitalia (Limnebius nitidus complex or the Limnebius punctatus subgroup, The presence of SSC seems to be more linked to the complexity of the genitalia, both for the characters present in the terminal segments of the abdomen and the extreme modifications of the legs. According to our reconstruction, the modification of the posterior legs appeared after the development of SSC in the abdomen, and they are also not linked to SSD. Thus, they are conserved in species with a secondarily rSSD close to 1, as for example in some species of the enitalia . As alreLimnebius was largely driven by changes in males, thus providing strong support for the prevalence of Rensch’s rule. However, the increase in SSD was not always linked to an overall size increase in both sexes, and was not always associated to the presence of male SSC, contrary to the expectations under the hypothesis of sexual selection as the primary cause of Rensch’s rule. Although most species with SSC had a strong SSD, with males larger than females, SSC are evolutionary more derived, appearing generally when species had already increased their size. In Bilimneus and Limnebius s.str. were largely due to an increase in the variance of the change in the later, in which males are generally larger than females and which includes the larger species and the species with the stronger SSD and the more complex genitalia. This raises the possibility that the primary driver for the evolution of male body size is simply their larger evolutionary variance, maybe related to the lack of constraints associated with egg development and reproduction likely acting on females. In Limnebius s.str., sexual selection, with the subsequent development of SSC, may have been triggered in lineages that already had larger males and complex genitalia, reinforcing these pre-existing traits. The stronger constraints in the variability of males in subgenus Bilimneus remains to be explained, but it may be related to unknown differences in mating behaviour or other traits related to reproduction.Our results demonstrate that the evolution of SSD dimorphism in the genus 10.7717/peerj.3060/supp-1Supplemental Information 1Click here for additional data file.


While colonoscopy is generally regarded as a safe procedure, colonic perforation can occur and the risk of this is higher when interventional procedures are undertaken. The presentation may be acute or delayed depending on the extent of the perforation. Extracolonic gas following colonic perforation can migrate to several body compartments that are embryologically related and it has previously been reported in the thorax, mediastinum, neck, scrotum, and lower limbs. This review discusses in detail the anatomical pathways that led to a rare case of widespread subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, and mediastinal shift from colonic perforation during a diagnostic colonoscopy. This is further supported by a description of the radiological images. Lower gastrointestinal endoscopy is commonly used for the diagnosis, treatment, and monitoring of a range of benign and neoplastic colorectal diseases. While colonoscopy is the standard investigation for examining the whole colon, flexible sigmoidoscopy is an alternative for visualizing the distal third of the colon. In England, the rate of colonoscopy and flexible sigmoidoscopy procedures is 71.6 to 194.1 per 10, 000 population per year, with regional variation in the rest of the United Kingdom.While colonoscopy is generally regarded as a safe procedure, complications such as bleeding and perforation and cardiorespiratory compromise can occur. The risk of colonic perforation is 0.2% in diagnostic colonoscopies and may be up to 10 times greater when therapeutic interventions such as polypectomies are undertaken.Perforation during colonoscopy may occur through several mechanisms and extracolonic gas following colonoscopic perforation has previously been reported in the thorax, mediastinum, neck, scrotum, and lower limbs.This is a review of a rare clinical case of acute colonic perforation during colonoscopy that presented with cervical and truncal subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, mediastinal shift, and cardiorespiratory arrest. A detailed discussion of anatomical planes and pathways that lead to this presentation is undertaken, which is further supported by a description of the radiological images.An 83-year-old Caucasian female was scheduled for a colonoscopy under general anesthesia to investigate unexplained anemia .She had a background of hypertension, osteoarthritis, paroxysmal atrial fibrillation, and colonic diverticulosis. She had a past surgical history of total abdominal hysterectomy for uterine prolapse and right total hip replacement. She was independent in activities of daily living and had a performance status of 0.To investigate the anemia, she was booked for oesophagogastroduodenoscopy (OGD), colonoscopy, and computed tomography (CT) scanning of the chest, abdomen, and pelvis to exclude malignancy.The OGD was normal, and the CT scan revealed extensive diverticulosis in the sigmoid colon with associated narrowing and thickening of this segment of bowel. An outpatient colonoscopy was attempted under sedation but the patient was unable to tolerate the procedure. The procedure was abandoned and the patient was rescheduled for a colonoscopy under general anesthesia in the endoscopy suite.On the day of colonoscopy, the patient was well. Induction of anesthesia performed by a consultant anesthetist was unremarkable. The colonoscopy was performed by a gastroenterology consultant and it was challenging because of poor bowel preparation and severe narrowing and tortuosity of a diverticular segment extending from the distal sigmoid to the mid descending colon. This segment was traversed, but at the level of the mid transverse colon, the patient's oxygen saturations dropped suddenly from 98% to 40% and there was an associated tachycardia of 160 beats per minute. Within 4 minutes of this sudden drop in oxygen saturation, the patient went into cardiac arrest, specifically pulseless electrical activity on the electrocardiogram monitor. The procedure was terminated and cardiopulmonary resuscitation (CPR) was commenced. The team that conducted the CPR noted that the patient had subcutaneous emphysema in the neck, chest and abdominal walls, and had a distended abdomen.During the second minute of cardiac compressions, the patient was found to have reduced air entry and hyper-resonance on percussion of the right hemithorax. This was attributed to a right tension pneumothorax and this was decompressed with a wide-bore cannula placed in the second intercostal space in the right midclavicular line.Upon decompression of the right tension pneumothorax, there was a return of spontaneous circulation and the oxygen saturation improved from 69% to 100%. An arterial blood gas revealed a pH of 7.36, partial pressure of oxygen of 15.2 on 15 L of oxygen, and a partial pressure of carbon dioxide of 6.08. A portable chest radiograph revealed bilateral pneumothoraces; the right-sided pneumothorax which was originally a tension pneumothorax had been converted to a simple pneumothorax, and on the left there was a simple pneumothorax. Two surgical chest drains were sited. The patient's temperature, pulse, and blood pressures were 36.0, 100 bpm, and 110/60 mm Hg, respectively. The abdomen once again was noted to be visibly distended and tympanic and there was a strong suspicion of colonic perforation.Once stable, a CT scan of the chest, abdomen, and pelvis was obtained. This was reported by a radiology consultant as showing a large-volume pneumoperitoneum and free gas in the retroperitoneum with signs of perforation at the hepatic flexure of the colon. Note was made of bilateral pneumothoraces with extensive subcutaneous emphysema in the neck, chest, and abdominal wall and pneumomediastinum.Shortly after this the patient was reviewed by the on-call surgical team and prompt arrangements were made for emergency laparotomy. At laparotomy, there was a perforation of the colon at the hepatic flexure with contained contamination around the proximal transverse colon and duodenum. A right hemicolectomy with exteriorisation of the ileal and colonic bowel ends as double-barrel stomas was carried out.Postoperatively, the patient was managed on the intensive care unit (ICU) and required cardiovascular (ionotropic) and respiratory support by way of mechanical ventilation for the first 4 days. She was treated for a lower respiratory tract infection and required reintubation for a short duration. She also received hemodialysis for 5 days. She was eventually discharged from ICU on nutritional support after a 28-day stay. At this stage, her stoma was healthy and functioning, and there were no ongoing surgical concerns. She was managed on a respiratory ward and started making progress. However, 6 days after being moved to the ward she deteriorated acutely and rapidly from a lower respiratory tract infection. She died 2 days later, 35 days after her original colonoscopy.Colonic perforation during colonoscopy may result from barotrauma, thermal injury, instrumental puncture of the bowel wall caused by the tip of the endoscope, or through interventions such as polypectomies and dilatation of strictures. The rate of perforation is variably reported and may be as low as 0.03% in diagnostic colonoscopies but up to 2.14% in therapeutic colonoscopies.In this case, the perforation occurred at the hepatic flexure of the colon, which is not a common location for iatrogenic perforation. The presence of pancolonic diverticulosis, poor bowel preparation, and the acute angle at the flexure may have been predisposing factors.The risk factors for colonic perforation include increased age, female gender, multiple comorbidities, low body mass index, low plasma albumin level, underlying bowel pathology such as Crohn's disease and previous colonic resection, patients undergoing therapeutic procedures such as polypectomy, dilatation and endoscopic mucosal resection, and patients from an ICU setting.Once colonic perforation has occurred, intraluminal gas may escape into the peritoneal cavity, the retroperitoneal space or both depending on the location of the perforation. Intraperitoneal perforations are the most common type. The ectopic gas may pass into different body compartments through distinct anatomical and fascial planes, as will be described below.The peritoneum is a serous membrane which encases the peritoneal cavity. It consists of two layers: a parietal layer that covers the abdominopelvic wall and a visceral layer into which the viscera invaginate . The coAnterior perforation at the hepatic flexure of the ascending colon, as in the case described above, led to gas escaping mainly into the peritoneal cavity 345. The mediastinum is the region in the thorax between the two pleural cavities . It conThe chest and abdomen originate from a single coelomic cavity during embryonic life. This cavity is lined by a serous membrane and the space deep to this membrane is the subserosal space. The coelomic cavity divides into the peritoneal, pleural, and pericardial regions. In the adult, the serous membrane of the peritoneum is the peritoneal membrane and the space below it is the subperitoneal or retroperitoneal space. The serous membrane of the thorax becomes the pleura, and the space deep to this is the subpleural or mediastinal space. The continuity of the subserosal space is maintained during subdivision of the coelomic cavity, forming the thoracoabdominal continuum which interconnects the subperitoneal  and subpleural  spaces. The mediastinal structures that traverse the diaphragm pass between these two spaces. Complete isolation of the thoracic and abdominal cavities occurs by means of the pleuroperitoneal folds by the 7th week of gestation.The esophageal diaphragmatic hiatus is in the muscular part of the diaphragm at vertebral level T10 and it admits the esophagus along with the anterior and posterior vagal trunks . It is The inferior vena cava passes through the central tendon of the diaphragm at vertebral level T8. Its wall is adherent to the margin of the diaphragmatic foramen and therefore does not provide an avenue for direct spread.There are additional congenital defects in the diaphragm that could facilitate the passage of gas to the mediastinum. Two defects exist in the retrosternal region between the sternal and costal attachments of the thoracic surface of the diaphragm forming foramina on either side through which the internal thoracic vessels pass. These are called the foramina of Morgagni, which were first described in 1761, and are lined by peritoneum. A tear in their peritoneal lining in the presence of pneumoperitoneum can permit the passage of gas cranially through the diaphragm .1819Between the costal and lumbar parts of the diaphragm are triangular areas covered by pleura superiorly and peritoneum inferiorly known as the lumbocostal triangles. These are weak areas in the diaphragm. Defects in these areas may cause congenital diaphragmatic hernia  or act as a potential trans phrenic route for the migration of gas from the abdomen, if there is a breach in the peritoneum.Therefore, gas or disease processes that follow these diaphragmatic hiatuses and defects will pass between subperitoneal  and subpleural  spaces, providing a route between the retroperitoneum and the mediastinum.While there was no clear evidence of congenital diaphragmatic defects on the CT images of this patient, it is important to be aware of these as potential routes for spread of disease processes between the abdomen and mediastinum.The patient underwent CPR and required needle thoracostomy and chest drain insertions for decompression of the pneumothoraces. This can be considered as another potential cause for the development of pneumomediastinum as well as subcutaneous emphysema in the neck.Our patient developed a tension pneumothorax on the right and a simple pneumothorax on the left and9. The thoracic cavity contains the right and left pleural cavities and the mediastinum. The pleura is a double-layered serous membrane, and like the peritoneal membrane, it is divided into parietal and visceral layers . The paSeveral reports exist on the development of pneumothorax following colonic perforation.Another point of consideration is that the pneumothoraces may have occurred from barotrauma as a result of intubation and ventilation. This may cause an air leak or rupture of subpleural bullae which may not necessarily present immediately after intubation and commencement of mechanical ventilation.Direct communication between the pleural spaces and the peritoneum can develop in the presence of malformation or defects in the pleuroperitoneal membranes.The patient developed subcutaneous emphysema in the neck and the trunk as demonstrated on the CT images 910. TAnatomical continuity exists between the neck, thorax, and abdomen as has been demonstrated in this review of a rare case. This explains the pathogenesis of colonic perforation presenting with pneumothoraces, pneumomediastinum, mediastinal shift, and widespread subcutaneous emphysema. Recognition and prompt management of colonic perforation during colonoscopy save lives.


Auditory Verbal Hallucinations (AVH) are prevalent in many psychopathologies but are also experienced by a minority of the healthy general population. There is cumulative evidence that the beliefs people hold about their voices  are strongly related to the impact of the voices  and to the coping strategies that they adopt . To date, research on resilience has identified many factors that promote wellbeing and that protect people from developing psychopathologies despite exposure to health or psychological adversities. However, no previous studies have examined resilience in people who experience AVH with and without need for care, and neither have the relations between resilience and beliefs about the voices been examined.Fifty persons who report hearing voices frequently were recruited online. Based on the presence of a psychiatric diagnosis, the use of antipsychotic medication, and on the consultation of a psychiatrist, they were then classified as being Healthy Voice-Hearers (HVH) or Patients (P). One hundred and nineteen healthy participants who have never experienced hearing voices were also recruited as a control group (CTRL). All participants completed the Resilience Scale for Adults. In addition, the HVH and P groups completed questionnaires that assess the beliefs they hold about their voices (the revised Beliefs About Voices Questionnaire) and voice characteristics .The data collection is currently underway, and thus the following results are preliminary. Kruskal-Wallis ANOVAs revealed significant differences between the three groups  on several resilience factors. In particular, post-hoc analyses demonstrated that the CTRL and HVH groups were more resilient than the P group for the perception of self and of future. In addition, the HVH group was found to be more resilient than the P group in terms of social competence. Finally, for social factors , results showed that the CTRL group was more resilient than the P group. However, the HVH group was not significantly different from the P and the CTRL groups. Concerning voice characteristics, Mann-Whitney tests revealed that, compared to the P, the HVH perceived their voices as being less omnipotent and malevolent, less negative and more positive, and showed less resistance against the voices. Finally, correlational analyses (Spearman) demonstrated that better resilience  was related to fewer negative beliefs about the voices, less resistance, lower voice frequency, and less negative and more positive emotional content.The present study showed that people who experience AVH without need for care have a different pattern of resilience compared to patients with AVH, and to healthy controls without AVH. In particular, the HVHs did not differ from the CTRL on the personal factors of resilience and did not differ from the patients in terms of social factors. In addition, better resilience  was found to be related to fewer negative beliefs about the voices, better coping strategies, lower voice frequency, and less negative and more positive emotional content. Taken together, these results show that resilience – and in particular, the personal factors – may be an important variable influencing the need for care in people experiencing AVH. The present study has important theoretical and clinical implications, in particular, suggesting that the personal factors of resilience may be a treatment target in order to diminish the impact of voices.


One of the economic evaluation techniques involves calculation of willingness to pay (WTP) for a service to find out the value of that service from the clients’ perspective. This study estimated WTP for both breast cancer and osteoporosis screening and comparatively examined the contributing factors. In fact, the comparisons served to provide an exact analysis of individual attitudes and behaviors in relation to screening programs for cancers and other diseases.This study was first designed in six scenarios several questionnaires concerning individual breast cancer and osteoporosis screening cases, and determined the WTP median in each scenario between people in Kerman Province of Iran in 2016. Then, the demand function for breast cancer and osteoporosis screening was formulated. Moreover, the factors contributing to WTP were examined through various scenarios in Stata and econometric techniques.The median and mean values of WTP in all the above scenarios were greater for breast cancer screening than for osteoporosis screening. Theoretically, the price assumed a minus sign whereas risk assumed a plus sign within the demand function formulated for both screening programs. Regarding the evaluated factors, age in breast cancer screening and risk of disease in osteoporosis screening were the major factors contributing to WTP.Breast cancer screening was more valuable than osteoporosis screening program from the perspective of the subjects. The programs can be successfully designed by concentrating on patients’ age groups in breast cancer screening and high-risk patients in osteoporosis screening. Since about 80% of deaths due to noncommunicable diseases occur in low-and middle-income countries and the most frequent causes of death in most countries, except in Africa, are NCDs , early pIt is a difficult task to measure the benefits of prevention or health promotion programs. Calculation of willingness to pay (WTP) can provide a technique to overcome that difficulty based on the principles of welfare economics. The WTP has been applied in studies where the decision-makers were government organizations and the stakeholders the society as a whole  and osteThis study focused on WTP for breast cancer screening among women living in Kerman, Iran. This WTP was compared with the corresponding WTP obtained for osteoporosis screening with regard to numerical values and the contributing factors. Such comparison mainly served to provide an exact analysis of individual attitudes and behaviors toward the value of screening programs –5 in canMany researches use this technique in health economic evaluations in other countries –8 but inThis was an applied, descriptive-analytical study involving field data collected from four culturally and economically different regions in Kerman, Iran during 2015. The regions were selected through expert opinion as contain all parts of city. Samples were gathered in proportion to the population of each region randomly. In the first stage, the scenarios were designed as a pilot through open-ended questions aiming to examine the WTP for breast cancer and osteoporosis screening. The scenarios were described to each subject who offered reasonable prices. Then, a mean value was obtained as a starting point for the proposed prices within the questionnaire. Each questionnaire consisted of six scenarios designed in two sections.In three scenarios, people were asked to assume high risk of disease for themselves and in three scenarios assume low risk of disease and answer the questions. Each section, scenarios were about individual WTP for implementation of a plan for screening all people with increasing government contribution in tree level (tree scenarios) 10, 50 and 90 percentages of the plan expenditures. These tree levels were designed to check reasonability of people answers. Declared prices increase with increase in level of government contribution. The first section of the questionnaire provided explanations about the disease, followed by several items revolving around WTP. Finally, there were a number of items to estimate the income, age, and gender of subjects (related to osteoporosis). As recommended by the economic studies, the subjects were asked about their monthly expenses instead of their income. Several experts in economics of health verified the WTP questionnaires. About 50 questionnaires in each category of breast cancer and osteoporosis were examined in another pilot to ensure the responses entail homogeneity and make sense.In WTP studies, the number of samples can be calculated according to Mitchell and Carson’s method, who designed a table displaying the minimum required sample size for acceptable levels of reliability and error in contingent valuation method (CVM) studies . This taHaving designed the questionnaire at the training stage, we held several in-person interviews in each studied region, trained the health volunteers and delivered the questionnaires to them. After a twenty-day deadline, the questionnaires were completed, and their data subsequently collected and analyzed. At this stage, the data were analyzed to ensure none was corrupted.The WTP in each scenario was obtained by suggesting prices that were higher and lower than the initial price the subjects had, depending on their preferences, either accepted or rejected. Finally, the last choices made by the subjects were collected to obtain the individual WTP in each price scenario. Although it is better to use the median rather than the mean in calculation of WTP, the latter was also considered in order to draw more extensive comparisons of WTP between the two screening programs.After calculating the cumulative frequency at different prices, the demand function was formulated by inserting the risk factors and integrating the first and fourth, second and fifth, and third and sixth scenarios, which were different only in terms of risk levels.Then, the regression analysis was employed to identify the factors contributing to WTP. This stage explored the risk factors, age, and income. As for the osteoporosis screening, the impact of gender was examined by importing a few dummy variables. Furthermore, the data were analyzed in terms of variance heterogeneity, collinearity, and other econometric pre-tests.The median of WTP in all the proposed scenarios tended to be higher for breast cancer screening than for osteoporosis screening .The mean of WTP in various scenarios was higher for breast cancer screening. The results are presented in The results of demand function formulation for breast cancer screening and osteoporosis screening are given in In the formulated demand functions, the Breusch–Pagan test confirmed the heterogeneity of variance, whereas the VIF results confirmed there was no co-linearity.The median of WTP or the value of the program from individual perspectives in all scenarios was greater for breast cancer screening than osteoporosis screening. Moreover, the mean difference of WTP for the two screening programs confirmed that WTP in all scenarios was greater for breast cancer screening. In this regard, the difference was statistically significant. This finding was inconsistent with the assumption that subjects tended to perform osteoporosis screening rather than breast cancer screening due to lower fear of being diagnosed in non-cancerous cases. In fact, individuals believe breast cancer screening is more valuable. This finding can be justified through the importance of cancers, the critical aspect of early diagnosis and the peace of mind achieved through cancer screening , 12. PeoAssuming an increase in the risk of disease for subjects in both screening programs, there was greater WTP. This was consistent with all the studies focusing on the impact of risk on WTP .According to the results, there was no significant difference between women’s and men’s WTP for osteoporosis screening. Although women tended to be more risk-averse than men were. Women and men are equally risk-averse under conditions where uncertainty intensifies . Since tThe price left a negative effect on demand and a positive effect on risk. Theoretically, there is an inverse correlation between price and demand , indicatIn examining the factors contributing to WTP for breast cancer and osteoporosis screening, risk or household expenses/income had a positive effect on WTP, and that this relationship was identical in both screening programs. Individuals with greater risk and income were more willing to pay. Moreover, patient’s age was inversely correlated with WTP for breast cancer screening, whereas it was directly correlated for osteoporosis screening. Older people believe to be at a greater risk for osteoporosis. Consequently, older individuals were more likely to perform osteoporosis screening. On the other hand, the risk of breast cancer increases with age  even thoWTP was affected significantly and positively by household income (questioned under “household expenditures” in the questionnaire to reduce bias). The positive impact of income on WTP was proven .This study had some limitations that one of them is no direct supervision on filling questioners. It was not possible because of large sample size. For reduction this limitation, researchers held several training classes for the health volunteers. However, in the regression like other regressions, some factors were not considered, too. Doing open interviews about factors, affecting willingness to pay could complete the research that was not possible for the researchers so they had not entered some qualitative factors in the model.Ethical issues  have been completely observed by the authors.


Currently, researchers have to apply separately to individual biobanks if they want to carry out studies that use samples and data from multiple biobanks. This article analyzes the access governance arrangements of the original five biobank members of the Biobank Standardisation and Harmonisation for Research Excellence in the European Union (BioSHaRE-EU) project in Finland, Germany, the Netherlands, Norway, and the United Kingdom to identify similarities and differences in policies and procedures, and consider the potential for internal policy “harmonization.” Our analysis found differences in the range of researchers and organizations eligible to access biobanks; application processes; requirements for Research Ethics Committee approval; and terms of Material Transfer Agreements relating to ownership and commercialization. However, the main elements of access are the same across biobanks; access will be granted to bona fide researchers conducting research in the public interest, and all biobanks will consider the scientific merit of the proposed use and it's compatibility with the biobank's objectives. These findings suggest potential areas for harmonization across biobanks. This could be achieved through a single centralized application to a number of biobanks or a system of mutual recognition that places a presumption in favor of access to one biobank if already approved by another member of the same consortium. Biobanking and Biomolecular Resources Research Infrastructure-European Research Infrastructure Consortia (BBMRI-ERIC), a European consortium of biobanks and bioresources with its own ethical, legal, and social implications (ELSI) common service, could provide a platform by developing guidelines for harmonized internal processes. Aspects of access raise ethical and legal questions as well as practical challenges.B3 Drawing on these, biobanks have developed specific internal procedures and policies to govern access to their samples and data. In practice, it is these internal processes, such as contractual agreements, access procedures, and specialist committees, which play a pivotal role in the governance of access.4There are general legal frameworks for data protection, which establish a set of common legal rules and principles for access and data sharing, as well as providing a number of exemptions for research. Within the research field, there have been a number of policy documents for sharing data , which provide guidance that is specific for research and biobanking in particular.The variation in access governance arrangements between biobanks has the potential to impede large-scale health research. This is because these arrangements are not designed from the perspective of the researcher, who must invest significant time and effort applying to each biobank separately without being certain of the nature of samples or data available for research until all the biobanks respond. However, it may be possible to develop a level of “harmonization” of internal governance arrangements, which can respect the sovereignty of each biobank within the national and international legal framework, rather than attempting to develop biobank-specific national laws or guidance.The need for such integration is emphasized by the European Commission as “essential to obtain the large numbers of participants and samples necessary to conduct research investigating, for example, the interplay between genetic, lifestyle, environmental and social factors that determine health and (complex) diseases” . Although, as we demonstrate below, there are differences between biobanks in terms of their objectives and requirements, this form of research is within the scope of all biobanks studied here.5 to identify the main similarities and differences in policy and procedure, and makes recommendations for increased harmonization of internal governance among European biobanks. BioSHaRE-EU is a pan-European research consortium that aims to facilitate data sharing across multiple biobanks and databases, with a focus on the scientific, bioinformatics, and ethical and legal elements of harmonization and standardization. Its biobank members are all legally independent entities spread across eight European countries. They provide a case study for the main similarities and differences in governance of access in well-developed cohorts and biobanks.This article analyzes the access governance arrangements of the five original biobank members of the Biobank Standardisation and Harmonisation for Research Excellence in the European Union (BioSHaRE-EU) project6 This article argues that it may be possible to streamline access policies and procedures within the pan-European research infrastructure, Biobanking and Biomolecular Resources Research Infrastructure-European Research Infrastructure Consortia (BBMRI-ERIC), proposing a form of “harmonized” internal governance of biobanks.The law in this area is currently nationally fragmented. Even the newly adopted EU General Data Protection Regulation, which harmonizes some aspects of data protection, will allow Member State derogations—permitted variations—on specific issues such as processing of health data for research purposes without consent, suggesting that further national variation of data protection law is likely. Such fragmentation contrasts with soft-law and guidance that advocates harmonization of access to biobanks.7 the Bermuda Principles in 2003,8 Fort Lauderdale Agreement in 2003,9 as well as the Toronto Statement in 2009,10 which developed a set of suggested “best practices” for funding agencies, scientists, and journal editors. More recently, the Framework for Responsible Sharing of Genomics and Health-Related Data (2014) of the Global Alliance for Genomics and Health11 reassessed these principles with a human rights perspective; and the Nuffield Council on Bioethics released a report on the ethical issues around the collection, linking, and use of data in healthcare and biomedical research.12 In the United Kingdom, the Expert Advisory Group on Access (EAGDA) established by the Medical Research Council, the Economic and Social Research Council, Cancer Research UK, and the Wellcome Trust has also published a report on “Governance of Access,” to enhance the dissemination of good practice across the funders.13In recent decades, international bodies have sought to identify and express fundamental principles of access in health research in general policies such as the OECD Principles and Guidelines for Access to Research Data from Public Funding,14 and the HUGO statement on Human Genetic Databases 2002.15 These policies recommend that biobanks should have as a minimum a transparent access policy that is readily available for participants, researchers, and third parties using the biobank. Recommendations for the contents of access agreements include the following: the nature of the material available; the purposes for which the material may be used; requirements for additional ethical review; intellectual property arrangements; access fees; ownership or “custodianship” of the material; consent provisions; requirements to ensure confidentiality; and limits on users and uses of materials.A number of specific guidelines of best practices for access in biobanking and genetic research databases have also been developed, such as the OECD Guidelines on Human Biobanks and Genetic Research 2009Charter of principles for sharing bio-specimens and data, together with a template for general MTA.16 These documents aim to improve the governance and audit of sharing data and specimens across different jurisdictions. There have also been proposals for a harmonized access agreement, such as the P3G Generic Access Agreement,17 which addresses both the sharing of data and samples and offers a template to assist or inform researchers seeking access to population studies.Recognizing the varying regulatory approaches of different jurisdictions toward access in biobanks, internal governance procedures such as material transfer agreements (MTA) have thus far been prioritized by the ethical community and research consortia to authorize the transfer of human biological materials and data outside the geographical jurisdiction from which they originated. Within the framework of international research consortia projects, researchers have developed a 18 They are funded by the European Union, Member States, and other associated states but exist as separate international organizations, although with lines of accountability and reporting to the European Commission. On this basis, the European Commission established the Biobanking and Biomolecular Resources Research Infrastructure as an ERIC (BBMRI-ERIC) to integrate quality controlled biobanks and bimolecular resources across Europe, in 2013.ERICs were established by the European Union in 2009 as a means of promoting and furthering research in Europe.19The field of research and health is one of limited competence for the European Union; it shares competence with Member States in the field of research (this means both may legislate on these issues according to Art. 4 TFEU) and may only harmonize law in this area, subject to the principles of subsidiarity and proportionality, where the goal of regulation cannot be better achieved at national levels. For this reason, BBMRI-ERIC is not a platform for legal harmonization but may provide a Europe-wide opportunity for the development of streamlined approaches and soft-law governing research and access to data, which Member States could accommodate or adopt within their own legal frameworks.This article analyzes the access governance arrangements of the original five biobank members of the BioSHaRE-EU project to identify similarities and differences in policies and procedures, and consider the potential “harmonization” of aspects of data governance through structures such as BBMRI-ERIC.20 KORA,21 LifeLines,22 HUNT,23 and UK Biobank.24 As well-established biobanks with well-developed governance arrangements, these provide a case study of similarities and differences within the EU legal framework. The key similarities and differences are identified below. Information on access requirements for each biobank was provided by colleagues within the jurisdictions of each biobank, as well as identified through publically available policy documents and regulations.The BioSHaRE-EU project involved fourteen biobanks. In this article, we analyze the formal data access governance arrangements of the five original BioSHaRE—EU biobanks—Finrisk,The five original BioSHaRE-EU biobanks are very similar in their governance structures and funding as they are all prospective biobanks or longitudinal studies. The FINRISK Study is a population survey on risk factors on chronic, noncommunicable diseases and it is based on a project that was part of the World Health Organization Monica Project. The UK Biobank is long-term population study investigating the impact of genetic predisposition and environmental exposure, and it is a registered charitable company funded by the Department of Health and other organizations. KORA is also financed by public funds allocated by the Federal Ministry of Education and Research and the State of Bavaria, and it is focused on the study of the development and course of chronic diseases.HUNT includes different population surveys carried out in different periods and it is funded by the Norwegian Institute of Public Health. LifeLines is funded by the University Medical Center Groningen and it has a broad scope, encompassing studies on epigenetic, biomedical, environmental, and psychosocial factors in relation to healthy aging, disease development, and general well-being.The BioSHaRE-EU biobanks share a similar organizational nature, as in all cases, they are based, totally or partially, on public funding, which is typical of many biobanks. The nature of the material each biobank makes available is similar in the BioSHaRE-EU biobanks. For example, FINRISK studies are based on cross-sectional population surveys and there are different types of biosamples available such as DNA, serum, and plasma. KORA-gen is a platform to provide phenotypes, genotypes, and biosamples for collaborative genetic epidemiological research; LifeLines comprises a longitudinal cohort and a biobank, including a data warehouse and biomaterial.As BioSHaRE-EU biobanks are all legally independent entities, researchers need to contact each cohort individually to obtain access authorization. Access policies differ across these biobanks. In some cases, biobanks do not set out information in a specific access policy, but the essential requirements are found in other documents. For example, access information in KORA can be found in the project's agreements for data transfer, while informative brochures are freely available on the HUNT biobank website, where participants may also find all the relevant information regarding the whole process . For participation in Lifeline, the adult protocol describes the program for adults participating in the study . The UK Biobank has a comprehensive Access Policy, governed by principles enshrined in the Biobank's self-regulatory Ethics and Governance Framework and monitored by the specifically created UK Biobank Ethics and Governance Council.The spectrum of the persons entitled to access the data may vary depending on the biobank and this is reflected in the BioSHaRE-EU biobanks. Data sharing policy guidance recommends that biobanks must indicate to donors the uses allowed and the purposes under which researches can be conducted so that participants may provide an informed consent. In some cases, access may be limited to nonprofit institutions , while others allow access to commercial companies. For example, the UK Biobank allows commercial companies to access data, as long as it is for conducting research in the “public interest.” Researchers from the private sector are not eligible to access data of the FINRISK biobank, while LifeLines welcomes other public and private partners. Currently, researchers have to apply individually for access rather than institutional agreements being in place. This gives greater control to the biobank managers as to who can access samples and data rather than this being the responsibility of the researcher's institution. This places the responsibility for oversight largely on the biobank.www.ukbiobank.ac.uk/access-to-the-resource). LifeLines' Scientific Board consists of principal investigators who have the responsibility, among others, to secure the scientific quality and utility of the collected data and to review submitted research proposals for use of LifeLines data. The review of the access requests for KORA biobank is performed by a Steering Committee, which will approve applications within 3 weeks. Within the UK Biobank, the Board of Directors has overall responsibility for the access procedures and all access decisions. It delegates oversight of the review process to its Access Subcommittee. In the case of the FINRISK Study, the research plan must be approved by a committee at the National Institute for Health and Welfare, and linkages to other registries require separate applications for permission. There are significant differences between BioSHaRE-EU biobanks as the DAC may be internal or external to the biobank,25 and the list of the members may or may not be publicly available. Sometimes biobanks have a scientific committee with the overall decision-making authority over access and use of the resource and an advisory board, an independent body that advises the scientific committee on governance issues (www.generationscotland.org/images/stories/GS_MAPP.pdf).Most biobanks have a body appointed to review access applications, usually known as data access committees (DACs). The composition and the nature of the DACs may vary across the different biobanks with no set formula; often the public or participants are not represented, but there may be nonscientific representation. For example, UK Biobank's data access subcommittee is currently chaired by a lawyer  but with the Norwegian Social Science Data Services (NSD). This is a separate public body linked to the Ministry of Education and Research providing assistance with data gathering, data analysis, and issues of methodology, privacy, and research ethics.26 Another model is that of UK Biobank, where researchers register and have a relationship with UK Biobank through an online portal  and guidance is provided by the biobank on their website (www.ukbiobank.ac.uk/register-apply). As an example of the criteria used to assess whether an applicant is a bona fide researcher, the UK Biobank registration form requires a CV, list of peer-reviewed publications, and research department contact information so that the biobank can confirm identity and position of the applicant.27Registration aims to verify the identity of researchers who wish to have access to a biobank and to confirm their bona fides before being recognized as an approved researcher. This is generally a common requirement, but the procedures for registering may differ from one biobank to another. For example, in the Norwegian HUNT biobank, researchers do not register directly with the biobank  approval from its governing REC, which means that, for the “great majority” of proposed uses of the resource, researchers will not need to obtain separate ethics approval.27 The application process frequently involves communication between the researcher and the biobank with an opportunity to provide further clarification and information to assist the access committee's decision. If an applicant is advised that the biobank is inclined to decline access, there may be an opportunity to request that an application is reconsidered. For example, UK Biobank allows a request for reconsideration with reasons within 3 months of a decision.Next is the application phase where the scientific merit of the proposed study will be scrutinized, addressing such issues as the compatibility of the proposed study with the cohort/biobank's objectives and whether there has been approval for the research by a Research Ethics Committee (REC). The way in which an application is evaluated varies across biobanks. Most biobanks have a single-stage application, with the exception of UK Biobank, which requires a “preliminary application” to help researchers determine their likelihood of success and indicative costs. As part of an application, the majority of BioSHaRE-EU biobanks require separate REC approval. However, there is no European law requiring this, and there is some variation among the biobanks.After the access application has been successfully submitted, reviewed, and approved, the access agreement is the final step of the request process. The contractual relationship between partners may differ. In some cases, the contracting party is the single researcher , and in other cases, it is the researcher's institution that appoints a principal investigator for each project (as with the Norwegian HUNT Biobank). An agreement will also generally detail the purposes for which the biobank may be accessed, including the commercial utilization of the data or the result. For example, although FINRISK biobank does not allow access to researchers from the private sector, it encourages cooperation under an intellectual property perspective since it recognizes coauthorship, patent sharing, as well as the return of data and results to the individual biobank/study. A similar collaborative approach is also reached through licensing agreements; for example, the UK Biobank is the unique owner of the intellectual property rights in the data in the resource, and it grants the applicant a limited, revocable, worldwide, royalty-free, nonexclusive license (but not any ownership rights) to use the samples and data for the permitted purpose only. The Dutch LifeLines biobank provides an exclusive right to use the data for a predetermined period of time and scientific results become publically available.Within the BioSHaRE-EU biobanks, there are a number of different access requirements, which means it is currently not possible for researchers to apply through a single system to access samples and data from a number of biobanks based in different countries. The biobanks in the BioSHaRE-EU project have developed their access policies independently over a number of years, in different countries across Europe, according to national laws, procedures, and norms. This has resulted in differences in the composition and the nature of DACs, which researchers need to be aware of. These differences have implications for researchers.First, the type of researchers and the range of organizations eligible to access the biobank resources vary; in some cases, commercial companies may access data if they are conducting research in the “public interest” (UK Biobank), whereas researchers from the private sector are not eligible to access the FINRISK biobank.There are also differences in access procedures that researchers must follow. In some cases, preapplication advice is provided by a purpose-built body, for example, LifeLines biobank's expert center, whereas in UK Biobank, a “preliminary” application stage provides an early check for researcher's suitability, likelihood of success, and anticipated costs. Most BioSHaRE-EU biobanks require a single main application and within this application, researchers may have to fulfill different criteria.REC approval is required by most biobanks and cohorts within BioSHaRE-EU. The variation in approaches of local RECs may form a significant barrier to access to multiple biobanks. This is not a barrier in all countries, however; within the UK legal and ethical framework, the great majority of proposed uses of data held by UK Biobank are covered by its own “generic” REC approval as long as the terms of this are reflected in the MTA. This may well streamline the process for researchers, but could have implications in the future if access procedures are harmonized across biobanks according to a minimum standard that reflects the majority.The terms of MTAs themselves also vary between biobanks, with particular differences relating to ownership and commercialization. Despite these differences, on the basis of our analysis, there are some possibilities for improving the system of access governance across European biobanks. As data access requirements move away from mere requests to principal investigators and more formalized governance structures are put in place, our analysis identifies similarities and differences to biobanks that will aid the international biobank community in developing harmonized approaches to governance of access.The main elements of access are the same across the BioSHaRE-EU biobanks; bona fide nonprivate sector researchers conducting research in the public interest are entitled to access and must register in some way to do so. The application process in all cases will consider the scientific merit of the proposed use and determine compatibility with the cohort or biobank's objectives. These are elements that could be harmonized across the biobanks. Perhaps more fundamentally, a central body providing preapplication guidance to researchers and perhaps even a single centralized application system at a supranational level could greatly improve the efficiency of access to multiple biobanks.The BioSHaRE-EU project has introduced some harmonization of data access to streamline the process of applying to multiple cohorts. A researcher is able to apply to a central Access Coordination Committee (ACC) and their harmonization team who ensure the feasibility of harmonizing variables and performing analysis using DataSHIELD. A central IT team can help to develop processing algorithms that local IT teams install and use. This procedure focuses solely on IT harmonization and excludes all ethical and legal considerations, which are still considered by local DACs individually. This centralized support can increase efficiency of applying to multiple biobanks, but within the current regulatory framework, researchers still need approval from each cohort.28 systems, which could facilitate access in compliance with legal requirements across territorial boundaries.29 They would enable connection between the wider community of researchers and the biobanks and vice-versa, without necessarily substituting the specific national access processes. Instead, they could represent a different solution for cross border research. Biobanks could be propelled to adhere to such a system as a way to create new forms of collaborations and potentially find new opportunities to address the sustainability challenge. This would enable researchers to access multiple data sets using a “fast-track” procedure, which could be designed following common standards and in compliance with the relevant data protection rules. Such a system could be implemented within existing international platforms.However, new technologies may also unlock the potential to develop e-governance30 This European consortium of biobanks and bioresources is governed by an assembly of members and their appointed director-general.31 Within its own statutes, BBMRI-ERIC has established an ELSI Common Service,32 which monitors ELSI issues related to biobanks and could provide proposals for addressing joint matters for the biobanking community on the European level (http://bbmri-eric.eu/common-services). BBMRI-ERIC is also obliged to report annually to the European Commission, including any circumstances that threaten to jeopardize the achievement of the task of the ERIC (Art. 17 of the ERIC regulation). While BBMRI-ERIC could not develop legal proposals for harmonization of access, it could influence the EU's proposals in this area and perhaps,19 through the ELSI common service, develop some harmonized internal processes for access that could be adopted by constituent biobanks. BBMRI-ERIC incentivizes biobanks to become a member by offering a series of tools and services as well as expertise and support for biobanking. Such incentives may play an important role in encouraging individual biobanks to harmonize governance arrangements in the future.While streamlining governance of access may not be a straightforward task, there are already a number of platforms that present opportunities for improvement as well as incentivizing individual biobanks to join these efforts. An important potential platform for increased harmonization, centralization, and e-governance is BBMRI-ERIC.Although a partially centralized and harmonized system of access might make health research across Europe more efficient, this may take time to develop. More immediate term solutions could be designed acknowledging diversity across biobanks by providing access to data across a group of biobanks, such as the BioSHaRE-EU biobanks, on the basis of a mutual recognition of application approvals between biobanks. Such a system might place a presumption in favor of access to data in one biobank when an application has already been granted by a partner resource. Local scrutiny might not be done away with entirely but a presumption in favor and a lighter review could be considered a form of “proportionate governance” of access. While the existing system has a number of benefits in terms of maintaining control of oversight by the individual biobank, there is the potential to streamline common access procedures across biobanks in Europe to facilitate research that requires samples and data from a number of biobanks. BBMRI-ERIC has the potential to greatly assist this process by developing some guidelines for harmonized internal processes.


Widespread application of research findings to improve patient outcomes remains inadequate, and failure to routinely translate research findings into daily clinical practice is a major barrier for the implementation of any evidence-based guideline. Strategies to increase guideline uptake in primary care pediatric practices and to facilitate adherence to recommendations are required.Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents into a mobile clinical decision support (CDS) system for healthcare providers, and to describe the process development and outcomes.Our objective was to operationalize the US National Heart, Lung, and Blood Institute’s To overcome the difficulty of translating clinical practice guidelines into a computable form that can be used by a CDS system, we used a multilayer framework to convert the evidence synthesis into executable knowledge. We used an iterative process of design, testing, and revision through each step in the translation of the guidelines for use in a CDS tool to support the development of 4 validated modules: an integrated risk assessment; a blood pressure calculator; a body mass index calculator; and a lipid management instrument.The iterative revision process identified several opportunities to improve the CDS tool. Operationalizing the integrated guideline identified numerous areas in which the guideline was vague or incorrect and required more explicit operationalization. Iterative revisions led to workable solutions to problems and understanding of the limitations of the tool.The process and experiences described provide a model for other mobile CDS systems that translate written clinical practice guidelines into actionable, real-time clinical recommendations. Cardiovascular disease (CVD) is the leading cause of death in the United States  and accoIn 2006, the US National Heart, Lung, and Blood Institute (NHLBI) established an Expert Panel to develop comprehensive evidence-based guidelines addressing the known risk factors for CVD among the pediatric population, including family history, age, sex, nutrition and diet, physical inactivity, tobacco exposure, blood pressure (BP), lipids, overweight and obesity, diabetes mellitus, predisposing conditions, metabolic syndrome, inflammatory markers, and perinatal factors. The guidelines are intended for use by a broad audience of pediatric care providers—such as pediatricians, family practitioners, nurses, nurse practitioners, physician assistants, and registered dietitians—to assist in the promotion of cardiovascular health and the identification and management of specific risk factors from infancy into young adult life, with an integrated format to address the 14 major risk factors simultaneously.Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, is more than 400 pages and it is available as a searchable online version or can be downloaded as a PDF from NHLBI’s public website [Pediatrics in 2011 [In practice, pediatric care providers are credible messengers of health information, and the guideline recommendations are intended to accommodate the delivery of health messages to patients and their families by all members of the care team. The Expert Panel identified childhood health maintenance visits as an ideal context for engaging patients to increase awareness, initiate risk-reduction strategies, and promote cardiovascular health. The NHLBI guidelines provide recommendations that are specific to the age and developmental stage of the patient, considering not only the relation of age to disease expression, but also the ability of the patient and family to understand and implement medical advice. Management algorithms provide staged care recommendations for risk reduction within the pediatric care setting and identify risk factor levels that require referral from the primary care setting to a specialist. The guidelines also identify specific medical conditions, including diabetes and chronic kidney disease, associated with increased risk for accelerated atherosclerosis and provide recommendations for ongoing management of children and adolescents with these diagnoses. The report, entitled the  website . A guide in 2011 .Failure to routinely translate research findings into daily clinical practice is a major barrier for the implementation of any evidence-based guideline and is related to barriers of knowledge, attitudes, and clinical systems . In a seThe adoption of electronic health records in primary care, as enabled by the Health Information Technology for Economic and Clinical Health (HITECH) Act and the pursuit of satisfying meaningful use objectives, has not inhibited the use of clinical decision support (CDS) tools in practice. Defined by Osheroff et al  as “provIntegrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents was expected to pose a variety of challenges that were unique to the composition of the content. These issues include (1) the complexity and integrated nature of risk assessment and management, (2) the volume of information provided in the final report, (3) the establishment of prevention as a clinical priority among a nondiseased target audience, and (4) the delivery of multifaceted recommendations within the time-constrained context of the pediatric primary care setting.From the outset, implementation of the Evidence-based clinical practice guidelines represent substantial effort on the part of their authors and considerable financial support to sustain years-long review and synthesis of scientific evidence. Despite the investment to rigorously develop guidelines, implementation efforts have often been less well supported and often unsuccessful in improving care, and other efforts have reported outright implementation failures -20. ThisYoung Hearts, Strong Starts; the methods and results from a cluster randomized trial of guideline adoption using quality improvement techniques to integrate the CDS into clinical workflows are described elsewhere by LaBresh et al [Consequently, in this paper we describe the process and outcomes of a project to operationalize the NHLBI guidelines into a mobile CDS system and provide multimedia artifacts associated with each step in the conversion process. The CDS was made available to pediatric primary care providers through an intervention called sh et al ,22. At tsh et al .Evidence-based clinical practice guidelines are defined by the Institute of Medicine as “systematically developed statements intended to assist practitioner and patient decision-making about appropriate healthcare for specific clinical circumstances” . HoweverWe used an iterative approach to the design, testing, and revision of material through each step in the translation to support the development of 4 validated modules: an integrated screener for risk assessment, a body mass index (BMI) calculator, a BP calculator, and a lipid assessment and management instrument. This information architecture was informed initially by the structure of the guideline content and reinforced by stakeholder input on clinical decision making during an initial well-child visit and subsequent follow-up to address specific findings. Our approach is described below in more detail. This layer consists of the narrative and figures of the comprehensive evidence-based guidelines documents published by NHLBI to address the known risk factors for CVD, including family history, age, sex, nutrition and diet, physical inactivity, tobacco exposure, BP, lipids, overweight and obesity, diabetes mellitus, predisposing conditions, metabolic syndrome, inflammatory markers, and perinatal factors. Our initial effort focused on deconstructing the guidelines into a tabular framework of triggers , recommendations, and supportive actions, as organized by known risk factor. We then used the deconstructed guidelines as a roadmap to articulate the business logic to document how a patient’s presentation to a clinician would qualify the patient into each known risk factor category. This approach to structuring the guideline content also enabled authoring a series of use cases for potential clinical encounters, beginning with an integrated risk assessment, then progressing to follow-up encounters based on the recommended treatment and follow-up for the mitigation of specific risk factors.In this layer, we added structure to the guidelines. The core organizing concept for the knowledge is a recommendation that has been triggered by the presence of a specific risk factor. From this layer onward, the emphasis is on processing within the CDS, and the recommendations excluded any statements that were not patient specific. Because domain experts are expected to be the primary authors of knowledge presented in this layer, we engaged the NHLBI Expert Panel Chair responsible for authoring the guidelines to support ongoing review of the conversion. This stage yielded a complete guideline framework in a tabular format, a matrix to illustrate how each variable triggers each recommendation, and a summary narrative of use cases.In this layer, the knowledge is specified with sufficient structure so as to make it computable and precise. This knowledge is independent of the implementation in a particular type of CDS tool or of the workflow in a particular clinical setting; however, it serves to formally define all the data elements and logic required to do so. The objective of this layer is to communicate the knowledge in the guidelines to CDS implementers to inform development of executable code. We relied heavily on a collaborative team of clinical informaticists and developers to support the translation of clinical domain requirements for computer implementation.In this layer, the knowledge is structured for use within a specific type of CDS system. This knowledge is less likely to be sharable because often it includes elements that apply only to that setting; for example, local codes for data items, details of local clinical services, and idiosyncrasies of how the end user interacts with the system. Our implementation was centered on the Personal Health Intervention Toolkit mobile technical framework that has been described elsewhere .Based on the multilayer framework, we created narrative use cases based on models of the clinical decision-making process, in addition to class diagrams in the unified modeling language and equivalent XML schemas, for representing guideline recommendations in the semistructured and the structured recommendation layers. We did not create a knowledge representation model for the unstructured layer because that comprises the free-form published guideline document. Further modeling of the executable layer is of limited utility given the specific implementation context that was used for this project.We subjected the CDS tool to rigorous expert review throughout all stages of the conversion process. Once compiled, the app was unit tested and subjected to formal software quality assurance testing of the fully integrated tool. We developed over 400 single-expression test cases to test individual CDS rules. These cases tested the output of a specific recommendation based on data element inputs defined in the rules. For these tests, values at, below, and above the rule boundary were tested.We developed over 70 scenarios to exercise the system under realistic conditions and to test data element inputs across multiple domains and thresholds. In addition to tests that verified the correct recommendation, code was generated from each rule and each rule was tested to ensure it resulted in only its specified recommendation output. We tested each numeric value boundary by cases that included the thresholds and one or more values of the unit in whole numbers above or below the threshold. Values were tested in each tool and the integrated assessment regardless of duplication .We used an iterative process of design, testing, and revision through each layer of conversion, resulting in the development of a management instrument and 4 validated modules: an integrated assessment, a BMI calculator, a BP calculator, and a lipid assessment. Formatting content in each successive layer enabled expert review of the variables, triggers, and recommendation copy. On the basis of the layered representations and conversion process, we refined detailed recommendations for ease of presentation on a mobile device and developed logic to eliminate display of duplicative recommendations or supportive actions. In addition, we identified a misalignment of categories used for age-based recommendations and overlap in the NHLBI guidelines for individuals in the infant to 3-year-old and 3- to 11-year-old groups. The results of the formative user-centered design and user experience testing , and impWhen the user first enters the app on its home screen, there is the option of entering 1 of the 4 modules noted above see . Along tThis module incorporates assessments of BMI, BP, and other risk factors, and then provides users with a patient summary and US National Institutes of Health (NIH) recommendations based on the patient’s risk factor information.First, the user is asked to enter the patient’s date of birth, and the app automatically calculates the age. Then the user enters the patient’s sex, height, and weight, and the app automatically computes the BMI and the corresponding BMI-for-age percentile based on the US Centers for Disease Control and Prevention’s BMI-for-age growth chart  and indiThe user is asked to enter the patient’s systolic and diastolic BP, and if the user hits a designated button, the app calculates the BP percentile based on the NHLBI’s BP tables for children and adolescents .The user is then asked to indicate whether the patient has any of the following conditions: hypertension, dyslipidemia, type 1 diabetes mellitus, type 2 diabetes mellitus, none of these, or unknown. If so, the user is asked to categorize the change in each of the condition as improving, not improving, or unknown. Then the user is asked whether the patient has any other high or moderate risk conditions, with response options of yes, no, or unknown. “Risk conditions” is underlined and shown in a different color, a technique commonly used on the Internet to indicate that the user can click on a link to get the definition. The user is then asked to categorize the patient’s physical activity level as sedentary, moderate to vigorous, vigorous, or unknown, and whether this is a decrease in physical activity level . The user is then asked whether the patient currently smokes  and whether the patient has a smoke-free home . Then the user is asked about parental risk factors; namely, whether either parent is obese , whether either parent has dyslipidemia , the mother’s total cholesterol (or unknown), and the father’s total cholesterol (or unknown). Finally, the user is asked whether the patient has a positive family history of CVD . “Positive family history of CVD” is underlined and displayed in a different color indicating that the user can click on this link to get the definition.When a user indicates that data entry is complete, the app automatically moves to the recommendations screen showing a patient summary of the data entered. Then, based on the patient’s risk factors, the user is shown the relevant NIH recommendations, including the evidence grade (A-F), related to family history, nutrition and diet, physical activity, tobacco exposure, lipids, and overweight and obesity, as well as supportive actions to take or more information, in some instances.If the user has already entered information in the integrated assessment screener, then the app displays the relevant previously entered data in this module. The user simply needs to click on the Calculate BMI button to see the BMI, BMI-for-age percentile, and indication of whether the patient is overweight or obese. When a user indicates that data entry is complete, as with the integrated assessment screener, the app automatically presents the recommendations screen showing a patient summary of the data entered and the relevant NIH recommendations.In some instances, the user may only be interested in using the BMI calculator. If so, the user is asked to enter the same information described above under the BMI portion of the integrated assessment screener  to obtain the BMI information, a patient summary of the data entered, and the recommendations.As with the BMI calculator, if the user has already entered BP information in the integrated assessment screener, then the app will display the previously entered data in this module. In instances where the user is only interested in using the BP calculator, they are asked to enter the same information described above under the BP portion of the integrated assessment screener . All users are then asked to enter additional BP data in this module: how the BP was measured at this visit  and up to 3 BP readings. Then the user clicks on a designated button and the app calculates the average systolic and diastolic BP values, as well as the systolic and diastolic BP percentiles. As with the other modules, when a user indicates that data entry is complete, the app automatically moves to the recommendations screen showing a patient summary of the data entered and the relevant recommendations.As with the BMI and BP calculators, if the user has already entered information in other modules, then the app will display the relevant previously entered data in this module . In instances where the user is only interested in using the lipid assessment, they are asked to enter this information. Then the user simply needs to click on the Calculate BMI button to see the BMI, BMI-for-age percentile, and indication of whether the patient is overweight or obese. All users are then asked to enter the type of sample that was drawn . As with the other modules, when a user indicates that data entry is complete, the app automatically moves to the recommendations screen showing a patient summary of the data entered and the recommendations.The NHLBI integrated guideline is long and extremely complex as a result of the desire to put all relevant cardiovascular risk-reduction recommendations in a single document. Because we know that guideline complexity is a barrier to guideline use , the CDSCabana et al  noted thTo overcome the challenges of translating clinical practice guidelines into a computable form for use in a CDS clinical system, we used a multilayer framework to convert the evidence synthesis into executable knowledge. We used an iterative process of design, testing, and revision through each step in the translation of the guidelines for use in a CDS tool to support the development of 4 validated modules: an integrated risk assessment; a BMI calculator; a BP calculator; and a lipid management instrument. The process and experiences described here provide a model for other mobile CDS systems that translate written clinical practice guidelines into actionable, real-time clinical recommendations.