The scientific literature dealing with food security is vast and fragmented, making it difficult to understand the state of the art and potential development of scientific research on a central theme within sustainable development.The current article, starting from some milestone publications during the 1980s and 1990s about food poverty and good nutrition programmes, sets out the quantitative and qualitative aspects of a vast scientific production that could generate future food security research. It offers an overview of the topics that characterize the theoretical and empirical dimensions of food security, maps the state of the art, and highlights trends in publications’ ascending and descending themes. To this end the paper applies quantitative/qualitative methods to analyse more than 20,000 scientific articles published in Scopus between 2000 and 2020.Evidence suggests the need to find more robust links between micro studies on food safety and nutrition poverty and macro changes in food security, such as the impact of climate change on agricultural production and global food crises. However, the potential inherent in the extensive and multidisciplinary research on food safety encounters limitations, particularly the difficulty of theoretically and empirically connecting the global and regional dimensions of change (crisis) with meso (policy) and micro  dimensions. Food insecurity is a timely and multidimensional problem positioned at the crossroads between the right to food and health in developing and rich, industrialized countries. However, it is unclear how scientific production reflects this multidimensionality overall and whether the recent COVID-19 pandemic has shed new light on the issues at stake. The analysis presented in this article aims to give a systematic review and meta-analysis of the vast amount of scientific food security research produced over the past twenty years. This work aims to offer an overview of the topics that characterize food security’s theoretical and empirical dimensions, map state of the art, and highlight trends in scientific publications’ ascending and descending themes. A systematic literature review sets out quantitative and qualitative aspects which could generate future food security research.Since the 1960s, with the approval of precursor USA federal anti-poverty programs  Mechlem . It reseAcademic research developed many approaches to food insecurity during the 1980s and 1990s. The right-to-food-based approach to food security suggests that human dignity, rights acknowledgment, transparency, government accountability, citizens’ empowerment, food, and wellbeing should be considered in welfare programs. The right-to-food approach required governments to adopt specific programs and meet precise obligations to combat poverty Maxwell . The rigIn the 2000 Plan for Action regarding food and diet in Europe, the World Health Organization (WHO) argued that nutrition security in the 21st century depends on production that meets dietary needs and enables equal access to appropriate food while controlling misleading promotional messages , developed by the Food and Agriculture Organization (FAO), focuses on food consumption experience, living conditions, and individual contexts , applied to all publications in a given research domain Janssen , we descThere is not a comprehensive literature review on food security so far, but only partial reviews Candel . TherefoTo conduct our bibliometric analysis, we started by compiling a list of words and concepts related to food security based on seminal works in the literature and the authors’ knowledge of the topic. The list included the following terms: food security, food insecurity, food aid, food poverty, nutrition quality, food solidarity, and food stamps. Subsequently, we compiled a list of possible combinations of these terms using Boolean operators, and we used them as search strings to explore the title, abstract, or keywords of publications within the Scopus database. The choice of “food security” (in quotation marks) as a keyword resulted from an iterative process that involved multiple searches using all the compiled combinations and discussions among the authors. As a result, this keyword returned the highest number of articles . Moreover, the articles citing the term “food security” also covered all the other terms and combinations, while the reverse was not valid. Hence, we verified that the concept of “food security” is the most comprehensive and that it contains other relevant frames, such as food poverty, nutrition poverty, and, to a lesser extent, food safety.Due to the database consistency and the marked increase in the number of articles per year, we decided to focus on literature published during the last two decades, thus analyzing the articles produced between 2000 and 2020. Furthermore, we decided to analyze separately the literature published between January and July 2021 (the current year) to avoid a misinterpretation of the results. The 2021 literature is relevant for identifying a variation in themes and focuses after the COVID-19 pandemic.A first search using the selected keywords returned 34,931 documents. To narrow the analysis, we decided to focus the search on peer-reviewed articles written in English, as they constitute the core of the international literature. In addition, we cleaned the resulting database by removing articles with no abstract and duplicates. To select which duplicate would be kept in the database, we respected the following criteria: the most recent, the longest abstract, and correct formatting. The final database contained 21,574 articles. For the first fundamental analysis of the database, we used the automatic analyses provided by Scopus and complemented them with analyses made through Microsoft Excel. The aim was to list the academic journals, countries, and scientific areas of the articles published.The second step of the analysis focused on the thematic dimensions covered in the food security literature. We performed a topic detection on the articles’ abstracts to achieve this aim, using automatic content analysis. Automatic and semi-automatic content analyses are evolving trends in the literature. These methods exploit algorithms and software to apply statistical analysis to textual data in electronic format  that best represent a lexical world from the distance of the chi-square between the classes” . Still, it was possible to use the analysis to identify new topics and trends in the literature on food security after the COVID-19 pandemic. Furthermore, the analysis of the keywords complemented this analysis and allowed us to answer the third research question.Finally, we investigated the articles published in Scopus between January 2021 and July 11, 2021 (the last search conducted) using the same procedure applied to the main corpus. After the cleaning procedure, the 2021 database consisted of 2,533 articles . As for the main corpus, we performed the analysis using both Microsoft Excel and Iramuteq software. However, in this case, the application of Reinert’s  method dDue to the high number of articles included in the dataset, this review did not aim to investigate the specific content of articles. Instead, it aimed to identify the main trends in the literature and the topics that constitute the core of the theoretical and methodological debate around food security.The present section describes some characteristics of the dataset analyzed, namely the corpus dimension, science areas, and journals most interested in food security, as well as how food security articles published between 2000 and 2020 developed over time.Table It is also worth noting that geographically, the publications are mainly concentrated in the Anglo-Saxon countries, with U.S. academia producing almost 30% of the literature. Other than the obvious issue of the English language, the strong preponderance of articles published by British and U.S. universities can be linked to the long tradition of these countries in food security and food assistance programs and evaluation. The automatic analyses performed by the Scopus website allowed us to identify the most relevant scientific areas explored in each country. Both the USA and UK distribute their production rather evenly among different scientific areas .China represents an exception to the English-speaking countries, being the third most prolific producer. China has seen a rapid increase in articles published since 2009, with more than half of the studies focusing on ES and ABS. This timing in Chinese scientific production may be due both to the first major food security policy document released by the Chinese central government in 2004 to combat food poverty Ghose  and the As shown in Fig. The attention to food security observed in Fig. Sustainability, thus reflecting the strong link between the issue of food security and sustainability, in particular with regard to the environmental and social aspects of the latter. In addition, food security has a dedicated journal, thus confirming once again its importance in the academic world.As observed in Section After mapping publications on food security, we can observe the empirical data that allow us to answer the first research question:RQ1: What are the main thematic dimensions linked to the theme of food security?A first attempt to identify the most recurrent issues analyzed by the food security literature can be made by looking at the keywords proposed by the authors, which outline the focus of the articles. As we can see from Table After a first analysis of the most discussed topics in the literature, we proceed to the analysis of the thematic clusters. The application of Reinert’s  method tTable Below is a short description of the content of each cluster and its perspective on food security:low-incomewoman, female), and schools. The American Supplemental Nutrition Assistance Program (SNAP) receives considerable attention within this cluster, as one of the oldest and broadest national food security programs. Hence, food security is analyzed in its dimension related to nutritional quality , observing the impact of different factors  on food insecurity at the individual level. The measurement of food insecurity is central in this cluster, as highlighted by words such as survey, score, questionnaire, and interview. Through these methods, the literature aims to measure the impact of food security programs in contrasting food insecurity and improving the nutritional status of the participants. Due to its size and its separateness from the rest of the literature, we analyze this cluster in greater depth in the next section.Cluster 1: “Domestic programs for diet quality” is the biggest thematic cluster in the literature. Moreover, as shown in Fig. temperature, season, rainfall) and agricultural practices  on the yield productivity of different crops . The approach to food security in this cluster is purely scientific, and it aims to increase and improve food production to guarantee access to food.Cluster 2: “Agriculture” focuses specifically on agricultural production, investigating the influence of different factors on food production. Specifically, it observes the impact of climatic events , to social and justice perspectives , to food systems and food sovereignty (governance). It uses both empirical case studies and theoretical approaches (theory) to discuss the issue and concept of food security. The diversity of approaches reflects the multidisciplinarity of the literature, as previously observed.Cluster 5: “Research approaches” is a rather composite cluster which includes the different strategies and policies that governments adopt for food security and adaptation. Agricultural policies are central in this cluster, with natural resources and land management as essential elements of adaptation strategies and farmers’ support. The cluster analyses all phases involved in the policy process, examining the definition of an agenda, the decision-making process, the planning of a strategy, the identification of tools, and the adoption phase, which includes the implementation, strengthening, and building of capacities. Participatory practices, as well as technology and innovation, receive much attention within the cluster. Thus, this cluster focuses on the improvement of food security through the adoption of strategies that mainly aim at strengthening the resilience, productivity, and sustainability of food production.Cluster 6: “Policy” deals with the It is interesting to observe the role “poverty” plays in the food security literature. While it is one of the most used keywords listed by authors, it does not appear as a frequent word in any clusters . This difference in importance could be that while poverty is considered a central issue in the food security literature, the articles focus on the causes, effects, and different dimensions of poverty, rather than on poverty itself. Causes and effects are treated in different clusters within the literature. Cluster 2 deals with climate change’s impact on the increasing number of people falling into poverty globally. Cluster 6 and, to a lesser extent, Cluster 5 deal with its effects through programs that aim to alleviate food and nutrition poverty.After the analysis of the thematic clusters and their evolution over time, we can answer the second research question:RQ2: How do these dimensions evolve, and how do they relate?Figure Figure compiled by authors.Still, we can observe how the “biotechnology” cluster has started to receive increased attention in the past five years, with a growing trend. Likewise, the “domestic programs for diet quality” cluster saw a spike in attention between 2006 and 2007. This increase is likely to be linked to the global food crisis caused by a shift in land use, from food production for human consumption to biomass production for biofuel. The drop-in food production caused a spike in the prices and a consequent increase in food insecurity, thus putting programs to improve food security high on the policy and scholarly agenda.–2007 and that a growing strand of literature focuses on the technological and biological aspects of food production for food security.The food security literature has seen multiple topics co-exist in the last two decades. The “policy” cluster has had the most stable presence in the literature, while other clusters have seen fluctuating trends. It is worth noting that the “diet quality” cluster received considerable attention in 2006The Cartesian planes Fig.  reflect As already observed in the descending hierarchy of the cluster , the six clusters can be grouped into three macro-clusters. The cluster “diet quality programs” stands alone, with little integration with the other clusters. The “agriculture” and “biotechnology” clusters form a macro-cluster dealing with food production. The articles about this macro-cluster focus on improving agricultural production, increasing its resistance to the changing climate, and guaranteeing food security in a world with a fast-growing population. The third macro-cluster includes the methodological aspects and combines the thematic dimension with the impact of global warming. The articles in the macro-cluster, then, focus on the policies that have been implemented to face the challenges proposed by climate change, mainly concerning land management and strategies to prevent and adapt to climate change. The second and third macro-clusters show similarities, but while the second one adopts a techno-biological perspective on the issue, the third employs a socioeconomic perspective.Hence, the thematic dimensions that can be identified in the food security literature comprise (a) domestic programs to tackle food insecurity; (b) policies to fight the challenges posed to global food security by climate change; and (c) analysis and technological improvements in food production to guarantee global food security.It is interesting to observe Cluster 6 in greater depth, as it represents a consistent part of the literature and a stand-alone cluster. To better understand its content, we applied Reinert’s  analysisThe methodological clusters show a clear division between qualitative methods, which focus on nutrition security  at the individual level, and quantitative ones, which deal with food security  at a more macro level. The qualitative methods, which represent the majority, present a solid link to interviews and participatory approaches and a temporal dimension (name of months), highlighting that attention is given to developing countries and the impact of seasonal cycles on agricultural production. Conversely, the quantitative methods investigate the statistical correlation among different phenomena  at the macro, and national level.The analytical clusters unfold into two different streams in the literature: one develops methodological strategies and techniques, and the other devises in-depth substantive analyses of the issue of food security. The first stream of articles analyses how to measure food security and which instruments to assess its causes and effects ought to be used, including the comparative approach. The second stream adopts a policy approach that aims to answer how to intervene by considering food insecurity programs organizational and institutional contexts. Intervention strategies are defined by analyzing of food security’s risk factors, which can be semantically attributed to a health dimension , and a behavioral and social dimension . These two dimensions are discussed together within the literature, showing how they are intrinsically connected in determining food security.The relevance of the methodological dimension and the attention to risk factors confirm the importance of developing appropriate tools to measure food security, both in terms of causes and effects, to design more appropriate food security programs.The global COVID-19 pandemic has had a consistent impact, from a socioeconomic standpoint and on academic production. Consequently, the COVID-19 impacts (direct and indirect) on the global and local scale increased scholars’ engagement and attention. Hence, it is interesting to analyze the 2021 literature on food security to observe whether the crisis has impacted academic production on the issue and new thematic dimensions have emerged.Thus, we can answer our third research question:RQ 3: What new dimensions of the issue do the literature highlight concerning the COVID-19 pandemic?The articles published in 2021 provide us insights into the COVID-19 impact on the issue of food security and whether the pandemic caused a change in focus in the literature.Sustainability, International Journal of Environmental Research and Public Health, Science of the Total Environment, and Journal of Cleaner Production). However, it is more likely that these trends are linked to the increased scholarly and public attention paid to climate change. In addition, China has confirmed its importance as a publisher of food security literature.In the first six months of 2021, 2,533 food security articles were published in 977 journals. The 2021 data also confirm the saliency of the topic and its multidisciplinary. However, while ABS remains the central area of focus (21.9%), we observed increased attention paid to ES (19%) and a decrease in focus on SS (13.8%). This result is in line with the growing trend in the cluster that deals with biotechnological aspects of food security and emerged by the journals publishing the highest number of articles on food security in 2021. Four out of five of the most active journals deal with ES  with the meso (policy) and micro  dimensions. Nevertheless, this greater connection can only benefit the action of governments and policies that have long been committed to this front.


Endometriosis affects ∼5%-10% of women of reproductive age and is often associated with painful symptoms like dysmenorrhea, dyschezia, dyspareunia, and even non cyclical pain.Cannabis sativaplant, which we will call cannabinoids in the following text, currently seem to be the main topic. In fact, increasing attention has been directed to the potential beneficial effects of these medicines in controlling the symptoms of patients with chronic pain.Cannabiscontains over a hundred chemical compounds that act on the endocannabinoid system, yet two are rather distinct, delta-9-tetrahydrocannabinol (THC), which is responsible for the psychoactive effects associated with the use of this plant, and cannabidiol (CBD), which does not produce psychomimetic symptoms.Thus, the clear clinical demand for more effective or lasting options for symptomatic relief, together with an increasing recognition of the participation of the central nervous system in the genesis and/or modulation of chronic endometriosis-associated pain,cannabis in naturaboth on relieving pain and reducing the use of pharmaceutical drugs as a form of self-medication. However, as the study was not controlled and the investigational products did not have a pharmaceutical grade as a standardized formulation, the conclusions and the reproducibility of findings are limited.A recent Australian national survey found that 13% of women with surgically confirmed endometriosis reported significant positive effects of usingcannabisor its derivatives for pain relief, despite the potential adverse effects, the lack of robust evidence on benefits and, consequently, the absence of clear recommendations on doses and/or composition to be used. In 2021 the International Association for the Study of Pain (IASP) published a statement positioncannabisand cannabinoids. Nevertheless, the association made it explicit that it does not endorse the use of cannabinoids until rigorous investigations and robust results clearly show the benefits and harms of its use in humans. The PAIN journal has even allocated an entire collection of 13 scientific articles representing the IASP's Presidential Task Force onCannabisand Cannabinoid Analgesia and calling for high-quality clinical trials to be initiated. Some of the concerns regarding the use of cannabinoids are potential reductions in neurocognitive performance, macrostructural and microstructural brain development, and alterations in brain function secondary to heavy use by adolescents,Considering the popular saying that “not everything that glitters is gold” there has been a growing concern in the specialized scientific community regarding the increasingly frequent use ofcannabis-derived products on the market linked to the promise of pain relief. Many serious groups and companies have devoted efforts to drug development, but international quality standards are not followed by all, which poses a health risk as it is impossible to guarantee a high level of quality, adequate pharmacovigilance, and extensive monitoring of adverse reactions. This can also lead to abusive and illegal use.In Brazil, cannabinoid-based medications are officially approved for use only in patients with refractory epilepsy with a THC concentration <0.2%. These drugs have a very high cost and any use outside the approved indication is off-label. In any case, we have seen a growing supply ofcannabisor its derivatives in the treatment of pain symptoms in women with endometriosis. Incentives have been made to disseminate the need for large clinical trials in this domain. To finish, I will restate a part of a text written by Michael EisensteinNevertheless, the prospect of good results is an encouragement to women with persistent symptoms and professionals who assist them to use cannabinoids, but it is necessary to be aware of the temptation of the premature clinical use of medication. Unfortunately, from a strictly medical and scientific point of view, it is currently impossible to guarantee the efficacy, safety and tolerability of


Different classification systems have been developed for endometriosis, using different definitions for the disease, the different subtypes, symptoms and treatments. In addition, an International Glossary on Infertility and Fertility Care was published in 2017 by the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) in collaboration with other organisations. An international working group convened over the development of a classification or descriptive system for endometriosis. As a basis for such system, a terminology for endometriosis was considered a condition sine qua non.The aim of the current paper is to develop a set of terms and definitions on endometriosis that would be the basis for standardisation in disease description, classification and research.The working group listed a number of terms relevant to be included in the terminology, documented currently used and published definitions, and discussed and adapted them until consensus was reached within the working group. Following stakeholder review, further terms were added, and definitions further clarified. Although definitions were collected through published literature, the final set of terms and definitions is to be considered consensus-based. After finalisation of the first draft, the members of the international societies and other stakeholders were consulted for feedback and comments, which led to further adaptations.A list of 49 terms and definitions in the field of endometriosis is presented, including a definition for endometriosis and its subtypes, different locations, interventions, symptoms and outcomes. Endometriosis is defined as a disease characterised by the presence of endometrium-like epithelium and/or stroma outside the endometrium and myometrium, usually with an associated inflammatory process.The current paper outlines a list of 49 terms and definitions in the field of endometriosis. The application of the defined terms aims to facilitate harmonisation in endometriosis research and clinical practice. Future research may require further refinement of the presented definitions.A consensus based international terminology for endometriosis for clinical and research use. Endometriosis is considered a spectrum disease with a variety of subtypes and clinical presentations. One consequence of this ambiguity is a large heterogeneity in published studies that are either evaluating diagnostic and therapeutic interventions in endometriosis patients in general, or investigating a certain subgroup based on a published classification, or a disease subtype, with a study-specific definition. The resulting heterogeneity makes it difficult to interpret and summarise published data and draw conclusions on best practice in care for patients with endometriosis.The need for standardisation has been repeatedly mentioned by experts in the field . The lachttps://www.who.int/classifications/icd/icdonlineversions/en/], and other recent publications attempting standardisation . In the International Glossary on Infertility and Fertility Care, endometriosis is defined as a disease characterised by the presence of endometrium-like epithelium and stroma outside the endometrium and myometrium, with further specification that intrapelvic endometriosis can be located superficially on the peritoneum , can extend 5mm or more beneath the peritoneum (deep endometriosis) or can be present as an ovarian endometriotic cyst (endometrioma)  introduced the concept that symptoms are an important aspect of ‘disease’ suffered by patients. Without symptoms, the occurrence of lesions per se might not necessarily be considered a disease, given that occurrence of lesions in the absence of symptoms may be considered a ubiquitous finding . A more etrioma) . For theetrioma) . The speetrioma) . Recent etrioma) , but furFor peritoneal or superficial endometriosis, some cases may only be identified following microscopic histological assessment of macroscopically normal peritoneum. This concept includes that the presence of endometrial-like tissue, and even if only endometrial stroma is found by the pathologist, can be considered endometriosis . HoweverDeep endometriosis is historically defined as extending 5mm under the peritoneal surface . As arguThe definition of Whitaker and colleagues (including elements from the ICD code) for ovarian endometriosis (cystic) or endometrioma was slightly rephrased, similar to the definition of peritoneal and deep endometriosis . As it iAlthough not subtypes, a definition was added for bowel and bladder endometriosis. Fallopian tube, pelvic sidewall and other lesions are to be included as peritoneal endometriosis or deep endometriosis, depending on the depth of the lesions.For extrapelvic endometriosis, there was consensus in the group that it should be defined as a separate entity. With regards to defining the possible locations, it was considered that vaginal disease and diaphragmatic disease may be extended abdominal endometriosis . For all other locations , it was agreed to use the term extra-abdominal endometriosis and to define it as endometrium-like tissue outside the abdominal cavity.Similarly, there was consensus to define iatrogenic endometriosis as an endometriosis subtype. The definition was formulated as lesions resulting from direct or indirect dissemination of endometrium following during surgery. Iatrogenic endometriosis has various manifestations resulting from different surgical procedures. The most common form of iatrogenic endometriosis is abdominal wall endometriosis - commonly involving the skin or subcutaneous layer of abdominal wall, but it can also involve the fascia and muscular layer - following Caesarean section. Other manifestations include episiotomy scar endometriosis or laparoscopic trocar site endometriosis, which involves various layers of abdominal wall, and endometriosis implants at various locations in the abdomen including peritoneum and visceral structures, such as bowel or bladder, attributed to mechanical uterine morcellation.Finally,  adhesions were defined based on the definition from the International Glossary on Infertility and Fertility Care, i.e. bands of fibrous scar tissue that may bind the abdominal and pelvic organs, including the intestines and peritoneum, to each other. They can be dense and thick or filmy and thin . Within Adenomyosis is defined by the International Glossary on Infertility and Fertility Care as a form of endometriosis marked by the presence of endometrium-like epithelium and stroma outside the endometrium in the myometrium . DiffereTo support the correct application of any future anatomical descriptive system, the locations where endometriosis lesions can be found were defined . The maiSpecific terminology for interventions to treat endometriosis is often used, but not consistently. For endometrioma interventions, definitions were deduced from a recent good practice paper for endometrioma surgery . Interventions for deep endometriosis were previously defined  and goodThe definition of reproductive surgery from the International Glossary on Infertility and Fertility Care was specified towards female patients, as the original definition includes both male and female reproductive surgery .Bowel shaving was previously defined as superficial excision of bowel serosal and subserosal endometriosis  that does not require suturing/closure , but othWith regards to ablation, the term is limited to obliteration of theinner surface of the cyst wall in cases of endometriomas and/or endometriotic lesions in cases of peritoneal endometriosis using electro- orultrasound high frequency-modes, laser, or plasma energy. Nonsurgical treatment options, such as sclerotherapy, can be defined as the destruction of the endometrial tissue using, for example, alcohol installation.For the different surgical techniques and definitions, it can be considered that surgery can be complete or incomplete, i.e. with visually fibrotic and/or endometriotic lesions left in place. This was not considered a relevant addition to the definitions, but should be included in the patient records.The lack of internationally agreed outcome parameters for endometriosis interventions largely affects the value of individual studies when attempting to draw conclusions for clinical practice . SpecifiThe current paper outlines a list of 49 terms and definitions in the field of endometriosis, as a result of a consensus-based approach. The list includes a definition for endometriosis and its subtypes, different locations, interventions, symptoms and outcomes. The aim of this terminology is to provide a standardised language for the description of endometriosis, to be disseminated and applied widely and to be used as the basis for a new descriptive system for endometriosis. Furthermore, the use of the defined terms should lead to harmonisation in endometriosis research and clinical practice. Further research in endometriosis, its diagnosis and pathogenesis may allow further refinement of the definitions provided.Different definitions are used for endometriosis, endometriosis subtypes, treatments and outcomes. This has significant consequences for research and clinical practice. The current paper is prepared by an international group of experts and lists a number of terms used in endometriosis, with a relevant and appropriate definition. Endometriosis is defined as an inflammatory disease process characterized at surgery by the presence of endometrium-like epithelium and/or stroma outside the endometrium and myometrium, usually with an associated inflammatory process. These definitions should result in harmonisation both in endometriosis research and in clinical practice.


The Institutional Animal Care and Use Committee (IACUC) became compulsory in 2008 by the Animal Protection Act in Korea. Seoul National University (SNU), which conducts 5% of Korea’s total animal protocol reviews and uses 10% of national laboratory animal usage, has been influential in the review of animal protocols and management of animal facilities. This study was undertaken to suggest the operational improvement of the IACUC. It focused on the case of SNU.The methodological framework consists of a qualitative approach. In particular, this study is focused on the grounded theory approach and sixty people were surveyed through purposeful sampling. Through this study, we found that various practical educations are necessary such as: (1) education for researchers on how to write a protocol, (2) standardization of screening criteria for various animal experiments by presenting various cases, (3) training on a detailed understanding of relevant laws and policies. In particular, an integrated management system, making it possible to share information among the related committees, would be essential for smoother operation of the IACUC.If various levels of education and the integrated management system are established, it will be possible to enhance the excellence of researchers and to better manage the operation of the IACUC. The Institutional Animal Care and Use Committee (IACUC) became compulsory in 2008 by the Animal Protection Act in Korea . In partAs animal experiments with genetically modified organisms and human materials gradually increase in research, communication with relevant committees such as the Institutional Review Board (IRB) and Institutional Biosafety Committee (IBC) is becoming essential. However, as the government departments managing these committees differ, the researchers, confused by complex regulations and guides, have raised dissatisfaction with the IACUC and the university. This is an issue faced by animal researchers, committee staff, and animal facility managers. Moreover, since the IACUC is an “institutional committee,” if it meets its purpose and values, its way of operation significantly varies between institutions and countries. A number of studies have analyzed the status of animal experiments and related guidelines , 3, 4; hGrounded theory is often used to explain specific cases or provide a study framework. Grounded theory is a qualitative research methodology that explores practical fields in order to explain specific social phenomena or obtain a new understanding of existing social phenomena. Therefore, grounded theory is a qualitative research methodology useful in understanding the social, psychological, and structural phenomena of humans and societies that are difficult to capture through other research methodologies , 6. GrouThis study was conducted by collecting opinions from related parties inside and outside the school regarding the operation of the IACUC at SNU (SNU-IACUC), which leads the animal experimentation-related field at national level and has an overwhelming scale in terms of quantity and analyzed respondents’ opinions using the grounded theory methodology. The study was also undertaken to suggest the operational improvement of the IACUC and other relevant committees, in addition to related organizations. This is useful information for animal experimenters, researchers, practitioners in the SNU and Korea, and related parties globally.The frequency and proportion of participants according to their majors, careers, and their roles within the IACUC are presented in Table As a result of examining the period during which the respondents conducted activities related to animal experiments such as research, facility management, protocol review, committee administration, etc., most of the reviewers and the principal investigators were classified as having over 10 years of experience in animal experiment-related experiences. If the respondents had performed research for over 10 years as a researcher and acted as a reviewer for the last five years, they were classified as those with over 10 years of experience in relation to animal experiments.All responses to the questions were summarized, while similar answers from the raw data were grouped into one item for the questionnaires voluntarily described by the respondents. Subsequently, the response rate for each item was summarized in the tables below.The results of a questionnaire surveyed to the administrators of each institution’s IACUC about the scale of each institution’s animal protocol reviews are shown in Table These results show that in order to achieve a seamless protocol review while satisfying both the APA (which is currently limited to 15 members) and the LAA , it is more realistic for SNU to operate at least three or more IACUCs. Although the restriction on the reviewer number in APA will be abolished soon, the majority vote of all enrolled members policy in the LAA remains unchanged. In the case of the IRB, SNU operates four committees in the Research affair, and the College of Medicine and the School of Dentistry each operate their own IRB.When performing animal experiments using human or transformed cells, approval from the IRB or the IBC and the IACUC is required. For smooth animal experiments, it is necessary to submit an animal protocol with prior approval from the IRB or the IBC in order for cells to be used. When the approval from multiple committees is required for an animal experiment, four out of six institutes  required the pre-approval from the IRB and/or the IBC prior to protocol submission for review by the IACUC. In addition, the other two institutions  responded that all necessary committee approvals were required at the time of actual animal testing or experiments without any specific order.In the US, when multiple committee approvals are required for the application of genetically modified organisms to humans or animals, there is no national-level guideline. However, each institution has its own guidelines. Some institutions require prior approval from the IBC for research involving animal experiment , 13, butTable In the operation of the IACUC, support from institutions is important, but autonomy and independence from institutions are also essential . In ordeSeveral noteworthy items were identified as requiring improvement in the operation of the IACUC through the survey. These are classified and summarized as follows.When the protocol was not approved, the researchers were asked to write whether they agreed with the review results, if they disagreed, they were required to state the reason, and their complaints and suggestions about the protocol writing and review procedure. The researchers commonly highlighted the inconsistency of the review and complained that the reviewer failed to provide a valid rationale when requesting that the number of animals be reduced Table . The forThe researchers basically accepted and respected the opinions and comments of the reviewers. However, as shown in Table In the open coding process, over 30% of the IACUC member respondents stated that the institution’s support was insufficient Table . RegardiThe results were collected by allowing each survey respondent to freely describe their suggestions for their affiliated institutions and related government ministries. These are shown in Table Therefore, for seamless animal experiments through the improvement of the IACUC operation, we propose two topics: (1) reinforcing the education for researchers and reviewers, and (2) preparing an integrated management system for the relevant committees .Various forms of case-oriented education for researchers and reviewers are necessary. In particular, since the acceptance of online lectures by institutional members has increased, it is necessary to create online lectures of various cases at the national or institutional level and share the contents. Rather than complaining about the related regulations, researchers want education to develop their understanding of procedures and regulations to accept the relevant points. Therefore, education support that reflects this is required, and considering that it is difficult for each institution to bear this independently, support, such as the development of curriculum by the relevant government bodies, is required.Administrators and animal facility operators are complaining about difficulties in managing the APA, the LAA, the Bioethics and Safety Act, and the Living Modified Organism (LMO)-related laws simultaneously, so that researchers find out if there are any illegalities in the contents stipulated in multiple laws. Consequently, researchers must be aware of this and prepare for it. However, in reality, researchers are unaware of this. To make this possible, it is necessary to prepare an integrated management system for the relevant committees such as the IRB and IBC.This study categorizes key issues based on “Grounded Theory” by collecting opinions from researchers, reviewers, administrators, and facility operators on the operating conditions of animal experiments and the IACUC in institutions equipped with animal facilities. Based on these results, we compare the merits of each in the case of maintaining the current status and pursuing an effective step-by-step change. In addition, we suggest a desirable improvement plan for the operation of the IACUC and related organizations by analyzing the opinions from the respondents.If the current procedure is maintained, there is a high possibility of preparing an animal protocol in a situation where proper information is lacking, as highlighted by those involved in animal experiments. Animal protocols that require amendment are subject to judgment such as “conditionally approved with a request for revision” or “re-review after revision,” so the protocol applicant reflects the reviewer’s comments and understands their errors through the revision and gradually writes a high-quality animal protocol. However, researchers believe that most of the items highlighted by reviewers (errors or mistakes in writing) can be avoided if there is prior education and training, which can shorten the time from submission to approval.Researchers are often dissatisfied with the reviewer’s review criteria, mainly because the reviewers make new comments about the protocol approved by other reviewers in the past and reject it. Not all IACUC members who conduct reviews are experts in animal experiments; therefore, it is important to educate reviewers to enable consistent reviews. In addition, the laws related to animal experiments (APA and LAA) are also being periodically revised, and even if the administrator of each institution is notified of this, the relevant information cannot be delivered to researchers in a timely manner or reviewers cannot recognize it. Therefore, it cannot be reflected in the protocol review. Regarding these legal changes, each institution should periodically educate reviewers and researchers in order to avoid future difficulties.Education for researchers on how to write a protocol according to the type of animal experiment As experimental techniques using animals are diverse and advanced, prerequisites for planning are increasing, and there are cases in which researchers fail to prepare a complete protocol because they are not well aware of it. If education in this regard is effective, researchers can easily determine what type of animal experiment is included by writing the protocol according to the research purpose. Therefore, unnecessary re-review will be reduced.Standardization of screening criteria for various animal experiments by presenting various cases for the IACUC members who review the protocol Since not all IACUC members who review the protocol are experts in the relevant animal experiments, it is occasionally difficult to decide what kind of decision suits each type of experiment. Each member has a variety of perspectives depending on their position . In addition, there may be differences of opinion between members with long-term review experience and new members. However, from the researcher’s perspective, since the least consistent decision is expected for the same animal experiment, each institution regularly educates reviewers using typical cases for each type of experiment as an example based on the protocol deliberation results previously accumulated. Consequently, it is necessary to help those who review the criteria to make a decision in a state of mutual agreement on some basic matters.Training on a detailed understanding of relevant laws and policies for administrators and animal facility operators Administrators and facility operators are in the position of receiving the most complaints from researchers. However, are also obliged to deliver the most recent and relevant information to researchers. In accordance with changes in society’s perception of companion animals, related laws are also periodically strengthened or revised; therefore, each institution needs to frequent communicate this to researchers. In addition, it is necessary to support them to receive the education provided by experts, or to attend public hearings on government policies and events of related societies and civil society organizations.The results of this study indicate that changes are inevitable to improve the management of animal experiment procedures based on the IACUC, including ethical perspective. Above all, various forms of practical education are necessary for all participants related to animal experiments, including researchers and reviewers (IACUC members). Consequently, three suggestions have been proposed in this study: (1) education for researchers on how to write a protocol according to the type of animal experiment, (2) standardization of screening criteria for various animal experiments by presenting various cases for the IACUC members who review the protocol, and (3) training on a detailed understanding of relevant laws and policies for administrators and animal facility operators. The reasons for each proposal are as follows.In addition to providing various forms of education, taking SNU as an example, we propose an integrated management system improvement plan for the relevant committees as shown in the schematic diagram below Fig. . As a reHowever, as research using genetically modified organisms or translational research becomes active, the need for information sharing between the IBC, the IACUC, and the IRB increases and researchers’ demands for an integrated organization to seamlessly manage them are also increasing. Therefore, the Research ethics team is continuously focusing on the Office of Research Integrity, which involves its original tasks such as publication ethics and conflict of interest in research and separately forms an integrated management organization or consultative body that manages mutual communication by overseeing the IRB, the IACUC, and the IBC. Furthermore, administrative and educational support for each committee will be provided by the IEPS for the IBC and by the ILAR, which is currently unconnected with the IACUC, for the IACUC. In the case of the IRB, it is proposed that the administrative and education support team will manage a total of six subcommittees , which are separately operated by Research Affairs, as depicted in Fig. It will be difficult for each individual institution to conduct all these trainings independently. As with the public IRB education program operated by the National institute for Bioethics Policy  and the The IRB, which reviews human research, and the IBC, which reviews the use of cells and tissues and LMOs, are managed and supervised by a government department different from the IACUC. As animal experiments become increasingly sophisticated, studies that require approval from both the IACUC and the relevant committee are increasing. Consequently, rather than prescribing prerequisites for the deliberation of a specific committee, it is desirable to create an integrated management body for the relevant committees within the institution that effectively communicate when researchers conduct animal experiments. This will ensure that the animal facility operator or members of each committee conducting a review can more easily verify the relevant protocols with each other. Such a system can support researchers to conduct more ethical and rational animal experiments while complying with the relevant laws. In addition, the integrated management body must focus on the education of the researchers. Many institutions in the US have various educational service programs in their division or office of research compliance , 22. TheThe results of the surveys suggest that institutions that conduct animal experiments must continuously provide education related to their duties for researchers and the IACUC members. In addition, they must establish a unified/integrated management organization or consultative body with relevant committees such as the IRB and the IBC. If greater levels of education and an integrated management system are established, it will be possible to enhance the excellence of researchers and to better manage the operation of the IACUC.The methodological framework consists of a qualitative approach. The study was conducted with the IRB approval from the SNU School of Dentistry . The survey was conducted by email and the participants provided informed consent.Theoretical sampling is purposeful sampling according to categories that we developed and these categories are based on theoretical concerns. Sixty people were surveyed through purposeful sampling. In the case of the SNU researchers, the main respondents, the target principal investigators, and graduate students/postdocs were selected to reflect the representativeness of each campus and major colleges. In addition, animal facility operators, administrators, and the IACUC members of each institution were selected as survey subjects from institutions that model IACUC according to the type of institution such as private company, university, and hospital.SNU conducts 5% of Korea’s total animal protocol reviews and also uses 10% of the national laboratory animal usage. It is a vast research institute that consumes approximately 350,000 experimental animals per year, mainly rodents, at 15 official animal facilities located on four campuses . This isTherefore, the questionnaire was designed for the principal investigators and researchers who submit animal protocols which will be reviewed by the IACUC and the animal facility operators who manage the laboratory animals. However, for the analyses related to the operation of the IACUC, comparative analyses must be performed according to the type and size of institution including university, public institution, and private company. Therefore, in the case of the IACUC members and administrators, a survey was conducted targeting the IACUC members and administrators in universities , public institutions, and private companies that operate the IACUC in Korea.The questionnaire was composed of items necessary for improving the operation of IACUC based on the opinions of experts in the field, such as animal facility operators and administrative personnel, referring to various suggestions of SNU animal researchers posted over the past several years. The survey targets were classified as the IACUC members, administrators, animal facility operators, principal investigators, and researchers (postdocs and graduate students). In addition, the questionnaire contents were divided into the IACUC members, administrators, animal facility operators, and research personnel  according to their duties.The survey was conducted and analyzed as follows. First, similar answers were grouped in the data, categorized, and open coding was performed to suggest response rates for each item. Subsequently, items (topics) showing significant results were extracted, and among them, the key issues necessary for operational improvement of the IACUC were selected and survey results were derived through an axial coding process. Subsequently, the study was conducted through the process of searching for alternatives through selective coding, which analyzes the questionnaires asking about differences in opinions by groups.


The large (dromedary and Bactrian camel) and small  camelids are an old family of domestic animals used by humanity for thousands of years, but until recently camelids were bred in only very specific ecosystems  and in a traditional way. This close relationship between the animal and its ecosystem has maintained the camelid family in a certain marginality, in terms of demography . Yet, for 30 to 40 years, we have observed two important changes in the camelid breeding. First in their farming system with the emergence of more intensified farming, and second, in the geographical expansion of those species, even into completely new ecosystems. It is no coincidence that the European Association of Animal Production has opened a special session on the camelid sector for their annual meeting in Western Europe.Animal Frontiers, some examples of the current questions and perspectives regarding this family. With remarkable biological models as well as interesting producing animals and elements of remote ecosystems, the different questions regarding the species of this family could stimulate animal scientists to be more involved in “camelidology.”However, those changes have several consequences for scientists. Indeed, the intensification process in camelid farming requires scientists to describe and understand the impact of those changes on the physiology, metabolism, and health of the animals, to set up and develop new biotechnologies for a more rational breeding , to expand knowledge regarding their products , or to investigate their biodiversity for implementing a reasoned selection policy. It is the objective of the present special issue to offer to the readers of The first paper (Faye) of this special issue, proposed by B. Faye, is asking the question of the current changes in camelid demography worldwide with a focus on large camelids. The title is formulated as a provocation (“Is the camel conquering the world?”), but as demonstrated in the paper, the camel has continued its expansion from its domestication from similar desert ecosystems in the Arabian Peninsula (for dromedary) and in Central Asia (for Bactrian). The new situation is the implementation of new camel farming systems out of their classical biotope as well in more humid ecosystems of Africa or Asia as in the temperate milieu of Europe and North America. In that new context, the camel becomes less the “ship of the desert” and more and more a productive animal for the modernized agricultural sector.a priori as the opposite approach to the “traditional and harmonious way of life” of the camel in their desert in terms of welfare. Yet, if the intensive management could disturb the camel metabolism oriented to water and food shortage management by providing access to a good feeding and hygienic environment, this could facilitate the safe production (milk) of “happy and healthy” camels.Obviously, as indicated above, the expansion of the camelid family is not only a matter of geography, but also of function. The contribution of Nagy et al. is based on the strong experience of the authors who are managing the biggest intensive camel dairy farms in the world where camels are bred “as dairy cows.” The title of the paper  gives clearly the main elements comprising the intensification process. The authors underlined the importance of good management practices. Indeed, intensive farming systems appear Those authors have also mentioned the interest in assisted reproductive technologies to enhance the efficiency of a selective breeding program, but one constraint in the camelid family is the low reproductive performance, a limited factor of the intensification. Notably, camelids are classified as induced ovulatory species where copulation is the main stimuli for ovulation induction. The review of Paiva et al. entitled “The ovulatory and luteotropic actions of the male-derived nerve growth factor (β-NGF) in South American Camelids” gives an interesting overview of the mechanisms explaining this particularity of the members of the camelid family. The authors underline notably the role of the neurotrophin β-NGF and its potent luteizing hormone-releasing effect, leading scientists to consider that it could be possible to use this molecule as a biotechnology tool to enhance fertility in intensive farm systems. Indeed, if the induced ovulation can be regarded as an adaptation process in a context marked by harsh conditions, it might be possible to get away from this constraint in more favorable food and health contexts.We should also highlight that interesting advance has been made to understand the genetic mechanism of fiber traits. In this sense, the paper of Anello et al. described a detailed review regarding the state of the art on genetic factors that could influence the quality of fibers of South American Camelids. Mutations have been identified as responsible for some monogenic or oligogenic traits enabling molecular testing to assist breeding decisions. The recently developed 76K single nucleotide polymorphisms array for the alpaca will facilitate the identification of genes affecting more complex traits through genome-wide association studies.It is known that feeding is one of the important pillars of animal breeding. The camels accustomed to spending more than 8 hours a day grazing in extensive systems can be disturbed in intensive farms where they received more concentrated energetic (and proteic) feeds. Thus, the investigation of the ruminal flora could provide useful information on the microorganisms  and their functions to improve the feeding efficiency in such new context. The paper of Al-Jassim focused on the digestive microflora (“Foregut microbiology of the Arabian camel”) is an interesting review regarding the up-to-date knowledge of both the identity of this population and its physiological and biochemical characteristics. Moreover, the paper also emphasizes the fact that a part of the bacterial community in the camel gut is still unknown in the public database, thus opening a field of new investigations. Moreover, the co-habitation of camels and cattle in the same grazing area could lead to an alteration of this bacterial community in both species.Historically, large camelids were animals of the nomads, merchants, and warriors. As such, they moved frequently in the arid and semi-arid parts of the world, following war and trade routes across important deserts in Africa and Asia. Consequently, the mixing of different camel “breeds” throughout history leads to a panmictic population with a certain low diversity of their genotypes. Until recently, phenotypes only were investigated to identify the ecotypes . It is, for example, the case of Akhmetsadykova et al. who underline the interest of these kind of studies, especially in a country like Kazakhstan where both domestic camel species (dromedary and Bactrian) are cohabiting, sometimes in the same farm. Beyond the genetic diversity, and the practice of crossbreeding between these two species, the paper recalls the cultural and economic importance of camel in the country. Milk, meat, and wool productions, even if they appear globally marginal in the country, the relative increase of the camel part seems to emphasize the role of these animals in a future marked by climatic changes.However, in less than 20 years, camel genetics has made great progress, notably with the use of molecular tools and genomic investigation. The three following papers are devoted to camel biodiversity. Kohler-Rollefson is exploring how to conserve this biodiversity (“Camel Biodiversity—and how to conserve it”). The author is recalling that the current biodiversity is the result of farmers’ practices throughout history. Indeed, the cameleers have achieved an empirical selection to obtain phenotypes adapted to certain functions , but with the introduction of biotechnologies of reproduction in intensive systems, the risk is linked to the narrowing of gene pools. Consequently, the preservation and conservation of the biodiversity, as for other species, is to maintain in-situ breeding supported by local communities. In such context, the author concludes that such approach will have a double advantage: to ensure the conservation of camel biodiversity and to strengthen the food security of the local population living with their camels.Camelus bactrianus)” write about the use of genomic tools to measure the genetic divergence between different strains of Bactrian on the Asian continent. Thus, it is assumed that Bactrian camels were first domesticated in Central Asia less than 4.45 thousand years ago, probably in more western areas than previously believed , and then migrated back to East Asia around 240,000 years ago. The biodiversity is then explored by using new technologies, such as mitochondrial genome, nuclear genome, and whole-genome sequencing, allowing a good understanding of the current variability. The authors also consider the importance of preserving the wild Bactrian camel which is appearing as a full-fledged species different from the domestic Bactrian.In their paper, the Chinese team working on Bactrian camel genomic  also considers the importance of biodiversity conservation. After a nice phenotype description of the different Bactrian breeds in Central Asia , and the current knowledge regarding the history of double-humped camel domestication, the authors of the paper “Review of genetic diversity in Bactrian camel . For the future, the authors suggest focusing research on pangenomes and comparative genomics, . Such an approach could support a better knowledge of diversity in relation to adaptation, production traits, and performance.Finally, to complete this special issue, it was necessary to consider camel production which was the subject of the two last papers, devoted to milk and meat, the most economically important products of large camelids . The paper from Konuspayeva et al. focused on camel milk  is a tentative response to the common assertion that “camel milk is rich in minerals” contributing to its exceptional nutritive value. Yet, the analysis of the scientific literature indicates results conflicting with this “rich milk” narrative. Indeed, except for the cations  which play an important role in water metabolism and electrolytic balance, the other major minerals  are not exceptionally high and even, according to some authors, in less quantity than in cow milk. It is the same for trace elements (like for vitamins except vitamin C) which are in similar or lower concentrations than cow milk, except probably iron and zinc. Beyond this description, the authors emphasize the lack of research looking for the impact of the diet composition on mineral status of camel milkThe last paper from Kadim et al. entitled “Nutritional values and health benefits of dromedary camel meat” aims to investigate the functional properties of the camel meat. As with camel milk, camel meat is regarded as a healthful product for regular consumers. It is known that the protein quality (in terms of amino acid composition) of camel meat is the highest among all common meat consumed by humans. It should also be recalled that camel milk is characterized by a low concentration of cholesterol and globally fat proportion. But the authors also emphasize that for other elements , camel meat is comparable to other red meat. The health effect that could be attributed to camel meat consumption, except for low cholesterol which can be a strong commercial argument, is due to the good balance of the different elements that compose it. However, a significant improvement could be expected by better slaughtering and cooking conditions.Animal Frontiers cannot cover all the topics regarding camelid science and all disciplines linked to this marginal but emerging species in a context of diversification of livestock farming and growing integration of camel products in a globalized economy. However, it is expected that this special issue will stimulate the scientific interest of animal scientists, especially in Europe, for these strange animals.The present issue of Conflict of interest statement. None declared.


The first Danish symposium on evidence-based deprescribing was held in September 2019. The symposium aimed to increase the awareness of deprescribing in general, to discuss the importance of deprescribing, and, thus, a potential consensus on key issues on a national deprescribing agenda. The invited keynote speaker, Barbara Farrell, from the Bruyére Research Institute, Ottawa, Canada, presented their thorough work on deprescribing guideline development and application. The symposium consisted of two parts: Part 1 concentrated on establishing the need for deprescribing in our society. Part 2 consisted of a panel debate that put the practical application and implementation of deprescribing in perspective to the input from the audience and the structure of the Danish healthcare system. The panelists represented key stakeholders, e.g., clinical pharmacists, general practitioners, hospital doctors, Danish Health Authority representatives, health politicians concerning deprescribing in Denmark. The event allowed 145 participants to discuss the importance of implementing deprescribing in a Danish setting. This commentary highlights and discusses the major themes that characterized the symposium: “why deprescribe?”, “deprescribing research” and a theme dedicated to “problems of concern.” The emergence of these themes formed the basis for the discussion of new strategies and a proposal for a future gold standard to succeed in deprescribing. The term deprescribing first appeared in the literature in 2003,,How to deprescribe a medication can be a challenge, and until recently, no evidence-based deprescribing guidelines have been available. Such deprescribing guidelines have been developed in Canada and Australia.Inspired by the Canadian initiative, the Capital Region of Denmark quickly did take action to publish Danish versions of deprescribing algorithms. The Danish versions have been approved by the association of general practitioners in the Capital Region of Denmark (KAP-H) and the Medicines Committee of the Capital Region of Denmark, whose most important task is to ensure rational pharmacotherapy inthe regional hospitals, psychiatry, and primary care. The Danish deprescribing algorithms were subsequently submitted to the Danish Health Authority to ensure that the messages were according to Danish standards and recommendations.The first Danish symposium on evidence-based deprescribing was held at Copenhagen University Hospital Bispebjerg in September 2019 by The Department of Clinical Pharmacology, The Medicine Unit. The members of the organizing committee are reflected in the author list.The symposium aimed to increase the awareness of deprescribing in general, to meet and discuss the challenges of deprescribing among stakeholders involved in deprescribing activities from different perspectives. It will be tried to reach a consensus on key issues on a national deprescribing agenda. Finally, the symposium aimed to present and disseminate knowledge of the Canadian deprescribing guidelines and the new Danish deprescribing algorithms among Danish health care professionals.This commentary will highlight and discuss the main themes and problems of concern identified during the symposium; not least, the commentary will discuss requests to and a proposal for a future gold standard on how to address and succeed in deprescribing for the benefit of patients, healthcare professionals, and the health care system.22.1To achieve a broad and realistic picture of the real-world polypharmacy challenges and to be able to assess the future potential of deprescribing, we invited key stakeholders as speakers, panelists, and participants, to spread awareness of deprescribing and practical execution of deprescribing activities in Denmark. The key stakeholders were represented by researchers, general practitioners, hospital doctors, clinical pharmacists, community pharmacists, an official from the Danish Health Authority, and health politicians. They shared their expertise within different aspects of deprescribing: Rational pharmacotherapy, evidence-based medicine, polypharmacy, and shared decision making across the health care system. The one-day symposium was fully booked with 145 registrants, 11 presenters, and 9 panelists.2.2,idea card (Appendix A) and an introduction to slido.com app was handed over. The participants were encouraged to use the idea card to write down their ideas and reflections on implementing awareness of deprescribing in their work environment. The slido.com app collected inputs and questions from the audience for the later panel debate. The completed idea cards were collected at the end of the event and used by the organizing committee to evaluate the reflections of the audience to utilize these when working to improve the deprescribing implementation in Denmark.At the beginning of the day, the participants received learning material with supportive recommendations on rational pharmacotherapy, including the Canadian and Danish deprescribing guidelines and algorithms.slido.com app. A post-meeting in the organizing committee was held to consider and discuss new strategies and actions toward improving the national and international deprescribing collaboration, the evidence-based deprescribing research, and the implementation of guidelines.The event was divided into two parts (see program of the day in Appendix B). Part 1 concentrated on setting the stage for the need for deprescribing in our society, introducing the Canadian method for developing evidence-based deprescribing guidelines, the state of the art of deprescribing research, and the political visions for national medical safety, including the importance of deprescribing. At the symposium's opening, participants were welcomed by the chief medical officer at The Copenhagen University Hospital Bispebjerg and the head of the organizing committee. Part 1 was delivered by presentations followed by discussions from different health care providers perspectives, e.g., the Head of Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, clinical pharmacists (deprescribing pioneers) from Canada, and the head of The Health Committee at The Danish Regions that is the interest organization for the five regions in Denmark. Part 2 consisted of the panel debate, which put the practical application and implementation of deprescribing in perspective to the attitude of the audience and the structure of the Danish healthcare system. The panel debate was held in the final hours of the symposium and included all former speakers as panelists. During parts 1 and 2, notes were collected by three notetakers from the organizing committee. Notes were listed for each presentation and discussion. After the symposium, the major themes and suggestions from the participants were identified by the principles of qualitative content analysis3The common themes and subthemes that characterized the presentations and discussions during the symposium are seen in 3.13.1.1Initially, the key speaker's presentation gave an in-depth insight into why deprescribing is important. Through her many years of work as a clinical pharmacist with polypharmacy patients, it was her experience that she had been able to increase the quality of life of these patients by a deprescribing intervention.,Presenters and the audience emphasized that the population is getting older, and the use of medications increases with age. More people suffer from chronic illness, multimorbidity, and polypharmacy.3.1.2At the symposium, the worldwide interest in deprescribing was highlighted. Important initiatives exist within the World Health Organization (WHO), The National Institute for Health and Care Excellence (NICE), and national initiatives focusing on medication safety, multimorbidity, and polypharmacy. In 2017, WHO initiated the Third Global Patient Safety Challenge: “Medication without harm.” Denmark is a part of this challenge that aims to, globally, reduce the level of severe, avoidable harm related to medications by 50% over 5 years. One of the categories that the effort focuses on is polypharmacy and how addressing polypharmacy can reduce medication with harm.3.1.3,,,Deprescribing is proposed as an intervention to reduce the harm associated with inappropriate polypharmacy.3.23.2.1,Some research groups are planning to conduct randomized placebo-controlled trials testing deprescribing of standard care medication, and some with varying study-quality have already been conducted.3.2.2The level of evidence in deprescribing was of great concern for the participants. There was among the assembly a future wish for establishing a solid evidence base concerning the effect of deprescribing tested in randomized placebo-controlled trials, where this is considered ethically sound. Besides this, it is important to investigate and evaluate a potential deprescribing effect on individual patients. This may specifically refer to the individual patient's ability to metabolize a given drug, e.g., in the presence of CYP450 polymorphism. The symposium called for greater national/international deprescribing collaboration, where the execution of the critical clinical trials could be coordinated and valid data on the clinical effect of deprescribing could be obtained.3.2.3,,So far, clinical intervention studies are struggling to show a clear benefit in favor of the intervention. A systematic review and meta-analysis from 2016core outcomes were: Harm , clinical outcome , healthcare utilization , knowledge , medication-related outcomes  and patient-related outcomes . These core outcomes should be combined with preference-based deprescribing decisions for individual patients, which means that a successful outcome depends on meeting the specific patient preferences or goals.,,The selection of relevant outcomes was of great concern for the participants. Outcomes in deprescribing studies often include a reduction in the number of medications and an assessment of the appropriateness of drug treatment.3.33.3.1A general concern among the assembly was that treatment guidelines mainly included treatment of single conditions such as diabetes, asthma, and stroke without considering any comorbidity of the individual patient and a potential prioritization of the treatment of various concomitant diseases. Hence, very few guidelines advise on when and how to deprescribe. This was cited as one reason for the high prevalence of polypharmacy. A general practitioner among the participants justified this by saying that physicians strive to do the best for their patients. The general perception among physicians is that the best thing one can do for their patients is to offer them a treatment recommended in an evidence-based guide. It is, however, important to be aware that treatment guidelines are not necessarily appropriate for the individual patient to follow, e.g., beta-blocker in an asthmatic. Deprescribing is not yet covered by the treatment guidelines, which contributes to a lack of focus among physicians on the importance of reducing inappropriate medications. This may indicate that the general practitioners need more training in appropriate prescribing and reconsidering the continued need for a drug treatment before initiating another. The prescribers need to see deprescribing as part of good prescribing practice, including medication initiation, dose titration, changing or adding medications, or deprescribing medications.In addition, the physicians are unsure whether they comply with the Danish Agency for Patient Safety's recommendations if they do not comply with the treatment guidelines because this is currently perceived as the right way to treat patients. Especially, the young physicians were concerned about deprescribing medications among polymedicated patients. They were concerned about the lack of evidence for deprescribing in the form of, e.g., medical flare-ups and the potential negative impact on quality of life. These concerns seemed to be a great barrier to implementing deprescribing. This is problematic, as many of the real-world patients are older patients with multimorbidity and polypharmacy with a great need to deprescribe and prioritize medications.The evidence supporting the deprescribing guideline recommendations was questioned at the symposium, as the availability and quality of evidence are often low. However, it was emphasized that prescribing guidelines often have the same issue. It was also pointed out that guidelines rarely involve elderly, multimorbid patients, making it challenging to medicate this patient group appropriately.Hence, combining prescribing and deprescribing guidelines in the future was a request from both the developers of the deprescribing guidelines and the health care professionals present at the symposium. In addition, the guidelines should preferably include older people and patients with comorbidities to support physicians in prioritizing medication and achieving an appropriate prescribing pattern for these patients.3.3.2,,During the discussions, it became clear that shared decision-making should be a mandatory part of a deprescribing process. Studies indicate trends to an increased quality of life, adherence, and commitment to patients' decisions when they are part of the decision-making process.3.3.33.3.3.1Silo medicineThe silo mentality is believed to reduce the efficiency of overall patient care. Unfortunately, it is difficult to avoid silo medicine due to the structure of the healthcare system today, where general practitioners are supposed to see the full picture of a patient's treatment – but this is a difficult and time-consuming task that is not always possible in practice, especially, for patients with polypharmacy and multimorbidity. The organization of the health care system may have an impact on the medication management of multimorbid patients. Thus, optimizing communication between patients, general practice, hospitals, acute care facilities, and nursing homes must be well established and easily accessible. It can be imagined that a shift to a holistic healthcare system will break down silos between sectors and support higher quality collaborative care.3.3.3.2The organization of the health care system was only superficially discussed, although there was apparently a general agreement among the participants that the structuring of the health care system has a great influence on the increasing number of polypharmacy patients in Denmark. Structural changes connecting prescribing and deprescribing with the emphasis on encouraging more thorough medication monitoring and reevaluation, and deprescribing was suggested.The communication between health care professionals is expected to be significantly improved by optimizing electronic health records. These could advantageously contain automatic system-generated deprescribing recommendations based on the individual patient's medication list, diagnoses, patient adherence, and redeemed medications at the pharmacy.,Other important focus areas concerning optimizing rational prescribing and encouraging deprescribing were mentioned. Participants agreed that deprescribing is about better prescribing processes, which requires targeted training of health care professionals in prescribing medication appropriately. For this training, the prescribing/deprescribing guidance tools, ‘Beers criteria for potentially inappropriate medication use in older adults’ and ‘STOP/START criteria for potentially inappropriate prescribing in older people’ published by American Geriatrics Society 2019 and 2015, respectively, can be recommended to use.At the symposium, the national health political visions for deprescribing were presented. The political visions supported the views presented at the symposium: Patients should only receive the medication needed, there should be more focus on reducing polypharmacy, attention to that medications not always are the right solution for the patients, doctors should be educated in rational pharmacotherapy, and finally, we need independent research to support clinical decision making.4The future gold standard to succeed in deprescribing●Do not hesitate to consider deprescribing medications of vulnerable patient groups.●Ensure focus on solid research that can document the effect of deprescribing●Consider deprescribing based on the practice of evidence-based medicineIn general●Define clear guidelines for initiation, monitoring, reevaluation, and deprescribing medicine●Include considerations on prioritizing medications for multimorbid polypharmacy patients●Encourage shared decision making and awareness of patient preferences●Preferably base the guidelines on research results obtained by RCTs or external clinical evidenceCombine treatment and deprescribing guidelines●Avoid silo medicine by increasing communication between sectors and specialties●Interprofessional education of health care professionals in rational pharmacotherapy●Engage patients through shared decision makingCoherence of the health care system●Follow up on patients who have received deprescribing interventions●Note and document the observed deprescribing effects●Collect these experiences to build an evidence base for clinical practiceContribute to evidence generation in clinical practiceAlt-text: Unlabelled BoxBased on the themes that emerged and other outcomes from the symposium, a future gold standard was proposed to achieve a shared vision to succeed with deprescribing.With this symposium, attention has been drawn to the importance of evidence-based deprescribing in the health care system. The first step in a hopefully future national and international collaboration concerning deprescribing between health care stakeholders has now been taken.Until now (2021), we believe that the symposium has already created attention to – and had a certain impact on - the focus on deprescribing.During the symposium, the Danish Health Authority encouraged participants to seek funding from the authority to develop deprescribing guidelines and has now funded the development of a national clinical guideline regarding deprescribing of- and continued treatment with inhaled steroid in patients with chronic obstructive pulmonary disease (appendix G). The guideline was published in April 2021 as the first Danish deprescribing guideline. Under the auspices of the Danish Health Authority, an initiative has also been taken to translate a national ‘deprescribing list’ into English to use this in the scientific literature and thereby contribute to international awareness of deprescribing.In addition, it can be mentioned that the Danish deprescribing algorithms are now widely used in the Capital Region of Denmark. Several publications and interviews in press media within the area and pilot studies in two Danish regions dealing with the testing of the integration of pharmaceutical competencies in general practice regarding medication review and deprescribing among polypharmacy patients.Funding for the planning and holding of the symposium was provided by the Department of Clinical Pharmacology, Copenhagen University Hospital.None.