Introduction. Old hospitals may promote inefficient patient care processes and safety. A new, functionally planned hospital presents a chance to create an environment that supports streamlined, patient-centered healthcare processes and adapts to users' needs. This study depicts the phases of a facility planning project for pregnant women and newborn care processes (beginning of life process) at Turku University Hospital. Materials and Methods. Project design reports and meeting documents were utilized to assess the beginning of life process as well as the work processes of the Women's and Children's Hospital. Results. The main elements of the facility design (FD) project included rigorous preparation for the FD phase, functional planning throughout the FD process, and setting key values: (1) family-centered care, (2) Lean thinking and Lean tools as the framework for the FD process, (3) safety, and (4) cooperation. Conclusions. A well-prepared FD project with sufficient insight into functional planning, Lean thinking, and user-centricity seemed to facilitate the actual FD process. Although challenges occurred, the key values were not forgone and were successfully incorporated into the new hospital building. Hospital patient care processes are often forced to adapt to impractical facilities. The premises used for different functions of the same process can be scattered around the hospital, a far cry from seamless patient care. Planning a new hospital presents a unique opportunity to address this issue .Functional planning should guide the design of a new hospital  and aim  Lean thinking was an integral framework for the functional planning of the process , the need for a new hospital building was identified. The facilities at H1, which was planned in the 1950s and built in 1968, were becoming obsolete: there were operation bottlenecks, problems with the quality of indoor air, frequent sewage breakdowns, and fire safety issues . Renovatess , and a project coordinator.Three researchers analyzed design reports and meeting documents in order to assess the beginning of life process. The current structure of the process was identified and depicted using a particular patient flow analysis and value stream mapping. The patient flow analysis focuses on describing patients' physical movements in the hospital , 13. ValThe structure of H1 was identified as outdated. The hospital layout poorly supported current work processes, which had been revised in the decades since the old hospital was built. Due to the suboptimal hospital layout, work processes were dispersed across several units of the hospital on four different, but not adjacent, floors. In addition, the elevators were commonly sluggish. This caused unnecessary waiting and back-and-forth transfers of patients from one unit to another see . The patThe insufficient number of patient rooms (12) in the labor and delivery unit caused unnecessary waiting for both mothers and the nursing staff. Only one delivery room in the labor ward had a birth pool, and mothers took turns using the bathing facilities during labor contractions. The lack of space in the delivery rooms and the electric cords lying on the floor presented safety concerns. This was exacerbated by the lack of HC personnel.The area in the delivery room used for newborn resuscitation and monitoring was small. Therefore, the newborns requiring longer observation or procedures after initial resuscitation were transferred to the NICU, leading to frequent NICU admission.The mothers of infants cared for at the NICU stayed in the prenatal maternity ward. This caused frequent daily traffic as mothers visited their infants several times a day and returned to their ward for care and meals. After NICU care, as soon as they were stable, over 60% of infants were transferred to the postnatal maternity ward so that mother-infant separation was minimized. Ideally, maternal care and parent beds would be located in the NICU to avoid a large number of within-hospital transfers. In most cases, the limited number of family rooms in the postnatal maternity ward prevented the overnight presence of fathers.The groundwork for the functional design was carried out years before the actual process was initiated. In 2001, a lifecycle decision was made regarding the old H1 Women's and Children's Hospital. It was concluded that the facilities were outdated and needed to be renovated or replaced. However, no official decision was made until 2011, when hospital replacement was agreed upon and the functional design process officially commenced.Before the actual design process commenced, however, the Department of Pediatrics and the Department of Obstetrics and Gynecology held several joint meetings about their visions for a new hospital. Held between 2005 and 2009, these meetings generated reports about the projected needs of the new hospital space. Key personnel from the Department of Pediatrics and the Department of Obstetrics and Gynecology visited new perinatal centers and centers undergoing renovations or building processes in the United States , Canada , and Sweden  to gain insight into state-of-the-art solutions. Key personnel acquainted themselves with the planning processes of these international sites. One crucial observation was that a certain number of key fundamentals should be clearly and thoroughly determined prior to the facility design (FD) process and prioritized during the process. Furthermore, information sharing between hospitals was seen as pertinent. Systematic participation in HC FD forums  also provided essential knowledge about other hospitals' state-of-the-art innovations and whether they had been good solutions from the users' perspective or nonoptimal solutions which had led to bottlenecks and other unintended functional problems.n = 17) was founded in 2011 and called The Beginning of Life Group. Its main focus was on developing a functional plan for the beginning of life process including pregnancy, labor, and newborn care. The planning group held approximately 20 design meetings. H1 administration attempted to allocate up to 30% of key personnel's work time for the FD project to cover a six-month period.A multidisciplinary planning group  were systematically sought and eliminated. Reducing the number of patient transfers within and between units was an important strategy to eliminate unnecessary work steps . Another strategy was to decrease the travel distance when transferring sick newborns from the delivery room to the NICU. Flexible, modifiable rooms were planned for the NICU that could accommodate the changing needs of a patient throughout their hospital stay .The group aimed to improve patient and staff safety by various means: effort was made to develop disturbance-free treatment periods, such as fewer transfers within and between units, thereby decreasing communication errors by the staff and minimizing hazards related to the transfer of sick patients. Moreover, single family rooms isolated the patients and their relatives from other patients, decreasing the likelihood of spreading infections.The group named enhanced cooperation as one method for breaking the boundaries of old silos and reorganizing care based on patient care pathways. This was pursued by creating a single process with a common goal: getting the mother and baby home healthy. The new environment would decrease boundaries between units, even including a stabilization room for newborns in the delivery room where both neonatal nurses and midwives would work together. Midwives would provide care for mothers and their infants in the NICU. The physical proximity of the prenatal maternity ward to the labor and delivery room and the NICU aimed to enhance synergy, cooperation, and communication between the staff of these units.A parent representative was invited to take part in The Beginning of Life Group so that patient and parent perspectives were taken into account. The representative held discussions with a larger group of parents in a peer-support group in order to bring their views into the planning process.The Beginning of Life Group started by discussing the main values that would guide the planning process. Four values were chosen based on the group discussion :Family-cInformation gathered from the staff and secretaries regarding supportive functions proved useful to the design group.The planning group assessed patient and information flows in order to avoid unnecessary traffic within the hospital and to increase the efficiency of the units. Tools such as value stream mapping were utilized for a patient flow analysis, starting from pregnant women and caesarean sections through to neonatal intensive care and transitions to home. Bottlenecks, functional problems, other forms of waste in the process, and potentials for synergy were identified using root cause analysis. Comments and problems were marked with yellow and red tags, respectively. Furthermore, simulations using a stopwatch were carried out to assess throughput times of critical connections between operating units. After the analysis, the planning group redesigned the whole process according to the four defined key fundamentals.The key values in the beginning of life process, especially family-centered care, were not up for compromise. These values were subsequently adopted by each of the six functional design groups planning the new Women's and Children's Hospital. The project coordinator and a Lean consultant worked with each of the groups to ensure the desired design methods and values were comprehended.Functional planning was followed by layout planning alongside the architects. It was seen as favorable that the design team had the chance to alter the hospital layout. The whole staff was involved in commenting on the layout draft based on their experience with clinical processes.One of the most beneficial structural changes in the developed functional model was the placement of the prenatal maternity ward, the labor and delivery room, and the NICU on the same floor and in immediate proximity to each other. This was done to enable synergies leading to decreased patient traffic and transfers. This would lead to better collaboration between the staff of different units and more continuity in care.To ensure efficient use of space, functional triage models were suggested for both obstetric and neonatal admissions. When there is a triage space that allows staff to observe the mother on entering the hospital or the newborn after birth, it is more likely that they will be admitted to the most suitable ward.The goal of the obstetric triage model was to combine pregnant women's emergency care process with delivery room admissions. It was planned for the triage to be located in immediate proximity to the prenatal maternity ward, but for either prenatal maternity ward or labor ward midwives to function as triage nurses. The elective maternity outpatient clinic was to be separate from the emergency care. All acute care was to proceed through a single pathway, in which a midwife was to admit the new patient. All telephone consultations from outside the hospital were to be taken in a centralized call center in the triage space, allowing mothers to be monitored from home before arriving at the hospital . Mothers were to be assessed for care or follow-up needs and then either transferred from the triage to the labor and delivery room, to the prenatal maternity ward, or back home if labor was not in progress. Separating the emergency process was expected to decrease traffic in both the maternity outpatient clinic and the labor and delivery room. The labor and delivery room could therefore focus on mothers in active labor and delivery as the prenatal maternity ward would admit emergency patients. The rooms in the prenatal maternity ward were planned for one patient, but with an additional bed for the spouse according to the philosophy of family-centered care.The inclusion of triage for newborns means that they can be monitored and treated in an adequately sized and equipped stabilization room located in the labor and delivery unit until the need for more extensive intensive care is identified or ruled out. Newborn infants may therefore avoid NICU admission if the symptoms resolve spontaneously and the initial laboratory tests or X-rays rule out the need for longer or more intensive monitoring or treatment. This saves staff costs as well as reserving space for specialized functions. The stabilization room was to have space for a mother's bed next to the newborn.The integration of obstetric operating rooms for caesarean sections in the labor and delivery room makes the transfer to operation quicker, improves the safety of the mother and the newborn, and improves the efficient use of space as one stabilization room can be used for all newborns whether they are born vaginally or by caesarean section.In the NICU, single family rooms were designed to accommodate the immediate family of an infant. Modifiable rooms in the NICU enable the care of both mother and infant in one room from admission until transition to home. Importantly, this decreases parent-infant separation for this vulnerable infant population and for parents who are developing an attachment relationship with their child. Parents and family members expressed their appreciation for a feeling of individuality , peacefulness (no other patients in the room), and protection of privacy .The innovations in hospital structures set new demands for the HC personnel, which need to be acknowledged for the benefits of the new structure to be realized. Parents and family members expressed their sensitivity to and the importance of staff attitudes and explained how the feeling of being welcomed affects their willingness to utilize hospital space and to participate in the care of their infant in the hospital. The staff needed to acquire new skills as the new process was different to the old practice, which comprised separate staff for mothers and infants and less parental involvement in the hospital care of their infant. In 2009 the H1 NICU developed and initiated a goal-oriented training program for the entire staff about delivering care in partnership with parents (Close Collaboration with Parents Training Program™)  to prepaThe family rooms were to be located as close as possible to the central monitoring stations to minimize the distance between the staff and their patients. The central monitoring stations were seen as valuable for maintaining good teamwork between staff members. A curve-shaped layout was seen as functional for this purpose.The functional model for the beginning of life process can be seen in Parents are able to participate in the care of their infants.The spouse is able to participate in the care of the mother.The patient discharge process may become quicker.The new model incorporated several desired benefits for patients, parents, and the hospital. The functional model for the beginning of life process simplified and streamlined patient flows and made them more flexible. The new model is believed to create a positive effect on infants' recovery and growth, as well as lowering patient and parent stress level due to increased physical and emotional closeness. Increased feelings of security and decreased levels of stress for the mother may also result from enabling the father's presence. If parents or support persons can be present within the hospital, the workload of hospital personnel might reduce in the long run:The original plans of The Beginning of Life Group were significantly altered during subsequent phases of the building project because the original budget estimate was reduced from €207 million to €158 million. This meant that major spatial reductions had to be made, which in turn decreased the functionality of the space. The required compromises impacted work processes due to heightened competition for space between the units in the hospital.The design group wished they had been able to engage in earlier and closer contact and communication with the project architects. H1 cooperated with an architect company along the way but committed to them relatively late in the planning process, after funding for the architects had already been agreed upon. Optimally, the architects would have been included in the functional planning group. The functionality had to be explained and demonstrated separately to the architects, which significantly delayed the completion of sketches and also wasted time and effort in the planning process. Several FD group members were not satisfied with the initial sketches by the architects. Thus, the group decided to design the initial sketch of the new hospital independently, without the guidance of architects. After H1 committed to the architecture company, the exchange of information and the relationship gradually improved.Many functional weaknesses of the old hospital were identified by the leaders and the experienced staff, who were active in initiating preparation for the FD several years before the official mandate was given to prepare a functional plan for a new hospital. The process of learning about different solutions and their strengths, weaknesses, and relevance to the local project was time consuming. It was able to be done cost-effectively when combined with other professional travel during the early stages of the process.When the official FD phase finally began, a large amount of documentation had been studied and several international visits and work periods in modern design settings had been carried out. The information had been discussed and reflected on in staff meetings. This facilitated the FD process and improved the design quality.The planning group represented a wide range of professionals who had extensive experience in their roles and many international experiences to draw on for comparison. The inclusion of a patient representative in the planning group was seen as beneficial as her presence and active participation emphasized the patient perspective. Moreover, her contacts with key stakeholders were believed to facilitate the design process. It was seen as a significant weakness that the architects responsible for the layout were not chosen early on in the process, and thereby not included in the group. A real-time link with an architect company might have created solutions to problems which remained unseen in this process.While clinicians' responsibilities can limit their participation in FD work groups , H1 alloWhen the total budget was decided, significant compromises had to be made. At this stage, the clearly determined key values and core goals were critical to keep in mind as priorities. In the planning phase, the priority level of each key value was carefully considered and established. Thus, H1 was able to develop structures for providing family-centered care, for supporting patient safety, and for implementing Lean principles and cooperation.In Finland, HC is largely provided by the public sector. Thus, competition between hospitals differs from countries in which local, privately funded hospitals compete against each other. Lack of financial competition supports open knowledge sharing between hospitals both within and between countries. Humbleness and open-mindedness in sharing knowledge, FD information, and learning from and collaborating should be prioritized in areas where human lives are at stake . In addiThe main focus for healthcare technology assessment (HTA) frameworks is to evaluate the properties and effects of a certain health technology, addressing the direct and intended effects and consequences of the technology. This helps in informed decision-making regarding health technologies. The HTA Core model is a methodological framework for production and sharing of HTA information . It consAs the top priority for the beginning of life process, family-centered care is likely to provide several benefits. First of all, single family rooms bring family members together and provide privacy, individuality, a sense of closeness, peacefulness, and protection, which have been shown to benefit all family members . There iModifiable single family rooms in neonatal intensive care units support three of the key values of the planning: family-centered care, patient safety, and waste minimization. This model increases time efficiency as patients stay in one room for the duration of their hospital stay. The same care team also works with families for the entire time, which is favorable because lack of continuity is one of the most common complaints from parents . This moIn order to successfully integrate parents in the care team it is advisable to prepare staff with training and practice in advance. In traditional intensive care units, parents have commonly had a passive role, primarily being recipients of information. To make the parents' role meaningful, they need to become information providers and active decision makers alongside staff . HospitaA complex care process for mothers and infants includes many challenges. It is not necessarily known beforehand who requires more medical attention. Close collaboration and information sharing between staff that specializes in obstetrical and newborn care is crucial for success. The physical closeness of the maternal prenatal ward, the labor and delivery room, and the NICU is especially vital in emergency situations.H1 utilized a unique method of conveying information to the functional work groups in the FD project: a project coordinator from the beginning of life process joined all of the other planning groups and divulged information and working methods. The working methods included value stream mapping, the Lean framework, and brainstorming sessions using extreme models as the starting point , 13. ThuAs the budget unexpectedly decreased during the project, significant spatial reductions had to be undertaken. Attempting to find answers, H1 FD personnel resorted to Lean hospital design, which suggested the centralization of HC work processes in order to utilize the space efficiently, with a focus on critical connections for patient flow . H1 embrThe triage model aimed to organize HC personnel among the care pathways in a way that would, ideally, suit the patient flow. By utilizing value stream maps, each step among the patient care pathway was optimized and the bottlenecks that were hindering the provision of efficient patient care were eliminated . The keyDespite the vast majority of scientific evidence pointing to the benefits of family-centered care , 32, mixIn the wake of stifling pressure to create enhanced facilities for providing efficient HC, H1 FD personnel have demonstrated self-initiative and creativity in laying the groundwork for the FD process. Rigorous preparation has paid dividends and facilitated the FD process. Family-centered care, patient safety, Lean thinking, and cooperation were chosen by The Beginning of Life Group as the key values needed to achieve the core goals for the new hospital. This strategy was successful, as the four fundamentals have made a strong imprint on the FD process and have visibly guided it.The FD based on functional planning is a good start. The ultimate quest lies in implementing the new functional schemes into the new facilities. Thus, the employees hold the keys to making the changes enabled by the new design. Implementing the functional principles among the staff is an ongoing process. Strong, determined, and insightful leadership should provide a solid foundation.


Purpose. The present study aimed to investigate the impact of a 6-month multicomponent exercise program (MCEP) on physical function and cognitive parameters of normotensive (NTS) and hypertensive (HTS) older patients and verify if age can influence the adaptations in response to the exercise. Methods. A total of 218 subjects, 101 NTS and 117 HTS, were recruited and underwent functional and cognitive evaluations before and after six months of a MCEP. The program of exercise was performed twice a week, for 26 weeks. The physical exercises were thought to mimic the activities of daily living and, therefore, aggregated functional and walking exercises. Exercise sessions were performed at moderate intensity. Results. Data indicated that HTS and NST patients showed a similar increase in the performance of walking speed test and one-leg stand test after the MCEP. Regarding age, results did not show differences in the magnitude of adaptations between old and young HTS and NTS patients. Conclusions. Data of the present study indicated that a 6-month MCEP was able to increase equally balance and mobility in NTS and HTS patients. Moreover, data demonstrated that aging did not seem to impair the capacity to adapt in response to exercise in both groups. The aging process is a continuous phenomenon accompanied by alterations in some physiological systems, collaborating with the development of geriatric syndromes and chronical diseases, such as hypertension (HTN) –3. In faHowever, several evidences have been indicating that HTN not only is strongly associated with cardiovascular risk factors, but also can lead to physical and cognitive impairments in older adults in a time-dependent fashion –8. In tuMulticomponent exercise programs (MCEP) emerge as a possible type of physical exercise able to prevent the deleterious effects of aging on the organic system, improving physical functioning, and cognitive capacities , 11. ThiNevertheless, just one study, which was performed with a low-sample size, recorded the effects of a MCEP on functional parameters of hypertensive patients . MoreoveTherefore, the present study aimed to investigate the impact of a 6-month MCEP on physical function and cognitive parameters of normotensive (NTS) and hypertensive (HTS) older patients and verify if age can influence the adaptations in response to the exercise. (H1) of the present study is that MCEP is capable of inducing significant improvements in functional and cognitive parameters of NTS and HTS older adults, regardless of age.Based on aforementioned data, the alternative hypothesisThe present study has a quasi-experimental design, which aimed to investigate the effects of a 6-month multicomponent exercise program (MCEP) in the functional and cognitive parameters of normotensive (NTS) and hypertensive (HTS) older patients. Therefore, patients were undergoing functional and cognitive evaluations before and after 6 months of MCEP. All volunteers signed the informed consent form and completed all measurements. This study was approved by the Research Ethics Committee of the University of Campinas (UNICAMP). This study was developed in accordance with the Declaration of Helsinki and according to Resolution 196/96 of the National Health Council.A total of 101 NTS and 117 HTS untrained patients were recruited from two specialized healthcare centers for older adults in a town located in the metropolitan area of São Paulo, Brazil. Volunteers were recruited by convenience and asked verbally by the medical team and researchers about their participation in the study. All subjects provided informed consent before enrolment.The exclusion criteria were use of hormone replacement and/or psychotropic drugs, cerebrovascular disease , pulmonary disease, neurological or psychiatric disease , musculoskeletal disorders, comorbidities associated with greater risk of falls and any kind of dizziness, and blurred vision or lightheadedness when rising or remaining standing for long, which could indicate orthostatic hypertension and/or labyrinthitis. The inclusion criterion was age ≥60 years. Patients of both genders were accepted in the present study. After the application of the exclusion and inclusion criteria, 218 older women were included in the analyses.The volunteers were subdivided into NTS and HTS groups according to previous clinical diagnosis of HTN. Since both healthcare centers serve a large number of patients and the medical team  is of limited size, the pathological conditions were simply recorded by the head physician and head nurse of each center. A specialist  who was not affiliated to and was outside the center then made the diagnosis of HTN, according to the guidelines .In summary, before the participants began the activities in the centers where they were recruited, a medical consultation was conducted and an extensive list of medical exams was required . If the patient showed any signal of HTN, such as high blood pressure levels during the first visits in the centers, he/she was invited to measure blood pressure levels, at least, three times, during different periods of the day at home. If her/his blood pressure evaluations remained elevated, he/she was referred to a cardiologist. After they underwent specific medical consultation  and perform all specific exams  , patientAll volunteers were instructed to refrain from physical exercise for the 96 hours, as well as drinking coffee, alcoholic, and energy drinks during the 24 hours before all evaluations. Although alimentary ingestion was not controlled, subjects were instructed to maintain the habitual food intake throughout the period of the protocol. All volunteers ensure that these parameters were not altered during the protocol. Evaluations (pre and post) were performed 120 hours before and after the beginning and the end of the physical exercise program, respectively.Before the performance of the tests, an experienced researcher detailed the procedures of each test. The volunteers performed all tests twice and the higher value recorded in each test was used in the analysis. During all tests, verbal encouragement was provided to ensure that volunteers reached the best performance possible. The present protocol was used by our group elsewhere .Volunteers were requested to rise from a chair five times as fast as possible with their arms crossed in front of the body. The stopwatch was activated when the volunteer raised their buttocks off the chair and was stopped when the volunteer seated back.The one-leg stand test was performed with the volunteers standing in a unipodal stance with the dominant lower limb, the contralateral knee remaining flexed at 90°, the arms remaining crossed in front of the chest, and the head being straight. A stopwatch  was activated when the volunteer raised their contralateral foot off the floor and was stopped when the contralateral foot touched the floor again.To measure walking speed, a three-meter walking speed test was performed. Volunteers were required to walk a distance of five meters at their usual and fastest possible cadences (without running). Before the evaluation, both feet of each volunteer were to remain on the starting line. Measurement was initiated when a foot reached the one-meter line and was stopped when a foot reached the four-meter line. The one-meter intervals at the beginning and end were used to avoid early acceleration and/or deceleration.The Time Up and Go (TUG) test involved getting up from a chair without the help of the arms, walking a distance of three meters around a marker placed on the floor, coming back to the same position, and sitting back on the chair. The test began when a researcher shouted a “go!” command. The stopwatch was activated when the volunteers got up from the chair and was stopped when they were seated again.TUG cognitive test was accomplished to evaluate EF. This test is performed equally to the conventional TUG; however, a cognitive task  must be accomplished during the motor task. Therefore, after the signal of the evaluator, the volunteer performed the route—stand up from the chair, walk three meters, turn around, walk three meters back, and sit down again—naming as many animals as he/she could remember. This task was performed out loud, allowing the evaluators to confirm if the volunteers were, in fact, accomplishing the task. The time spent to perform the task was recorded for evaluation .The MCEP was performed twice a week, on nonconsecutive days, during 26 weeks at the fitness center of an institutional center for elderly care and living (Centro de Convivência do Idoso [CCI]), Poá, Brazil. The program was designed to offer exercises that would mimic activities of daily live (ADL) gestures, thereby inducing neuromuscular adaptations to maintain the subjects able to perform the ADL. Each exercise session was composed of twelve different exercises stations. The structure of each exercise session was defined by the sequence of one functional exercise followed, immediately, by a brief walk. Therefore, exercise session was composed of approximately 12 minutes of functional exercises, 24 minutes of walk, and 12 minutes of rest. Approximately each session of exercise was composed of 50 patients. A physical trainer professional with larger expertise on exercise training to older people supervised all sessions (OI). Volunteers were instructed to avoid the Valsalva maneuver during the performance of exercises.The functional exercises were changed during the whole program. However, they always represented ADL with a large necessity of the activity of the lower limbs, as, for example, standing and sitting on the chair, picking up a weight off the floor and putting it on top of a structure, and transferring a weight from one place to another. Balance and proprioception exercises were also composed of functional exercises, as one-leg stand. At most three balance and/or proprioception exercises were used in each session. To complete the list of physical exercises, upper limbs resistance exercises were added.All functional exercises were performed for one minute. The brief walk was performed for two minutes. Thus, after the end of each functional exercise, volunteers must walk from one point to another (30 m), around a cone, come back to the initial line (30 m), and start the path again until completing the two minutes. A rest interval of 60 seconds was adopted between the stations.The control of exercise intensity was accomplished by the rating of perceived exertion (RPE) method using the adapted Borg scale (2001)  , which wDetermination of the Prevalence of Pathologies and Use of Medications. The prevalence of pathologies and consumption of medications was determined by reviewing the medical records of each subject. As aforementioned, the head physician and the head nurse of the medical centers recorded the pathological conditions, and a specialist not affiliated with the centers made the pathologic diagnoses. Records were reviewed by two researchers (HJCJ and SSA), and data were compared. Kolmogorov-Smirnov test. Since data did not demonstrate normal distribution, nonparametric statistics were performed. Baseline comparisons between the groups for age and morphological  and hemodynamic  parameters were performed using two-sided Mann–Whitney test for unpaired samples. Intragroup comparisons in the different periods  were performed using Wilcoxon matched-pairs. Kruskal-Wallis test was performed to compare the differences of intergroup (mean and delta [%  Δ]). Cohen's effect size (ES) d was calculated to assess the magnitude of the results. Cohen's effect size d was calculated to assess the magnitude of the results. The effect size was classified according to Rhea, 2004 ) and the time of walk performed inside the functional exercises, since some exercises required that the volunteer translocase from one location to another for one minute. This characteristic is a possible explanation for the lack of changes in muscle strength in the present study, since aerobic stimulus requires the predominant action of slow-twitch muscle fibers (type I), which have a high capacity to keep muscle working for a long time, avoiding muscular fatigue, considering that the resistance imposed to skeletal muscle contraction occurs in a low and/or low to moderate levels. However, these fibers have low capacity to generate tension, which impairs their capacity to cause large improvement in muscle strength and muscle mass. Indeed, evidences indicate that older adults who engaged for a long time in physical exercise programs with high aerobic component show muscle strength and muscle mass values similar to sedentary matched-controls .Furthermore, both studies, the present study and the study of de Moraes et al. , showed Therefore, taken together, these data indicate that, due to the prevalence of aerobic components in the exercise session, added to an inappropriate resistance component, the protocol of MCEP used in the present study was not a profitable stimulus to elicit morphological changes in muscular architecture, as well as being able to reach a threshold necessary to cause adaptations of the neuromuscular components associated with improvement in muscle strength. However, interestingly, the lack of changes in muscle strength did not impair the improvements in the performance of usual and maximal walking speed, as well as on balance test, observed in both groups after MCEP.In this sense, it is known that muscle power, compared with muscle strength, seems to decrease early and in a larger magnitude during aging , 34 and Besides the functional tests, the present study also investigated the effects of MCEP on EF in NTS and HTS patients, through dual task (TUG associated with a cognitive task). EF is a cognitive capacity composed of other cognitive domains , which allow the subject to create, develop, and perform a strategy to perform an aim, evaluate the outcomes, and, if necessary, change the strategy during or at the end of the task, creating new strategies for the future . TherefoJust few evidences evaluated the effect of MCEP on cognitive domains in older adults , 41. HowThis study was also developed to verify if age plus pathological condition  could be a confounding factor in the magnitude of adaptations after MCEP. Our data accepted null hypothesis and show that age did not seem to alter the response of HTS patients after MCEP. Cross-sectional studies have been discussing the possibility that HTS patients present impairment on physical function , 8, 42. Plausibility besides its theory is based on the continuous vascular damage in the arteries responsible for the transport of blood to the brain areas accountable for mobility , which could impair muscle movement throughout time and, consequently, muscle adaptations in response to physical exercise . MoreoveP value for balance test was equal to 0.05. Interestingly, in the seminal study from Hausdorff et al. [However, it is important to mention that a Mann–Whitney test was performed between HTS < 75 and HTS > 75 groups to evaluate differences between functional and cognitive tests. Again, data did not demonstrate significant differences between the magnitudes of alterations. Nonetheless, the f et al. , the autf et al. . Rosano f et al.  showed af et al. . Therefon = 5) of the present study is a limitation factor and probably responsible for this absence of alterations. Thus, we encourage future studies with larger samples of NTS ≥ 75.On the other hand, NTS ≥ 75 patients did not present significant improvement in performance after MCEP. These data are complicated to be discussed, since scientific literature pointed out the possibility that HTS patients show impairment in adaptations, but not NTS. In our view, the sample size , must be assumed. Moreover, future studies that aim to use MCEP should increase the number of sets of resistance training in the protocol, since this approach can collaborate to increase in the magnitude of alterations after MCEP, mainly in muscle strength. Due to all the aforementioned data, which highlight the importance of muscle power in the context of aging and functional capacity, the measurement of dynamic muscle power should be added in the methodology. However, the present study indicates that this model of MCEP should be studied in better design models of scientific studies . Lastly, more information about the cognitive status and level of education of the volunteers of the present study was not collected. These data are important and could collaborate to a better explanation about the results shown in the present study.Therefore, the present study indicates that a 6-month MCEP is able to increase equally balance  and mobility  in NTS and HTN adults. Therefore, aging did not seem to be a confounding factor, impairing the capacity of older HTS patients to adapt to physical stimulus. Thus, the current data indicate that this MCEP can be used to improve muscle functionality of several hypertensive patients, independently of age. This seems to be a good option to public health programs that have the necessity to offer short-time services to several patients in the same time.


Laboratory animal studies are used in a wide range of human health related research areas, such as basic biomedical research, drug research, experimental surgery and environmental health. The results of these studies can be used to inform decisions regarding clinical research in humans, for example the decision to proceed to clinical trials. If the research question relates to potential harms with no expectation of benefit , studies in experimental animals may provide the only relevant or controlled data and directly inform clinical management decisions.Systematic reviews and meta-analyses are important tools to provide robust and informative evidence summaries of these animal studies. Rating how certain we are about the evidence could provide important information about the translational probability of findings in experimental animal studies to clinical practice and probably improve it. Evidence summaries and certainty in the evidence ratings could also be used (1) to support selection of interventions with best therapeutic potential to be tested in clinical trials, (2) to justify a regulatory decision limiting human exposure (to drug or toxin), or to (3) support decisions on the utility of further animal experiments. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach is the most widely used framework to rate the certainty in the evidence and strength of health care recommendations. Here we present how the GRADE approach could be used to rate the certainty in the evidence of preclinical animal studies in the context of therapeutic interventions. We also discuss the methodological challenges that we identified, and for which further work is needed. Examples are defining the importance of consistency within and across animal species and using GRADE’s indirectness domain as a tool to predict translation from animal models to humans. Laboratory animal studies are used in a wide range of human health related research areas, such as basic biomedical research, drug research, experimental surgery and environmental health. The results of these studies can be used to inform human research, for example to unravel pathophysiology and mechanisms of action of treatment and to select therapeutic interventions to be tested in clinical trials. If the research question relates to potential harms with no expectation of benefit , studies in experimental animals may provide the only relevant data.However, systematic reviews (SRs) can provide robust and informative summaries of animal studies . In a rihttp://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2054-703X/homepage/EditorialBoard.html], was launched in 2014.SRs of animal studies are relatively novel. Published guidance is emerging on how to develop a protocol for a SR of animal studies, comprehensively search for experimental animal studies, appraise the risk of bias of the included studies, and perform meta-analysis (MA) to estimate the pooled effect of the interventions –11. TablSRs of animal studies can facilitate healthcare decisions such as selection of interventions with therapeutic potential to be tested in clinical trials, regulatory decisions limiting human exposure (drugs or toxicants) or decisions on the utility of further animal studies. In addition, evidence from animal studies can inform clinical management decisions, if other evidence is lacking. The level of certainty in the evidence plays an essential role in these decisions, but guidance regarding the assessment is lacking.An important next step is, therefore, to develop guidance on how to interpret the results of a SR of animal studies and to rate the certainty in the evidence . Meta-analysis of the included studies and assessment of the certainty in the evidence might contribute to improving the probability of translating findings in experimental animal studies to human studies and clinical practice. Following this hypothesis, a higher certainty in the evidence would be related to higher success rates in applying the results to human clinical questions (i.e. higher translatability).The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach is the most widely used method to rate the certainty in the evidence and strength of health care recommendations –15. GRADFor systematic reviews, the endpoint of a GRADE assessment is a rating of the certainty in the evidence for each outcome. A summary of evidence, which includes this rating, is presented in GRADE evidence profiles (EP) or Summary of Findings (SoF) tables –27.To arrive at an evidence-based healthcare decision, information additional to the evidence of the effectiveness is needed. GRADE therefore offers ‘Evidence to Decision’ (EtD) frameworks –31. GradThe aim of this paper is to explore how the GRADE framework can be used to assess the certainty in the evidence of preclinical animal intervention studies. Preclinical animal intervention studies are experimental studies in which the investigator controls the intervention . These sAlthough this paper is about evaluating the body of evidence of preclinical animal studies in the context of clinical treatment, the presented GRADE approach could possibly be applied to evidence from animal studies in the field of toxicology and environmental health, but further research is needed .Intended users of the framework are systematic reviewers and others interested in transparent and explicit evaluation of experimental animal evidence, for example preclinical and clinical researchers, pharmaceutical companies, potential funders of clinical or animal research and ethical committees.The proposed GRADE approach to assess the certainty in the evidence from preclinical animal intervention studies is based on the main principles of GRADE and was Step A: We surveyed how authors of SRs of animal studies addressed certainty in the evidence. The starting point was a recently published SR on all instruments that assess risk of bias and other methodological criteria in animal research . This reStep B: To identify additional GRADE (sub)domains, we surveyed which aspects of certainty in the evidence are currently assessed and reported in SRs of animal intervention studies. We therefore performed a systematic literature search  OR Systematic survey[tiab] OR Critical survey[tiab] OR Systematic surveys[tiab] OR (systematic overview[tiab] OR systematic overviews[tiab]) OR critical overview[tiab] OR systematic review[tiab] OR systematically review[tiab] OR critical review[tiab] OR systematic reviews[tiab] OR critical reviews[tiab]) NOT (letter[pt] OR newspaper article[pt] OR comment[pt]).Component 2: animal studies: Pubmed searchfilter (ref)Filters used: Publication date from 2012/01/01 to 2013/12/01.Inclusion criteria: systematic review or meta-analysis in title; aim of SR was to investigate an intervention with aim to improve human medicine; pdf available in Radboud Medical LibrarySelection procedure:Selection of papers was alphabetically ordered and each 5th paper was initially selected to be screened for details of the quality assessment;In case the selected paper did not assess study quality in the method section, also the chronologically following paper was selected and screened.The search resulted in 204 SRs of preclinical animal intervention studies, and random sample of 88 SRs were examined. Three authors  studied the Methods sections of these papers and identified 1) whether a methodological quality assessment had been conducted  and which methodological criteria had been taken into account, and 2) if (and which) methodological quality indicators were used as eligibility criteria. Thirty-nine possibly relevant criteria  were ideIn summary, the analysis of both the tools presented in the paper of Krauth et al, and the methods and discussion section of random selected systematic reviews of animal studies resulted in 108 criteria (n = 32 +n = 39 + n = 37). After removing the duplicate criteria, 59 criteria remained. Most of these criteria (n = 44) could be classified in one of the eight GRADE domains  applied GRADE to a selection of three SRs of preclinical animal intervention studies on different topics.Step D: Based on the previous steps and the GRADE approach for human studies MWL and CRH developed the draft GRADE approach for preclinical animal intervention studies.Step E: In several brainstorm sessions, two group expert meetings and two consultations with experts see , applicaStep F: To illustrate the practical use of the approach, and some of its challenges, we applied the drafted GRADE approach to an existing systematic review of animal studies on the use of probiotics for severe acute pancreatitis .Steps A to F resulted in the GRADE approach for assessing the quality of the evidence from preclinical animal intervention studies in the context of clinical treatment.The proposed GRADE approach for preclinical animal evidence  follows Define and frame the clinical question , comparator(s) and patient important outcomes )Scope the evidence and proceed with next steps if evidence from animal studies is needed to answer the questionFormulate preclinical PICO , intervention, comparator and outcomes related to the patient important outcomes defined in the clinical PICO)Collect animal studies evidence and summarize the effect estimates by outcomeAssess risk of bias, imprecision, inconsistency and publication bias■Evidence from preclinical animal studies compared to preclinical PICO■Evidence from preclinical animal studies compared to clinical PICO Assess indirectness forAssess factors that may lead to upgradingRate the certainty in the evidence for each outcome considering all GRADE domainsAssess and rate the quality of the evidence from animal studies by outcome and relate these to the clinical questionIn the proposed approach , the oveFor the probiotics for pancreatitis example, the clinical PICO was: “What is the impact of probiotic prophylaxis (I) compared to no probiotic prophylaxis (C) in patients with predicted severe acute pancreatitis (P) on infectious complications, mortality, (multi)organ failure, need for surgical intervention, antibiotic resistance, increased hospital stay, abdominal complaints and adverse events) (O)”.The second step  is to scFor the probiotics for pancreatitis example, we assume that the intervention has not been tested in humans.The third step is to formulate the preclinical PICO . As the In the probiotics for pancreatitis example, the preclinical PICO was defined as:P: laboratory animals with induced acute pancreatitis I: probiotic treatmentC: no probiotics or vehicle onlyO: mortality, histopathology of the pancreas, bacterial translocation to the pancreas and mesenteric lymph nodes.One of the important clinical outcomes in severe acute pancreatitis is the number of infectious complications. This is because secondary infection as a consequence of an inflamed pancreas is considered to be the main cause of death. In animal experiments, histopathology of the pancreas and bacterial translocation are the most representative outcomes because the animals are sacrificed at the end of the experiment and entire organs can be extracted and studied to provide more detailed information about the nature and presence of infectious complications .The optimal application of GRADE requires an up-to-date and well-conducted SR of animal studies , 25. A sA GRADE EP summarizes the SR results. Standard elements are the number of studies and participants, study design, relative effect, baseline risk (risk in the control group) and corresponding absolute effect and certainty in the evidence , 39.We identified several issues in developing an EP to summarize the results of animal SRs. Some of these issues reflect differences in the current status of developing SRs in human and animal research. Examples of these differences (with focus on MA) are presented in To calculate absolute effects, defining a baseline risk is needed. When the aim of the review is to inform clinical decisions the clinical baseline risk might be most appropriate. If the aim of the review is to explore if an intervention could be promising for clinical use a baseline risk based on animal data, which relates directly to the estimated effect, might facilitate interpreting the results of the animal studies.Another issue is presentation of the summarized treatment effect  in the light of the often substantial amount of variability and statistical heterogeneity among studies in SRs of animal studies.In SRs of animal studies, variability in species, interventions and/or outcomes is often deliberately chosen as the aim of these reviews are explorative. Including different species is common because there is currently no evidence-based approach of how to choose the preferred animal model(s) that would answer the clinical question best.Reasons for heterogeneity are explored using subgroup analyses to provide important information to generate new hypotheses and guide the design of clinical trials. No statistical heterogeneity may indicate that the effects are broadly generalizable, or can simply mirror that the intervention has only been tested under the most propitious circumstances, and that further research is required. In human SRs the ideal situation is no heterogeneity. In animal SRs what can be considered as acceptable amount of heterogeneity is not known, but merits further investigation.Interpretation of the pooled effect size as the estimated treatment effect may not be appropriate in case of substantial statistical heterogeneity. One could argue that proceeding to clinical trials is only sensible when the pooled effect in animal studies is sufficiently large and meaningful for the clinical situation. In that case, the magnitude of the effect and surrounding heterogeneity are relevant. Depending on the amount of statistical heterogeneity, authors may consider presenting the pooled effect size, effect size categories  or the direction of the effect in the GRADE EP.To avoid inappropriately pooled effects, meta-analysts need to carefully explore inconsistency and avoid statistical synthesis of too heterogeneous data. In animal research this would mean, for example, choosing the animal model that would answer the clinical question best, or to restrict the variations in the intervention or outcomes. However, as explained above, this is influenced by the aim of the review.In the probiotics for pancreatitis example, the mortality risk in the animal studies was lower in the probiotics group, but the confidence interval (CI) was very wide and included no effect . The risk in the control animals undergoing no treatment or placebo treatment  was 47.2%. A baseline risk for mortality in patients could be estimated at 10–30% .Preclinical animal intervention studies are experimental studies in which the investigator controls the intervention . In our In rating the certainty of the evidence we propose to assess–by outcome–the GRADE downgrading factors a) risk of bias, imprecision, inconsistency and publication bias, followed by b) two layers of indirectness and c) considering upgrading . The lasTrials may incur risk of misleading results if they are flawed in their design or conduct. Therefore, the risk of bias of the individual studies needs to be assessed as one of the steps of performing a SR. There are several tools available to assess risk of bias of animal studies , for exaAlthough rigorous SRs demand assessment of risk of bias of the included studies, currently this is not common practice in SR of animal studies . This imIn the probiotics for pancreatitis example, risk of bias was assessed with SYRCLE’s risk of bias tool . Risk of2 (describes the percentage of the variability in effect estimates that is due to heterogeneity rather than sampling error (chance)) [Inconsistency is typically assessed by considering the overlap between confidence intervals (CI), the magnitude and direction of effect of the individual studies, the p-value of the test for heterogeneity and Ichance)) . The GRA2. Second, heterogeneous results overall could be consistent within species, therefore two levels of inconsistency can be present: within species and across species. For example, when all species included in the analysis show the same direction of effect, we are more certain that the intervention effect is robust across different species, including humans. In that case we would not downgrade for inconsistency even if the results overall are heterogeneous.Several challenges remain in assessing inconsistency. First, heterogeneity in animal research can be expected, as a result from the often exploratory approach. In other words, part of the heterogeneity is intentionally induced and, in that case, should not be part of the certainty of the evidence grading because it can be explained. The issues with regard to inconsistency are: a) how to separate induced and explained from unexplained heterogeneity; and b) how to interpret I2 of 0.0% and a p value of 0.73. The three studies were conducted in rats. For the histopathology outcomes (6 studies in rats) the CIs did not overlap and I2 was 85% , indicating substantial heterogeneity. The results of five out of the six studies favored probiotics. However, the effect size (odds ratios) varied greatly among those five studies. For histopathology, inconsistency is a concern and was a reason for downgrading.In the probiotics for pancreatitis example, inconsistency was not a concern for mortality: the CIs of the three studies were overlapping and there was no statistical heterogeneity as indicated by an ITo judge imprecision, GRADE suggests focusing on the 95% CIs around the effect estimate and calculating the optimal information size . Results are imprecise when based on relatively few patients/animals and few events, which usually leads to wide CIs around the (summary) estimate of the effect. For SRs, results are precise if the OIS is met and the CI excludes no effect, or if the CI overlaps with no effect and the CI is very narrow (precise estimate of no effect). GRADE suggests rating down if the OIS is not met, or if the OIS is met and the CI overlaps no effect and fails to exclude important benefit or important harm. This implies setting thresholds for clinically relevant differences .The most important issues for animal studies are how to calculate the OIS and set meaningful thresholds for clinical relevance. In animal intervention studies the experimental unit can be the cage, as for ethical welfare reasons individual housing of the animals is not always possible . This reFurthermore, as explained in step 4, in interpreting the results of preclinical animal studies, the direction of the effect is often perceived to be more important than the exact magnitude of effect. In that case judgment of imprecision will be based on whether the confidence interval includes no effect or not.If effect size matters, one could consider categories of effect size . While absolute rules are not available, raters could consider downgrading for imprecision if the CI overlaps two or more categories; in such instances an appropriate explanation should be provided. Another suggestion could be to set the thresholds based on the effect sizes of effective drugs, if such information is available.As for GRADE applied to human research setting thresholds for appreciable benefit or harm remains challenging –some migIn the probiotics for pancreatitis example, the 95% CI around the Odds Ratio (OR) for mortality was wide, ranging from 0.24 to 1.22 and, applying GRADE’s guidance it included appreciable health benefit and harm possibly altering a clinical decision. The total sample size was small . Thus, one would certainly rate down for imprecision.Publication bias is a systematic underestimation or overestimation of the underlying beneficial or harmful effect due to the selective publication of studies. GRADE suggests considering downgrading for publication bias if the majority of studies was relatively small with positive results and commercially funded or if the review authors failed in conducting a comprehensive search.Sena et al used the CAMARADES database to identify systematic reviews of animal studies of acute ischemic stroke and investigated the existence and impact of publication bias in these SRs. Based on Egger regression and trim-and-fill analysis the authors concluded that publication bias was likely and treatment efficacy was over estimated . KorevaaIn the probiotics for pancreatitis example, we could not formally assess publication bias because of the small number of studies. It might be worthwhile to also consider the grey literature, contacting experts about unpublished studies and reviewing conference abstracts, which we did not do for this example.Direct evidence comes from research that directly compares the interventions in which we are interested when applied to the populations in which we are interested and measures outcomes important to patients . CertainIn the context of GRADE for animal studies two layers of indirectness are proposed: the first layer considers indirectness from preclinical animal studies to the preclinical animal PICO. The second layer considers indirectness from animal models  to humans . This second layer of indirectness is called translatability see .An alternative approach is to consider all indirectness as one factor and to relate the evidence that was found directly to the clinical PICO, as the purpose of synthesizing the animal research was answering a clinical question.An important challenge is to make a judgement about the choice of animal model. For example, does a ‘lower’ animal model representing the same metastasis-associated protein as humans (e.g. transgenic mouse) better reflect clinical pathophysiology than a ‘higher’ animal model expressing the species-specific metastasis-associated protein (e.g. pig)? Different animal models represent different aspects of the disease, and animal models that reflect all aspects of the clinical disease in one model are rare.In the probiotics for pancreatitis example, there was serious indirectness. For the first layer of the two-layer approach, the timing of inducement of disease causes indirectness, as in some studies probiotics were administered before onset of the disease. The preclinical PICO aimed for probiotic treatment in animals with acute pancreatitis. In addition, one can debate if some of the animal experiments used a model for multi organ failure instead of acute pancreatitis.For the second layer, indirectness of preclinical evidence to clinical PICO (translatability), histological damage and bacterial translocation were assessed as a measure for loss of function and infectious complications. However, these are surrogate outcomes for patient important outcomes, e.g., histological damage does not necessarily mean loss of function. In the clinical context, our question addresses probiotics administered to patients with severe acute pancreatitis, whereas in most animal studies the probiotics were administered before induction of pancreatitis. Acute pancreatitis was induced in various ways in the included animal models . Because there is no guidance available yet on how to decide which animal model reflects the clinical situation best, we did not take this into account in this example. This guidance will be developed and published in a future paper.In the GRADE approach, non-randomized  studies start as low certainty evidence, because of the high risk of confounding bias. In some situations however, upgrading the certainty from low to moderate (and perhaps even to high) certainty is appropriate. The factAlthough most preclinical animal studies are experiments, upgrading may be relevant. The concept of upgrading might be different and warrants further research. For example, upgrading could be relevant where effects are consistent across different species. The US Food and Drug Administration (FDA) prefers and, in many cases requires testing of candidate drugs on at least two species (one rodent and one non-rodent) before moving on to human clinical trials . In our To arrive at a rating of the certainty in the evidence , all eight factors need to be considered . SimilarIn the probiotics for pancreatitis example, we had serious concerns about risk of bias and imprecision for the outcome mortality. As a result, we downgraded the evidence by two levels, from high to low certainty in the evidence. We downgraded the evidence by an additional level, from low to very low, because of indirectness.We presented a first version of the GRADE approach for assessing the certainty in the evidence from preclinical animal studies in the context of therapeutic interventions. In general, the generic GRADE approach appeared to be applicable. Our analysis of aspects of certainty in the evidence in a sample of systematic reviews and examples , however, showed that further operationalization of some of the GRADE domains is needed. For example, while rating down the certainty level due to risk of bias works similarly, the judgment of indirectness requires taking into account translatability to the clinical situation. We could not identify any additional downgrading factors. Consistency of effects across species was suggested as an additional upgrading factor.One of the aims of this paper is to highlight methodological challenges. We identified several: 1) summarizing the findings of the animal evidence synthesis , 2) calculating the OIS and defining clinical relevance thresholds (imprecision), 3) defining relevance of consistency within and across species (inconsistency), 4) specification and defining translatability/indirectness, and 5) the criteria for upgrading.Regarding the probiotics example, we conclude for now that our certainty in the evidence for mortality was very low. In light of the methodological challenges, however, the final rating for certainty of the evidence might be different. Based on our certainty in the evidence assessment in this paper, proceeding to clinical trials would probably have been deemed premature. We would be inclined suggesting that more well-designed, executed and reported animal studies were necessary for a more valid estimation of the treatment effect in humans.This conclusion is somewhat preliminary as no other factors were taken into account when going from evidence to decision. Developing an EtD framework for grading the strength of recommendations in the context of animal studies is a topic for further research. For example, in the decision to proceed to a first clinical trial for an intervention with therapeutic potential, evidence from animal studies provides only one of a number of evidence domains relevant to this decision. Other considerations include findings from in vitro research, human ex vivo studies, human genome wide association studies  and similarities  with drugs known to be effective. Each of these should be considered, with the same rigor, to inform optimal decision-making.Although this is, as far as we are aware, the first paper on application of the GRADE approach to preclinical animal intervention studies, comparable approaches come from the field of environmental health . The NavGRADE provides a framework for a systematic, transparent and explicit assessment of the certainty in the evidence and strength of recommendations. Applying this approach to preclinical animal research could contribute to reducing research waste, either in animals or patients, and perhaps also to unraveling the mechanisms behind the low translational success rates of animal studies.A potential barrier to implementation of the GRADE framework in animal studies is the lack of transparent reporting , 53. TheIn summary, we tailored to the GRADE approach to assessing the certainty in the evidence from preclinical animal intervention studies. Further work will concentrate on performing case studies, addressing the identified methodological challenges and on creating a research agenda. We recently established a multidisciplinary GRADE for animal studies project group (as part of the GRADE working group) that has started to further develop the framework and work on case studies such as the example presented here. This group will discuss strategies and pitfalls with developing GRADE based frameworks in a variety of research fields Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


To review the current comprehensive care for nonsyndromic craniosynostosis and nonsynostotic cranial deformity and to offer an overall view of these craniofacial conditions.The review was conducted in the PubMed, SciELO, and LILACS databases without time or language restrictions. Relevant articles were selected for the review.We included the anatomy and physiology of normal skull development of children, discussing nuances related to nomenclature, epidemiology, etiology, and treatment of the most common forms of nonsyndromic craniosynostosis. The clinical criteria for the differential diagnosis between positional deformities and nonsyndromic craniosynostosis were also discussed, giving to the pediatrician subsidies for a quick and safe clinical diagnosis. If positional deformity is accurately diagnosed, it can be treated successfully with behavior modification. Diagnostic doubts and craniosynostosis patients should be referred straightaway to a multidisciplinary craniofacial center.Pediatricians are in the forefront of the diagnosis of patients with cranial deformities. Thus, it is of paramount importance that they recognize subtle cranial deformities as it may be related to premature fusion of cranial sutures. Cranial deformities are a common complaint in pediatric units, since 25% of infants of single pregnancies and 50% of multiple pregnancies have some degree of skull deformity at birth. In general, parents usually recognize these changes in the first weeks or months of life.In this report, we review the anatomy and physiology of normal skull development of children, discussing nuances related to nomenclature, epidemiology, etiology, and treatment of the most common forms of craniosynostosis. The clinical criteria for the differential diagnosis between positional deformities and craniosynostosis are also presented, allowing the pediatrician subsidies for a quick and safe clinical diagnosis.The present study is a literature review, with a descriptive approach. We performed a literature review by searching the Medline (PubMed), SciELO, and LILACS databases without time or language restrictions. The final literature review was performed on July 2015. To identify all relevant articles  about the current comprehensive care for nonsyndromic craniosynostosis and nonsynostotic cranial deformity the following search terms were used: “nonsyndromic craniosynostosis”, “nonsynostotic cranial deformity”, “positional deformity”. “nonsynostotic posterior plagiocephaly”, and “positional plagiocephaly”. Each relevant study was individually reviewed to identify information concerning normal skull development of children, nomenclature, epidemiology, etiology, diagnosis, and treatment of the most common forms of nonsyndromic craniosynostosis and nonsynostotic cranial deformity.The skull of a newborn is composed of multiple bones and sutures that make it malleable and subject to external forces that deform it, to enable its passage through the birth canal and to accommodate the encephalon, since the brain volume is quadrupled in the first two years of life.The skull is composed of four major sutures , three secondary sutures , and four main bones . The metopic suture separates the frontal bones from each other, the sagittal suture from the parietal bones; the coronal suture from the parietal and frontal bones, and the lambdoid suture from the parietal and occipital bones.Under physiological conditions, the cranial sutures progress into fusion with different initial periods of fusion according to each major suture . The samAn important detail is that the skull bones are membranous (without a prior cartilaginous phase), which results in growth through the bone deposit in the region of the sutures; this growth occurs perpendicular to the suture. For example, coronal sutures allow the anterior-posterior growth of the skull, while the sagittal suture allows growth of the biparietal skull.The definition of craniosynostosis is the premature fusion of one or more cranial sutures. The occurrence is approximately one for 2000 to 2500 live births.-Craniosynostosis are classified as primary or secondary. Primary craniosynostosis results from genetic and environmental influences, being classified as simple and complex. Complex craniosynostosis are divided even further into nonsyndromic and syndromic .5-8 Du---,,-Multiple hypotheses have been proposed to explain the pathogenesis of abnormal suture fusion. Both environmental  and genetics factors  predispose to craniosynostosis.Pediatricians are expected to be able to recognize skull deformities and to diagnose them as either craniosynostosis or a positional skull deformity. If a skull deformity is present, the physical examination and clinical history (key features described in the next subheads) are the most helpful and revealing pieces of information in the child's evaluation. A previous published anamnestic flowchart,In rare and difficult cases, when the examination and history are not diagnostic, a good-quality four-view radiographic series  might be sufficient to exclude craniosynostosis and avoid further radiation exposure.After the clinical suspicion (or confirmation) of craniosynostosis, the children should be referred to a multidisciplinary team specialized in craniofacial anomalies .-,In this context, patients with craniosynostosis not surgically-treated can develop several complications such asIt is the most common form of simple craniosynostosis and accounts for 40-60% of cases, being more prevalent among males (75-85%). The skull has an elongated and narrow shape, similar to a boat, hence being called scaphocephaly .20 Upon Surgical treatment is indicated between 3 and 12 months of age, and procedures may vary from a simple endoscopic resection of the sagittal suture to total reconstruction of the skull, depending on the severity of the clinical presentation. In our service, we recommend surgery between 6 and 9 months of age and use the craniectomy in a “π” fashion (named Hung Spun procedure),,-It is the second most common form, accounting for up to 25% of craniosynostosis cases. The closure of a coronal suture is called anterior plagiocephaly,,,Early fusion of the coronal suture leads to a flattening of the frontal bone and the ipsilateral orbital rim to the fusion, with a compensatory contralateral frontal bossing.Therefore, surgical treatment is indicated for correction of the morphological skull deformity and its repercussions on the face, but also because of strabismus and risks of developing ICH. We recommend the procedure between 6 and 9 months of age, when there is already sufficient bone maturity for remodeling. Basically, a front-orbital advancement associated with frontal remodeling is performed and releasing both coronal sutures.Corresponds to 10% of all craniosynostosis and predominates in males (75-85% of cases). Early fusion of the metopic suture restricts the transversal growth of frontal bones, and in more severe cases can restrict the expansion of the anterior fossa, which leads to hypoteleorbitism, and consequently to trigonocephaly . MetopicThe increase in the anterior fossa volume is the main objective in the treatment of patients with trigonocephaly, as well as frontal remodeling and fronto-orbital advancement. The best time for treatment is between 6 and 9 months of age.This is the rarest form of simple craniosynostosis, with an incidence of about 0.3 per 10,000 live births, corresponding to approximately 1.0-5.5% of all craniosynostosis. When evaluated in a population of children with occipital flattening , it is responsible for only 0.9-4.0% of the cases.Fusion of a lambdoid suture leads to an occipital deformity  with a trapezoidal shape, while the fusion of both lambdoid sutures leads to brachycephaly . In addiSurgical treatment is based on volume expansion of the posterior portion of the skull  and releasing the lambdoid sutures. However, this region has large venous drainage, with innumerable scalp veins that cross the bone toward the dural sinuses, greatly increasing the surgical risk of a craniotomy and bone remodeling. In our service, we choose a posterior distraction technique, in which the cranial volume is gradually increased, significantly reducing the risk of bleeding and need for blood transfusions.The term plagiocephaly means oblique skull and corresponds to a unilateral or bilateral occipital flattening, which may arise due to the continual influence of external forces on the immature skull  or because of premature fusion of one or both lambdoid sutures . Anterior plagiocephaly can be used to define the cranial deformation characterized by premature unilateral fusion of the coronal suture.Positional or deformational plagiocephaly is the most common cause of plagiocephaly Based on the introduction of the campaign to prevent Sudden Infant Death Syndrome (“Back to Sleep”), in the beginning of the 1990s - which recommended that babies remain in the supine position - a significant increase in the incidence of children with positional plagiocephaly was noticed (5-48%).Diagnosis is eminently clinical, and the differentiation with synostotic plagiocephaly  is essential.Pediatricians should perform a physical examination with the aid of the parents; initially, the patient remains on the mother/father's lap facing the pediatrician and after facing the parents; finally, the examiner should observe the child from a superior view. During the physical examination, symmetries between the skull, forehead, and ears should be carefully analyzed.Positional plagiocephaly presents a format of a parallelogram skull, while synostotic posterior plagiocephaly has the shape of a trapezoid.The diagnosis and treatment of positional plagiocephaly are clinical.,In addition to the guidelines, therapeutic measures can be employed, such as how to force the baby to sleep on the contralateral side of the deformity, to encourage moving the location of the crib and changing table, in order to force the baby to turn his head to the side he is on, besides stimulating the baby to sit. Such measures are effective until 4-6 months as treatment of positional plagiocephaly.The prevalence of positional deformity tends to decrease with age and may be as low as 3.3% at 2 years of age, which highlights the natural ability of skull remodeling.Cranial deformities are common complaints and highly prevalent in the routine of pediatricians. Although the vast majority of children present positional deformities, early diagnosis of craniosynostosis and referring them to specialized treatment in a timely manner is critical to optimize surgical outcomes. The diagnosis of positional deformities is usually clinical, and treatment consists of simple guidelines and measures to prevent worsening the condition. When there is a diagnosis of craniosynostosis, a multidisciplinary approach of the child with craniosynostosis is crucial for a greater surgical success rate and to minimize complications.


In previous review articles the attention of the biocatalytically oriented scientific community towards the marine environment as a source of biocatalysts focused on the habitat-related properties of marine enzymes. Updates have already appeared in the literature, including marine examples of oxidoreductases, hydrolases, transferases, isomerases, ligases, and lyases ready for food and pharmaceutical applications. Here a new approach for searching the literature and presenting a more refined analysis is adopted with respect to previous surveys, centering the attention on the enzymatic process rather than on a single novel activity. Fields of applications are easily individuated: (i) the biorefinery value-chain, where the provision of biomass is one of the most important aspects, with aquaculture as the prominent sector; (ii) the food industry, where the interest in the marine domain is similarly developed to deal with the enzymatic procedures adopted in food manipulation; (iii) the selective and easy extraction/modification of structurally complex marine molecules, where enzymatic treatments are a recognized tool to improve efficiency and selectivity; and (iv) marine biomarkers and derived applications (bioremediation) in pollution monitoring are also included in that these studies could be of high significance for the appreciation of marine bioprocesses. Currently there is enormous interest in marine biotechnology with the worldwide flourishing of editorial initiatives  hosting important experimental results and surveys from several projects, especially those belonging to the FP7 program and to the topic “Blue growth” of H2020, potentially providing clues that will aid development of enabling technologies in the field. The oceans are the world’s largest ecosystem, covering more than 70% of the earth’s surface. They host the greatest diversity of life in unexplored habitats. The Census of Marine Life, evaluating marine biodiversity, ascertained that at least 50% and potentially more than 90% of marine species are undescribed by science . Only a Marine sources  are of scientific interest in that the origin of marine biomolecules  features all marine bioprocesses. Knowledge of these biocatalysts and their habitat-related properties such as salt tolerance, hyperthermostability, barophilicity and cold adaptivity (of great interest for industry) is necessary for bioprocesses exploitation. One of the most explicative aspects is related to the stereo-chemical properties of a marine enzyme. Substrate specificity and affinity, as evolved properties that are linked to the metabolic functions of the enzymes, are key aspects. Two review articles already appeared in 2010  and in 2In the present review, a new approach for searching the literature and presenting a more refined analysis is adopted with respect to previous surveys. The focus of the literature search is centered on the enzymatic process more than on a single novel activity. This survey is developed according to the biotechnological field of applications where bioprocesses, based on marine enzymes and/or marine biomasses, are central. Focusing on enzymatic processes rather than on single activities helsd us to recognize the fields of application. For the first, a biorefinery value-chain, the provision of biomass is one of the most important aspects, with aquaculture as the prominent sector. In the food industry the interest in the marine domain is similarly developed to deal with the enzymatic procedures adopted in food manipulation. Moreover, as for the selective and easy extraction/modification of structurally complex marine molecules, enzymatic treatments are a recognized tool to improve efficiency and selectivity in fine chemistry processes to get access to bioactive compounds and provide complex core blocks ready for hemisynthesis. In closing, the field of marine biomarkers and derived applications (bioremediation) in pollution monitoring could be of high significance for the appreciation of marine bioprocesses. In the fields indicated above, the selected primary articles are presented in tabulated form, picking up different aspects of importance in short explicative notes to avoid a huge amount of text. Selected modern review articles are listed under each paragraph to depict the present state of the art of the related field.A survey of the literature has been conducted mainly by using the database ScienceDirect with access to 3800 scientific journals in major scientific disciplines. The search was based on two terms: (i) “enzymatic processing”  and (ii) “marine” . How to manipulate these queries to get an effective result in terms of the number of hits was first investigated using the search functions offered by the database. In particular, the W/in function (proximity operator) has been found useful for the first query, with the keywords used in the query sorted into phrases (low numbers), sentences (medium) and paragraphs (high) of the hit. This result is then refined by using the AND operator with the word “marine” in all fields. The resulting pattern of these searches is as follows: W/3 (137 hits), W/4 (153), W/5 (161), W/15 (256) and for W/50 (442). As a comparison, a more general coverage alternative search was also used, adopting the same keywords, in the Scopus database. It resulted in a similar score (478 hits), thus confirming the choice of ScienceDirect as the reference database when using W/50. This has been the value adopted for searching for articles for this review. An interesting detail is the yearly distribution of the hits shown in  below. TA future sustainable economy based on renewable resources is the main point of the concept of a biorefinery. Research and development studies have been underway for many years in different parts of the world to replace a large fraction of fossil resources. The most important aspect of a biorefinery value-chain is the provision of biomass with a consistent and regular supply of renewable carbon-based raw materials . One of The idea here is to depict both the state of the art about marine enzyme-based bioprocesses and the importance of marine-originating feedstocks in biorefinery. Therefore, biocatalysts and biomass are the two fundamental elements on which the analysis of primary articles in the literature is based here .Dendryphiella arenaria [Non-conventional sources of cellulase enzymes have been sought for a long time. As mentioned in an old report, the identification of these biocatalysts in the marine fungus arenaria  dates baarenaria . The focarenaria . SubstraYarrowia lipolytica of marine origin is a biocatalyst of interest in metabolic engineering studies used to expand the substrate range [Obviously lipases are also considered a convenient tool for converting a wide range of feedstock oils into biodiesel . A studyte range . Entrieste range . AnotherG. turuturu  applied to bioprospecting in understudied environments help to identify a greater repertoire of novel biocatalysts with complementarity about properties . Marine enzymes offer hyperthermostability, salt tolerance, barophilicity, cold adaptability, chemoselectivity, regioselectivity and stereoselectivity , thus acAs for carbohydrate-active enzymes, selective and easy manipulation of structurally complex marine polysaccharides provides homogeneous core blocks (oligosaccharides) for analysis and hemisynthesis. This constitutes the core of a sustainable process when using renewable resources. Other preminent examples of enzymatic treatments as a tool to improve the extraction efficiency of specific bioactive compounds from seaweeds were recently reviewed  and laboDue to our specific design of search terms in querying literature databases, the coverage of articles dealing with the simple prospecting, isolation and identification of new marine biocatalyst(s) is partial; however, however those found are included in this section. Indeed, most articles listed in Tabulation of primary articles in this section  is basedCandida genus in marine environments, with only a few species isolated from these environments [C. rugosa and C. antarctica are among the terrestrial yeasts, so biocatalysis-related articles dealing with these quite famous commercial lipases are not listed here. Interesting examples of oxidoreductases are also found in the literature, both for direct biocatalytic applications (including examples of immobilized enzymes) and for biogenetically related studies , is transformed by marine microbes and bioprocesses involving this molecule and derivatives are of interest for assessing the ability of relevant enzymes to realize these transformations.Finally, it is worth mentioning in this section a remarkable review focused on the biosynthesis of oxylipins in non-mammals. Biocatalysts involved in pathways related to these biomolecules carry interesting and unusual catalytic properties for biocatalysis. A detailed biocatalytic knowledge of enzymatic catalysis in these reactions is needed to plan a possible direct in vitro biocatalytic lab-scale production of useful products . With thAmong the studies on marine sources for enzymes, the fields of marine biomarkers and bioremediation applications are of high significance in this context . Mytilus edulis and the expressed proteins identified participate in α- and β-oxidation pathways, xenobiotic and amino acid metabolism, cell signalling and oxyradical metabolism [In the list of parameters that are usually considered when assessing exposure to environmental pollutants in aquatic ecosystems, biotransformation enzymes (phase I and II), biotransformation products and stress proteins are of high interest for enzymatic processing. It is of value, for example, that a unique set of protein expression (signature) for exposure to different chemical compounds has been recognized for tabolism . Bioremetabolism . An additabolism . A recent report of a European project in this field characterizes novel hydrocarbon degrading microbes isolated from the southern side of the Mediterranean Sea. Exploiting and managing the diversity and ecology of microorganisms thriving in these polluted sites is a major objective in terms of increasing knowledge of the bioremediation potential of these poorly investigated sites .In Searching within records used in this review for the names of class of enzymes, oxidoreductases, transferases, hydrolases and lyases are equally represented, while isomerases and ligases are less often used as keywords. However, only 30% of the total records contain such names for classes, with common names of biocatalysts more often adopted in titles, abstracts and keywords. Thus, in this section a few other topics, difficult to insert in previous sections, are covered.Streptomyces lydicus collected from estuarine and marine areas in India was found to be a potent producer of polygalacturonase [Enzymes acting on 1,4 glycosidic bonds between galacturonic acid residues in pectin were investigated for the improvement of banana fiber processing. At least one actinomycete strain of turonase . In a study to reduce the cost of aquaculture of fish cobia by adding crustacean processing waste, an investigation of the endogenous chitinolytic enzymes in cobia was conducted. It suggested substantial endogenous production of enzymes of the chitinolytic system and that the activity from chitinolytic bacteria was not significant . An interesting study based on enzymology tools was conducted for demonstrating the enhanced mixing processes between the sediment and the overlying waters of the Delaware Estuary. The authors used fluorescently labeled polysaccharides to determine the effects of suspended sediment transport on water column hydrolytic activities . Posidonia oceanica during environmental surveys. Although the set is composed of known kits  principal enzymatic activities, metabolic capabilities and benthic mineralisation processes were all studied [In another report, a rapid and easy-to-use set, composed of semi-quantitative kits, was adopted for the investigation of the heterotrophic bacterial community in meadows of  studied . 2 sequestration methods proposed in order to capture and concentrate CO2 from combustion gases, the biomimetic approach [A particular aspect is related to carbonic anhydrases; it is worth mentioning in this review since it was recently discussed in a book devoted to these enzymes from extremophiles and the possible biotechnological applications for which they can be used . Among tapproach  could inapproach , and anoapproach .One of the recent transnational calls of ERA-NET (ERA-MBT), an action funded under the EU FP7 program, was focused on biorefinery and entitled “The development of biorefinery processes for marine biomaterials”. The projects were required to develop the production of a large number of different products and novel processes through the application of biotechnological knowledge. Further technological developments to improve the integration and optimisation of the processing steps were required. In this realm seaweed biomass seems to have great potential as a raw material in a biobased economy, offering advantages such as no competion with food production, absence of fertilisers or pesticides in the value-chain and positive relapses removing an excess of nutrients from marine environments. However, a few key areas where development is still needed are technology for the improvement of large-scale cultivation and fractionation, and the identification of new marine microbial strains to break down macroalgal polysaccharide.The use of macroalgae in food preparation is a classical topic in food applications found when inspecting the primary articles listed in Current Opinion in Chemical Biology; they stated that “At least a third of this planet’s biomass resides in the oceans, and the rules of the marine biochemical game seem to be fundamentally different than those described in our biochemistry textbooks.” [As for fine chemistry and laboratory techniques, different case studies recently illustrated the importance of biocatalysis, considering the specificities of marine enzymes with respect to their terrestrial counterparts . Ketone tbooks.” .In the bioremediation field,  is very Bioresource Technology, Food Chemistry, Process Biochemistry and Chemosphere together account fornot far off 100 articles. The top specialist marine-oriented journal was Algal Research, with only eight papers. Inserting representative primary articles in the tables and excluding the ones that do not belong resulted in the current total number of references. Therefore, scientific interest in marine enzymatic processing can be considered successfully published in non-specialized journals such as the ones cited above; the separation of fields, as adopted here, is only for ease of discussion. This has already been mentioned above for marine biomass-centered studies that could have been listed under food applications or biorefinery, or for enzymatic activities used for polysaccharide manipulation that could have been listed under fine chemistry and lab techniques instead of biorefinery. Fewer than half of the results from our literature search are cited in the references list. About 20% of the hits are represented by books or reference works that were hardly used here. Additionally, only four scientific journals hosted more than 10 articles of the remaining corpus: In conclusion, all these aspects point to a final consideration of the importance of an interdisciplinary network in setting up successful research projects enabling the identification of an arsenal of enzymes and pathways greatly in demand for biotechnological applications. In continuing this research effort, further refining of the scientific literature could be of interest; exploration of the fields individuated above should be continued in depth, in specialized journals, in a manner that could help to reveal sub-fields along with more details pointing to a single process with room to discuss a single enzymatic activity.