Given the amount of time and resources invested in implementing quality programs in hospitals, few studies have investigated their clinical impact and what strategies could be recommended to enhance its effectiveness.To assess variations in clinical practice and explore associations with hospital- and department-level quality management systems.Multicenter, multilevel cross-sectional study.Seventy-three acute care hospitals with 276 departments managing acute myocardial infarction, deliveries, hip fracture, and stroke in seven countries.None.Predictor variables included 3 hospital- and 4 department-level quality measures. Six measures were collected through direct observation by an external surveyor and one was assessed through a questionnaire completed by hospital quality managers. Dependent variables included 24 clinical practice indicators based on case note reviews covering the 4 conditions . A directed acyclic graph was used to encode relationships between predictors, outcomes, and covariates and to guide the choice of covariates to control for confounding.Data were provided on 9021 clinical records by 276 departments in 73 hospitals. There were substantial variations in compliance with the 24 clinical practice indicators. Weak associations were observed between hospital quality systems and 4 of the 24 indicators, but on analyzing department-level quality systems, strong associations were observed for 8 of the 11 indicators for acute myocardial infarction and stroke. Clinical indicators supported by higher levels of evidence were more frequently associated with quality systems and activities.There are significant gaps between recommended standards of care and clinical practice in a large sample of hospitals. Implementation of department-level quality strategies was significantly associated with good clinical practice. Further research should aim to develop clinically relevant quality standards for hospital departments, which appear to be more effective than generic hospital-wide quality systems. Substantial research has been undertaken on the assessment and improvement of the quality of health care delivery in the past 30 years. While considerable progress has been made, quality and safety problems persist and the debate on how to accelerate and sustain quality management is more relevant than ever –4. In reQuality management systems can be understood as sets of interacting activities, methods, and procedures used to direct, monitor, control, and improve quality of care . They usWhile variations in clinical practice are well documented, there is little evidence on factors associated with the uptake of quality management activities by hospitals or on their impact on clinical practice. A recent systematic review identified a number of studies exploring factors positively associated with the implementation of quality management systems . PreviouThe study was conducted as part of the “Deepening our understanding of quality improvement in Europe (DUQuE)” project, which was funded by the European Union’s Seventh Research Framework Program. The overall aim of the project was to study relationships between organizational quality improvement systems and organizational culture, professional involvement, and patient empowerment at hospital and department levels, and to analyze the quality of health care delivery in terms of clinical effectiveness, patient safety, and patient experiences. In previous work, we explored the effects of hospital-level quality management systems on quality activities at the department level, and found mixed results, with positive but weak associations . Our speIn this multicenter cross-sectional study, data were collected at the hospital-, department-, and patient-level through questionnaires administered to managers and health professionals, retrospective case note reviews, and direct observation. Hospitals with more than 130 beds were randomly selected in each the participating countries: Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey. Including criteria was to reach general acute care hospitals, with a minimum hospital size of 130 beds that had a sufficient volume of care to ensure recruitment of 30 patients per condition over a 4-month period (a sample frame of a minimum of 90 patients). Specialty hospitals, hospital units within larger hospitals, and hospitals not providing care for the four clinical conditions of study were excludedn each hospital, detailed information was collected on 4 conditions: acute myocardial infarction, vaginal deliveries, hip fractures, and stroke. For each condition, we reviewed 35 consecutive cases that fulfilled the study’s inclusion and exclusion criteria study. Data for the clinical practice indicators were retrieved through retrospective case note review using a standardized data collection sheet and a manual translated into the local language. The review of case notes was organized locally according to protocol and performed by trained hospital staff with clinical background knowledge and experience with local clinical and documentation practice and not being involved in the practice being assessed. Other department’s data was retrieved from the department seeing most patients from the studied condition and emergency area (if applicable). All data were collected between May 2011 and February 2012. The data collection strategy was informed by a sample size calculation that took into account the multilevel structure of the study . The broThe outcome variables consisted of a set of 19 single clinical practice indicators selected based on a review of the literature and a systematic rating procedure by individual experts and relevant European scientific societies to assess their relevance, applicability, and feasibility. In addition, 5 clinical practice summary measures were constructed see . Each clClinical practice summary indicators*Acute AMI: a) Was reperfusion therapy given on time ?; b) Were all appropriate medications  prescribed (or contraindicated) at discharge?Routine vaginal deliveries: Were there any birth-related complications , instrumentation needed during vaginal delivery, third- or fourth-degree laceration, or newborn Apgar score <7 at 5 minutes)?Hip fractures: What percentage of recommended care was delivered? Stroke: Did stroke patients receive appropriate care?: *Clinical practice summary indicators had 3 possible values: “Yes”, “No”, or “Not applicable”.Predictors at the hospital level**•Quality Management Systems Index (QMSI). The QMSI is an overall measure of the extent of implementation of quality management systems and has 9 dimensions: 1) quality policy documents, 2) quality monitoring by hospital board, 3) training of professionals, 4) formal protocols for infection control, 5) formal protocols for medication and patient handling, 6) analysis of performance of care processes, 7) analysis of performance of professionals, 8) analysis of patient feedback, and 9) evaluation of results.-Quality Management Compliance Index (QMCI). The QMCI is a measure of how the hospital management oversees hospital quality program initiatives and has 4 dimensions: 1) quality planning, 2) monitoring of patient/professional opinions, 3) monitoring of quality systems, and 4) improvement of quality through staff development activities.-Clinical Quality Implementation Index (CQII). The CQII measures the implementation of quality efforts throughout the hospital and analyzes continuous improvement in clinical areas with 7 dimensions: 1) prevention of hospital infections, 2) medication management, 3) prevention of patient falls, 4) prevention of patient ulcers, 5) routine testing of elective surgery patients, 6) safe surgical practices, and 7) prevention of patient deterioration.**All quality management measures are rated from 0 (lowest possible score) to 10 (highest possible score). Methods for the construction of all measures, including results from the factor analysis and rationale for the dimensions selected are provided in detail elsewhere –21.Predictors at the department level***Specialized expertise and responsibility (SER). This assesses professional expertise and the allocation of clinical responsibilities. [ilities. Evidence-based organization of pathways (EBOP). This assesses the extent to which departmental organizational processes incorporate evidence-based care recommendations  [t tools) –26.Patient Safety Strategies (PSS). These identify the application of strategies for ensuring patient safety recommended by international agencies including patient identification, hand hygiene, medication management, resuscitation processes and adverse event declaration [laration , 26Clinical Review (CR). This assesses the use of clinical audit and systematic monitoring as part of department-level quality management activities. [ivities. ***All department quality measures were rated on a 5-point Likert scale and were common to all conditions, except EBOP, which was based on specific evidence findings for each condition.Predictor variables measuring characteristics of quality management system implementation included 3 quality index scores at the hospital level and 4 quality measures at the department level that cover complementary aspects of quality management systems. These measures were build on previously validated tools, and their detailed (psychometric) properties are described elsewhere –21 see . One of Additional variables collected and included in multivariate analyses included the country in which the hospital was based, hospital teaching status (teaching versus non-teaching), hospital size , hospital ownership (public versus private), and the gender and age of each patient included in the chart review population.We hypothesized that the implementation of hospital-level quality management systems and department quality activities (positively) predicted on clinical practice for all 4 conditions analyzed . We first described the hospitals in the sample, the mean scores for hospital- and department-level quality measures, the characteristics of the patients in the chart review population, and compliance with clinical indicators for each pathway analyzed. For categorical variables we calculated frequencies and percentages. For continuous variables, we calculated the mean and standard deviation. We provide details on missing data in the descriptive tables, but multivariable analyses excluded patients with incomplete records for any of the variables .A directed acyclic graph (DAG) was used to depict our knowledge and assumptions about the (plausible) relations between predictors: hospital quality management measures, quality activities at the department level, and clinical practice indicators. Variable selection for the statistical models in this paper was guided by the DAG shown in The edges in this graph encode relationships between predictors, outcomes, and covariates, and are governed by rules that affect choice of covariates to control for confounding –29. For We estimated multivariate binomial logistic models with random intercept by hospital to account for clustering of patients within hospitals for all clinical indicators except percentage of recommended care delivered in the hip fracture pathway, for which we used multivariate ordinal logistic mixed model . Our models were adjusted for confounding fixed effects at the country level (country), hospital level , and patient level , in addition to quality measures as dictated by the DAG in th framework of EU DG Research. Ethics approval was granted through the Bioethical Committee of the Department of Health of the Government of Catalonia, Spain on 12th February 2010, in writing by Dr Josep M Busquets, responsible for bioethics at the Department of Health. Data collection in each country complied with confidentiality requirements according to national legislation or standards of practice of that country. Patient records and other information was anonymized and de-identified prior to analysis.DUQuE fulfilled the ethic requirements for research projects as described in the 7n = 58, 79.4%) and almost half had a teaching function Overall, 276 departments from 73 hospitals in 7 countries (87% of expected) provided valid data. The hospital and department characteristics are shown in A total of 9021 clinical records (77% of expected) were analyzed. Their characteristics are shown in Descriptive results for the clinical practice indicators are shown in At the hospital level, positive associations between quality management system and clinical indicators were found for only 4 of the 24 indicators analyzed: reperfusion therapy given in AMI , delivery of 75% of recommended care to hip fracture patients , admission to a specialized stroke unit  and administration of aspirin/antiplatelet drug within 48 hours of arrival at hospital . In this last case, a weak negative association was found with QMSI .At the department level , we founWe also observed positive associations for a majority of the single indicators (5/6 indicators in AMI and 3/5 in stroke). Negative associations only were observed for one quality measure for 1 of 4 indicators for both deliveries and hip fracture. The percentage of positive associations between quality management systems and clinical indicators was substantially greater for indicators with level A evidence (7/10). Full table on the Association Between Hospital-Level Quality Measures and Clinical Practice Indicators is provided in Table A in Our study is the largest of its kind in Europe to examine the impact of quality management on clinical practice. The results demonstrate wide variations in the implementation of hospital- and department-level quality management systems and in performance assessed by clinical practice indicators. Mean compliance with clinical practice indicators was 76.3%, demonstrating substantial room for improvement in EU hospitals. Previous studies have found similar variations in clinical practice based on the analysis of care received by both the general population –32 and hWe found limited and weak associations between hospital-level quality management implementation and clinical indicators for all 4 conditions analyzed, but strong and clinically relevant associations for department-level quality management and clinical indicators for AMI and stroke. The observed effects remained strong and robust for both conditions after formal sensitivity analysis for uncontrolled confounding, selection bias, and measurement error using modern bias modeling methods –38  and 1 specific measure (evidence-based organization of pathway), which while distinct for each condition, had the same structure in terms of patient flow . These 4 department-level quality measures seem to be associated with clinical practice indicators in AMI and stroke. Further studies are needed to investigate whether implementation of the above quality activities could be used to develop best practice recommendations applicable across hospital departments. If this were possible, a quality model for clinical departments combining department responsibilities, evidence-based organization, patient safety strategies, and quality review (audit and feedback) could be drawn up to provide guidance for clinical leaders when designing the organization of their departments.This study has a number of limitations that need to be highlighted. First, we cannot draw conclusions on causality due to the cross-sectional nature of the study. Second, the medical records analyzed may have been more complete and comprehensive in some countries than in others . Third, This study demonstrates significant gaps between evidence and practice for 4 common clinical conditions in a large sample of European hospitals. Our findings suggest that the implementation of department-level quality strategies is significantly associated with good clinical practice. Further research should aim to develop clinically relevant quality standards for hospital departments, as these appear to be more effective than the current widespread investment in generic, hospital-wide quality management systems.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


Juvenile Localized Scleroderma (JLS) and Juvenile Systemic Sclerosis (JSSc) form a group of rare pediatric diseases that can lead to significant morbidity. Evidence-based guidelines are sparse and management is mostly based on physician’s experience. Consequently, treatment regimens differ throughout Europe. In 2012, a European initiative called SHARE (Single Hub and Access point for pediatric Rheumatology in Europe) was launched to optimize and disseminate diagnostic and management regimens in Europe for children and young adults with rheumatic diseases.One of the aims of SHARE was to provide evidence based recommendations for diagnosis and treatment of Juvenile Scleroderma.The Journal of Applied Behavioral Science July 1971 7: 466-492]. Recommendations were accepted if more than 80% agreement was reached.Evidence based recommendations were developed using the European League Against Rheumatism (EULAR) standard operating procedure. An expert committee was instituted, consisting of pediatric rheumatologists and experts in Juvenile Scleroderma. The expert committee defined search terms for the systematic literature review. Two independent experts scored articles for validity and level of evidence. Recommendations derived from the literature were evaluated by an online survey. Those with less than 80% agreement during the online survey were reformulated. Subsequently, all recommendations were discussed at a consensus meeting using the nominal group technique [Delbeq AL. A group process model for problem identification and program planning The literature search yielded 1550 articles for JLS and 8562 for JSSc, of which 52 and 37, respectively  were considered relevant and therefore scored for validity and level of evidence. 42 articles  were scored valid and used in the formulation of the recommendations. 11 recommendations for diagnosis and 7 for treatment were suggested in the online survey on JLS. Ten recommendations for diagnosis and 6 for treatment were accepted with more than 80% agreement after the consensus meeting. Six recommendations for diagnosis and 5 for treatment were suggested in the online survey on JSSc. 6 recommendations for diagnosis and 4 for treatment were accepted with more than 80% agreement after the consensus meeting. Topics covered for diagnosis and for treatment were, for JLS, disease activity assessment and response to therapy, disease severity and damage assessment, extra-cutaneous involvement , topical treatments  and systemic treatment ; for JSSc disease severity and damage assessment, diagnosis of skin involvement, lung involvement and Raynaud's phenomenon, treatment of skin, lung and vascular involvement and autologous stem-cell transplantation.The SHARE initiative provides recommendations for diagnosis and treatment for Juvenile Scleroderma and thereby facilitates improvement and uniformity of care throughout Europe.None declared.


Additional publications were provided by Sedentary Behaviour Research Network members. The methodological quality of the systematic reviews was evaluated using recommended standard criteria from AMSTAR. For each review, improper use of causal language in the description of their main results/conclusion was evaluated. Altogether, 1,044 review titles were identified, 144 were read in their entirety, and 27 were included. Based on the systematic reviews with the best methodological quality, we found in children and adolescents, strong evidence of a relationship between time spent in sedentary behavior and obesity. Moreover, moderate evidence was observed for blood pressure and total cholesterol, self-esteem, social behavior problems, physical fitness and academic achievement. In adults, we found strong evidence of a relationship between sedentary behavior and all-cause mortality, fatal and non-fatal cardiovascular disease, type 2 diabetes and metabolic syndrome. In addition, there is moderate evidence for incidence rates of ovarian, colon and endometrial cancers.Medline; This overview based on the best available systematics reviews, shows that sedentary behavior may be an important determinant of health, independently of physical activity. However, the relationship is complex because it depends on the type of sedentary behavior and the age group studied. The relationship between sedentary behavior and many health outcomes remains uncertain; thus, further studies are warranted. Physical inactivity, or lack of moderate to vigorous physical activity, However, recently a new paradigm in the physical activity field has emerged. During the last decade, a growing number of systematic reviews have been published.Thus, the aim of this overview was to synthesize the current evidence of the relationship between sedentary behavior and health outcomes during the time periods reported in the systematic reviews. Moreover, for each systematic review a methodological quality assessment was performed.To be included in our overview, reviews had to describe the search methods used and the inclusion criteria of the original articles.Excerpta Medica (Embase); PsycINFO; and Web of Science. Keywords related to exposure  and method  were included in the search. Detailed information on the combinations of search terms used in our search strategy is shown in A comprehensive search was performed up until September 2, 2013 using Medline; To be included in the overview, articles had to be systematic reviews, with or without a meta-analysis that examined the relationship between sedentary behavior and health outcomes among observational studies. We excluded the following types of reviews: reviews in which sedentary behavior was inappropriately defined ; and narrative reviews of the literature. Because of the large number of review articles initially selected, we excluded those examining other aspects of sedentary behavior i.e. interventions to reduce sedentary behavior; determinants/correlates of sedentary behavior; the tracking of sedentary behavior; and different methods for measuring sedentary behavior.All eligible systematic reviews included were examined and extracted independently by two reviewers (LFMR and MRL). The data extracted included information on author(s), year, age group, type of sedentary behavior, outcome measure, whether a meta-analysis was conducted, and quality assessment of the original studies , eligibiAll included reviews were evaluated by two independent reviewers (LFMR and JPRL) using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool . [44], [strong, moderate, insufficient or no evidence . Reviews were rated as qualified causal if words such as “may” or “suggest” were included to describe their main results. Finally, reviews were considered acceptable if the inference was based on associations or relationships. This methodology has been used by Brown et al. For each review, improper use of causal language in the description of their main results/conclusion was evaluated . A revieNo ethical approval was required.A total of 1044 potentially relevant articles were initially retrieved from the databases searched. Of those 1044 articles, 424 were retrieved from Medline, 248 from Embase, 333 from Web of Science, and 39 from PsycINFO.  Another We found no review articles examining sedentary behavior in middle-aged adults or in the elderly . As shown in Among the 27 systematic reviews, 17 did not restrict the type of sedentary behavior in the research question,In general, the systematic reviews’ eligibility criteria were based on age, language, date published, and study design . PhysicaBased on AMSTAR, we assessed the methodological quality of the 27 reviews included in the overview see . For chiThe level of scientific evidence synthesized for each outcome according to age group and sedentary behavior type is shown in the Seven systematic reviews investigated the association between sedentary behavior and mortality in adults.In Ford et al., According to Wilmot et al., Although some systematic reviews have indicated an association between sedentary behavior  and cancer-related mortality, Five systematic reviews investigated the association between sedentary behavior and cardiovascular disease in adults. Five systematic reviews investigated the association between sedentary behavior and cancer in adults. Five systematic reviews concluded that there is a significant and positive association between sedentary behavior and type 2 diabetes in adults, regardless of physical activity level. One systematic review evaluated the association between sedentary behavior and metabolic syndrome; In children and adolescents, two reviews have been published. In adults, time spent in sedentary behavior (television viewing and screen-time) is associated with metabolic syndrome, regardless of the level of physical activity. Fourteen systematic reviews examined whether sedentary behavior was associated with body mass index, weight gain, overweight/obesity and adiposity in children, adolescentsIn a meta-analysis including randomized controlled trails, Tremblay et al. In contrast, in adults, the obesogenic effect of sedentary behavior is not supported by observational studies. For Thorp et al. Few systematic reviews have examined whether sedentary behavior is associated with mental disorders in children, In children and adolescents, sedentary behavior (screen time) was associated with depression; however, evidence was based on cross-sectional studies. Four systematic reviews investigated the association between sedentary behavior and musculoskeletal disorders. Other systematic reviews analyzed whether sedentary behavior was associated with: physical activity, In children with emotional and environmental difficulties, there is insufficient evidence for the association between television viewing and aggressiveness. Systematic reviews have investigated the association between sedentary behavior and other health outcomes, such as bone health, Two recent systematic reviews found a significant inverse association between television viewing time and academic performance, as measured by IQ, grades/grade point average, and performance on standardized tests.Other studies showed that, in children, increased television viewing time was associated with poor psychosocial health . There is insufficient data to draw any conclusions regarding the relationship between sedentary behavior and bone mineral density Of the 27 reviews included in this overview, 24 (89%) made a correct use of causative language taking into account the design of the included studies . Among aThe present overview summarizes the current knowledge about the role of sedentary behavior on human health. The main limitations of this overview were that we drew conclusions based only on systematic reviews of observational studies. Unfortunately, we identified very few systematic reviews of RCTs in our initial research strategy. In addition, the main focus of the RCT reviews were only to analyze the efficacy of interventions to reduce sedentary behavior and/or the effect on short-term health outcomes. It is important to highlight that the observational evidence between sedentary behavior and different health outcomes reported in this overview is complex, depending on the type of sedentary behavior and the age groups studied .In children and adolescents, there is strong evidence of a relationship between sedentary behavior (based on TV viewing and screen-time) and obesity. Moreover, we found moderate evidence for blood pressure and total cholesterol, self-esteem, social behavior problems, physical fitness and academic achievement (based on TV viewing and screen-time).In adults, we found strong evidence of a relationship between sedentary behavior and all-cause mortality, fatal and non-fatal cardiovascular disease , type 2 diabetes (TV viewing and screen-time) and metabolic syndrome . In addition, there is moderate evidence for incidence rates of ovarian (sitting time), colon (TV viewing) and endometrial cancers  and type 2 diabetes (sitting time).Finally, there is inconclusive evidence for certain health outcomes in adults , children and adolescents , and thus, further studies are needed.Reviews included a predominance of cross-sectional studies, which do not allow us to infer causality between variables. Although prospective studies with high methodological quality may provide better insight of the role of sedentary behavior on human health, residual confounding may still exist. Ideally, randomized controlled trials should be conducted to confirm deleterious effects attributed to some sedentary behaviors. However, a high-quality randomized controlled trial designed to analyze the effect of sedentary behavior on endpoint health outcomes may be unfeasible because of its high cost and reduced compliance with the intervention. Nonetheless, other epidemiologic study designs  to obtain an accurate measure and contextual information of sedentary behavior. From our point of view, future systematic reviews should assess the quality of the original articles and make conclusions based on it. Other AMSTAR items that were infrequently performed/reported and merit future considerations were: prior design of the systematic review, the use of two independent reviewers and data extractors, inclusion of grey literature, list of included and excluded articles selected, evaluation of heterogeneity and publication bias. Systematic reviews of observational studies should also detail how confounding variables  were assessed in each original study. In addition, the main limitations involving meta-analysis of observational studies  should be rigorously considered. Finally, no systematic reviews have been exclusively performed in elderly individuals. Therefore, we encourage future investigations of sedentary behavior in this age group because they spend most of their daily time in sedentary activities. File S1Search strategy.(DOCX)Click here for additional data file.File S2Characteristics of the systematic reviews examining the relationship between sedentary behavior and health outcomes.(DOC)Click here for additional data file.File S3Eligibility criteria and extraction of physical activity adjustment within the systematic reviews.(DOC)Click here for additional data file.File S4Methodological quality assessment of systematic reviews.(DOCX)Click here for additional data file.File S5Level of scientific evidence for associations between sedentary behaviors and health outcomes, by age group and type of sedentary behavior.(DOCX)Click here for additional data file.File S6Aims, main results and use of causative language in systematic reviews of sedentary behavior and health outcomes.(DOCX)Click here for additional data file.Checklist S1PRISMA Checklist.(DOC)Click here for additional data file.


Citizen science has gained widespread currency as a tool for ecological research over the past decade. However, in the discipline of urban ecology, the existing contributions and future potential of citizen science engagement, specifically in terms of knowledge gain, have not yet been comprehensively explored. Here, we present a systematic review of published work on the urban ecology of birds and butterflies in relation to their use of citizen science data between 2005 and 2014. We compared the number of studies that used citizen science data to the number of studies that could potentially have employed data derived from citizen science. The take-up rates of citizen science data were 21% and 26% for birds and butterflies respectively. Most studies that employed citizen science used volunteer-derived data as primary data, and adopted Collegial, Collaborative and Contributional engagement modes to the exclusion of Contractual and Co-created arrangements. There was no evidence that citizen science studies investigated a different organismal scale (community vs. species) compared to the urban ecology literature. For both taxa, citizen science contributions were lower than expected compared to their representation in the urban ecology literature for studies on species-environment relationships at landscape and micro-environment scales, as well as behavioural ecology in general. Other research topics that could benefit from further citizen science involvement include breeding studies and guild analyses for birds, and multi-taxa studies for butterflies. Promising models of citizen science engagement for urban ecology are highlighted in relation to their thematic foci and methodological detail, and a number of research questions that could be productively addressed using citizen science are identified. The dynamics of contemporary engagement between citizen science and urban ecology described by this review could inform the design and refinement of urban ecology–citizen science programmes in order to optimise their scientific contributions. Citizen science (hereafter known as CS)—the mass involvement of non-professionals in scientific research—has gained significant traction over the past decade as a tool for advancing ecological science ,2. The psensu stricto as a field of scientific enquiry make it exceptionally accessible to citizen science involvement: (a) a strong history of amateur interest in biology as a whole [Urban ecology (hereafter known as UE) in the traditional sense is defined as ecological research conducted in an urban setting ,7, and a a whole , (b) the a whole , and (c)This paper examines that first and most fundamental aspect of research for both CS and UE: the choice of a scientific question. It is imperative that CS programmes and projects should define problem statements that are clear, feasible and useful to the scientific community. This inherits broader concerns expressed by scientists over the practical outcomes of general conservation monitoring programmes in relation to their design and focus ,14. HoweWhereas other authors have written about various aspects of the practice and application of CS projects focused on ecology, these have generally addressed other aspects of the CS life-cycle. For example, several excellent reviews of CS in relation to general ecological research exist –17. MuchThe specific aims of this review were:To identify the main themes open to CS involvement that urban ecological research has addressed in the past decade for birds and butterflies, and to quantify the extent to which CS datasets have actually contributed to these themes;sensu Shirk et al. [To characterize different paradigms of CS k et al.  that havTo assess what is known about trends of research efforts by theme, and identify potential themes for CS to generate new knowledge;To discuss the implications of the findings from (I), (II) and (III) on the design of CS programmes for biodiversity monitoring in urban areas.In 2015, the National Parks Board of Singapore (NParks) launched a range of Community in Nature (CIN) CS programmes to involve the community in biodiversity monitoring and research programmes including the Garden Bird Watch, Butterfly Watch and BioBlitz, as part of the NParks CIN Biodiversity Watch and NParks CIN Biodiversity Survey @ Parks series. Our proximate motivations for this study were thus to understand specific angles of data analysis which would optimise the scientific contributions of these programmes, identify practical options for refining survey protocols in service of specific research objectives, and to target research topics which could be suitable for the development of new programmes. We hope that this review will serve as a useful reference for designers and managers of similar UE-CS programmes of the types of hypotheses that have been valued by the scientific community over the past decade. This knowledge could be further applied to refine survey protocols to optimise both pure and applied scientific outcomes of such programmes.Birds (Aves) and butterflies (Papilionoidea) were selected as focal taxa for this review for three main reasons: (a) sufficient ecological work has been undertaken for these taxa that broad literature trends may be gleaned over the past decade alone, (b) birds and butterflies, especially the more eurytopic species, are less dependent on the preservation of contiguous tracts of pristine habitat for their persistence, and thus show practical promise for responding positively to targeted landscape interventions in urban areas, (c) they generally hold a cross-cultural appeal for laymen, to the extent that CS programmes involving these taxa may be typically described as enjoying vibrant social support. For example, birds and butterflies were recently shown in a comprehensive database of biodiversity-related citizen science projects to account for the most number of CS projects, relative to other faunal taxa .www.prisma-statement.org) guidelines in We searched five databases for journal articles relevant to the practice of UE and CS published from January 2005 to July 2014. General search statistics are reported in accordance to PRISMA , whereas the third level provided finer thematic resolution on the specific hypotheses/aims of the study (Category). Through an iterative process, 61 categories belonging to 19 research domains were identified . The catWe note that since the use of volunteers to collect ecological data pre-dates the use of the term ‘citizen science’, drawing conclusions about the thematic coverage of CS in bird and butterfly ecology based only on papers that included this term specifically could have severely underestimated the actual usage of such datasets . Therefoad hoc records of species presences contributed by volunteers over variable spatial and temporal scales) to be Collegial in the sense that contributions were solicited on a case-specific basis.To further identify associations between specific types of CS used in relation to the research themes identified above, we recognised two main types of CS contribution. Firstly, we categorised “primary” use in terms of whether the CS data was used for key analyses, and “secondary” use when it was relied upon as a supplementary but not indispensable resource. Secondly, we applied the framework for understanding the spectrum of options for public participation in scientific research identified by Shirk et al.  Table 3Table 3. We calculated the contributions of CS to urban ecological research as the percentage of studies which used CS data overall for each taxon, as well as separately for each research category (Research aim 1). To characterise associations between the engagement mode and primary/secondary use paradigms of CS in relation to urban ecological research (Research aim 2), we used non-metric multi-dimensional scaling (NMDS). To determine whether the investigative scale of CS papers (species versus community-level) was different from that of the overall UE literature, we used Fisher’s exact tests.To identify specific domains and categories with a higher potential for CS involvement (Research aim 3), we first used tree maps to identify the key categories whose proportional representation in the CS literature was most dissimilar to that found in the overall UE literature. Tree maps were useful for visualizing the overall allocations of categories between CS and UE for both domains and categories simultaneously; however, they did not identify categories with zero representation in CS. To account for this, and to quantitatively identify specific categories of UE for further investigation by CS, we calculated the standardised values (z-scores) of all categories by subtracting the mean and dividing by the standard deviation of the number of studies identified in the CS and UE datasets accordingly . We thentreemap [vegan [All statistics and graphs were generated using R 3.1.2 , with thtreemap  and vegap [vegan .The number of journal articles selected for urban bird ecology greatly exceeded those selected for urban butterfly ecology (562 vs. 61 respectively). For simplicity, the main groups and categories of research questions identified for both taxa are described together, and the main research themes of urban butterfly ecology are regarded as being  completely nested in those of urban bird ecology .Overall, of the 623 journal articles on the urban ecology of birds and butterflies, 131 (21%) used citizen science datasets . This prMost studies that employed CS used data collected in the Collegial engagement mode (43%), while reliance on the Contributional and Collaborative modes was approximately equal. This pattern was slightly different for butterfly studies, which showed roughly equivalent contributions from Collegial and Contributional modes. Two clarifications are needed for interpreting the relationships between engagement modes and thematic categories shown in The vast majority of papers which used CS data used it for primary analyses , and this trend was more pronounced for butterflies (100%) compared to birds (89%). For birds, certain thematic categories displayed a greater tendency to use CS data in a supplementary manner. These included breeding studies as well as those investigating surrogacy of environmental responses between multiple taxa and species distribution modelling .p = 0.92), or separately for birds (p = 0.84) or butterflies (p = 0.17), although proportionally more butterfly UE studies addressed community-scale question compared to CS studies.Using Fisher’s exact tests, there was no evidence of a difference in focus in terms of ecological scale (community vs. species) between CS studies and the overall UE literature either overall  , and evea priori principle for identifying which mode of CS engagement may be best suited to particular research objectives. Based on the publication record, topics primarily focused on regional and global spatial patterns have benefited well from Collegial engagement modes, whereas questions focused on long term population trends seem well-suited to Collaborative modes. Ecological questions that are more focused in time and space appear to be most practically pursued within Contributional engagement frameworks.Whereas the general merits of citizen science for investigating broad spatial and temporal scales have been recognised , and CS It is interesting that the research themes investigated by the Contributional and Collaborative CS engagement modes were well separated for birds, but not for butterflies. This could be because the design of broad-scale butterfly surveys appears to have developed along a more integrated fashion, as compared to the clearer methodological bifurcation between Atlases and Breeding Bird Surveys for birds.We found no Contractual CS studies in this review. This could reflect either the lack of incentive of civil societies to publish data collected by commissioned scientists, or concerns over data sensitivity, and so is most likely an artifact of the approach we adopted for paper selection. However, that no studies could be described as Co-created according to Shirk et al.’s definition  is more Whereas no studies used CS as secondary data for studying urban butterfly ecology, those that did for birds used CS data on bird occurrence and abundance to investigate species-specific breeding parameters. The CS approach has clear merits for locating breeding sites of more quiescent species, but this secondary use could be adapted more widely to inform sampling stratification schemes investigating a much greater variety of research questions (c.f. later discussion on the merits of the Neighborhood Nestwatch Program).Lastly, that there was no evidence that CS tended towards investigating either community-level or species-level phenomena compared to the overall distribution of investigative effort in UE in general suggests that CS contributions could be relatively insensitive to the ecological scale of analysis. This is a positive finding, suggesting that volunteer interest could be effectively channelled across a range of biological scales.Considering that the practice of CS depends critically on modes of social organisation and administration available to programme managers in specific social contexts, it may often be the case that the engagement mode required for a CS project pre-empts and constrains the formal identification and codification of specific research questions. This is supported by the tendency for particular research categories to cluster around the different CS engagement modes . TherefoThe second section of this discussion elaborates on specific research objectives that could benefit from more CS involvement based on differences in z-scores of their distributions in the CS and UE literature respectively. These were identified based on incidences of contrasting findings from the same research questions encountered in the specific subset of UE screened by the authors over the course of this review. We note that these objectives are not intended to map out general research directions for urban ecological  research as a whole, for which we refer to the reader to recent reviews by McDonnell & Hahs  and ShwaCollegial CS: for birds, the research categories investigated by Collegial-mode CS were clearly grouped into four categories that mostly enjoy high CS involvement, namely Competition: macro, Analysis: foraging and Species Distribution Modelling: current. Practically all Collegial-mode CS studies identified for urban bird ecology were Atlas projects, of which several contributed at least two papers: (1) Birdlife Australia Atlas, (2) eBird, (3) Spanish Atlas of Breeding Birds and (4) New York State Breeding Bird Atlas (NYSBBA), 5) Ontario Breeding Bird Atlas (OBBA). Of these, the OBBA provides the most parameters , whereas the NYSBBA does not report abundance measures but is conducted on a finer-resolution grid (5x5 km cells). Tulloch et al.  Ontario –45, so wFor butterflies, two distinct sets of categories have been explored by citizen scientists using the Collegial mode: phenology studies (Phenology: migration & Phenology: climate), and Behaviour: diet. Among the butterfly monitoring projects represented by contributions to scientific journals, the survey model developed by the Chicago-Illinois Butterfly Monitoring Network is arguably the most commendable in terms of producing data which could contribute to a greater variety of research categories, in particular long-term population trends . In compContributional CS: of the research categories which have been explored using the Contributional mode of CS for birds, those also identified as having a high potential for an expanded role for CS in general included Breeding: micro and Breeding: meso , Table 6ad hoc approach to volunteer recruitment tailored to specific, time-bound project objectives.Another theme associated with Contributional CS studies for birds was Environment: micro; two CS programmes that have successfully investigated this in the urban context are the Tucson Bird Count  and the For butterflies, among studies which used data generated using the Contributional mode, two are assessed to have a higher potential for supporting multiple angles of research: the Spipoll protocol of France , and theCollaborative CS: the possibility of Collaborative CS contributing to more information on the influence of the environment on bird diversity at landscape scales (Environment: meso) is considered first; two of the few programmes that have successfully investigated this theme using Collaborative CS are the Ontario Breeding Bird Count  and the For butterflies, reasonably clear associations between Collaborative CS and the categories Environment: macro ,59 and PEnvironmental influence at landscape scales (Environment: meso): studies investigating the influence of meso-scale (landscape) environmental variables on bird and butterfly diversity within urban areas were the most numerous of all the research themes for both taxa, but less than 10% employed citizen science overall, and none at all did so for butterflies . The rolBesides habitat connectivity, two other promising research angles that could be productively examined with CS are the roles of isolation and age on urban wildlife communities. While isolation  is expected to exert a negative influence on species richness based on the island biogeography theory and this has been corroborated in some urban areas for both birds ,77,78 anad hoc observations of plant-animal interactions, to standardised surveys of individual trees or plant species in a contributory format.Environmental influence at microhabitat scales (Environment: micro): three major groups of urban microhabitat variables that have been investigated for their effects on bird and butterfly diversity involve structural, floristic and anthropogenic aspects. Of these, the influence of vegetation composition and green space maintenance regimes corresponding to the latter two topics could be considered more broadly applicable to a range of other taxa, since they are theoretically less dependent on organismal body size. Specifically, the question of how to balance conservation needs across both urban flora and fauna is one that deserves more sustained research attention. Although the basic association between plant species richness and faunal species richness may be intuitive and quite general, specific quantitative relationships identifying (novel) mutualisms between urban plants and animals are needed to effectively optimise urban landscapes for ecosystem-scale conservation. The general nature of this question renders it open to investigation with multiple modes of CS, from Collegial Managed green spaces constitute a sizeable proportion of available habitat in urban areas, yet relatively few published studies have investigated how the maintenance regimes in parks and precinct greens could be affecting bird and butterfly diversity. Shwartz et al.  found thAnthropogenic disturbance from noise or human traffic could affect urban wildlife by limiting access to resources that could otherwise be more heavily exploited. These effects may be more taxon-specific. For example, there is evidence that anthropogenic noise negatively impacts urban bird populations ,83–85, wBehavioural studies : Although behavioural studies could in theory benefit from Collegial-style contributions from citizen scientists, a very low proportion of studies focused on urban bird and butterfly behaviours employed CS datasets (n = 4/59). Quantitative records of wildlife diet and foraging would be useful for understanding species responses to fine-scale urbanisation gradients  and pin-The feasibility of citizen scientists collecting data on wildlife movements, specifically in relation to urban infrastructures and human disturbance, is quite likely to be limited to conspicuous diurnal animals. Nevertheless, the adaptability of diverse wildlife to anthropogenic environments may depend crucially on their ability to negotiate local barriers to resource use such as tall buildings , glass wad hoc observations of how wildlife use urban landscapes for foraging [Guild analysis (adaptive guilds): the avoider-adapter-exploiter framework developed by Blair  has sincforaging  and reprforaging , and secforaging  and/or aforaging , exotic foraging , predatoforaging  or compeforaging . To the foraging , knowledMulti-taxa studies (surrogacy): the quest to identify management surrogates , i.e. spAn important caveat is offered with respect to the research questions discussed above: the historical approach adopted above could offer limited insights towards prospects for the use of CS in UE over the long term, especially in response to developments in mobile technology and database infrastructure . This isThe above discussion has considered potential avenues for expanding CS contributions to urban ecological questions that could be generalised beyond the two taxa examined. Substantial synergies of effort and outcomes exist where CS meets UE. This review is a first step in describing the character of the science at the interstices of these two disciplines, and mapped out the broad themes relevant to engaging meaningfully with both these two scientific domains at this point in their development. Urban ecologists can benefit by making more intentional and systematic efforts to design volunteer-led primary data collection, while amateur scientists and citizen volunteers have much to gain from pooling resources with each other and with professional ecologists. We hope that the synthesis of perspectives provided in this review will facilitate deeper dialogue and engagement between these young and promising fields of scientific enquiry.S1 Table(DOC)Click here for additional data file.S2 TableUE: Urban Ecology, CS: Citizen Science, NDMS: Non-metric multidimensional scaling.(XLSX)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.S4 Table(XLSX)Click here for additional data file.S5 Table(XLSX)Click here for additional data file.S6 Table(XLSX)Click here for additional data file.


This study is aimed to conduct a systematic literature review regarding the associations between psychiatric symptoms, functional impairments, and quality of life in patients with CMT (Charcot–Marie–Tooth). The PUBMED, PsycInfo, SCIELO, and LILACS electronic databases were used, and the following search terms were employed: CMT, HMSN (hereditary motor and sensory neuropathy), mental disorder, quality of life, psychiatry, psychiatric, and psychological without the use of time-limit filters. According to the adopted inclusion criteria, 20 studies were included and appraised. These studies indicated that patients with CMT exhibited an increased trend toward depressive symptoms compared with the general population. In addition, CMT patients were exposed to a higher risk of reduced quality of life and significant sleep impairment. Considering the comorbidity of CMT with other psychiatric disorders, the heterogeneity of the instruments used to evaluate the psychiatric symptoms compromised the ability to compare the studies examined. Our results indicate a need for a systematic evaluation of these conditions to minimize the impairments and decreased quality of life caused by CMT. Patients with CMT exhibited an increased trend toward depressive symptoms compared with the general population. In addition, CMT patients were exposed to a higher risk of reduced quality of life and significant sleep impairment. CMT disease or HMSN (hereditary motor and sensory neuropathy) is the most common inherited disease of the PNS  affecting approximately 1 in 2500 individuals Skre, . CMT is At least 45 causing genes have already been identified and several others are still coming  language: English or Portuguese; (b) studies examining the psychiatric indicators and quality of life in patients with CMT; and (c) studies without date limit filters. The last search was conducted in January, 2014. The exclusion criteria were as follows: (a) studies related to other neurological disorders; (b) epidemiological studies related to CMT; (c) studies performed in animals; and (d) genetic, clinical, and/or epidemiological studies related to CMT. Using the search terms and inclusion and exclusion criteria, 20 studies were selected, and their relevance was assessed by a psychiatrist and a clinic psychologist.Only one study was qualitative descriptive  studies investigating the comorbidity of psychiatric disorders in patients with CMT      could not be performed due to the diversity of instruments employed to assess the distinct outcome variables. Thus, future studies must demonstrate homogeneous methodologies to statistically confirm the clinical evidence. The importance of studies that separate the patients with various CMT subtypes and those that use structured interviews to accurately estimate the association between CMT and psychiatric disorders should also be highlighted.


Mary-Ann Davies and Emma Kalk reflect on recent research by Rashida Ferrand and colleagues into barriers to provider-initiated HIV testing for older children in Zimbabwe.Please see later in the article for the Editors' Summary PLOS Medicine:This Perspective discusses the following new study published in doi:10.1371/journal.pmed.1001649Kranzer K, Meghji J, Bandason T, Dauya E, Mungofa S, et al. (2014) Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study. PLoS Med 11(5): e1001649. Rashida Ferrand and colleagues combine quantitative and qualitative methods to investigate HIV prevalence among older children receiving primary care in Harare, Zimbabwe, and reasons why providers did not pursue testing.Prevention of mother-to-child transmission (PMTCT) interventions have significantly reduced vertical HIV transmission but coverage is uneven and substantial gaps remain PLOS Medicine, Rashida Ferrand and colleagues In this week's Barriers to HIV testing of older children and adolescents are multifactorial, operating at the level of the individual, health care facility, community, and national legal framework. There is perceived lack of importance of HIV testing of older children . Common misconceptions include the belief that HIV testing is only required for symptomatic children Disclosure and stigma are frequently reported reasons for older children not being tested. Indirect disclosure of parental status, coupled with parental guilt and the belief that a child's knowledge of his/her HIV status will cause stress and exacerbate the disease are strong disincentives to testing Ferrand and colleagues highlight the challenges of HIV testing of older children in a study of provider-initiated HIV testing and counselling (PITC) for children aged 6–15 years in routine primary health care clinics in Harare, Zimbabwe Ferrand and colleagues' findings indicate that clear HIV testing policies for children and guidance on guardianship, together with training of HCWs on such policies are needed. The HCW interviews indicated confusion about testing guidelines and regulations. Even in countries such as South Africa and Lesotho where children may consent to testing independently from 12 years of age, HCWs need training to assess the capacity of children to give full informed consent In their study Ferrand and colleagues observed that 95% of children who tested positive for HIV were linked to care, in contrast to much lower proportions reported from other studies Ferrand and co-workers conducted their study in routine care clinics so their findings are likely generalizable and a good reflection of routine practices. Nevertheless, as HCWs had to document reasons for not testing, the proportion of patients offered PITC may be substantially higher than in other settings. The fact that >90% of infected children had a previous missed opportunity for testing indicates suboptimal pediatric PITC coverage in most routine settings.The emphasis on early HIV diagnosis and ART initiation in infants and young children is appropriate and should continue. However, it needs to be accompanied by strengthening later PITC of older children to “mop up” those not identified through PMTCT follow-up and to prevent morbidity and mortality. Improving PITC for older children may be one of the first steps in strengthening of health services for older children and adolescents. Future research should focus on identifying “best practices” for PITC in older children and adolescents that are effective, feasible, and appropriate for sub-Saharan African settings.


This network has enriched research and workforce training and produced a synergy between state and federal levels. The Emerging Infections Program (EIP) is a collaboration between the Centers for Disease Control and Prevention and 10 state health departments working with academic partners to conduct active population-based surveillance and special studies for several emerging infectious disease issues determined to need special attention. The Centers for Disease Control and Prevention funds the 10 EIP sites through cooperative agreements. Our objective was to highlight 1) what being an EIP site has meant for participating health departments and associated academic centers, including accomplishments and challenges, and 2) the synergy between the state and federal levels that has resulted from the collaborative relationship. Sharing these experiences should provide constructive insight to other public health programs and other countries contemplating a collaborative federal–local approach to collective public health challenges. In 1994, the Centers for Disease Control and Prevention (CDC) created the domestic Emerging Infections Program (EIP) as part of the response to the 1992 Institute of Medicine report recommending “the development and implementation of strategies that would strengthen state and federal efforts in U.S. surveillance”  highlights of what being an EIP site has meant for participating health departments and associated academic centers, including accomplishments and challenges, and 2) the synergy between the state and federal levels that has resulted from the collaborative relationship. We hope that sharing these experiences will provide constructive insights to other public health program areas and other countries that are contemplating a collaborative national–local approach to collective public health challenges.Several critical state-level, surveillance-related infrastructural enhancements have resulted from being an EIP site. First, federal EIP funding has been substantial. In 2014, EIP sites received an average of $3.6 million for personnel (including indirect costs), laboratory support, and supplies for all EIP projects in which they participated. This funding paid for a range of staff members, from 22 full-time equivalent (FTE) persons (spread over 27 positions) in the site with the smallest amount of personnel support to 58 FTEs (spread over 80 positions) in the site with the highest level of personnel support. The FTEs included staff in collaborating academic centers but excluded students in training positions.Having additional epidemiology staff made it possible to conduct gold-standard surveillance for all diseases of EIP interest, with routine auditing of laboratories becoming an accepted feature of laboratory surveillance, thereby ensuring as close to 100% reporting from laboratories as possible. The experience and contacts from these efforts have made it possible for those running programs for non-EIP diseases  to incorporate audits into their surveillance activities.Streptococcus (GAS) disease, and bacterial foodborne illness to enable typing and antimicrobial susceptibility testing, critical to the expanded surveillance role EIP sites have served for these infections. Updated laboratory capacity to perform pulsed-field gel electrophoresis enabled the EIPs to be in the forefront of identifying and investigating foodborne pathogen clusters and methicillin-resistant Staphylococcus aureus (MRSA) strains  in contributing toward emerging infections work. These networks were used effectively during 2001–2003, before bioterrorism-related preparedness funding became available to support extensive communication systems in all states.Third, in 2010, the EIPs began to conduct surveillance for health care–associated infections. Addition of capacity in this area has enabled EIP sites to move beyond encouraging hospitals to enroll in the National Healthcare Safety Network and produce annual reports of infection rates by hospital. EIP sites have established systems for ascertaining the number of central line–associated bloodstream infections within their entire catchment populations. Associated validation studies have identified limitations of definitions and enabled more complete case ascertainment. Methods have been established to enable estimation of the total number of nosocomial infections among hospitalized patients, setting the stage for repeated estimation to monitor trends over time  disease, and hospitalizations for influenza. The training relationship established between the Tennessee Department of Health and Vanderbilt University led directly to the prompt recognition and investigation of a recent large, multistate outbreak of fungal meningitis caused by a contaminated injectable steroid product. In Maryland, faculty from Johns Hopkins University designed and led a multisite study using EIP data on risk factors for invasive meningococcal disease among high school students.Collaborations with academic health centers have enabled much greater flexibility in the types of surveillance and special studies that the EIPs and, correspondingly, the respective state health departments can undertake. These collaborations not only provide ready access to students looking to participate in research and public health practice projects but also provide easier access for hiring staff for specific short-term projects, making special risk factor studies easier to conduct. In addition, academic center–based staff can conduct intensive surveillance in smaller catchment areas, and interested faculty can collaborate in and enhance population-based surveillance research projects, including tying them into their clinical networks and efforts to seek funding. In Connecticut, for example, faculty from the Yale School of Medicine have taken advantage of, become involved in, and enhanced EIP surveillance for ehrlichiosis, neonatal sepsis, group A GAS disease, chronic liver disease, and precancerous cervical lesions caused by human papillomavirus (HPV) infection; they also have contributed to design and analysis of studies of the effectiveness of pneumococcal, rotavirus, and HPV vaccines. Infectious disease faculty and fellows at the Oregon Health and Science University have contributed to Oregon’s studies of Escherichia coli (STEC), hospitalizations for influenza, C. difficile diarrhea , and precancerous lesions caused by HPV infection. Diseases with data that have enabled local reinforcement and enhancement of prevention efforts include neonatal GBS, meningococcal disease, pneumococcal disease, influenza, salmonellosis, and HPV infection. As a result of having and using these data at a local level, EIP sites have become a resource to other states about how such data can be used.Being an EIP site has meant conducting surveillance and obtaining local data for diseases for which the site was not previously conducting surveillance, implementing and evaluating prevention activities that could be or were being used without evaluation by other states, and using the data to reinforce existing or establishing new local disease control guidance. Diseases with new surveillance data for local use have included neonatal GBS and MRSA infections, invasive GAS disease and pneumococcal disease, non-O157 Shiga toxin–producing The state-based EIP sites have contributed to the larger EIP in more ways than conducting the agreed-upon surveillance projects and special studies that have provided national-level data leading to new understanding and prevention initiatives on many fronts (C. difficile infections (2006 FoodNet Steering Committee meeting), and routine analysis of data using area-based socioeconomic measures (2012 Steering Committee meeting). These ideas cut across internal CDC boundaries at the time they were proposed. MRSA and C. difficile infections had been largely considered nosocomial problems, housed in CDC’s Division of Healthcare Quality Promotion. Initially, finding the right group at CDC to take an interest in the community perspective proved challenging. Measurement and ongoing monitoring of health conditions and risk factors incorporating measures of socioeconomic status other than race/ethnicity was neither centralized nor a routine concern for most CDC infectious disease programs. As a result, the Steering Committee established a Health Equity Working Group to develop standards and set the agenda for incorporating measures of socioeconomic status into routine EIP surveillance , surveillance for community-associated C. difficile infections, a successful endeavor that resulted in its becoming a core EIP surveillance project . When such data were used in EIP sites as background rates in binomial probability calculations, they enabled rapid identification of food vehicles in outbreaks of salmonellosis, campylobacteriosis, and E. coli O157 infection . In addIn another article in this issue, Vugia et al. have summarized the contribution of EIP sites to training of the current and future public health workforce . Whether a given EIP endeavor constitutes “research” meeting the federal definition (i.e., “designed to develop or contribute to generalizable knowledge” [With time, activities and expectations for EIPs have expanded, a fact welcomed by most sites. However, funding for the administrative work required by such expansions, including budget, contracts, and IRB tracking, and for hiring experienced epidemiologists to lead new projects has not always kept pace. EIPs note that funding increasingly must be directed to specified projects, leaving them with little flexibility and reduced ability to move beyond collecting data to writing articles for publication or crafting new protocols. As a consequence, such activities are increasingly left to CDC, jeopardizing some of the synergy of the collaborative partnership.Given the challenges we describe and the frequent necessary coordination of surveillance and epidemiologic activities between local hospitals, laboratories, health departments, and state and federal partners, the structural setup that most EIP sites worked out is one in which the program is located within the lead state health department with or without a co-location within the lead partner school of public health or medicine.The collaborative nature of the EIP has resulted in enhanced surveillance and laboratory capacity and communication networks in the 10 state public health departments. In addition, it has enriched research and public health training at the partner academic centers and produced synergy with the involved CDC programs, broadening the creativity and data analytic and dissemination capacity of all involved entities.EIP site-specific peer-reviewed publications, Connecticut and Minnesota, 1996–2014, and published multisite analyses led by staff in EIP sites, Connecticut and Minnesota, 1995-2015.


Two processes for regional environmental assessment are currently underway: the Global Environment Outlook (GEO) and Intergovernmental Platform on Biodiversity and Ecosystem Services (IPBES). Both face constraints of data, time, capacity, and resources. To support these assessments, we disaggregate three global knowledge products according to their regions and subregions. These products are: The IUCN Red List of Threatened Species, Key Biodiversity Areas , and Protected Planet. We present fourteen Data citations: numbers of species occurring and percentages threatened; numbers of endemics and percentages threatened; downscaled Red List Indices for mammals, birds, and amphibians; numbers, mean sizes, and percentage coverages of IBAs and AZE sites; percentage coverage of land and sea by protected areas; and trends in percentages of IBAs and AZE sites wholly covered by protected areas. These data will inform the regional/subregional assessment chapters on the status of biodiversity, drivers of its decline, and institutional responses, and greatly facilitate comparability and consistency between the different regional/subregional assessments. This is now paralleled by assessment processes on biodiversity and ecosystem services2. However, while much climate change science is primarily global, biodiversity and ecosystem services are much more geographically variable3. Their assessment is therefore most useful in a multi-scale framework4.Assessment of evidence to underpin responses to challenging societal issues is increasingly recognised as one approach to bridging the science-policy interface. The Intergovernmental Panel on Climate Change is a frequently cited example5 was published in 2012, and the sixth, now underway, will incorporate regional/subregional assessments. Meanwhile, IPBES has been established, and its regional/subregional assessments are currently beginning6.Such multi-scale environmental assessment processes are now underway. The United Nations Environment Programme (UNEP) compiles a periodic GEO. The fifth editionGlobal biodiversity and conservation databases hold much relevant information for these assessment processes, given the importance of consistency between different regions. Such databases are typically delivered as spatially explicit global knowledge products, and so can be analysed to inform regional/subregional assessment processes. However, both limited GIS capacity and frequently abbreviated timeframes pose severe challenges to the timely preparation of such analyses. Moreover, such regionalisation is sensitive to assumptions in data preparation and analytical settings, which if not standardised among regions can yield non-comparable results. Given the intention that the GEO and IPBES regional/subregional assessments will feed into respective global assessments, this standardisation is critically important.Here, as a contribution towards these regional/subregional environmental assessment processes, we provide disaggregations of three scientifically robust and commonly used global knowledge products. These present assessment of the risk of species extinction and associated distributional and other information (The IUCN Red List of Threatened Species), of sites contributing significantly to the global persistence of biodiversity , and of protected areas (Protected Planet). We regionalise policy-relevant combinations of each according to the GEO and IPBES regions/subregions. These will inform the regional assessment chapters relating to the status of biodiversity, drivers of its decline, and institutional responses, reflected as, e.g., Chapters 3, 4, and 6 respectively in the IPBES ‘Generic scoping report for the regional and subregional assessments of biodiversity and ecosystem services’ , and Section 2 ‘State of the Environment’ of the GEO regional assessments in assessing the status and trends of biota and ecosystems. The generic scoping report for IPBES regional/subregional assessments (IPBES/3/6/Add.1), the rationale for which is to promote coherence across the assessments, specifies that these will draw on relevant datasets.The variation between these regionalisations is remarkable. It provides great support to the regional assessment approach, given that this variation is masked by global reporting. We leave inference regarding causes of this variation to the assessment processes themselves, but note that contributing factors will surely include variation in underlying biogeography, intensity of anthropogenic drivers, and capacity for conservation response.7, species populations8, forest carbon9, and protected area management effectiveness, equitability, ecological representativeness, and connectedness10. UNEP-WCMC is undertaking such regionalisation for other measures of the state of nature and drivers of change. Other emerging knowledge products, for example to assess risk of ecosystem collapse11, and will also be candidates for such disaggregation once they achieve global coverage.Disaggregation of other knowledge products would complement our work. Examples could include regionalisation of forest coverFinally, given the dynamic nature of all three knowledge products used here, we emphasise the importance that assessment processes build capacity for customised analysis. For future regional/subregional analyses, it will be necessary to repeat such analyses, because the data will be outdated by then. If systematic disaggregations of global datasets such as those presented here become unnecessary in the future, because capacity to undertake such analyses has by that point been developed within each region, this would be an excellent measure of the success of the capacity-building efforts associated with processes to assess biodiversity and ecosystem services. Clear guidelines will still be necessary to standardise data analysis across regions, as a precondition for comparisons in space and time.12  and IPBES13  are documented in The regionalisations slated for use by GEO14 (http://www.iucnredlist.org) is a knowledge product derived from assessment of species extinction risk against the IUCN Red List Categories and Criteria15. The IUCN Red List of Threatened Species dates back five decades16. Stimulated by the 1984 Road to Extinction Conference17, a process was initiated to establish quantitative categories and criteria for assessment of extinction risk18, and this standard was eventually approved in 2000 by IUCN Council19. The nine mutually-exclusive categories of extinction risk are: Not Evaluated (NE); Data Deficient (DD); Least Concern (LC); Near Threatened (NT); Vulnerable (VU); Endangered (EN); Critically Endangered (CR); Extinct in the Wild (EW); and Extinct (EX). In addition, a flag can be applied to denote Critically Endangered species which are ‘Possibly Extinct’ and ‘Possibly Extinct in the Wild’20. It incorporates robust protocols for handling uncertainty21 and guidelines for application at national and regional levels22. Required documentation for all assessments includes not only application of the categories and criteria, but also distribution maps, and application of standard classification schemes, e.g., for threats23. Its application is supported by detailed, regularly updated guidelines24. As a risk assessment protocol, The IUCN Red List of Threatened Species does not drive priorities for any particular type of action25 but rather informs a broad scope of policy and practice ranging from threatened species legislation through to Environmental Impact Assessment27.The IUCN Red List of Threatened Species19. These data are maintained in an underlying database, the Species Information Service (SIS), and are freely available for non-commercial use according to published terms28, and under data licence for commercial use through IBAT29.The IUCN Red List of Threatened Species is a dynamic knowledge product. Version 2015-2 includes assessments of 77,340 species against the IUCN Red List Categories and Criteria30, and there have been two assessments of all mammals31, amphibians32, and reef-building corals33. Third reassessments are underway for mammals and amphibians, and comprehensive global assessments of reptiles and fishes are far-advanced, with the former building off existing assessments of all chameleons14, and all seasnakes34, and the latter all sharks and rays35, tarpons and ladyfishes36, parrotfishes and surgeonfishes37, groupers38, tunas and billfishes39, and hagfishes40, as well as angelfishes, blennies, butterflyfishes, picarels, porgies, pufferfishes, seabreams, sturgeon, and wrasses14. Other animal groups that are already comprehensively assessed include freshwater caridean shrimps41, cone snails42, freshwater crabs43, freshwater crayfish44, and lobsters14. Among plants, comprehensive assessments are complete for cacti45, conifers46, cycads47, seagrasses48, and species occurring in mangrove ecosystems49. In addition, a sampled approach to Red Listing50 has been implemented for reptiles51 and dragonflies and damselflies52, and is being implemented for various other invertebrate53 and plant55 taxa. The IUCN Red List has a target of assessing 160,000 species, stratified taxonomically, to serve as a ‘barometer of life’ representative across species and ecosystems56.All bird species have been assessed six times by BirdLife International57. A Standards & Petitions Sub-Committee, independently appointed by and accountable to the SSC Chair, serves to adjudicate petitions against particular assessments or disputes related to the Red List Categories and Criteria.The IUCN Red List of Threatened Species is governed by a Red List Committee, the Chair of which is appointed by the Chair of the IUCN Species Survival Commission . The Red List Committee comprises equal representation from SSC, the Global Species Programme of the IUCN Secretariat, and the Red List Partnership. The latter comprises a dozen institutions who contribute $200,000 or more annually towards the delivery of the Red List Strategic PlanFor larger taxonomic groups that have been assessed comprehensively , listed above, we present total numbers of species occurring in each region/subregion, for GEO .For the taxonomic groups that have been assessed multiple times, it is possible to derive Red List Indices, which are indicators of the aggregate rate at which all species in a given taxonomic group are moving towards extinction76. Rodrigues et al.76 successfully applied this downscaling technique to grid cells, ecological regions, and countries. We extend this downscaling to the regionalisation slated for GEO (Data citation 5) and IPBES (Data citation 6).It is possible to downscale Red List Indices spatially by combining information on species’ changes in Red List status with the range maps compiled as required documentation for each species’ assessment. For any given taxon and over a given assessment period, the weighted annual change in Red List status is a measure of the relative annual contribution of each region/subregion to the overall change in the global Red List Index for that taxon. Specifically, this measure is calculated for any given region/subregion as a weighted species richness divided by the number of years in the assessment period, where each species is weighted by: i) the number of genuine category changes in The IUCN Red List of Threatened Species during the assessment period , and ii) by the fraction of the species’ range occurring within the region/subregion77. They are identified by assessment of sites against standard criteria for the presence of threshold levels of significance for threatened biodiversity (based on Red Lists), range-restricted biodiversity, ecological integrity, and biological process. In 2004, IUCN’s Membership requested ‘a worldwide consultative process to agree a methodology to enable countries to identify Key Biodiversity Areas, drawing on data from the IUCN Red List of Threatened Species and other datasets, building on existing approaches’ (WCC-2004-Res-013). An initial formulation of the scientific basis for identification of KBAs was published by Eken et al.78, extended into best practice guidelines by Langhammer et al.79 In response to published critique81, the World Commission on Protected Areas (WCPA) and SSC convened a joint taskforce to consolidate standards for KBA identification. Building from six technical workshops and 12 regional workshops, this taskforce released a consultation document for public comment77 in 2014 and final revisions to this are currently underway for presentation to IUCN’s Council.Key Biodiversity Areas (KBAs) are sites contributing significantly to the global persistence of biodiversity30. The criteria have also been applied in the marine environment to identify >3,000 marine IBAs including 120 in Areas Beyond National Jurisdiction82. IBA data are freely available for non-commercial use according to published terms83, and under data licence for commercial use through IBAT29.The mandate that the process for consolidation of the standard for identification of KBAs must ‘building on existing approaches’ is important, because a number of such processes have been in place for four decades. BirdLife International  first established such criteria for the identification of Important Bird Areas  in the late 1970s. National processes, led by BirdLife International partner NGOs, have now undertaken site assessment following these criteria in >200 countries and territories, yielding identification of >12,800 IBAs in total84, butterflies85, plants86, freshwater biodiversity87, and marine turtles88, mammals89, and other biodiversity90. In North America, the Natural Heritage Programs have since the 1970s utilised similar criteria to identify ‘B-ranked’ sites91. The Alliance for Zero Extinction (AZE), established in 2004 and comprising 88 biodiversity conservation NGOs, is dedicated to the identification and safeguard of all KBAs holding effectively the entire global population of at least one Critically Endangered or Endangered species92. A total of 587 AZE sites have been identified, with these data freely available for non-commercial use93, and available under data licence for commercial use through IBAT29. Among other contributors to the identification of KBAs94, the Critical Ecosystem Partnership Fund, which has based its ‘ecosystem profiles’ on KBAs for more than a decade, particularly stands out.Numerous other organisations have utilised similar criteria to identify important sites for, e.g., amphibiansWhile all of these approaches, and thus KBAs as an umbrella standard, identify sites of importance for biodiversity, these are not necessarily important for any particular type of conservation action. Thus, they are intended to inform, but not prescribe site-level actions for practice and policy, including the establishment of protected areas at national level, and the designation of sites according to regional directives  and international conventions .95. Here, we therefore report the total numbers, mean sizes, and percentage coverages of IBAs and AZE sites across the regionalisation proposed for GEO (Data citation 7) and IPBES (Data citation 8).While KBAs have not yet been identified globally using the criteria in the standard being developed, the mandate that the KBA standard and its application must be implemented ‘building on existing approaches’ allows us to have confidence that sites identified by those existing approaches which have been applied globally will be retained as KBAs of international importance under the new standard. The two such existing approaches that have been applied globally are IBAs and AZE sites96 (http://www.protectedplanet.net). It is based on a United Nations Economic and Social Council (ECOSOC) mandate dating back to 1959 for the compilation of the UN List of Protected Areas (ECOSOC Resolution 713 (XXVIII)), and implemented by IUCN-WCPA and the UNEP-World Conservation Monitoring Centre97. Protected Planet data are freely available for non-commercial use according to published terms98, and under data licence for commercial use through IBAT29. It follows the IUCN definition of a protected area as ‘A clearly defined geographical space, recognised, dedicated and managed, through legal or other effective means, to achieve the long-term conservation of nature with associated ecosystem services and cultural values’ across six protected area management categories99, where the data are available. Since 1981 it has been maintained as a database, and for the last decade it has been made available as an online knowledge product100. In addition to formal, government-reported data, Protected Planet also compiles protected area data from other sources, and is in the process of strengthening its coverage across protected area governance types101. In the future, the WDPA is likely to be expanded to include data on ‘other effective area-based conservation measures’, once the definition of such sites has been agreed97. This definition is still under discussion102, and an IUCN-WCPA task force has been created to provide recommendations on such definition.Protected Planet is a knowledge product reporting on the location, status, and management of the world’s protected areas, underpinned by the World Database on Protected Areaset al.10). Here, we disaggregate the latest such statistics according to the regionalisations for GEO (Data citation 9), and IPBES (Data citation 10).Global summary statistics for the coverage of land and sea by different protected area categories are presented in the Protected Planet reports . These indicators were incorporated into recent assessments of progress against the targets of the Convention on Biological Diversity’s Strategic Plan for Biodiversity68. Here, we therefore derive the latest regional statistics for: proportions of IBAs fully covered by protected areas, for GEO , rather than through GIS analysis of the range maps. The only exception is for ABNJ, within which species occurrences are by definition not coded for national occurrence, and so for which we derive occurrence from GIS analysis of species range maps (none of the species included occur only in ABNJ). We count species as occurring if they occur in at least one of a region’s countries; and species as endemic if they are not listed as occurring in any countries outside of a given region . We present these data for each of the following taxa: mammals; birds; seasnakes; chameleons; amphibians; sharks and rays; selected bony fish groups ; freshwater caridean shrimps; cone snails; freshwater crabs; freshwater crayfish; lobsters; reef-building corals; cacti; conifers; cycads; seagrasses; and plant species occurring in mangrove ecosystems. Resulting data can be found in Data citation 1 and Data citation 3 for GEO  and in DFor both GEO and IPBES, total numbers of threatened species occurring in and endemic to each region/subregion, and proportions of the total number of species and number of endemic species occurring within each region/subregion that are threatened, are derived from the documented occurrence of species in countries. The only exception is for ABNJ, within which species occurrences are by definition not coded for national occurrence, and so for which we derive occurrence from GIS analysis of species range maps (none of the species included occur only in ABNJ). We count species as occurring if they occur in at least one of a region’s countries; and species as endemic if they are not listed as occurring in any countries outside of a given region . We present these data for each of the following taxa: mammals; birds; seasnakes; chameleons; amphibians; sharks and rays; selected bony fish groups ; freshwater caridean shrimps; cone snails; freshwater crabs; freshwater crayfish; lobsters; reef-building corals; cacti; conifers; cycads; seagrasses; and plant species occurring in mangrove ecosystems.The proportion of threatened species can be calculated for all groups that have been comprehensively assessed, but the number of threatened species is often uncertain because it is not known whether Data Deficient (DD) species are actually threatened or not. Some taxonomic groups are much better known than others , and therefore a more accurate figure for proportion of threatened species can be calculated. Other, less well known groups have a large proportion of DD species, which brings uncertainty into the estimate for proportion of threatened species. The reported percentage of threatened species for each region and sub-region is therefore presented as a best estimate within a range of possible values bounded by lower and upper estimates:Lower estimate (‘lower bound’)=% threatened extant species, assuming all DD species are not threatened, i.e., (CR+EN+VU)/Best estimate (‘mid-point’)=% threatened extant species, assuming DD species are equally threatened as data sufficient species, i.e., (CR+EN+VU)/Upper estimate (‘upper bound’)=% threatened extant species, assuming all DD species are threatened, i.e., (CR+EN+VU+DD)/Resulting data can be found in Data citation 1 and Data citation 3 for GEO  and in D76. Category changes encompass the following categories, in order of increasing extinction risk: LC; NT; VU; EN; CR; EW and EX (including CR (Possibly Extinct) and CR (Possibly Extinct in the Wild)). Resulting data can be found in Data citation 5 for GEO and in Data citation 6 for IPBES. This approach requires an assumption that changes in extinction risk are evenly spread across all species ranges. While this will never be wholly valid, for regions as broad as those proposed for the three assessment processes in question, it will be a close approximation, because such a high proportion of species are endemic to single regions  and even to single subregions (66% for both GEO and IPBES).For both GEO and IPBES, downscaled Red List Indices for mammals, birds, and amphibians are derived as the sum, for all species occurring in the region/subregion, of each species’ number of genuine category changes on The IUCN Red List of Threatened Species , multiplied by the proportion of the species range occurring within the region/subregion, divided by the number of years of the total assessment periodFor both GEO and IPBES regions and subregions, we present the total numbers and mean sizes of IBAs and AZE sites, and merge site coverage into two layers (one each for IBAs and AZE sites) to calculate percentage areas of each region and subregion covered by IBAs and AZE sites respectively. Resulting data can be found in Data citation 7 for GEO and in Data citation 8 for IPBES.For both GEO and IPBES, we present regional and subregional summary statistics for the coverage of land and sea by different protected area categories. Resulting data can be found in Data citation 9 for GEO and in Data citation 10 for IPBES.104. Resulting data can be found in Data citation 11 for GEO for IBAs , and plotting the 95% confidence intervals around median protected area coverage accordinglyfor IBAs , in Datafor IBAs , in Datafor IBAs , and in for IBAs . No AZE 105) to the other four criteria106. They examined all bird species globally for 1988–2004 and all Australian species for the much longer period, 1750–2000. They found that the expected rates associated with the thresholds for extinction risk used under the E Criterion were broadly consistent with the observed rates, with the exception of category change from Critically Endangered to Extinct, for which the data revealed many fewer extinctions than predicted from the E Criterion thresholds. They speculated that this mismatch is explained by the disproportionate focus of conservation action on Critically Endangered species, and indeed there is good evidence that conservation efforts have prevented the extinction of a substantial number of Critically Endangered species108. Other approaches to validating the IUCN Red List Categories and Criteria involved retrospective testing based on a reconstructed past extinction109, and prospective testing based on projected future extinctions due to climate change111. Both types of studies concluded that the IUCN criteria can not only identify species that would be extinct without conservation effort, but do so with substantial warning time.The primary technical validation of the IUCN Red List Categories and Criteria undertaken to date compared actual movement of threatened species through the Red List Categories with that predicted assuming equivalence of the E Criterion , with the selection frequency of cells outside IBAs. It found the former to be much higher than the latter, as predicted if such threshold approaches to identification of important sites genuinely identify sites of high irreplaceability for the global persistence of biodiversity. Montesino Pouzols et al.120 undertook a similar validation, comparing KBAs identified in Madagascar, Myanmar, and the Philippines to results of their global analysis of important areas for terrestrial vertebrates, finding similarly consistent results.Di Marco 121–123, finding that representation of threatened species in other taxonomic groups is high. Equivalent tests have not yet been undertaken for marine or freshwater biodiversity. Finally, provision also exists for documentation of KBAs as ‘candidate sites’ suspected by experts as holding threshold levels of threatened species, but for taxa that have not yet been formally assessed for the global IUCN Red List or which have not yet been formally documented to occur at the site. No aggregated analyses have yet been undertaken of these candidate sites.Several tests have also been undertaken to examine the degree to which IBAs represent important sites for biodiversity more generally97. The data are collected directly from governmental agencies while data gaps are provided by other authoritative sources such as NGOs or secretariats of international conventions  or regional entities . All data providers are requested to sign a Data Contributor Agreement which ensures the data published in the WDPA have been approved by the data provider and comply with the terms and conditions of use of the original data.The compilation of the World Database on Protected Areas is underpinned by a formal ECOSOC mandate for national submission of protected area datasets to compile the UN List of Protected Areas (ECOSOC Resolution 713 (XXVIII)), technical validation of the data focuses on tracking changes in the completeness of the dataset and working closely with data providers to ensure the veracity and quality of the information provided through a clearly predefined working protocol97 implemented in 2010. As a result, the WDPA has experienced a great improvement in quality in the past years. For example, the proportion of protected areas represented in the dataset as mapped polygons, as opposed to latitude-longitude centre points alone. Between 2003 and 2015, this proportion increased from 39.5 to 91.1%.The quality of the WDPA is ensured by the WDPA data standardsFor the numbers of species and of endemic species in each of the GEO and IPBES regions and sub-regions (Data citations 1–4), we recommend presentation following the horizontal proportional bar chart used in How to cite this article: Brooks, T. M. et al. Analysing biodiversity and conservation knowledge products to support regional environmental assessments. Sci. Data 3:160007 doi: 10.1038/sdata.2016.7 (2016).