Peri-implantitis is of high prevalence with the popularity of dental implants nowadays. Guidelines or consensus have been developed in succession, and we are little-known about their quality. The objective of this study is to evaluate the methodological quality of these guidelines and analyze the consistency of the clinical recommendations.We searched for guidelines or consensus on prevention, diagnosis, and/or treatment of peri-implantitis through PubMed, Web of Science, Cochrane Library until January 15th, 2022. In addition, we also searched the websites of the American Dental Association, International Team for Implantology, FDI World Dental Federation, and some guideline collection databases. Appraisal of Guidelines for Research & Evaluation II methodological quality instrument was used to assess the selected guidelines. Furthermore, we described the consistency of recommendations across the included guidelines.In total, 15 guidelines were included. The mean values of the six domains score all below 50%. The mean scores of Applicability were lowest . As to the overall quality, eleven (73%) were recommended after being modified, and four (27%) were not recommended. Among the clinical recommendations, 53 (67.09%) are for treatment of peri-implantitis, 13 (16.46%) for monitoring issue, 7 (8.86%) for diagnosis, 3 (3.80%) for the disease prevention.Improving methodology quality and strengthening clinical evidence is essential in the future guideline development in a range of disciplines for improving the treatment effectiveness of people with peri-implantitis. And there is a lack of integrated guidelines in the case of the COVID-19 pandemic.The online version contains supplementary material available at 10.1186/s12903-023-02904-4. Peri-implantitis is a pathological condition occurring in tissues around dental implants, characterized by inflammation in the peri-implant connective tissue and progressive loss of supporting bone , 2. As wWe conducted an assessment of the quality of CPGs on peri-implantitis with the AGREE II instrument. The study protocol was registered in PROSPERO (CRD42021285546) and the results are reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements .We searched the public databases including PubMed, Web of Science, Cochrane Library, and websites of relevant organizations  and grey databases  up to January 15th 2022. Reference lists searching and experts consulting were conducted to ensure a comprehensive review. The search words included “peri-implantitis”, “peri-implant disease”, “guideline”, “recommendation” and “consensus”, and more details of search strategy could be seen in Supplementary material part 1.We included documents that focused on the diagnosis or management of peri-implantitis. The documents should be developed by international, national health organizations or stomatology societies. Only documents in English would be eligible. Keeping up with these criteria, two researchers screened the documents respectively and disagreements were resolved by discussion and consensus.Where available, the following information from each article was extracted using a pre-set data extracted form, including title, acronym of the guideline, publication date, country applied, region, type of guidelines, issuing society full name, type of publication, development method, evidence-grading system, strength of recommendations, quality of evidence, developers and number of developed organizations and so on.Four experienced researchers independently appraised each eligible guideline by using the AGREE II instrument, which provides an objective evaluation to assess the quality of guidelines. This tool consists of six domains  and two overall guidelines assessment. According to the instruction, a total score more than 60% will be determined as “recommended”, a score range 30% from 60% as “recommended with modification” and below 30% as “not recommended”.We carefully read each document and extract clinical recommendations related to peri-implantitis, and the strength of recommendation and quality of evidence subsequently. The extracted content mainly includes the recommendations on the prevention, diagnosis, and treatment of peri-implantitis. In terms of The criteria for classifying the strength of recommendation and quality of evidence is generally different for most the guidelines. To solve this problem, we use a new comprehensive classification criterion and an additional word file shows this in more detail, which we can redefine and compare the recommendations.We conducted a descriptive analysis on the general characteristics of the included guidelines. For each item, the minimum score was 1 (the lowest score) multiplied by the number of reviewers, and the maximum score was 7 (the highest score) multiplied by the number of reviewers. Domain scores were calculated by adding the scores of individual domain items and scaling the total as a percentage of the maximum possible score for that domain: [(obtained score) – (minimum score)] / [(maximum score) – (minimum score)]. The domain scores are presented per domain per CPG as percentages with the mean score for all CPGs.Fifteen guidelines met the inclusion criteria Fig. . Six 40 Only oneEditorial Independence , Scope and Purpose  and Clarity of Presentation  had higher average scores. Stakeholder Involvement  had lower average scores. Rigor of Development  and Applicability  had the lowest average scores. As for the overall evaluation, eleven (73%) were recommended with modification, and four (27%) were not recommended. Overall quality as assessed by the AGREE II tool was dis-satisfactory  provided the level of evidence (low:2), and 1 (1.27%) provided with the strength of recommendation (weak:1) Table . Among tNowadays, dental implantology has become more frequent to treat aesthetic and functional problems induced by natural tooth loss. and the incidence of peri-implant diseases also increased correspondingly. As an irreversible disease, peri-implantitis used to result in the implant loss. Prevention, diagnosis, and treatment are of equal importance in peri-implantitis management. To our knowledge, this is the first study that critically appraise the scientific evidence and recommendations of guidelines or consensus on peri-implantitis.Scope and Purpose, Stakeholder involvement, Clarity of Presentation, Rigorous of development, Applicability, and Editorial Independence) were less than 50%. Considerable discrepancies between documents were seen as reflected by the wide IQRs. As the result shows, the score was lowest in the Applicability, indicating there is still a distance to take the evidence provided into practice. Regarding the score of Rigor of Development scores and Stakeholder Involvement were second and third lowest respectively, there is a need to improve the methodological quality and include patient’s views in the further development. Besides, only one guideline was given the strength of the recommendations and quality of evidence. More detailed, 98.73% of guidelines did not given the recommendation strength, and 97.46% were ungraded quality in view of currently insufficient evidence. Even provided, the recommendation was based on the simple review of several observational studies, which may be of poor quality.In terms of 15 consensus or guidelines in peri-implantitis, median scores for six AGREE II domains  have a positive impact on preventing peri-implant mucositis from proceeding into peri-implantitis. Undoubtedly, patients play an important role in good oral hygiene carried out consistently and thoroughly. However, it’s vital that the regime demonstrated by hygienist and therapist or nurse oral health educator is easy, achievable and simple so that it becomes embedded in the patient’s daily routine . In addiThe existing guidelines consistently suggest monitoring necessitates along the presence of dental implant. During support periodontal treatment (SPT), a regular assessment of peri-implant health is recommended to identify disease at an early stage , 22, andDiagnosis of peri-implantitis depend heavily on radiological examination. The diagnosis basically divided into two conditions based on whether there is previous examination data.It’s highly agreed by AAP&EFP  and BOA&It’s well-recognized among current guidelines that as to treatment of peri-implantitis, surgical augmentative peri-implantitis therapy leads to improved clinical and radiographic treatment outcomes, which is considered to be superior to non-surgical therapy in resolving peri-implantitis , 21, 28.Our study systematically searched and summarized the available guidelines and consensus on peri-implantitis, and furtherly appraise the methodology quality with AGREE II. As our result shown, the overall quality was unsatisfactory, and especially in Applicability. As to the recommendations on peri-implantitis management, it covers prevention, diagnosis and treatment, which serves as a clear guidance for clinician to daily practice, while the recommendation strength and quality needs to improve. However, there are inevitable downsides to this study. Firstly, some guidelines published not by medical organization or in English were excluded, which may result in a bias towards total situation. Secondly, although we have conducted a comprehensive research, some documents may be updated during the process of appraisal. Since the COVID-19 epidemic is still ongoing, COVID-19 infection may exacerbate peri-implantitis or affect patients’ follow-up . The proAlthough Osseointegration and implant therapy, peri-implant inflammation have been put up respectively in the 60 and 90 s in the last century, peri-implantitis seems to be a “new disease” based on the quality of current guidelines. To further improve the quality of peri-implantitis guidelines, it is necessary to do a good job of investigating real clinical needs. Clinical questions arise mainly from surveys of guideline users, especially front-line clinicians, or current literature . The source, quantity, and composition of clinical problems not only determine the length of the guidelines and the content of recommended opinions but also influence the dissemination and application of the guidelines. When the clinical problems are highly relevant to first-line clinicians and the problems are clearly expressed, the implementation effect of the guidelines will be better, and vice versa.Improving methodology quality and strengthening clinical evidence is essential in the future guideline development in a range of disciplines for improving the treatment effectiveness of people with peri-implantitis. And there is a lack of integrated guidelines in the case of the COVID-19 pandemic.Below is the link to the electronic supplementary material.Supplementary material part 1. Literature Search Strategies. Supplementary material part 2. A composite grading system for ranking recommendations in guidelines of COVID-19. Supplementary material part 3. PRISMA 2009 Checklist. Supplementary table 1. General characteristics of eligible guidelines. Supplementary table 2. AGREE II domain scores of included guidelines and overall assessment.


This article was migrated. The article was marked as recommended.BackgroundWidening participation to health science degrees is a vital part of our efforts to ensure a high-quality pool of graduates in clinical fields. With the increasing usage of multiple mini interviews for selection to these courses, it is crucial that we recognise the biases within these selection processes.AimsThis paper aims to examine recently published literature to determine the extent to which demographic factors  impact on MMI scores for applicants to health science degrees.MethodsA literature search was conducted using the Medline and SCOPUS databases for literature published from 2015 to present. Relevant papers were identified through a Boolean search, and individually analysed to determine their relevance to this review.ResultsThis review identified nine relevant papers. Biases were identified in all four domains, but the evidence was mixed and of varying quality. The strongest evidence for a bias was found in papers looking at socio-economic background.ConclusionFurther research is required to determine the extent to which the MMI approach is biased against certain groups of applicants, and to identify ways to address these imbalances, as evidence of the impact of demographics on MMI score has been identified. The topic of Widening Participation (WP) is experiencing a lot of attention at present. A recent consultation by the Department of Health on expanding undergraduate medical school places includes a focus on how universities will ensure they are recruiting underrepresented demographics, which highlights the current atmosphere with regards to WP . Given tA broad range of attributes and skills, both cognitive and non-cognitive, is vital for everyone working in the clinical environment . Deciding which attributes to test poses a challenge for health science institutions. Of all the tools available to selection committees, from standardised admission tests, such as the UK Clinical Aptitude Test or the Pharmacy College Admissions Test, to personal statements and academic achievement, the interview has perhaps undergone the most change in recent years.Interviews allow institutions to assess candidates against an extremely wide range of criteria, depending on the assessment aims of each institution; from biomedical knowledge and statistical ability, to communication skills and empathy. It is perhaps surprising therefore that there are only two main interview modalities that are currently employed by health science institutions: Multiple Mini Interviews (MMI’s) and panel interviews .MMI’s were first developed in 2004 to improve upon the relatively poor predictive validity of the contemporary non-cognitive assessments, such as panel interviews and personal statements . Their uGiven the current emphasis on WP, and the importance of the selection process to health science degrees in determining the make-up of the workforce in health professions, it is vital that any hidden biases within the MMI system are well understood. Bias in health science selection procedures, which refers to the phenomenon wherein attributes other than those designed to be assessed  affect performance in an assessment , has theThis review will examine the recently published literature to investigate the extent to which MMI’s can be discriminatory in terms of age, sex, socio-economic background (SEB), and race. This will update the findings of the BEME Guide No. 37, which provided an insight into the literature on this topic from 2004-2014 . While dth October 2017. The search used to generate the literature for this review was:The literature search for this review was conducted on Medline and SCOPUS on 15(mmi OR “multiple mini interview*” OR “multiple-mini-interview*” OR “multiple-mini interview*”) AND The search was limited to papers published since 2015 to ensure it provided an update to the BEME Guide No. 37, the literature search for which was updated in 2014 . This isThe nine papers identified examined entry onto three different health science courses: six for medicine, two for nursing, and one for pharmacy. A summary of these papers can be found inSix papers investigated the impact of applicants’ age on MMI score; three in applicants to medicine, two to nursing, and one to pharmacy . Two stust year students, who had already passed a panel-based interview and gained entry to the course, which may have impacted the results. It was also heavily dominated by female students (92%), which limits the generalisability of the findings.Traynor et al.  found thLeduc et al.  used theFour other studies  found no impact of age on MMI result . These fSeven papers investigated the effect of sex on MMI score. Four papers examined medical school admissions; two, nursing school admissions; and one, pharmacy admissions. Two papers identified a significant impact of sex on MMI score, while the other four did not.expect female applicants to possess these skills, and therefore mark them more highly. The authors of this study recommend a longitudinal, health outcome based approach to investigate this further. None of the other studies included in this analysis showed any significant effect of sex on MMI scores  on MMI scores .Leduc et al. used a self-assessment form to categorise applicants into those with a family income of either <$100,000, $100,000 to $250,000, or >$250,000, and compared the MMI scores for applicants within these categories. It found that students who declared a parental income of >C$250,000 had significantly higher MMI scores (M=252.8) than those in the C$100,000 to C$250,000  and <C$100,000  groups. This study is limited by the fact that it relies on the applicants’ self-assessment of family income, but nonetheless draws into question the validity of the process.Jerant et al.  examinedTaylor et al.  found noThis study has several limitations. As discussed previously, it does not examine the reasons behind differences in success rates among applicants with different demographics. While confirmation bias in the examiners may explain these differences, in many instances the true reasons could be more complex, with an interplay of valid and invalid factors influencing the score candidates receive. Further, this review has not examined the impact of the demographics of the assessor on the levels of bias within the MMI system, which presents an interesting topic for further study. Lastly, this review has presented no evidence regarding the ways in which these impacts should be mitigated.This review has found mixed evidence for the impact of demographics on MMI score for the selection of health science students. For all aspects examined in this review , there is some evidence of bias within the MMI process, most convincingly in terms of candidates’ socio-economic backgrounds. This demands further research, with the aim of determining the long-term impact of bias on health outcomes, and the methods through which these biases can be mitigated.•MMI’s have been increasingly employed in recent decades•The last major investigation into the validity of this assessment type was completed in 2014•This review has found mixed evidence, with some studies indicating the presence of bias•Educators should take steps to mitigate the impact of these biases•More research is needed to investigate the potential reasons behind this dataGerens Curnow is an undergraduate medical student at the University of Exeter, currently undertaking an MSc in Clinical Education. This review has been migrated. The reviewer awarded 4 stars out of 5 A very well written and balanced paper with some new references on the subject. Although there are quite a few papers now in circulation regarding the MMIs, there seems to be work still to be done, especially in the area of how MMIs probably need to be adapted to the widening access admission programmes.A paper all involved in student selection should readReviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 4 stars out of 5 This is a well written and interesting paper which covers an important topic. The MMI is increasingly used in student selection, and this paper which covers research from 2014 onwards adds to the evidence produced in the BEME guide. Although the results show a mixed picture in how the age, gender, race and socio-economic status of applicants can effect success at MMI, some evidence of decreased performance in those from lower socio-economic groups is an important finding in the drive to widen access to the health professions. This calls for more research and a balance of admissions criteria. An enjoyable read that will be of great interest to all involved in student admissions.Reviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 4 stars out of 5 Very thoughtful paper and I enjoyed reading it. The four demographics selected that were selected for this study are Age, sex, race, and socioeconomic background are very interesting. Mni-multiple interviews itself is a very curious topic in the current medical students' selection and admission process. There are many articles in favor of MMI vs Traditional interviews. But the same way we have some papers in the literature offering no special added advantage with MMI. One such paper published recently in Academic Medicine Journal is "Do Multiple Mini-Interview and Traditional Interview Scores Differ in Their Associations With Acceptance Offers Within and Across Five California Medical Schools?"Thank you for providing the detailed analysis based on the literature regarding the bias associated with age, sex, race, and socio-economic background for scoring in MMI. There was no conclusive evidence as author quoted. It requires further research. This paper is interesting for interviewers and admissions committees of the medical programs.Reviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 4 stars out of 5 This is an interesting study examining the impact of four demographic characteristics  on performance in multiple mini-interviews (MMIs). The methodology of the study/review is well described. Limiting the search to the Medline and SCOPUS databases may have excluded some studies dealing with this topic. MMI is being increasingly used for admission to health profession schools. The paper is well written. Educators involved in admissions to health professions schools will find this manuscript of special interest.Reviewer Expertise:NANo decision status is available


Retained surgical sharps (RSS) is a “never event” that is preventable but may still occur despite of correct count and negative X-ray. This study assesses the feasibility of a novel device (“Melzi Sharps Finder®” or MSF) in effective detection of RSS.The first study consisted of determination of the presence of RSS or identification of RSS in an ex-vivo model (a container with hay in a laparoscopic trainer box). The second study consisted of determining presence of RSS in an in-vivo model (laparoscopy in live adult Yorkshire pigs) with 3 groups: C-arm, C-arm with MSF and MSF. The third study used similar apparatus though with laparotomy and included 2 groups: manual search and MSF.In the first study, the MSF group had a higher rate of identification of a needle and decreased time to locate a needle versus control . It also had increased accuracy of determining the presence of a needle and decreased time to reach this decision . In-the second study, the accuracy of determining the presence of a needle and time to reach this decision were comparable in each group . In the third study, MSF group had higher accuracy in determining the presence of a needle and decreased time to reach this decision than the control . Multivariable analysis showed that MSF use was independently associated with an accurate determination of the presence of a needle .The use of MSF in this study’s RSS models facilitated the determination of presence and localization of RSS as shown by the increased rate of identification of a needle, decreased time to identification and higher accuracy in determining the presence of a needle. This device may be used in conjunction with radiography as it gives live visual and auditory feedback for users during the search for RSS. A retained surgical item (RSI), which is defined as an unintended retention of a foreign object in the operative field, is a serious event with potentially life-threatening complications. Accordingly, it is categorized under “never event” by the National Quality Forum. Since 2012 when the Joint Commission started publishing data on sentinel events, RSI has been the most frequently reported sentinel event –7. As a Every RSI has a significant cost, both to the hospital system and the patient. If recognized during the surgery, it may significantly increase the anesthesia time while increasing the risk of iatrogenic injury during the search. If recognized after, it requires an additional surgery to retrieve the item. In fact, one large case report suggests that RSIs are responsible for approximately 70% of surgical re-interventions . PatientA RSS is defined as a lost sharp, most commonly a needle, not recovered prior to the patient leaving the operating room. Currently, most hospitals employ an RSS protocol that consists of strict needle counts after each case and utilization of radiography if the counts are inconsistent. However, correct counts do not necessarily mean an absence of RSS as one study found that 88% of RSI events occurred despite of a correct count , 15. In In an attempt to increase the ability to find surgical sharps not detectable via X-ray, The Melzi Sharps Finder® (MSF) was developed Fig. . MSF is ex-vivo and in-vivo studies to evaluate the utility of the MSF in (1) determining the presence of a needle in the abdomen after a miscount, and (2) locating a lost needle known to be in the abdomen.The MSF Fig. a is an FThe MSF was evaluated in a “needle in a haystack” setting, in which suture needles were hidden in a laparoscopic trainer box filled with hay. Three users, consisting of one PGY-3 general surgery resident and two PGY-4 urology residents, were instructed on the basics of how to operate the device, but were not trained in how to perform a search. The users were allowed to develop their own method to search for the needle.3 container and then placed into a Laparoscopic Trainer Box . Users were randomly assigned to the control or device group in a 1:1 fashion via a random number generator for each study and were blinded to the needle location. The control group was allowed to use one grasper and a free hand to navigate through the hay in the container while the device group was given MSF in place of a grasper. The users were allowed to use their hands to move the hay or the container. The suture needle was considered found when directly visualized on the camera in the Laparoscopic Trainer Box  C-arm with manual search using laparoscopic instruments, (2) C-arm with MSF, and (3) MSF alone. Each trial was further randomized to needle size (9 mm versus 26 mm), needle location  and the presence of a needle (with a 2:1 ratio of present versus absent). Block randomization was performed to ensure equal sample sizes. The length of each trial was capped at 5 min. Primary endpoints included user accuracy in determination of presence of needle and time to determine the presence of needle. Prior to each trial, the user was informed of a needle miscount and the size of the missing needle. In arms 1 and 2, a C-arm was used to obtain an X-ray of the abdomen at the beginning of each trial. The C-arm was not able to image the entire abdomen in one field of view and so each quadrant of the abdomen was imaged in a sequential fashion. The user and a radiologist interpreted the images in real time. If a needle was identified in one quadrant, the remaining quadrants were not imaged. If either the user or the radiologist decided that a needle was present on X-ray, the user was then instructed to begin searching for the needle using laparoscopic instruments alone (group 1) or laparoscopic instruments and the MSF (group 2). The user was given maximum of 5 min from the time of X-ray to locate the needle. If the user and radiologist both decided that there was no needle seen on X-ray, the trial was concluded. The users in group 3 were given the MSF without X-ray to determine the presence of the needle and locate it. Of note, plain radiography was unavailable and so we utilized a C-arm device to take still images as a substitute form of radiography.Male Yorkshire pigs  were anesthetized to a plane of surgical anesthesia. Laparoscopic access to the abdomen was obtained and the abdomen was insufflated to 15mmHg. Three 5 mm trocars were placed with a midline periumbilical camera and two assistant ports on either side of the midline. Similar to Male Yorkshire pigs  were anesthetized to a plane of surgical anesthesia. The abdomen was accessed with a midline laparotomy incision extending from the xyphoid process to the pubic symphysis. Users were randomized to two groups to determine if the needle was present in the abdomen, and to locate the needle if present: (1) manual search alone and (2) manual search with assistance of MSF. The trials were randomized regarding the presence of needle, needle size, needle location in the same fashion as Clinical Scenario 3. The user was given a maximum of 5 min to decide. In both scenarios 3 and 4, if a user in a non-MSF arm incorrectly decided that there was no needle present in the abdomen, they were then provided with MSF to continue their search. The time to recover the needle with the MSF was recorded separately. Additionally, a systematic search was used in a subset of laparotomy trials to determine if this would independently increase the user’s accuracy or time.Data were analyzed using IBM SPSS Statistics for Windows, Version 27.0 . Chi square test and unpaired t test were used to compare outcomes between two groups while ANOVA was used to compare outcomes amongst three groups. Multivariate linear regression analysis was performed to correlate independent and dependent variables in this study. Statistical significance was determined when the P-value was less than 0.05.A total of 101 trials were performed for Clinical Scenario 1. The control group (n = 50) successfully located the needle in 11 (22.0%) trials, compared to a success rate of 98.1% in the device group (n = 51) (p < 0.001). In addition, in the trials when the needle was found, the device group located the needle significantly faster than the control group .The control group (n = 34) correctly determined the needle’s presence 58.8% of the time while the study group’s accuracy (n = 34) was 100% (p < 0.001). The study group’s time to determine the presence of the needle was significantly shorter than that of the control group .A total of 101 trials were performed . The size of the needle was 9 mm in 49 trials (48.5%) and 26 mm in 52 (51.5%) trials. The MSF was used in 77 trials (76.2%) and X-ray was utilized in 19 trials (18.8%). A needle was present in the abdomen in 66 trials (65.3%) and accurate determination of the presence of a needle was achieved in 86 trials (85.1%).A total of 52 trials were performed with 9 trials in arm 1 , 10 trials in arm 2 (X-ray and MSF), and 33 trials in arm 3 . The distribution of needle size, needle location, and the presence of a needle between arms were comparable. The accuracy and speed of determining the presence of the needle in each group was comparable.A total of 49 trials were performed with two groups using the laparotomy porcine model: manual search group (n = 15) and MSF group (n = 34). The distribution of needle size, needle location, and the presence of a needle between the groups were comparable. The success rate of the MSF group was significantly greater than that of the manual search group . The time to determine the presence of a needle was also significantly lower in the MSF group .When multivariable logistic regression analysis was performed controlling for surgical approach (laparotomy vs. laparoscopy), needle size, needle presence, needle location and C-arm use, the use of the MSF was independently associated with an accurate determination of the presence of a needle Table . The useex-vivo laparoscopic model and the in-vivo porcine model of laparoscopy and laparotomy.This study assessed the feasibility of using MSF to determine the presence of a miscounted needle and identify misplaced needle in the surgical field. MSF significantly improved the time to determine the presence of a needle and the time to find a lost needle in the both the In Clinical Scenario 1, the instrument allowed the users to quickly process through the hay and locate the needle without any visual cues based on auditory and visual signal. As each user sifted through the hay, the device was specific enough to guide the user to the needle within millimeters using the changes in the signals. As a result, the success rate of identification of the needle was 96% and the average time to localize was less than two minutes. The difficulty of directly visualizing the needle in the haystack is demonstrated by the 22.0% rate of needle identification without the device. This rate likely would not have improved significantly even if the users were allowed more than five minutes.Clinical Scenario 2 tested the user’s ability to accurately determine whether a needle was present in the haystack. The MSF group had 100% accuracy while taking less than 5 min to decide. It is worth noting that in most trials, the user made this determination based solely on the device’s auditory feedback without visualizing the needle. This is akin to the detection of RFID embedded sponges with a wand external to the patient . Withoutex vivo model, the MSF was further evaluated in live porcine models.This laparoscopic model simulated the difficulties encountered in finding a needle in a real surgical field: poor visualization, narrow optics, a large heterogenous space, and the potential for the needle to shift positions. Recognizing the inherent limitations of this in-vivo trials were designed to simulate an intraoperative needle miscount in a human patient. Our porcine model aimed to simulate clinical scenarios of RSS with anatomic similarity, dynamic location of the needle in midst of the search, interference of standard operating table with its metallic components, respiratory and cardiovascular variations and limitations of surgical approach (laparotomy and laparoscopy).The in-vivo results suggest that MSF is non-inferior to C-arm in its accuracy of determining the presence of a needle. Groups that used MSF had a very high accuracy in determining the presence of a needle . When compared to manual search, MSF demonstrated a significant improvement in user accuracy (97% vs. 46.7%). MSF had a positive predictive value (needle present) of 95.4% and negative predictive value (needle absent) of 100%. The time to determine the presence of a needle was also significantly shorter when using the MSF by an average of almost two minutes. In addition, multivariable analysis demonstrated that MSF use is independently correlated with a significant increase in the accuracy of identifying a lost needle in the abdomen, and MSF use had a stronger correlation to accurate determination of needle presence than X-ray.The The time to determine the presence of a needle was similar between C-arm and MSF. However, this does not factor in the additional time needed to obtain and interpret an X-ray, though in our trials both the C-arm and radiologist interpretation were immediately available. Our trials also imaged the abdomen by quadrants with the option to obtain additional images as needed to better examine certain quadrants, which may increase its sensitivity by focusing the radiologist’s attention. This arrangement is likely unrealistic in a clinical setting. The delay in obtaining and interpreting an X-ray has significant impact as it lengthens anesthesia time and increases perioperative risk for the patient while also taking up valuable OR time for the staff and the health system. The use of MSF may help to eliminate this time by effectively ruling out presence of needle without waiting for the X-ray or its interpretation.Though there have been significant technological advancements to prevent soft retained items such as the radiofrequency identification of sponges, there has not been a widespread adoption of devices to prevent or aid in finding an RSS. One study explored the use of UV fluoroscopy to retrieve fluorescent coated needles and found that using the device improved surgeon’s time to retrieve the needles . HoweverCurrently, in the case of a miscount, the patient is kept under anesthesia while the surgical team performs a manual search and/or awaits X-ray images to be obtained and interpreted by a radiologist. In recent survey data, this is estimated to take 31–40 min of additional time per miscount event . The comex-vivo and in-vivo experiments and the statistical analysis was robust to demonstrate that MSF is effective in determining a presence of a needle and finding it, if needed.This study has several limitations and shortcomings. included a limited sample size. It is possible that the results may have been different with more trials. However, our outcomes were consistent throughout both Due to the nature of the device indiscriminately finding metallic objects, there was an unusual situation that required the research coordinator to intervene during one of the laparoscopic trials. Persistent false positive signals were found while searching through the pig’s stomach and small bowel, assumed to be due to the pig’s ingestion of bars of the cage and metal filings. As a result, this required adjustment of sensitivity of the device, which allowed the user to facilitate effective search for the needle. During the laparotomy trials, this was not an issue.Because MSF is a user-operated device, the results from this study may be affected by human error. As previously stated, the users were not instructed in how to conduct an intra-abdominal cavity search with MSF. As a result, each user had a different approach to their search, and this may have been a confounder in this study. While beyond the scope of this study, the authors encourage the use of a systematic search when using MSF to maximize accuracy and efficiency. We recommend the following methodology:Sweep the right upper quadrant, making sure to include the large area obscured by the liver, especially the posterior side of the liver and the hepatoduodenal ligament.Search above the body of the stomach and the gastrocolic ligament.Retract the stomach caudad and search the left upper quadrant including perisplenic region.Sweep the right and left paracolic gutters.Perform a pass over the bowel prior to manipulation. When running each portion of the bowel, sweep ahead of the area you are about to manipulate, beginning with the jejunum at the ligament of Treitz and running the bowel to the terminal ileum.Perform a sweep of the lower mid-abdomen and pelvis making sure to arrive on either side of bladder.In addition, when the users were surveyed regarding their experience with the device after the trials, they collectively felt that the use of a sweeping motion or making concentric enlarging circles while working in different quadrants was the most effective way to rule out a sharp in a specific area.ex-vivo and in-vivo models of RSS appears to facilitate determination of presence and localization of surgical sharps. The study groups with MSF resulted in increased accuracy of determination of presence of a needle in the surgical field, increased rate of successful identification of a lost needle and decreased time to its identification. Future clinical trials are needed to validate and corroborate the findings from this experimental pilot study.MSF is an FDA-approved device designed for use in both minimally invasive and open surgeries to detect metallic objects in the surgical field. It gives live auditory and visual signals to guide users to the location of the metallic body. In this multiphase preclinical study, the use of MSF in


Understanding how treatments work in the real world and in real patients is an important and complex task. In recent years, comparative effectiveness research (CER) studies have become more available for health care providers to inform evidence-based decision making. There is variability in the strengths and limitations of this new evidence, and researchers and decision makers are faced with challenges when assessing the quality of these new methods and CER studies.To (a) describe an online tool developed by the CER Collaborative, composed of the Academy of Managed Care Pharmacy, the International Society for Pharmacoeconomics and Outcomes Research, and the National Pharmaceutical Council, and (b) provide an early evaluation of the training program impact on learners' self-reported abilities to evaluate and incorporate CER studies into their decision making.To encourage greater transparency, consistency, and uniformity in the development and assessment of CER studies, the CER Collaborative developed an online tool to assist researchers, new and experienced clinicians, and decision makers in producing and evaluating CER studies. A training program that supports the use of the online tool was developed to improve the ability and confidence of individuals to apply CER study findings in their daily work. Seventy-one health care professionals enrolled in 3 separate cohorts for the training program. Upon completion, learners assessed their abilities to interpret and apply findings from CER studies by completing on online evaluation questionnaire.The first 3 cohorts of learners to complete the training program consisted of 71 current and future health care practitioners and researchers. At completion, learners indicated high confidence in their CER evidence assessment abilities (mean = 4.2). Learners reported a 27.43%-59.86% improvement in capabilities to evaluate various CER studies and identify study design flaws . Additionally, 63% of learners indicated that they expected to increase their use of evidence from CER studies in at least 1-2 problem decisions per month.The CER Collaborative has responded to the need for increased practitioner training to improve understanding and application of new CER studies. The CER Collaborative tool and certificate training program are innovative solutions to help decision makers meet the challenges they face in honing their skills to best incorporate credible and relevant CER evidence into their decision making. What is already known about this subjectIn recent years, formulary decision makers have demonstrated an interest in comparative effectiveness research (CER) and in using CER studies to inform their coverage and reimbursement policies.Despite this interest, barriers such as insufficient awareness and understanding of CER methods and a lack of tools to assess the quality of CER studies prevent its widespread use by formulary decision makers.Without skills and training in new CER methodology, formulary decision makers may not feel equipped to evaluate or use CER findings for decision making, even when studies provide invaluable information.What this study addsThe CER Collaborative tool and certificate training program are resources designed to help formulary decision makers strengthen their CER knowledge and skills in order to evaluate CER studies in a transparent and consistent fashion.The CER Collaborative certificate training program improves participants' confidence to critically appraise diverse CER study designs and use evidence from CER studies in their decision making.Innovative solutions are necessary in order for practitioners to develop the necessary skills and capabilities to incorporate evidence from CER studies in their decision making.1 Decision makers often desire additional information on longer-term outcomes, comparisons of multiple treatment options, or assessments of treatment effectiveness in “real-world” settings based on patient populations or provider settings similar to their own. To help bridge this gap, there is an increasing interest and investment in comparative effectiveness research (CER).2 A large part of the CER investment extends beyond traditional randomized controlled trials (RCTs) to include varying and newer study designs and analytic techniques  to inform decision making.3Health care decision makers, including pharmacists, clinicians, administrators, and pharmacy and therapeutics (P&T) committee members, align scientific evidence with therapeutic guidelines and drug coverage policies. Their responsibilities extend beyond determining whether a treatment or intervention works to also include the evaluation of how well a treatment or intervention works compared with other treatment options in the populations they care for. Often there is a notable gap between the evidence desired and the evidence available at the time of decision making.4 Evidence from other CER studies, such as indirect treatment comparisons or network meta-analyses (NMA), can fill these gaps when comparisons across treatment options are lacking. For example, to assess the benefits of using alendronate, risedronate, and teriparatide for the risks of vertebral, hip, and nonvertebral/nonhip fractures, the NMA technique was used to evaluate the evidence from 32 RCTs to inform benefit design.5 Understanding how to use evidence from newer techniques, such as NMA, allows decision makers to assess a broad range of comparisons with greater confidence and to improve decision making.6Decision makers want and need evidence on how various interventions work compared with other treatment alternatives, and CER studies using newer study designs can be helpful when evidence from direct, head-to-head, RCTs are missing.7 In contrast, the NLA guidelines include these trials as well as observational and genetic studies. The NLA developers recognized that, by limiting evidence to only that of RCTs, the results may not be generalizable to patients who are different from the populations studied in the trials. The differences in the evidence reviewed and guidelines followed alter recommended cholesterol treatment thresholds and modalities such as lifestyle and drug therapy.8 Clinicians need to determine which evidence guidelines are most relevant to their decision-making environment.In other scenarios, decision makers need to understand how various study designs may impact the relevance and credibility of the evidence used to inform care pathways and clinical practice guidelines. For example, differences exist between cholesterol treatment guidelines from the American Heart Association and American College of Cardiology (AHA/ACC) and the National Lipid Association (NLA). The AHA/ACC guidelines are primarily based on evidence from RCTs, systematic reviews, and meta-analyses of trials on atherosclerotic cardiovascular disease outcomes.11 Despite this interest, challenges exist because of the lack of perceived relevance of the evidence, insufficient awareness and understanding of the methods used to generate this information, and a lack of tools to assess the quality of the studies.14 The lack of tools and guidance on how to evaluate and use these new or unfamiliar study designs creates the possibility of 2 undesirable outcomes: (1) misinterpretation of new study data or (2) critical information not being used to inform decision making.15 To help solve these challenges, various roundtables and task forces recently recommended the development of tools to aid in the quality assurance and quality assessment of CER, as well as development of training for the producers and users of CER on how to generate, interpret, and apply CER findings.17In recent years, there has been increased interest on behalf of formulary decision makers, such as the Academy of Managed Care Format Committee, to use CER to inform coverage and reimbursement policies.18 The purpose of this article is to (a) provide an overview of the CER Collaborative online tool and training and (b) present baseline evaluation data on the impact of the tool and program reported by the first cohort of learners on self-reported abilities to interpret and use CER study findings.With this in mind, the CER Collaborative developed a tool and a training program to help address this need for real-world understanding and application of CER studies.17 Its work is based on the premise that a uniform and well-accepted approach to CER assessment enables clear communication between researchers developing evidence and decision makers using evidence.The Academy of Managed Care Pharmacy, International Society for Pharmacoeconomics and Outcomes Research, and National Pharmaceutical Council comprise the CER Collaborative. The collaborative was formed to provide greater uniformity and transparency in the evaluation and use of evidence for coverage and health care decision making, with the ultimate goal of improving patient outcomes.19 To provide instruction on how to use the questionnaires, white papers and an online tool were developed to correspond to each study design and explain how to determine if the credibility and relevance of a study was sufficient to consider in decision making.22Development of the tool began with an extensive literature review of current CER methods, which was conducted by 5 task forces with membership representing various stakeholders from pharmacy practice, academia, industry, and health insurance plans. Four of the task forces were charged with reviewing available good practice standards and reports for various study designs . These elements were then evaluated to determine relevance from a health care decision maker's perspective. Next, questionnaires with domains and indicators were developed to assess the relevance and credibility of each study design .19 To pr23 This rating matrix includes questions to assess the comparative net benefit and the corresponding certainty from all the evidence.To further help formulary decision makers evaluate the entire body or totality of evidence , the fifth task force adapted an existing, widely used framework for synthesizing a body of evidence. The Institute for Clinical and Economic Review (ICER) Evidence Rating Matrix was adapted based on its validity, reliability, prior use, practicality, ease of use, and comprehensiveness.24 The online tool guides users through the analysis to reach an evidence rating, which is an important input to the decision-making process.The questionnaires, white papers, and adapted ICER matrix were combined into a publicly accessible, web-based tool. This tool is divided into 2 components. The first component, “Assessing Individual Studies,” uses the questionnaires to assess the credibility and relevance of the 4 different types of study designs. The second component, “Synthesize a Body of Evidence,” helps the decision maker use the ICER Evidence Rating Matrix as a framework for organizing evidence from multiple studies and study designs .24 The oThe initial work of the CER Collaborative was successful in generating a consensus approach and well-constructed tool. However, active participation and input from various stakeholder experts did not automatically result in rapid adoption of new tools and guidelines. Thus, the next step for the CER Collaborative was to disseminate the tool and guidance through an educational approach. To make the CER Collaborative online tool accessible to new users, an online educational program was launched in 2014.25 This program was developed, designed, and delivered through a partnership between the CER Collaborative and the University of Maryland School of Pharmacy. It was designed around the framework set by the CER Collaborative and the resources established as standards in the field (The CER Certificate Program (CCP), a web-based interactive course, was designed to teach pharmacists and other decision makers about CER study methods and how to use the CER Collaborative online tool.he field .The CCP is a course approved by the Accreditation Council for Pharmacy Education and is composed of 5 online, self-paced modules with background content, step-by-step instructions, and case-based application. The 5 modules cover 4 study designs relevant to CER, as well as guidance on how to synthesize a body of evidence. The trainees remain engaged in the program through active learning exercises and case studies. The 19 credit-hour certificate concludes with an interactive workshop among the trainees held either in person or via a synchronous web-based teleconference . During In October 2014 and April 2015, the CCP successfully certified 3 cohorts that consisted of 71 learners . To obtaSeventy-one learners successfully completed the CCP in 3 cohorts—1 group in October 2014 and 2 groups in April 2015. The majority of the learners were pharmacists; however, 1 physician and 7 students also participated in the program. All learners successfully completed the program evaluation after finishing the program. Learners indicated that the CCP prepared them to demonstrate and apply CER to formulary and/or medical decision making by increasing their abilities to evaluate CER methodological rigor and synthesize a body of evidence . When asDecision makers need to make treatment and formulary decisions based on sound evidence. To comparatively evaluate which treatments work best for which patients, decision makers must be equipped to evaluate the ever-expanding and ever-diverse CER published literature. This requires decision makers to demonstrate familiarity with the broad range of methods that go beyond randomized controlled clinical trials and to understand the nuances of the range of diverse study designs employed in CER.The CER Collaborative online tool and CCP are examples of new and innovative approaches designed to equip decision makers with the necessary resources to critically appraise CER studies. The online tool and the training program walk the user through a step-by-step process of evidence assessment, highlighting critical elements of study design to be assessed when evaluating studies. Through these resources, decision makers who are unfamiliar with newer and diverse CER studies can apply, with more confidence, the evidence from these studies in their decision making.Learners who completed the CCP recognized the importance and value of being able to adequately interpret study findings for sound decision making. After completing the program, they reported increased confidence in their ability to critically appraise diverse CER study designs and indicated that they would be more inclined to use the skills and resources gained through the program in their routine decision-making practices. More than half of the learners reported that they intended to incorporate CER evidence into 1-2 problem decisions per month. While the training program was described as time and resource intensive, the majority of the learners found it valuable.Program evaluation data indicate that the largest improvement in self-reported ability after taking the program was the ability to use the CER tool . This isIt is unknown if the CER Collaborative tools alone may improve the transparency, clarity, and uniformity of CER evaluation. As seen in the CCP learners' self-assessments, at baseline practitioners perceived a lack of ability to assess, analyze, and evaluate new CER studies. Participants in the CCP had the chance to not only learn about these types of new CER study designs but to apply the information to practical case studies. The CER Collaborative tool and CCP offer benefits for producers and users of CER. For students and managed care or drug information residents beginning their careers, the CCP provides a foundation to critically appraise and synthesize evidence. Existing practitioners, who often are familiar with RCTs and systematic reviews, can expand their confidence in using newer CER studies and apply study findings to real-world settings, compare multiple treatment options, or understand the impact for longer-term outcomes. In parallel, producers of research can increase the likelihood that the research produced will be relevant and credible for end users when designing, conducting, and reporting studies.There are 2 limitations that need to be noted with this early report, which was based on the first 3 learner cohorts. First, the numbers are small. As additional cohorts of learners complete the program, future analyses of their program evaluation data will allow an assessment using larger numbers. A second limitation is the self-reported data obtained from a one-time evaluation at completion of the CCP, with learners reporting on how they expect to use what they learned, not how they actually used it. This reporting does not determine whether or not learners used the information in their day-to-day work environments. Learners are now being asked to complete follow-up questionnaires at 2 and 6 months after completion of the CCP. Future analyses will examine how learners report actual use of the knowledge and skills gained in practice.To ensure that the clinical workforce has the requisite capabilities, the CER Collaborative developed an online tool and educational programming for practitioners to hone their CER knowledge and skills in order to enhance transparency and consistency in evidence evaluation. Based on data from the first 3 cohorts of learners enrolled in the CCP, it appears that the online training program increased the awareness, confidence, and skills to assess and apply CER evidence in day-to-day practice. Future evaluations are needed to assess the association of clinician awareness and understanding of newer CER methods with proper interpretation and use of CER study results, informed decision making, and improved patient care.


IntroductionTo provide high-quality surgical care, surgeons must critically appraise medical literature to adapt their clinical practice whenever convincing evidence emerges. This will promote evidence-based surgery (EBS). Over the last decade, we have organized monthly journal clubs (JCs) and more extensive quarterly EBS courses for surgical residents and PhD students, supervised by surgical staff. We evaluated the participation, satisfaction, and knowledge gained by this EBS program, to make the program future-proof and aid other educators.Materials and methodsAn anonymous digital survey was distributed via email among residents, PhD students, and surgeons of the Amsterdam University Medical Centers' (UMC) surgical department in April 2022. The survey included general questions on EBS education, specific course-oriented questions for the residents and PhD students, and questions about supervision for surgeons.ResultsThe survey was completed by 47 respondents from the surgery department of the Amsterdam UMC University Hospital, of whom 63.8% (n=30) were residents or PhD students and 36.2% (n=17) were surgeons. During one year of the combined EBS course and JCs, the EBS course was attended by 40.0% (n=12) of PhD students and was rated with a mean score of 7.6/10. JCs were attended by 86.6% (n=26) of residents or PhD students and received a mean score of 7.4/10. Reported strengths of the JCs were their easy accessibility and the acquisition of critical appraisal skills and scientific knowledge. A reported point of improvement was to focus more deeply on specific epidemiological topics per meeting. Of the surgeons, 64.7% (n=11) had supervised at least one JC and gave a mean score of 8.5/10. The main reasons to supervise JCs were the distribution of knowledge (45.5%), scientific discussion (36.3%), and contact with PhD students (18.1%).ConclusionOur EBS educational program, including JCs and EBS courses, was well appreciated by residents, PhD students, and staff. This format is advocated for other centers aiming to better implement EBS in surgical practice. The principle of evidence-based medicine (EBM) was introduced in the early 1990s to provide clinicians with the ability to identify, retrieve, appraise, and integrate research evidence into medical decision-making ,3. EBM hIt has been argued, however, that in surgical specialties, as compared to other medical specialties, additional obstacles exist to the implementation and practice of EBM. Such obstacles range from the technical or ethical considerations involved in conducting randomized clinical trials in surgery to reluctance to change some of the long-established surgical practices ,7. On thHowever, presenting this EBM paradigm in an integrated and relevant manner remains challenging , in partA study in our institution, published in 2016, showed the merits of a two-day evidence-based surgery course  . In thisAs a journal club is a well-established and popular method of post-graduate education in EBM, in particular critical appraisal, it may be a valuable addition to the evidence-based surgery course. Journal clubs are generally referred to as digital or face-to-face gatherings of interested individuals to discuss the medical literature and teach critical appraisal skills, and are one of the most frequently used traditional methods for teaching EBM ,13. SurvGiven the changes made in the way we offered the evidence-based surgery course and journal clubs, we felt the need to investigate in the present study how surgical PhD students, staff members, and residents perceive a modular evidence-based surgery course in combination with journal clubs and how they evaluate their personal process of acquiring new scientific knowledge and skills as an indispensable prerequisite of their lifelong learning. This could help improve future evidence-based surgery initiatives and might encourage other centers to adopt these practical teaching methods.This article was previously presented as a meeting abstract at the 2022 International Joint Conference of Healthcare Professionals, Bandos, Maldives, on July 19, 2022.Design and settingThis study was conducted in April 2022 as an anonymous digital survey, distributed among surgeons, PhD students, and residents of the surgery department of the Amsterdam University Medical Centers, located in the Academic Medical Center, Amsterdam, who had been able to attend the course and journal clubs during the past year. Available mailing lists of the staff members, PhD students, and residents were used to distribute the questionnaire. Participants who had attended more than one meeting were allowed to complete the questionnaire only once. The department offers gastrointestinal, vascular, hepato-pancreato-biliary, endocrine, and trauma surgery and has around 40 staff members, 30 first-year residents, and about 100 PhD students, although not all are involved in patient-oriented topics.The local medical ethics review board waived the need for a full review of this study as it did not involve patients and did not hamper routine patient care.Evidence-based surgery courseThe evidence-based surgery course has been provided for over 20 years in our department and now consists of four modules: 1) observational studies in surgery; 2) diagnostic accuracy studies; 3) systematic reviews; and 4) weighing the benefits and harms of a surgical intervention, based on a randomized clinical trial, also to facilitate shared decision-making. Every quarter, one of these modules is presented, and the course is repeated every year. A surgeon and a clinical epidemiologist lead the sessions, which take about three hours. In these sessions, they present a general introduction about the particular study design, followed by an interactive discussion about the critical appraisal of the article, including the impact of the findings on clinical practice and how to share this evidence with patients.To prepare for each module, participants receive an EBM manual with some background papers  and exercises . The course is voluntary for PhD students but mandatory for first-year residents in training; a small fee is required from both groups. Participants who have attended all four sessions receive a certificate that can be added to their portfolio for their PhD or surgical education.Journal clubThe journal clubs, which have been organized monthly for the last five years, are completely voluntary, free of charge, and take one hour each. They are led by one of the PhD students and are supervised by a staff surgeon and/or clinical epidemiologist. The paper selected for critical appraisal should have been recently published and was chosen by the PhD student in charge, in consultation with the supervising staff. The article should be timely and relevant for surgical practice and should address a particular methodological challenge, for example, the intention-to-treat principle, stepped-wedge cluster randomization, non-inferiority design, confounding, etc.www.cochrane.nl/resources) by email, at least one week before the journal club, in order to be well prepared. During the journal club, the paper is discussed and critically appraised regarding its methodological validity, the clinical relevance of the results , their precision, and the applicability of the findings to their own setting and patient population.Participants receive the article and the validated critical appraisal checklist appropriate for the article’s study design . The prototype of the questionnaire was scrutinized by the course teachers. The questionnaire was then sent out via email, and the initial non-respondents were reminded twice.Data analysisBaseline demographics were analyzed using basic statistics and were expressed as means or medians (with interquartile ranges) wherever appropriate, or as percentages for dichotomous variables. Statistical analysis was conducted using IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp. Written feedback was appreciated qualitatively.The questionnaire was completed by 28 surgical PhD students , two junior residents, and 17 surgical staff members . Their characteristics are shown in Table Journal ClubsTypically, eight to 15 participants attended each journal club. Some 87% of the participants attended at least one journal club, most of them three to 10 times. Residents and PhD students gave them an overall score of 7.4 out of 10. Topics discussed represented a range of relevant surgical issues: upper and lower gastrointestinal surgery, hepato-pancreato-biliary (HPB) surgery, and vascular surgery. Reported strengths of the journal club were its easy accessibility, the acquisition of critical appraisal skills (facilitated by using the checklists), and methodological knowledge. On the other hand, a desire was expressed for a deeper focus on a single methodological issue in each journal club. Participants preferred a face-to-face meeting to a digital one. They also suggested making the sessions mandatory to increase attendance.Of the surgical staff members, 67.7% attended at least one journal club; most of them had supervised one to three meetings. They gave them an overall score of 8.5 out of 10. When asked about their drive to participate, 45.5% answered "to distribute knowledge", 36.6% mentioned "to facilitate a scientific discussion", and 36.6% stated their wish to have contact with PhD students. The strengths mentioned by the staff were the interaction and input in the journal clubs and the combination of clinical and research activities. The suggestions for improvement focused more on the clinical impact and the possibility of changing policies based on the evidence presented in the paper. Also, the journal club could be even more profitable by writing a letter to the editor of the journal in which the paper had been published. Besides, addressing a broader range of surgical topics was advocated.Evidence-Based Surgery CourseApproximately 40% of all PhD students and residents attended at least one of the quarterly evidence-based surgery modules. They rated them an overall score of 7.6 out of 10. The main reasons for attending none or only a few modules were lack of time or having just started. The positive aspects reported were the well-structured conduct and a good focus on the most relevant methodological topics related to surgical research. This was seen as a valuable addition to the journal clubs. The discussions in small groups as part of the modules were appreciated. Those who had already obtained a master's degree in clinical epidemiology stated they had not gained much additional knowledge from the EBS course. Here also, the participants preferred face-to-face meetings over virtual meetings. As a suggestion for improvement, they proposed to create e-learnings to prepare for the session rather than a paper-based or digital manual.This survey showed that the combination of a modular evidence-based surgery course with regular journal clubs was appreciated by surgical staff, PhD students, and residents. This was illustrated by the high attendance rate. The meetings were considered easily accessible, with interactive discussions and input. The evidence-based surgery course was also appreciated as it deepened methodological knowledge, although it did not go beyond the master's level, which is a limitation for those who have already obtained their master’s degree in clinical epidemiology. Also, not all steps of EBM were addressed in the course, as the vast majority of the participants were already proficient in formulating clinical questions ) and searching for evidence in the MEDLINE  and Cochrane databases. The merits of a journal club could be further enhanced by zooming in on a specific methodological or epidemiological issue and addressing the impact on patients in clinical practice, and by using the outcome of the critical appraisal as input for a letter to the editor.www.cochrane.nl/resources), appeared to be helpful. More recently, open educational resources (OERs) have been proposed for residents to appreciate new evidence [So far, evidence in the literature has been controversial as to the impact of journal clubs on critical appraisal skills ,18, and evidence . These mImplications for surgical practiceThe journal clubs were an extension of our long-standing evidence-based surgery courses for PhD students . InvolviBroadly speaking, to ensure that EBM principles and skills take root in clinical practice, journal clubs should be an integral part of both preclinical and postgraduate education , not onlStudy limitationsAlthough the journal clubs and EBS courses were welcomed by the participants, it would also be interesting to see what the direct impact is on knowledge, skills, and daily clinical practice. A previous study in our center on the effect of the EBS course on the participants’ knowledge and skills regarding epidemiological terms and calculations of outcome measures was found to increase significantly shortly after every course . MetricsThis survey was conducted in an era where COVID initially necessitated digital meetings, which may have hampered interaction and discussion, but eventually, face-to-face meetings were allowed. Being able to compare those two phases led the participants to prefer face-to-face sessions to foster personal and scientific interaction.The response rate of this survey was limited, especially among residents, but its denominator is debatable. Those who last attended the modules and journal clubs over one year ago were not invited in order to avoid recall bias. Others could not be invited as they had moved to another hospital. Moreover, clinicians and researchers are frequently invited to participate in surveys and questionnaires for many studies, which may have led to some "survey fatigue". However, responses were obtained from participants as well as non-participants. Hence, we believe the impact of possible selection bias on the results is small.As this was a cross-sectional study, we cannot compare it to previous data to appreciate any improvement in the knowledge and application of EBM over time.The principles of evidence-based medicine including critical appraisal are essential to keep abreast of the new developments and available evidence in clinical practice in order to to ensure high-quality healthcare. Education in study methodology and practical skills through journal clubs seem synergetic for future clinicians in surgery. In the future, a regular checklist or test may be useful to assess the knowledge and progress of care professionals and researchers in surgery as to the application of EBM principles.


Research and therapy only has relevance when applied to an actual patient.To review a case study of a patient with hypertension and diabetes.The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) of 2004 recommends that a diagnostic workup include an assessment of risk factors and comorbidities using history, physical exam, and laboratory parameters. The presence of comorbidities influences drug selection. Patient evaluation should also include identification of possible causes of hypertension, such as renal arterial stenosis, and an assessment for the presence of target organ damage. Treatment is always influenced by the presence or absence of comorbidities. Lifestyle modifications are crucial to enhancing the success of pharmacologic therapy and should be ongoing. If lifestyle modifications do not work, the clinician must consider drugs. Study data and JNC 7 recommend beta-blockers for hypertension in patients with compelling indications, e.g., high risk for cardiovascular disease and diabetes.JNC 7 emphasizes that evaluation for hypertension includes the assessment for the presence of compelling indications, e.g., diabetes, hyperlipidemia, and high coronary risk. These comorbidities may inform and direct pharmacologic choices.