To improve our finding capabilities, we urgently need to improve how we search and the systems we use.We researchers have taken searching for information for granted for far too long. The COVID‐19 pandemic shows us the boundaries of academic searching capabilities, both in terms of our know‐how and of the systems we have. With hundreds of studies published daily on COVID‐19, for example, we struggle to find, stay up‐to‐date, and synthesize information—all hampering evidence‐informed decision making. This COVID‐19 Res Syn Meth. 2020) who commented on our 2020 paper and proposed a way of improving PubMed's and Google Scholar's search functionalities. Our response puts their commentary in a larger frame and suggests how we can improve academic searching altogether. We urge that researchers need to understand that search skills require dedicated education and training. Better and more efficient searching requires an initial understanding of the different goals that define the way searching needs to be conducted. We explain the main types of searching that we academics routinely engage in; distinguishing lookup, exploratory, and systematic searching. These three types must be conducted using different search methods (heuristics) and using search systems with specific capabilities. To improve academic searching, we introduce the “Search Triangle” model emphasizing the importance of matching goals, heuristics, and systems. Further, we suggest an urgently needed agenda toward search literacy as the norm in academic research and fit‐for‐purpose search systems.We respond to Klopfenstein and Dampier ( To stay up‐to‐date, we researchers would need to read hundreds of research papers a day(!). Particularly, the avalanche of COVID‐19 papers exemplifies how we are chronically information overloaded.Evidence synthesis is more important than ever, yet we lack the knowledge and systems to effectively and efficiently identify the evidence bases for systematic reviews.We claim that research discovery needs an urgent overhaul. Only with awareness of the basic concepts of academic searching, we can know how to make our search routines and systems fit‐for‐purpose.Our commentary clarifies these search concepts to point out the particularities of lookup, exploratory, and systematic searching. The “Search Triangle” model emphasizes that efficient and effective search only works when goals, systems, and heuristics are well matched.Awareness for the importance of search literacy and search education is needed across disciplines.Better search skills not only help in research, but anywhere online.We thank Klopfenstein and DampierIndeed, we were overwhelmed by the substantial attention given to our paperIn this article, we go beyond our original article and put the work of Klopfenstein and Dampier1searching) has become particularly evident in the current COVID‐19 pandemic: This pandemic is not only a medical crisis, but also an information crisis—not because there is no information on COVID‐19, but because there is more than we can handle. Recently, a Lancet editorial called this an “infodemic” and a “major threat to public health.”isearch COVID‐19 Portfolio, an expert‐curated data collection, lists 60 297 medical COVID‐19 publications, whereas 79% were listed between May and August 2020avalanche of evidence is more than any individual can process. For any particular intervention , one can find a confusing and conflicting set of studies purportedly demonstrating evidence for and against , and the Center for Disease Control and Prevention (CDC) giving an overview of various repositories. On the other hand, there are new tools for visualization, access, categorization, and analysis of COVID‐19 information , some of them via crowdsourced idea contests  or hackathons organized by institutions around the globe. This host of new initiatives is important means to fight the COVID‐19 infodemic with improved information access and analysis. However, we argue that the information overload problem is exacerbated by the insufficient nature of the search systems we must use to find relevant information. If the systems and practices we have in place—to discover, analyze, and evaluate evidence—were fit‐for‐purpose, we would not need to battle COVID‐19 with context‐specific fixes that do only little in battling infodemics in all the other contexts. We advocate that fixing existing search systems and practices is at least as important as building new resources on top. This means raising researchers' awareness and understanding about the objectives of searching, along with improving search heuristics and the search systems that make the avalanche of evidence accessible. Klopfenstein and DampierCurrently there is overwhelming research attention trying to solve these information challenges in a diverse suite of innovative ways, each aiming to make COVID‐19‐related information readily discoverable and analyzable. On the one hand, there are dozens of new AI‐ or expert‐curated repositories: for example, One of the most critical factors that can easily limit the quality of our work is the belief that how we search academically is perfectly fine.We argue that the COVID‐19 pandemic is an important time to consider how to improve academic searching altogether. In this text, we clarify some important concepts of academic searching that are the subject of frequent misunderstanding, we introduce the “Search Triangle”—a user‐centric search model to understand the key characteristics of academic searching, and we explore why and how we need to overhaul academic searching to better inform decision making  authors describe the concept using different terms; (b) many databases typically index records  based only on titles, abstracts, and keywords, missing potentially relevant terms in the full texts; (c) no single database catalogues all research; (d) poor search literacy in the research community means that errors or inefficiencies in searching are common; (e) paywalls restrict users' access to search facilities A suite of systems has been built to identify and assemble COVID‐19 relevant research to overcome these problems, making use of artificial intelligence (including machine learning), expert curation and screening for relevant information, and temporarily making resources Open Access.These are admirable, but necessary only because accurate and efficient identification of (free‐to‐access) relevant research across comprehensive free‐to‐use databases does not exist.2As Klopfenstein and Dampierlookup and exploratory searching as the two key search types.(p. 42) Here, the search process should be swift and efficient so as not to disturb the user's workflow. However, lookup searches can also be used by researchers or decision‐makers for cherry picking. From the avalanche of studies, it is relatively easy to select evidence that supports a pre‐held belief or dogma that portrays a biased picture of reality. Sometimes, this cherry picking is deliberate; selecting whichever study provides support for an argument or decision that has already been made . And sometimes it is unintentional: when the first evidence encountered is assumed to be representative. In general, users want efficient and convenient information retrieval, particularly in lookup searchesexplore the available evidence in the least biased way or, better still, to additionally search systematically to have all available evidence for a specific topic (including the counter‐evidence to one cherry‐picked paper). Only then, we can be sure that our conclusions and decisions are sufficiently evidence‐informed.There is much we can learn about searching from the information retrieval and information science literature: substantial efforts have been made to determine the types of searching at various level of granularity and the capabilities required by search systems. This discipline broadly distinguishes exploratory searches to enrich our understanding. In exploratory searches, the search goal is somewhat abstract.(p. 38) The heuristics that users employ and their ultimate goals change throughout the session as they make sense of the information, linking it to and adapting their mental models iteratively.As many topics are complex and require in‐depth understanding, and we cannot always trust anecdotal evidence (see lookup searches), we need systematic searches—which we claimed in our papersystematic searches, with the goal to (a) identify all relevant records (within the resource constraints) in a (b) transparent and (c) reproducible manner.While both lookup and exploratory searches are established concepts in information retrieval, they do not cover systematic searches are preceded by a thorough exploratory search phase.There are presently significant misunderstandings within the research community regarding what systematic searches should and should not entail. These misunderstandings have led to criticism of the systematic review method (compared to narrative reviews) which we find are unfounded—at least in view of the literature search phase that identifies the corpus of evidence for subsequent synthesis. A major criticism is that systematic reviews would not entail “hermeneutic circles” of iterative learning about a research concept, so that researchers would not include and reflect upon findings throughout the search process.do not themselves entail a learning process. They should be predefined, protocol‐driven, structured means of systematically searching, and extracting all potentially relevant bibliographic records. The search area is specified by these search steps  might use the same heuristics  search goals, determines the effectiveness and efficiency of finding and learning. We maintain that researchers—and indeed all information seekers—should understand the following three points that span a “Search Triangle”  topic.The heuristics: how can the search be best conducted? The user must ask which (set of) heuristics best attain the search goal. While simple lookup searches come relatively intuitively with user‐friendly search systems like Google Scholar,most specific first, wayfinding, snowballing , (post‐query) filtering, successive fraction, building blocks (via Boolean operators), or handsearching.The appropriate systems: which (set of) search system(s) best supports the required search type and the suitable search heuristics? It is important to know what can and cannot be accomplished, given the functional capabilities of a particular search system: eg, of the 28 systems analyzed in our paperThe appropriate We contend that good academic searching starts with users thoughtfully establishing what their search goals are: that is, what they want to know/find. Given their search goals, search‐literate users know which type of search they need to engage in and can thus then select appropriate 4To improve academic searching, we suggest an agenda that is rooted in three areas: (a) more awareness for the intricacies of academic searching; (b) better search education; and (c) pressure on search system providers to ensure their services are fit‐for‐purpose. We suggest key points that we believe the scholarly community must tackle, also jointly with institutions, publishing bodies, and search system providers.4.1search literacy is a crucial skill that does not come naturally through extensive computer and internet use, but needs to be trained in search education as part of research training.Improving our search practice starts by creating awareness that Search literacy becomes increasingly needed as the number of search systems increases and the functionality they offer is diversified and continually updated, making them more or less  suitable for specific search types. In recent years, we have seen the introduction of numerous new systems  and techniques  in academic search. Researchers must understand that these systems are all different and that system choice will heavily affect (or bias) what they will find. At the moment, the algorithms of so‐called semantic search systems  and the precise methods of how they select and rank what is shown on the results page are unknown. However, there is evidenceWe currently see an alarming absence of awareness for search system choice. This is evident in the many publications that confuse search system typesCall to action: We must raise awareness across research communities—among students, educators, journal editors, university teaching boards, and interest organizations—of the intricacies of academic searching and how it can be improved. Organizations like the Collaboration for Environmental Evidence,It starts with the users' goals: Raising awareness so users understand what goals they want to reach with their searching and with which (implicit) scientific standards the specific search types (lookup/exploratory/systematic) are associated.Search types: Raising awareness that searching is not always a quick “just Google (Scholar) it,” but in fact can be described by a “Search Triangle” that needs a matching of search goals/types with heuristics and systems  they do not offer. It is also vital to understand that searches can be biased through the use of algorithms to adjust the order of records in search results.4.2search literacy that enables quick choices of both heuristics and systems given an imminent information need involves more than the day‐to‐day search experience we researchers have at hand. Instead, it requires targeted search education. Such education has been shown to significantly improve search quality.To build Call to action: we must make search literacy a priority in research education:What needs to be taught? Since many researchers think their current search practices and systems suffice, we need to raise awareness about problems associated with search illiteracyWho teaches it? University libraries can play a key role in making emergent and established researchers and professionals search literate.How can it be taught? Search literacy can be taught as stand‐alone course or extend existing teaching concepts on digital literacy or information literacy, particularly also in courses on evidence‐based research.4.3not because of their adequacy for each of the three search types we describe,No two‐search systems are identical, and none is perfect. The reason for the great popularity of some systems is simpler and more efficient searching, faster results. Their aim is the fast satisfaction of researchers' information needs, without detours.In terms of functionality, two broad types of search systems exist at present: the traditional “comprehensive‐transparent”  and the newer “efficient‐slick” . The first type allows users to specify their search to the greatest detail, while the second identifies relevant results quickly. The most popular systems are efficient‐slick, while it seems the traditional systems have focused on new features rather than low latency and accessibility. The mission statements of some popular and newly created semantic systems—including Microsoft Academic, Semantic Scholar, and Meta—can be summarized with: all their search tasks, but rather in making users satisfied (and not smarter) sooner.While this increase in search efficiency is generally positive, it comes at a cost. We see two fundamental problems: first, in these semantic search systems it is opaque algorithms that decide about the “right” information that is shown (either absolutely or by order). We currently have neither insight, nor control over these decisions. This is particularly problematic for systematic searching, where our study has shown that all semantic search systems in our sample failed to meet the requirements.We researchers need the best of both worlds to ensure the best research outcomes: we need efficient‐slick and comprehensive‐transparent. We claim that, at present, systems could do much more in different areas than fine‐tuning for the sake of efficient lookup searching—particularly in the realm of evidence synthesis.Call to action:Greater transparency: Search functionalities – that is, what can(not) be done with a search system  and the applied (what is needed). We believe the tools and features of search systems would greatly benefit from effective guidance and feedback from the research community . By establishing clear rules (similar to what systematic search needs to fulfill), we can help to direct the improvement of search systems, and thereby improving access to future‐proof search functionalities. Here we need to involve information technology research methods that have a long history in investigating the performance of particular search features or technologies . Intelligent research discovery systems make it easier than ever to identify research that is relevant to us.systematic searching: both in terms of the inadequate systems we have at hand and the uneducated researchers that use them. If the available search systems were specifically tailored to the needs of search‐literate researchers, the evidence we could produce would be of significantly greater validity and at significantly lower cost. Facilitating and thus accelerating the creation of systematic reviews could particularly help in times of crises—such as we experience today with COVID‐19.We currently see the greatest search issues in We hope the clarification of academic search concepts, the advice in form of the “Search Triangle” model and our calls to action will help improving academic search. We hope our work informs decision making in academic searching and might prove useful in structuring and conducting search education toward search literacy as a methodical skill every academic exhibits and cherishes.The author reported no conflict of interest.


Objective: We aimed to summarize the clinical and pathological features of sclerosing angiomatoid nodular transformation (SANT) in spleen among five cases.Methods: Five cases  with SANT confirmed by pathological analysis between July 2010 and November 2019 in our hospital were included in this study. The clinical, imaging, and pathological data were analyzed retrospectively.Results: Three patients presented with mild abdominal pain or discomfort, while the other two were symptom free. Two patients received ultrasonography (US), and all patients underwent a computerized tomography (CT) scan in our hospital. The typical “spoke wheel” pattern was seen in two cases, and central calcification was detected in one case on the CT scans. All patients indicated peripheral enhancement around the SANT lesion during the arterial phase. Open or laparoscopic splenectomy was performed for treatment. No patient showed recurrence in the follow-up. The pathological characteristics of our cases were in line with those of previous literatures.Conclusions: Peripheral enhancement around the SANT lesion during the arterial phase should be taken into consideration for the diagnosis of SANT as an imaging sign on CT scans. Special attention should be paid to the splenic integrality during the laparoscopic approach, due to the probability of malignancy and the fragility of the spleen. Sclerosing angiomatoid nodular transformation (SANT), a rare non-neoplastic vascular disease affecting the spleen, is formally known as hemangioma or multinodular hemangioma . OfficiaThe study protocols were approved by the Ethics Committee of Shaoxing People's Hospital. Written informed consent was obtained from each patient for the publication of this article and any accompanying tables and/or images.We searched our pathological data and found diagnosed SANT cases based on pathological reports; then these reports were reviewed retrospectively. The clinical data of each patient were collected from the hospital records, including clinical materials and imaging results. Then the data were analyzed retrospectively by qualified staff experienced in the diagnosis of SANT. The post-operative complications were measured with the Clavien-Dindo classification .Two patients underwent ultrasonography (US)  in our hospital, and three other patients underwent US (parameters not available) in other hospitals. All the patients underwent a CT scan  prior to surgery after US which indicated a mass in the spleen. Before examination, a fasting state for 8–10 h was necessary for each patient. The CT scan range was from the diaphragmatic surface to symphysis pubis, and the enhancement consisted of an arterial phase (30–35 s), portal venous phase (60–65 s), and delayed phase (150 s). US results were analyzed by two sonographers, and CT scans were assessed by three radiologists. All the decisions on the diagnosis were made upon consensus.All the specimens obtained after surgery were fixed with 4% neutral formalin and processed by dehydration and paraffin embedding. Then the sections (3–4 μm) were subjected to hematoxylin-eosin (HE) staining, followed by observation under a light microscope to confirm the diagnosis of SANT. The immunohistochemical staining was performed by Envision plus. The sections were incubated with primary antibodies including CD34, CD31, CD8, and smooth muscle antibody (SMA)  and then with secondary antibodies plus a DAB chromogenic reagent (Dako). The pathological results were assessed by two pathologists blinded to this study. A detailed discussion was held until a consensus was reached in the presence of any disputes on the pathological reports.Five SANT cases were found throughout our pathological data, including four cases initially confirmed and one case confirmed after pathological analysis in a retrospective way. n = 1), middle pole (n = 2), and inferior pole (n = 2) of the spleen, respectively. Two cases showed a typical “spoke wheel” pattern . One patient presented with a Grade A pancreatic fistula (Clavien-Dindo classification: Grade II). These symptoms disappeared after oral administration of aspirin enteric-coated tablets (100 mg/day) for thrombocythemia and intravenous injection of somatostatin (3 mg/day) for the pancreatic fistula. No splenic vein thrombosis or other severe complications were detected. The mean hospital stay after surgery was 10 days (5–21 days). The median follow-up time was 40.5 months (8–116 months) with one patient lost in the follow-up, and no patient showed recurrence during this period.The intraoperative and post-operative data of these five cases are summarized in Grossly, there was a solitary well-circumscribed mass in the splenic parenchyma in each case. The cut surface indicated that there were gray-white stellate scars in the central part, with reddish-brown nodules scattered peripherally. HE staining indicated multiple angiomatous nodules, which were wrapped by collagenized fibrous tissues in all lesions . The angThe immunohistochemical results displayed CD34(−) CD31(+) CD8(+) for sinusoids, CD34(+) CD31(+) CD8(−) for capillaries, CD34(−) CD31(+) CD8(−) for small veins , and SMASANT is a rare benign vascular disease in the red pulp of the spleen. Previously, there was no consensus on the nomenclature for this clinicopathological pattern. It was usually misdiagnosed as hemangioma, hemangiosarcoma, inflammatory pseudotumor, hamartoma , and eveThe clinical manifestation of SANT is asymptomatic or non-specific, with most lesions identified incidentally  or durinGiven a lack of specific biomarkers for SANT, pre-operative imaging studies should be of relatively great importance. Although US can conveniently detect the heterogeneous echotexture in the spleen and the internal vascularity on color Doppler can provide some clues for SANT, definite diagnosis is still a challenge due to the various appearances of SANT in US images . In the Generally, splenectomy is considered as the first-line option for SANT , avoidinTo date, the pathological characteristics of SANT have been well-defined. Macroscopically, SANT usually presented as an isolated well-demarcated mass with a gray-white stellate scar in the central part. Besides, reddish-brown nodules were localized in the peripheral sites , 6. MultAccording to previous literature, the immunophenotype of SANT was almost similar among reported cases, which was featured by CD34(−) CD31(+) CD8(+) for sinusoids, CD34(+) CD31(+) CD8(−) for capillaries, and CD34(−) CD31(+) CD8(−) for small veins , 18, 19.SANT is a rare benign vascular entity affecting the spleen. A CT scan is relatively important for SANT diagnosis pre-operatively. Peripheral enhancement around the lesion during the arterial phase should be taken into consideration as an imaging sign on CT scans for SANT diagnosis. Open or laparoscopic splenectomy is an alternative for SANT treatment. Preservation of spleen integrality should be preferred, especially during the laparoscopic approach, because of the probability of malignancy and the fragility of the spleen. According to pathological features, SANT may originate from the red pulp of the spleen.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by The Ethics Committee of Shaoxing People's Hospital. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.HS wrote the manuscript. FL revised the manuscript. BL completed the data analysis. ZS collected the data. All authors have read and approved the article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Evidence presented within a courtroom should be clear so that the members of the jury can understand it. The presentation of distressing images, such as human remains, can have a negative effect on the jury since photographic images may evoke emotional responses. Therefore, it is important to understand how other visual mediums may improve comprehension, bias, or distress individuals. For this study, 91 individuals were randomly assigned one of three visual evidence formats in a mock courtroom exercise. These included photographs, 3D visualisations, or a 3D-printed model. The results show that the use of 3D imaging improves the juror’s understanding of technical language used within a courtroom, which in turn better informs the juror’s in their decision-making. The unbiased presentation and interpretation of data in the courtroom has been emphasised as one of the main issues in forensic science . UnderstThis problem is exacerbated with regard to skeletal trauma evidence as human remains should not be taken into the courtroom . MoreoveThree-dimensional imaging, virtual environments, and simulations are now becoming commonplace in the reconstruction and documentation of crime scenes, artefacts, and skeletal evidence –16. AmpaA script was created to mimic that of a courtroom trial. The scenario detailed two adult males leaving a public house. On their way home, one of the individuals survived a fall that had resulted in a severe head injury associated with a cranial fracture. The mock trial was created so that jurors could determine whether the victim fell or was pushed by the defendant. The script was read by voice actors who were used to play the prosecution, defence, judge, usher, and witnesses including the forensic anthropological expert witness. This recording was played to the jury, who also had access to the script in front of them.The forensic expert presented evidence about the head trauma sustained by the victim. For the cranium of the victim, an example from the archaeological excavation at Stanground South, Peterborough, was utilised . AlthougA full audio script of the mock trial was played to the mock jury. Jurors were a mix of jury-eligible students from Teesside University and volunteers from the local area. Traditionally, jury decision-making research has used college students . FurtherAfter the mock trial, jurors were independently given a questionnaire which requested the participants decision about whether the victim had been pushed or accidently fallen. The questions included their opinion on verdict, their confidence and reasoning for their verdict, the clarity of the evidence displayed, and their understanding of the technical language used throughout the trial. For the confidence- and clarity-based questions, the participants marked their opinion on a 100-mm scale (e.g. a mark at 100 mm gave 100% confidence). This was later converted into a percentage for quantitative analysis using the Statistical Package for Social Sciences (SPSS).For this study, full ethical approval was obtained through Teesside University’s ethics committee . Upon completion of the experiment, full disclosure of the entire study was declared.Ninety-one (82%) of the 111 participants who took part in the study fully completed their questionnaire and the results were incorporated in to the final analysis. The 20 questionnaires that were excluded from this research were due to the failure of the individual to sign the consent form. Although there were no comparisons made between males and females, the overall male to female ratio of participants was 28/63. Due to the accessibility of participants, 70% of mock jurors were between 18 and 21 years old. Of the varying visual presentations, 24 participants (26.3%) were randomly assigned the photographic images, 33 participants (36.3%) assigned the 3D printed models, and 34 participants (37.4%) assigned the 3D digitisations. Unfortunately, due to some of the questionnaires being incomplete, the total number of participants for each visual modality was not the same.p value between 3D digitisations and 3D-printed models was 0.061.Regarding the overall verdict of the findings, there was no significant correlation between the results Table . FurtherIn addition to the verdict, the participants could detail the reason behind their decision by free text. Interestingly, where the “not guilty” verdict was given, 37 (60% of not guilty judgements) gave their reasoning as, “insufficient evidence” within the trial. A large proportion of the remaining jurors (21/62) stated that their overall reason for a “not guilty” verdict was based on the “victim” having an “impaired judgement” (34%). On the other hand, the proportion of guilty verdicts was reasoned to be due to the “force required” to break the cranium . Other reasons stated included the relationship between the two individuals, the doubt displayed in the expert witnesses’ voice, and that the defence may be lying.p = 0.784). Likewise, a Kruskal-Wallis test also demonstrated no significance between the comprehension of the evidence and the verdict given  and 3D digitisations (73%) had a similar overall clarity with 3D-printed models (78%) being slightly more comprehensible. This showed no significance in correlation  and this difference is echoed by Ampanozi et al.  who encoHowever, the outcome is not quite that straightforward. In cases where the evidence is deemed clear by the jurors, then comprehension of technical language shows statistical significance. This suggests that the overriding influence on the juror is the evidence type itself as opposed to the language associated with it. Therefore, since imaging modality does not influence juror decision-making, we recommend the use of 3D imaging since, if this is used for all evidence types, greater technical understanding can be achieved.It may be argued that a limitation of this research is that the scenario is not realistic due to the use of an archaeological cranium to replicate an incident. This should be a consideration for future studies and perhaps clinical radiographs could be used. Alternatively, an archaeological cranium could represent data in a forensic anthropological context. Similarly, the results may demonstrate a sample bias because the majority of participants in this study were students. However, research on this topic has confirmed that this is not a cause for concern , 23.Several authors have stated that evidential findings must be presented to the court in a palatable and clear manner, while not compromising the integrity of the evidence displayed , 18. The


The requirement to serve the racing industry was a key driver of clinical approaches, strongly influenced in particular by the trainer. Participants widely disregarded the consensus case definition of IAD/mEA for British racehorses because of perceived differences in etiology, perceived lack of practicability, particularly of BAL sampling, and perceived lack of understanding of the British racing context by consensus authors. Participants shared a strong professional identity as pragmatic clinicians providing an individualized clinical approach based on direct experience, which was often prioritized as the most valuable evidence with which to inform clinical decision-making. Lack of alignment with international consensus presents a barrier to practicing and furthering evidence-based medicine. Improved dialogue and partnership in research would be valuable and further research tailored for this population, including continuing development of contextually acceptable diagnostic methods, may be required.Inflammatory airway disease (IAD) is a commonly diagnosed but variably defined syndrome of equine lower airway inflammation. The most recent American College of Veterinary Internal Medicine (ACVIM) consensus statement, informed by research evidence, recommends a case definition based on clinical signs , increased endoscopically-visible tracheal mucus, and bronchoalveolar lavage cytology, and proposes that the condition should be termed ‘mild-moderate equine asthma' (mEA). In British Thoroughbred racehorses, research to date has focused on airway inflammation defined by increased tracheal mucus and inflammatory tracheal wash sample cytology. It has been unclear whether or to what extent the ACVIM consensus statement has influenced the practice of British racing veterinarians. The aim of this qualitative study was to characterize and understand rationales for current practices relating to diagnosing and managing airway inflammation in British racehorses. Audio-recorded focus group discussions were conducted with 25 participants from four veterinary practices in England. Practices were purposively selected to represent those responsible for different types of racehorse, in different geographical regions. Thematic analysis of transcripts identified (i) an over-arching theme of  Inflammatory Airway Disease (IAD) is a commonly diagnosed but, historically, variably defined syndrome of equine lower airway inflammation. It is the most common form of respiratory disease in British Thoroughbred racehorses –3 and anTerminology has varied over the years and a variety of case definitions and assessment methods have been reported , 11–18. Elsewhere, particularly in the United Kingdom, research on racehorse airway inflammation has centered on increased endoscopically-visible tracheal mucus, coughing or increased inflammatory cells in tracheal wash (TW) samples e.g., , 24, 25], 2524, 2Given the anecdotal evidence that tracheal-based sampling remains standard practice on British racing yards, the aim of this study was to understand British racing veterinarians' rationales for current approaches to diagnosing racehorse lower airway inflammation. This required a qualitative research approach, which allows in-depth exploration of views, perceptions, and experiences underpinning rationales. Objectives were to characterize veterinarians' opinions and perceptions, and to understand the challenges they face, in relation to practicing evidence-based respiratory medicine.Ethical approval for the study was obtained from the Royal Veterinary College Social Science Research and Ethics Review Board (URN: SR2017-1224). Qualitative data were gathered through semi-structured focus group discussions. A topic guide was designed to capture current practices and opinions relating to the nature, diagnosis and management of lower airway inflammation, as well as familiarity with, and views on, the most recent IAD consensus statement. Focus group discussions were led by author TK, a non-veterinary researcher experienced in qualitative methods. Participation was voluntary and consent was obtained individually. Participants were first asked ‘What is IAD?,' followed by questions about diagnostic and treatment decisions, and were provided with an excerpt from the latest ACVIM consensus statement on IAD to guide discussions about its implementation.Four veterinary practices were purposively selected to represent contexts in which opinions were likely to differ, such as those responsible for different types of racehorses, including young (primarily 2-year old) racehorses in training for flat racing and older (>3 year old) racehorses in training for National Hunt (jump) racing, in different regions of England. Focus groups were arranged by TK via phone or email and held on practice premises between December 2017 and March 2018. Discussions were audio recorded and recordings were submitted to an external company for verbatim transcription. Transcriptions were assessed for accuracy by TK and sent to all participants to allow identification of any inaccuracies.An inductive thematic analysis was conducted on all transcripts by author TK, based on the method described by Braun and Clarke , from a In the results section, direct quotations are presented to illustrate findings and demonstrate grounding of the analysis in the original data. Respondents are identified by their focus group (FG) number and their individual respondent number (R).Focus group characteristics are summarized in serving the racing industry within which two further themes (ii) disregarding of the consensus and (iii) the pragmatic clinician were nested. An overview of themes and sub-themes is presented in Three key themes were developed from analysis of focus group transcripts: (i) An over-arching theme of It was evident throughout discussions that, for these participants, serving the racing industry was a key driver of clinical approaches to racehorse respiratory health. This was seen in particular through the strong trainer influence on when and how respiratory diseases are diagnosed and treated. The focus of diagnostic investigations for lower airway inflammation is endoscopic assessment of the amount and character of tracheal mucus. At the outset, it is usually the trainer who selects horses for endoscopy, often as a routine health check or because of training or racing plans rather than on the basis of any frank clinical signs such as coughing or poor performance:Generally, we don't initiate it. Sometimes we might say, “This horse isn't performing well - shall we scope it?”, but the vast majority of times the trainer has already decided what he wants doing .It's a large yard and [the trainer has] a long history of scoping a lot of horses - sometimes yard wide but often just pre-race and pre-declarations .This means that, on British racing yards, there is no standard or systematic method of monitoring, diagnosing, or managing racehorse respiratory health. Horses being examined endoscopically are not necessarily unhealthy and the scoping of outwardly healthy horses is regarded as proactive:The amount of work that goes into investigation will very much depend on the type of horses the particular trainer has and his understanding of the consequences, especially of not doing anything. Some trainers will only get you to look at the horses if they cough and others have got a much more proactive approach .The trainer's approach to this varies with personality, experience and training methods, general yard health, and stage of the racing season:We have some trainers who […] when they're in a rocky patch performance-wise, they won't automatically ring up the vet and say “I think the horses are ill” or look for a problem there. They'll think “Well, actually, it's a worse bunch of 3 year olds this year. We've had bad luck” .If a horse coughs once, a week before Royal Ascot, then they'll want it scoped and potentially treated. Or if a horse was coughing now, particularly with some horses this time of year moving from yard to yard and mixing with ages and mixing with populations - a certain amount of coughing is definitely tolerated this time of year .Veterinary involvement is therefore influenced strongly by trainer expectations, which are in turn driven by owner expectations, finances and other racing-related pressures such as the need to explain a disappointing race or season:[The trainer might say] ‘We've come to the races having told the owner “we should be in the placings today”' […] and they're then needing some genuine help in some cases, or an excuse in others .While the clinicians recognized that the commonly-seen lower airway inflammation would likely resolve without treatment, and with rest, they were under pressure to return horses to optimal health as quickly as possible, because of the requirement for the horses to perform athletically:The [young horse] condition that we're talking about is self-limiting and the horses will get over it themselves if you back off … But the owners don't really want to hear that you've backed off […] because they want to get on - which is why we take a more active, aggressive approach .The pressure on trainers to train and race leads to an expectation of treatment, and in particular of antibiotic treatment. This, therefore, puts pressure on clinicians to prescribe antibiotics, and raises the issue of antibiotic stewardship:It's consumer driven - clinical signs are really the only thing that the trainer or the owners are concerned about and  the quickest way to stop a bunch of horses coughing is to put them on antibiotics .by and large they will get a course of antibiotics before anything else” ), while others would often, or usually, perform culture and sensitivity testing before making treatment decisions:This was the area of greatest dissent amongst participants. Some clinicians described antibiotics as the first line of defense  and then you've got to suggest that [the trainers] don't canter the horse for several days afterwards, so the prospect of getting [trainers] to do that in horses who are anywhere near hard exercise is pretty limited .Further to the expected reluctance of the trainers, the participants themselves were not convinced of the diagnostic value of BAL compared with TW, with which they had much more experience and which they considered to be more appropriate for time-efficient health screening:Maybe I haven't been doing enough to see the extra benefits, but […] if I'm going in to scope a batch of 12 or 14 horses, I want to be doing that in less than an hour. I want to be four or five minutes per horse - just enough time to clean and tidy up and move onto the next one .I couldn't advocate that we'd get any more information, so for a routine screening, I think you'd have to strongly feel that the extra hassle, for want of a better word, is worth it .However, some used BAL sampling for the small minority of horses with recurrent or persistent problems, which might fit the consensus case definition of IAD/mEA:The only time I've been involved with BALs is when I've had a horse that has just manifestly failed to behave the way I thought it would in response to my clinical findings. It might be one a year. It's really low numbers .Overall, the view was that British racehorses are a unique population, in a unique setting, which people not experienced in that setting do not fully understand:We have a very unique selection or set of horses here. They're all housed together and the yards are all more or less back to back to each other and they're all very young - yearlings and born in 2016 now - […] and I think they're very highly densely populated, they're never turned out […] Everything that could possibly compromise their respiratory system is happening to these horses .Participants felt that the consensus was not reached by people with appropriate direct knowledge and experience of racing yards, or of the British racing industry in particular, who were perceived to be academics, or ‘university clinicians' rather than field clinicians:The problem is most of these consensus statements are from university clinicians - they're not actually working in the field we're talking about […] I just don't believe they've got enough experience of racing yards to be making that statement, to be honest .These academics have no idea of the type of pressure you come under when you are faced with a large yard that is coughing… if they think we're going to do hundreds of BALs - it's just not possible .Further to the objections to BAL based on practicalities, there was also a strong view that, while BAL is accepted elsewhere, it would not be culturally acceptable on British racing yards:I know the French, apparently they seem much happier with [BAL] as an idea but if you were to start suggesting it to British trainers – culturally they're not expecting you to do that .In addition to these explicit references to perceived outsiders, it was implicit elsewhere in discussions that participants shared a strong professional identity as pragmatic clinicians. They expressed that, within the context of serving the racing industry, they were providing a flexible, individualized clinical approach, although they also acknowledged that the ‘jigsaw' of accessible diagnostic information was sometimes unsatisfactory or frustrating. Direct personal or collective experience was commonly lauded as the most useful, available evidence on which to base clinical decision-making.Clinical approach to cases varied, often depending on the clinicians' understanding of trainer expectations, with different methods used in different yards according to trainer preference, particularly in relation to inflammation scoring:Trainers sometimes want a score on the whole package. We give a score on what we grossly see and then report the cytology findings, but some trainers have been used to a 0 to 10 score, which takes into consideration the gross endoscopy, the turbidity of the sample and then the neutrophil count, and they put the whole lot together and call it a Grade 7 inflammation or a Grade 4 .The protocol in that yard is to take a wash and make a score of the turbidity and add that to the score of the visual and then they sometimes grade them differently themselves .The clinical approach also depended on the clinician's knowledge of the long-term history or idiosyncrasies of individual horses:There's a sort of a cut-off at which we consider something to be ‘dirty' – a cumulative of a visual from the endoscopic [examination] and what you get in the [TW] sample, although we sometimes record that and report it differently to the trainers, based on, we know that there are some horses that always scope ‘dirtier' than normal but that's where they sit and we would probably be less harsh with our grading on those .Participants shared the opinion that the TW sample is valuable in the experienced hands of a clinician with appropriate knowledge of the yard or individual. One-off, snapshot endoscopic examinations or TWs were considered less valuable than repeated, sequential examinations:It makes such a difference having sequential results because you know that that horse always hovers around 60% macrophages - no matter what you do to it, it just seems to sit there - and you're happy enough. And then one day it's got 75% and you think “this is different than it usually is” .This was all viewed generally positively as a flexible individualized approach, built on an informed understanding of the client and the individual animals and providing the best clinical judgement on the case, given the available diagnostic information:It's part of the jigsaw - you've got to build up the picture of the general performance of the yard and that individual's performance. Like all these things in all parts of medicine they're part of the jigsaw of your decision-making process […]. You should never be too rigid with it. .Participants did express some frustration with the incompleteness of this diagnostic jigsaw, particularly the degree of uncertainty about what can be concluded from a sometimes conflicting combination of clinical and laboratory findings, all involving some element of subjectivity. This reduced confidence in the ultimate diagnosis, or treatment decisions:If you [submit a TW sample for cytological examination] and the cells aren't quite right and [the horse is due to run on] Saturday in a big race and they've just told you it's worked really well - what do you do? .We have horses that we scope that are visually dirty that still go and run and win big races – and so maybe they would have won by a greater margin or maybe it's just an individual thing and that horse is coping with it – but there's this big grey area where you've got horses that potentially have disease as defined by the cytological appearance of the lung and yet might not be showing any outward disease at all or any inhibition of performance .It was also recognized that there was an inherent systematic bias in the selection of horses for examination, for example, resulting from a desire to explain race disappointments, and a lack of any objective measures of lung function and ultimately performance:Very rarely are winners scoped […] If you keep looking for something, you'll find something, but the horses that are performing well may have the same issues .You do start to lose your, well your confidence, but you've got to keep returning to the fact that they can only run better when they don't have mucus there. Yes some will run fine but they can only run better if it's not there, surely? I think you've got to keep falling back on that position that with mucus or without mucus, you'd rather have them without mucus .Despite TW being a routine diagnostic tool, lack of standardization, both of clinical sampling and of laboratory processing of the samples, was an additional problem:I'm sure you can take a [TW] sample, split it, and send it to two different labs […] you could in theory get completely different conclusions depending on how that lab is preparing their slides .There's a big variation in sampling technique. Not just the timing of when it's taken, [or] the intensity that the horse has exercised - it's actually vet dependent as well .Therefore, although TW sampling remained the mainstay of their diagnostic investigations, participants agreed that TW cytology was not always useful. A flexible approach to investigation based on the trainer's requirements and the available jigsaw of other diagnostic information was needed.It was apparent during discussions that the most valued evidence on which to base this complex, clinical decision-making was direct personal or collective experience, regardless of contradictions with research-based evidence or the published consensus. This was particularly evident in the clinicians' defense of the TW sample. Despite the reported challenges of interpreting TW cytology, participants remained of the opinion that TW samples are valuable, and better than research suggests:The scientists do take a rather dim view of tracheal washes - they feel it's not representative, you're getting pharyngeal contamination. But experience has shown that it does provide useful information that is reflective of a general widespread lung issue .I think tracheal washing post-exercise does represent what's going on in the lungs and I say that based on the fact that I have occasionally done BALs and I haven't found that my results from BAL and tracheal washing are different, really .In fact, given the collective and cumulative experience of tracheal endoscopy and TW sampling over the years, clinical decisions were often based on subjective visual assessment of gross TW samples, without either cytological or bacteriological laboratory examinations:I would say as a general rule, [we] don't submit many tracheal samples to the laboratory. We used to do a lot and I think it's from that experience, of doing it a lot, that we often take the view that you could get as much information as you need, most of the time, from a visual of the trachea and/or the turbidity of the wash .Again there was a clear trainer influence relating to cost-saving and the pressure to optimize health and performance as quickly as possible. Waiting for the results of laboratory testing was perceived as an unnecessary delay if it would not significantly modify the decisions clinicians would make based on experience:We have [trainers who] are not really happy with routinely going to the expense of a trach wash and its laboratory costs as well and they will expect us to make some sort of judgement on the basis of - is it just excessive mucus? Is it mucopus? Is it frank pus with blood? I think it's not unreasonable on some of those to make a sort of semi-educated guess about whether this is likely to be just inflammatory or is there an infectious component? .Laboratory diagnostic work-up was sometimes reserved for those cases that were not responding to initial treatment:If they didn't respond to a decent course of initial antibiotics, you might then start to do some laboratory work or more typically put them on a trial of an anti-inflammatory drug and then re-scope them and see if they respond to that. It's trial and error .This pragmatic, ‘trial and error' approach was driven by the requirements of a heterogeneous group of trainers, the particular characteristics of the population of horses they train (regarded as unique), and the need to rely on personal and collective experience in the absence of suitably-tailored research-based evidence or consensus.The aim of this study was to understand British racing veterinarians' rationales for current practices relating to diagnosing and managing racehorse lower airway inflammation.Findings indicate that British racing veterinarians are striving to serve the racing industry within the constraints of culture, expectations, available resources and evidence, incorporating their collective clinical expertise and knowledge of individual racehorses, as well as owners' and trainers' preferences and demands. This is consistent with the Royal College of Veterinary Surgeons description of evidence-based veterinary medicine as requiring incorporation of “clinical expertise, the most relevant and best available scientific evidence, patient circumstances and owners' values' .Findings also highlight a general valuing of personal and collective experience over research-based evidence and consensus, in this specific context of racehorse lower airway inflammation. Reasons for this were both explicit  and implicit . These issues result in a lack of alignment with current international consensus, which is an inherent barrier to practicing and furthering optimal evidence-based respiratory medicine in this population of horses.The strong over-arching theme of ‘serving the racing industry' is not unexpected given that much veterinary work sits within the classic triad of clinician-patient-client, with the veterinarian's behaviors and decision-making driven in part by client needs or demands, which can lead to ethical discord . HoweverIn equestrian sport in general, it is argued that promoting evidence-based decisions over economics-driven decisions is an important aspect of a veterinarian's role . HoweverThe need to serve the racing industry also creates conflicts with best practice in the important area of antibiotic prescribing. As in other contexts, including both farm , 37 and It seems, however, that it is not only perceived client pressure that drives antibiotic prescribing on British racing yards. There was also a widely-held view amongst participants, based on collective experience, that airway inflammation is commonly caused by bacterial infections, particularly in young (yearling and 2-year old) racehorses. This is supported by published evidence of reducing prevalence of both IAD  and infections with age and time in training , 14, 42 Antibiotic stewardship was not a focus of our study, but it has been identified as an area of concern for equine practice , 44, andThe latest consensus statement on IAD/mEA does consider the possibility of an infectious etiology for the airway inflammation commonly seen in young racehorses in Britain . HoweverMore generally, our findings raise the question of how different types of evidence are valued or prioritized by field clinicians compared with academics. Study participants tended to highlight experiences, views and beliefs that contradicted research-based evidence, or consensus. The classical evidence hierarchy is often depicted as a pyramid, with anecdotal evidence and expert opinion at the base , and increasing levels of quality of research-based evidence ascending toward the peak . In the absence of research-based evidence perceived to be credible, relevant and practicable, the most valuable evidence available to the pragmatic clinician is their own personal and collective experience. The best research evidence has no impact on health and welfare if it is not implemented. BAL-based equine respiratory research is therefore of little value to this population while BAL remains unacceptable on training yards. We acknowledge that BAL is widely accepted internationally as the diagnostic tool of choice, and is reportedly well-tolerated in other equine populations including racehorses. However, on this matter there was no dissent among our study participants. Endoscopic assessment of tracheal mucus, with or without TW cytology, continues to be the mainstay of lower airway assessment on British racing yards. Given the strength and consistency of the views expressed across our participant groups, it is clear that adoption of BAL sampling would require a substantial paradigm shift, which will not be effected simply by ‘knowledge transfer' or reiteration of the message from elsewhere that BAL is the well-tolerated diagnostic tool of choice. An active, multi-directional exchange of information, or ‘knowledge translation' approach, with collaboration between those generating and those using evidence is required . Given tIn the absence of such a paradigm shift, more research seeking to develop other minimally-invasive field diagnostic tools, such as biomarkers in easily obtainable samples, or portable and suitably sensitive lung function tests, would be valuable for this equine population. Participants' experiences that TW cytology can be difficult to interpret, especially when it conflicts with clinical findings, are entirely consistent with research-based evidence to date. It is the lack of consistent evidence for a relationship between TW cytology and BAL cytology, poor performance, lung pathology, or lung function that excludes TW cytology from the consensus case definition , 51, 52.As this was a qualitative study, the sample of participants was purposively selected and necessarily small to allow for collection and analysis of in-depth data. Researchers more familiar with quantitative methods might have concerns about the representativeness or validity of this approach. However, the purpose of qualitative research is not to quantify, but to understand, perceptions, opinions, or rationales. Representativeness is therefore sought by sampling to capture likely diversity, rather than through probability sampling designed to achieve statistical generalisability . The reqThe raw data contain candid information of a potentially sensitive nature including individual/group identifiers and participants did not consent to wider dissemination of this. Appropriately anonymized excerpts of the data are presented in the paper and fuller excerpts could be made available on request to the corresponding author.This study was reviewed and approved by the Social Science Research Ethical Review Board, Royal Veterinary College. The participants provided written informed consent to participate in this study.JC proposed and designed the study. JC and TK co-designed the focus group schedule. TK recruited practices and participants and conducted all focus groups, data coding, and development of preliminary themes. TK and JC worked together to refine and develop final themes and co-wrote the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The role of Surgical Care Practitioner (SCP) was first introduced by the NHS in the field of cardiothoracic surgery more than two decades ago to overcome the chronic shortage of junior doctors, and subsequently evolved into other surgical specialties. This review aims to provide evidence on the current situation of SCPs’ clinical outcomes within their surgical extended role, with an emphasis on the cardiothoracic surgical field.A systematic search of PubMed, Scopus, Embase via Ovid, Web of Science and TRIP was conducted with no time restriction to explore the evidence on SCPs. All included articles were reviewed by three researchers using the selection criteria, and a narrative synthesis was undertaken.Ten out of the 38 studies identified were selected for inclusion. Only one study specifically investigated cardiothoracic SCPs. Three themes were identified: (1) clinical outcomes (six studies), (2) workforce impact (two studies) and (3) colleagues’ opinions (two studies). All studies demonstrated that SCPs provided safe practice, added value and were of benefit to workforce environments and surgical teams.Although the current literature provides assurances that the presence of SCPs within surgical teams is beneficial in terms of their clinical outcomes, their impact on the workforce and colleagues’ opinions, a significant gap was identified around the SCPs’ role within their surgical extended role, specifically in cardiac surgery. Thus, prospective clinical research is required to evaluate SCPs’ clinical impact. Across the UK, the National Health Service (NHS) has introduced new professional roles within multi-disciplinary teams due to the chronic shortage of doctors and the implementation of the European working time directive . These pAn SCP is defined by the Royal College of Surgeons as:a non-medical practitioner, working in clinical practice as a member of the extended surgical team, who performs surgical intervention, pre-operative and post-operative care under the direction and supervision of a consultant surgeon.” [“… urgeon.” SCPs were first introduced in the UK in the cardiothoracic surgical setting in the early 1990s in Oxford, and the role then evolved into other surgical specialities, including orthopaedics and general surgery . AccordiA narrative literature review was conducted to provide a comprehensive overview that would facilitate an understanding of the clinical outcomes associated with SCPs. An initial scoping search was performed using Google Scholar. A further in-depth search was conducted using PubMed, Scopus, Embase via Ovid, Web of Science and TRIP. All databases were limited to human studies, published in English, and full-text articles. No timeline restriction was imposed on the database searches, as the initial scoping showed that limited relevant evidence was available. The search keywords and synonyms are illustrated in Table A total of 38 articles were identified, with 33 articles sourced from the databases and five additional articles from back-chaining initially being selected for review. All studies were considered eligible except if published as a documentary, essay or review. Twenty-eight articles were subsequently excluded, as detailed in the PRISMA flowchart Fig. .Fig. 1PThree themes were identified from the gathered evidence, namely (1) clinical outcomes –13 2) w w2.TablSix studies were included under this theme, of which two were prospective empirical studies , 11, thrP = 0.0001) and cross-clamp time (P = 0.0001) between the study’s groups, favouring the SCPs’ group over the surgical trainees’ group, even though the mean number of grafts was similar between the two groups (P = 0.2). Furthermore, SCPs were found to provide an efficient and safe service when employed to perform minor surgical procedures, such as the removal of sebaceous cysts, skin tags, basal cell papillomas and lipomas, based on an audit conducted over four years [The presence of the SCP as a member of the extended surgical team in cardiac surgery was not only found to be significant in improving clinical outcomes compared to surgical trainees but also was extremely helpful not only to assist but even further to teach junior trainees the technique of conduit harvesting. This result was inferred in an audit based on a case-mix comparative analysis and the outcomes of coronary artery bypass grafts assisted by SCPs compared to surgical trainees . Statistur years . Similarur years .P < 0.001) [P < 0.001).Moreover, the results of a multicentre cohort study in an orthopaedic surgical setting revealed that mean operating time significantly decreased – from 90 min to 65 min – when surgeons were assisted by SCPs (< 0.001) . This fi< 0.001) , which fInclusion of SCPs can provide a valuable contribution to district hospitals , 15. In Only two studies investigated the value of SCPs from the team perspective. Quick  assessedP < 0.001) favouring SCPs in performing hip aspirations.As apparent from the identified themes, SCPs provided safe practice and were regarded as valuable members of the extended surgical team. However, although the SCPs’ role was first implemented in cardiac surgery in the early 1990s, over a decade passed before Alex et al.  conducteSince four of the studies reviewed , 12, 13 Hickey and Cooper’s  interpreEven in the case of Palan et al. , when crDespite the methodological flaws highlighted above , 11 and As shown in the results section, to date, there is no source of empirical evidence to support the results inferred by Williams et al.  and KumaBoth medical and non-medical personnel working with SCPs express positive perceptions about the SCPs’ role, as concluded by Quick , 17. HowAs evident from this review, only one study exists in the literature that highlights the continuation of the SCP in cardiac surgery, and this study was conducted as an audit . Thus, aThis review has significant implications for the SCP profession in cardiac surgery and other surgical settings, since it is the first review of its kind that has been conducted to determine and highlight the contribution of SCPs. The identified limitations and recommendations should be considered to integrate the research into clinical practice, forming evidence-based practice to shape the SCP profession within the surgical setting. In addition, this review has been led by a cardiothoracic SCP, and this may encourage other SCPs to conduct their own empirical research, as the majority of the studies in this review were conducted by surgeons, with the exception of three , 16, 17,Based on the available evidence, the role of SCPs in cardiac surgery has been found to be effective in acting as first assistants or in teaching basic surgical skills to junior doctors. Even within other surgical settings, the presence of the SCP has been found to be of benefit in terms of their clinical outcomes, impact on the workforce and colleagues’ opinions. However, this conclusion is weakened by several limitations that affect its external validity. Thus, this review advocates for prospective clinical research to examine the impact of SCPs in cardiac surgery and other surgical settings.


N = 30 858) communicated evidence of effectiveness, and 10 (N = 5078) communicated evidence of ineffectiveness. Random effects meta-analysis revealed that communicating evidence of a policy's effectiveness increased support for the policy , equivalent to support increasing from 50% to 54% . Communicating evidence of ineffectiveness decreased policy support , equivalent to support decreasing from 50% to 44% . These findings suggest that public support for policies in a range of domains is sensitive to evidence of their effectiveness, as well as their ineffectiveness.Low public support for government interventions in health, environment and other policy domains can be a barrier to implementation. Communicating evidence of policy effectiveness has been used to influence attitudes towards policies, with mixed results. This review provides the first systematic synthesis of such studies. Eligible studies were randomized controlled experiments that included an intervention group that provided evidence of a policy's effectiveness or ineffectiveness at achieving a salient outcome, and measured policy support. From 6498 abstracts examined, there were 45 effect sizes from 36 eligible studies. In total, 35 ( ReflThis work can be understood more broadly in terms of how changes in relevant beliefs (e.g. the perceived effectiveness of a policy) can engender a change in basic attitudes . PublicIndeed, the most likely response when confronted with disconfirming or contrary evidence is for the individual to move their belief toward the evidence –36. ThisIn other words, different ways of communicating the same information may be more or less successful at changing attitudes  and therUsing meta-analytic evidence synthesis, the aim was to assess whether communicating evidence that a policy is effective or ineffective changes support for the policy and if so, by how much. The authors hypothesize that both sets of evidence will change people's attitudes in the direction consistent with the evidence that they receive. Additionally, it is predicted that the effects will be larger when communicating ineffectiveness information due to negativity biases . The mod2.http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017079524). The data and code are available at https://osf.io/4gjur/.This systematic review is reported in line with PRISMA  guidelines . The rev2.1.Policies eligible for inclusion were actual or hypothetical policy interventions to tackle a problem that might be implemented by local or national governments, or by supranational bodies, such as the World Health Organization. Eligible studies include randomized experiments in which one group of participants received information about the (in)effectiveness or impact of at least one policy and a control group of participants that did not receive any information about the (in)effectiveness or impact of the policy. Within-participants, between-participants and quasi-experimental (i.e. experiments without random assignment) designs were also eligible.There were no restrictions on types of participants. Eligible interventions for the evidence of effectiveness analysis were those that provided information regarding evidence of the impact of the policy, in terms of the potential benefits, or how the policy would address a specified problem (i.e. be effective). This includes evidence that discusses qualitative or quantitative descriptions of the magnitude of the effect, or assertions that describe the effect without referring to its magnitude.Eligible interventions for the evidence of ineffectiveness analysis were those that provided information regarding evidence of the impact of the policy, in terms of the potential harms, or how the policy would fail to achieve its intended purposes (i.e. be ineffective). This includes evidence that discusses qualitative or quantitative descriptions of the magnitude of the effect, or describe the effect without referring to its magnitude. Both effectiveness and ineffectiveness interventions were eligible if they asserted that a policy was effective, even if they did not specify that the information originated from an expert or from research, e.g. ‘this tax would lead to a 1.6% reduction in obesity' . InterveEligible comparators were control groups that received no information pertaining to the effectiveness or impact of the policy. Eligible outcomes were the acceptability of a specific policy or set of policies, defined as the level of support or attitude toward the implementation of policy/policies, measured using response scales that allow for a binary assessment (i.e. support or oppose), or a graded degree of support or opposition. Measures of support for public or societal action in general, not linked to a specific action or policy, were excluded .2.2.(accept* OR support* OR favour* OR agree* OR attitude* OR opinion* OR perspective*) AND  AND experiment AND (information OR vignette OR narrative OR evidence OR statement OR frame OR framing) AND (effect* OR impact OR outcome OR consequence)The search strategy was developed with the assistance of an information scientist. Nine electronic databases were searched: ASSIA, EconLit, EMBASE, Open Grey, PsycINFO, Public Affairs Information Service, PubMED, Science Direct, and Web of Science. There were no restrictions on language or publication date. Search terms were as follows:These terms were selected and developed based on terms that were used in the eligible papers that we had already located prior to the review. Database searches were completed up to October 2017. Two researchers (K.S. and J.P.R.) independently screened title-abstract records for eligibility. Screening discrepancies were resolved by discussion. Full texts of provisionally eligible records were retrieved via electronic library resources, screened independently by two researchers (K.S. and J.P.R.), and judged to be eligible or excluded with reasons recorded. Database searches were supplemented with snowball searches and forward citation tracking (using Google Scholar) of eligible articles, and reference list searches of relevant review articles. Requests for further unpublished data were made to the corresponding authors of eligible articles.2.3.2.3.1.One researcher (either K.S. or J.P.R.) extracted information from eligible studies. Once extraction was complete, each researcher cross-checked the extraction completed by the other. Discrepancies in extracted information were resolved by discussion and by consulting with a third or fourth researcher if necessary (T.M.M. or S.v.d.L.).The following information was extracted from each study: author name, year of publication, country in which data were collected, setting, study design, sample characteristics , inclusion/exclusion criteria for participants, policy domain and proposed policy, details of the intervention(s) (using the below coding scheme), details of the information given to the control group, dependent variable(s), method of analysis, outcome data, and information needed for quality assessment.2.3.2.A coding scheme for interventions was developed prior to data extraction and conducted by two researchers in duplicate. Inter-rater agreement was high (93%). Discrepancies in extracted information were resolved by discussion and by consulting with a third or fourth researcher if necessary. Ten features of each intervention were coded: other information communicated , content of message , medium , length of treatment, proportion of information that was a statement of effectiveness, readability (assessed using the Gunning-Fog Index), source of information used, attributed source of information, and stated level of uncertainty, if any.2.3.3.k = 30), t statistics and sample sizes (k = 4), and odds ratios and sample sizes (k = 1). This means that one of the 35 effect sizes in the evidence of effectiveness meta-analysis was converted from a dichotomous outcome (, p < 0.0001 (without trim and fill).Communicating evidence that a policy was effective in achieving a target outcome increased support for the policy, SMD = 0.11, 95% CI , < 0.0001 . Assumin< 0.0001 . There w3.5.1.1.k = 9 effect sizes and N = 12 527. Communicating evidence that a policy was effective increased support for the policy, SMD = 0.12, 95% CI , p = 0.002. There was substantial and significant heterogeneity, Q (8) = 27.06, p < 0.001, 2I = 65%, T = 0.09, 2T = 0.01.The main analysis was re-run to test whether the significant overall effect remained after (i) excluding the studies that were at high risk of bias, and (ii) excluding studies that contained confounded interventions. Excluding studies at high risk of bias resulted in k = 11 effect sizes and N = 5870. There was no funnel plot asymmetry and therefore trim and fill was not used. The effect of communicating evidence of effectiveness increased support for the policies among these studies, SMD = 0.12, 95% CI , p = 0.002. There was no significant heterogeneity among these studies, Q (10) = 15.58, p = 0.112, 2I = 37%, T = 0.07, 2T = 0.005.Excluding studies that had confounded interventions resulted in 3.5.1.2.As seen in 3.5.2.p < 0.001 (Q (9) = 16.27, p = 0.062, 2I = 46%, T = 0.08, 2T = 0.007. This suggests that the intervention effects vary marginally more so than would be expected by chance alone. There were insufficient studies to run moderation and sensitivity-by-covariate meta-analyses.Communicating evidence that a policy was ineffective or leads to undesirable outcomes decreased support for the policy, SMD = −0.14, 95% CI ,  < 0.001 . Assumin < 0.001 . There w3.5.2.1.k = 3 effect sizes and N = 1198. There was no evidence that communicating evidence of ineffectiveness on policy changed support for policies, SMD = −0.08, 95% CI , p = 0.155. There was no evidence of heterogeneity, Q (2) = 0.87, p = 0.648, 2I = 0%, T = 0.00, 2T = 0.00.The main analysis was re-run to test whether the significant overall effect remained after excluding the studies that were at high risk of bias. Excluding studies at high risk of bias resulted in 4.The results of this systematic review show that public support for a policy can be increased by communicating evidence of its effectiveness. Policies relating to health, environment and gun crime were examined, among others, and the results appear to be robust across the different domains. The results also do not significantly vary with intervention characteristics, including whether evidence of effectiveness was presented alone or confounded with other information, whether uncertainty was expressed when communicating evidence, the readability of the intervention, or whether the statement of effectiveness was asserted or described . These results also suggest that public support can be decreased by communicating evidence that the policy is ineffective or has undesirable outcomes, such as costing money to implement. Due to the small number of studies in this second meta-analysis, it was not possible to test whether the effect varies based on study and intervention characteristics. In contrast to our predictions that communicating ineffectiveness would lead to greater changes, the effect sizes estimated by these two meta-analyses were similar. With a policy that receives approximately 50% support—such as a levy on sugar-sweetened beverages —communicAlthough the effect-size may seem relatively modest, small effects can have large real-world consequences . To contet al. communicated evidence that a tax on confectionery would impact childhood obesity and/or inequalities in childhood obesity. Although not all of the interventions had the desired impact on public support, the results suggest that when public support was increased, it was primarily mediated by a change in the belief that the tax was effective at reducing childhood obesity. One further study also demonstrated that communicating evidence of the policy's effectiveness increased both perceptions of policy effectiveness and support for the policy, consistent with the mechanism interpretation [The changes that were found in public support in the current study were probably driven by a change in beliefs about a policy's effectiveness. Only one study in this review examined this directly: perceived effectiveness was the mechanism behind the change in support . Across retation .These results also touch on the question about whether people update their beliefs and attitudes when exposed to evidence that contradicts or supports their pre-existing beliefs. There have been concerns that when the people are given evidence, they either ignore it or become even more entrenched in their current beliefs . Con4.1.The current study is the first of its kind to synthesize the available evidence concerning the impact of communicating evidence of a policy's effectiveness on public support. Given the mixed results of interventions that contain evidence of effectiveness –20,67, tWhile conducting this review at least two of the authors made decisions about study inclusion, data extraction, coding and quality assessment. When the decision was ambiguous or the two authors disagreed, a third, fourth, or occasionally a fifth reviewer would enter the discussion to resolve the decision. This process minimizes the likelihood of errors that arises from single reviewer decisions .The majority of the studies in the effectiveness meta-analysis (26/35) and ineffectiveness meta-analysis (7/10) were at high risk of bias. Interpretations of the pooled estimates should therefore be treated cautiously. However, despite this overall rating, there is reason to believe that this may be a harsh description of the included studies. The included studies were all randomized experiments and many included a nationally representative sample. The quality assessment tool assesses a range of different factors. In particular, one of these factors received lower quality ratings across studies: outcome validity and reliability. Only one study reported tests that their outcome measure was valid . DespiteThere was moderate heterogeneity in the primary meta-analysis and this needs to be considered when interpreting the findings. A proportion of this heterogeneity was due to interventions that include additional information (other than evidence of effectiveness) such as information about the magnitude or consequences of the problem that is being targeted. In a sensitivity analysis, interventions that only included evidence of effectiveness were analysed, and there was no significant heterogeneity. This suggests that the effect sizes are consistent when communicating messages solely about policy effectiveness.There was some evidence of funnel plot asymmetry for the evidence of effectiveness meta-analysis but not for the evidence of ineffectiveness meta-analysis. This may indicate publication bias, but other sources of bias could also explain this, such as language bias and outcome reporting bias . We addrThe majority of the primary research included in this review was conducted in the USA (25/36) and the majority of policies studied were in the domain of health (20/36). The results of the review may therefore be less generalizable to communicating evidence of effectiveness for policies other than health in countries other than the USA. However, in the meta-regression we did not find evidence that policy domain moderated the effect of communicating evidence but we note that this analysis had too low power to fully exclude this possibility.4.2.et al. would be a useful direction for this goal.Current studies preclude an estimate of effects in real-world settings, where multiple and competing messages are likely to be present. If a government desired to implement policies then competing messages may originate from a variety of sources. The results of the ineffectiveness meta-analysis suggest that opponents of policy can find success in communicating evidence that a policy is ineffective, which leads to reductions in support that are comparable in magnitude to communicating evidence of effectiveness. Online experiments have attempted to simulate how people respond to competing messages ,68,69, aThe meta-regressions conducted here suggested that the effect of communicating evidence on public support was not moderated by several intervention characteristics. However, this was based on associations rather than experimentation, and with a relatively small number of included studies, and a large number of confounding variables. Further research should investigate optimal communication methods from the perspectives of comprehension, accuracy and successful belief change ,48. One 5.In summary, this review provides the most robust evidence to date that communicating evidence that a policy is effective can increase support for the policy, and comparable decreases in support can be achieved by communicating evidence that the policy is not effective. These changes in support may typically be considered as small, yet could be meaningful when considered at the population level. Presidential elections and referenda decisions have hung on less.


Aerosol generating medical procedures (AGMPs) present risks to health care workers (HCW) due to airborne transmission of pathogens. During the COVID-19 pandemic, it is essential for HCWs to recognize which procedures are potentially aerosolizing so that appropriate infection prevention precautions can be taken. The aim of this literature review was to identify potential AGMPs in Otolaryngology - Head and Neck Surgery and provide evidence-based recommendations.A literature search was performed on Medline, Embase and Cochrane Review databases up to April 3, 2020. All titles and abstracts of retrieved studies were evaluated and all studies mentioning potential AGMPs were included for formal review. Full text of included studies were assessed by two reviewers and the quality of the studies was evaluated. Ten categories of potential AGMPs were developed and recommendations were provided for each category.Direct evidence indicates that CO2 laser ablation, the use of high-speed rotating devices, electrocautery and endotracheal suctioning are AGMPs. Indirect evidence indicates that tracheostomy should be considered as potential AGMPs. Nasal endoscopy and nasal packing/epistaxis management can result in droplet transmission, but it is unknown if these procedures also carry the risk of airborne transmission.During the COVID-19 pandemic, special care should be taken when CO2 lasers, electrocautery and high-speed rotating devices are used in potentially infected tissue. Tracheal procedures like tracheostomy and endotracheal suctioning can also result in airborne transmission via small virus containing aerosols. In the era of globalization, infectious disease outbreaks have brought unprecedented challenges to the medical community. Coronavirus disease 2019 (COVID-19), the clinical condition caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), rapidly became the world’s 6th public health emergency of international concern (PHEIC) declared by the World Health Organization since 2009 . A The included articles were categorized into various potential AGMP procedures. In this review an AGMP is defined as a medical procedure which has the potential to generate small (< 5-10um) aerosols that can travel greater than 2 m, and therefore an AGMP confers the potential for airborne transmission. In contrast, we defined droplet transmission as involving (larger) aerosols over short distances (< 2 m) directly from the infected person to the susceptible person via mechanisms such as coughing and sneezing. Each AGMP procedure category was assigned to a practicing Otolaryngologist Head & Neck Surgeon to review the evidence found in the articles, grade the evidence of the articles and develop recommendations for practice. The recommendations were created based on study design, the quality of research, directness of evidence and finally the balance between the potential harm of the procedure and the quality of evidence . Since tThe first literature search retrieved 44,110 articles (titles and abstracts), which were screened for potential eligibility. From this, 111 papers fit the inclusion/exclusion criteria, categorized into similar procedures and the second focused search was performed leading to 10 categorical procedures for review   investigated the aerosolization risk during endoscopic sinonasal procedures Table . In theiAggregated Evidence: Grade D: one experimental study.Recommendation:Based on limited evidence and clinical reasoning, powered instruments, which include the microdebrider and the drill, can result in droplet transmission and airborne transmission, and should be considered as droplet forming procedures and as AGMPs. Cold non-powered procedures are less likely to result in droplet or airborne transmission, as the patient is paralyzed during the procedure, and should be considered as potential droplet forming procedures, but not as AGMPs.Strength of recommendation: low.Smoke samples have confirmed that laser ablation of tissue can generate aerosols . There iAggregated Evidence: Grade C: two direct, cross-sectional studies, one indirect level 4 study, and two experimental studies.Recommendations: Consistent, direct evidence indicates that CO2 laser ablation of infected tissue can result in the spread of small, virus containing, aerosols. It is unclear if these aerosols can spread over longer distances, but given the small particle size generated by laser ablation, it is plausible. Laser ablation (CO2) should be considered as a droplet forming procedure and an AGMP.Strength of recommendation: strong.Three studies assessed particle concentrations during electrocauterization Table  24, 26,,26, 27. In contrast, Subbarayan et al. (2019) assessed the presence of viral DNA in electrocautery smoke produced during the resection of HPV16 positive oropharyngeal cancers . PCR anaAggregated Evidence: Grade C: four, direct cross-sectional studies, two experimental studies.Recommendations: There is consistent, direct evidence indicating that electrocautery can result in small aerosols with potential spread over longer distances. It is uncertain if this can actually lead to clinically relevant transmission of viable pathogens. Electrocautery in tissue with potential high viral loads, i.e. aerodigestive tract, should be considered as a droplet forming procedure and as an AGMP.Strength of recommendation: moderate.p < 0.01) .–39.36–39Aggregated Evidence: Grade C: two direct cross-sectional studies, one level 3 and two level 4 studies and two environmental studies.Recommendations: There is consistent evidence that endotracheal suctioning can result in the spread of small aerosols containing viable pathogens. Long distance spread of small aerosols remains possible under certain conditions. Endotracheal suctioning should be considered as a droplet forming procedure and as an AGMP .Strength of recommendation: strong.Three studies showed evidence of aerosol production during dental procedures and oropharyngeal surgeries within close proximity of the patient (within two meters) Table  27, 42,,42, 45. Aggregated Evidence: Grade C: three direct, and two indirect cross-sectional studies, and one experimental study.Recommendations: Consistent and direct evidence indicates the risk of small aerosol formation when high-speed rotating instruments are used in the oral cavity. One study also suggests that these aerosols can become airborne. The use of electrocautery and high-speed rotating instruments (powered instruments) within the oral cavity and pharynx should be considered as droplet forming procedures and as AGMPs.Strength of recommendation: strong.The aerosolized bone dust and irrigation fluid produced during drilling of the mastoid bone can become a potential risk for transmission of disease. Various viruses, including coronaviruses, have been documented in the middle ear mucosa during active infections , 48. TheAggregated Evidence: Grade D: three experimental studies.Recommendations: Indirect evidence from studies with varying quality indicate that drilling of the mastoid generates small aerosols. Mastoidectomy should be considered as a droplet forming procedure and an AGMP.Strength of recommendation: moderate.One experimental study was identified, which revealed that in 9 of the 15 subjects, bacterial contamination of the tip of Venturi atomizers was demonstrated Table  52].Ta.Ta52].Aggregated evidence: Grade D: one experimental study.Recommendations: One experimental study suggests that the nozzle tips of powered atomizers can get contaminated but no evidence that the action of the atomizer generates aerosols from the patient. The use of atomizers/nebulizers should be considered droplet forming procedures given the risk of coughing and sneezing but not an AGMP.Strength of recommendation: low.Surgical procedures using (CO2) laser vaporization, electrocautery and/or high-speed powered rotating instruments, like microdebriders, drills and saws, can result in airborne transmission of aerosols and should therefore be considered AGMPs. In addition, endotracheal procedures like endotracheal suctioning and tracheotomies should also be considered AGMPs as high tracheal airflow can result in airborne transmission of small aerosols. Nasal endoscopy, epistaxis management and in-office sinonasal procedures can induce sneezing and coughing of the patient. Although sneezing and coughing is considered to result in mainly droplet transmission, HCWs should be aware that the resulting clouds also contain small, inspirable aerosols, which can impose a risk, when they are working in close proximity to the patient , 7, 8.For the protection of HCWs during this COVID-19 pandemic, it is not only essential to recognize which procedures are aerosolizing, but physicians should also be aware of the distribution of SARS-CoV-2 throughout the body. The highest viral loads of SARS-CoV-2 have been found in the upper and lower airways, but the virus has also been identified in feces . Viral RFor Otolaryngologists performing aerosol generating procedures, guidelines on PPE use have been suggested in SARS-CoV-2 positive or suspected patients , 58. AltOne of the major limitations of this review is the fact that most recommendations can only be based on evidence from small, descriptive case-series, experimental studies or indirect retrospective cohort studies. Even if direct evidence was available, the clinical applicability of the various study results can be questioned during the current COVID-19 pandemic. Virus kinetics can differ significantly and this not only includes the potential to survive in aerosols, but also its sensitivity to heat and shear stress during drilling. Extrapolating evidence obtained from studies investigating the potential of airborne transmission and infection of HPV or influenza virus might not hold true for SARS-CoV-2.Given the limitations of the available research and knowledge surrounding this topic, we recommend HCWs err on the side of caution. As the risks of potential infection with SARS-CoV-2 are significant, a careful balance between the potential harms of the procedure and quality of the available evidence was considered in these recommendations. Therefore, a strong recommendation that a procedure is an AGMP can be provided despite the paucity of high quality and direct evidence. For example, regarding endoscopic use of microdebriders, due to high-speed rotation of the blade, the authors recommend the microdebrider be considered an AGMP as clinical experience intraoperatively conveys frequent microdebrider suction port plugging. To minimize the risk, we suggest the placement of a suction in the nose or suction catheter in the nasopharynx either in the contralateral nostril or via the oropharynx. The use of the suction near the surgical field is also recommended when using electrocautery or the CO2 laser. Furthermore, given the evidence that endotracheal suctioning is an AGMP, there is a similar theoretical risk of fenestrated suction use in the oral, ear and nasal cavity, for which we suggest the use of level 2 PPE precautions.These recommendations have been developed by reaching consensus between the authors during the COVID-19 pandemic. A summary of included procedures and recommendations are provided in Table During the COVID-19 pandemic, tracheotomy, endotracheal suctioning, the use of high-speed rotating devices, CO2 lasers and electrocautery on aerodigestive tissue should be considered AGMPs.