Appraisal Of Evidence Research Articles

Implications of living evidence formats for coverage decisions in the German health care system

Decision-makers consult systematic reviews and clinical guidelines to make informed coverage decisions based on the current state of evidence. Outdated recommendations in rapidly evolving areas such as lung cancer treatment, are challenging. The COVID-19 pandemic highlighted the need for good decision-making under uncertainty.The descriptive analysis of two samples of evidence bases for evidence synopses to prepare the decision on appropriate comparators shows that living systematic reviews and living clinical guidelines are rare (41/5,463; 0.75%) but present, with COVID-19 being the most common indication. We also describe some characteristics and quality issues of these living formats in the German context.We note an overlap between living and rapid formats, where updates may not adhere to methodological standards in evidence selection, appraisal and formulation of recommendations, or may lack transparency in their methodological processes. The need for critical appraisal of living formats is highlighted as crucial aspect.The production of living systematic reviews and clinical guidelines requires considerable resources and expertise. While there is a need for timeliness in decision making, especially in situations of high uncertainty such as the COVID-19 pandemic, the trade-off between time and quality needs to be balanced. The focus should therefore be on how best to select and process recommendations that are relevant for updating and those that are not.Regularly updated systematic reviews and clinical guidelines that adhere to recommended standards are important for decision-making bodies such as the Federal Joint Committee (G-BA). Transparent documentation of the process and methods used increases confidence in decision-making, even when the evidence base is not perfect.

Operationalizing shared decision making in clinical practice

Shared decision-making (SDM) requires a clear-eyed view of evidence certainty, context, and equipoise in clinical care. This paradigm of care builds on the foundational ethical principle of patient autonomy, further leveraging beneficence, nonmaleficence, and justice to provide bespoke care in the appropriate clinical setting. When evidence is carefully evaluated together with acceptability and feasibility, equity, cost-effectiveness, resources, and patient preferences, an individualized assessment of the trade-off between possible benefits and harms can optimize patient management. In the setting of a conditional recommendation, it is appropriate to engage in SDM with patient partners, to the extent each patient is willing and able to engage in the SDM process. Three conversations inform SDM and include team talk, option talk, and decision talk with discussion of the plan of care. During these conversations, clear communication strategies that are specific, measurable, achievable, realistic, time sensitive, and provide assessment of absolute (not just relative) risk are important to provide necessary education to patient partners. Follow-up is key to ensure that decisions lead to effective treatment. Through this process, it is necessary to minimize cognitive overload and promote a minimally disruptive medicine approach. The acronym “HOW” promotes a holistic appraisal of evidence in context, open-minded teamwork with patients and families, and willingness to be a listening presence while serving as a partner and guide and appreciating the multidimensional and unique nature of each individual. SDM is and will continue to remain a cornerstone of appropriate medical care in settings of clinical equipoise.

Practice guideline of influenza vaccination and antiviral drugs use in children(2024 editon)

Influenza is the most common acute respiratory infectious diseases among children in China. The annual seasonal influenza outbreak has a significant impact on children's health, poses a significant disease and socioeconomic burden, and arouses a wide public concern. In recent years, a number of new influenza vaccines and influenza antivirals have been approved for use in children, expanding the choices for prevention and treatment of influenza. Pediatric Infection Group, Chinese Society of Infectious Diseases of Chinese Medical Association and Infection Group, Pediatric Expert Committee of National Health Commission Capacity Building and Continuing Education, and China Clinical Practice Guidelines Alliance Methodology Committee organized a multidisciplinary guideline development group (GDG) consisting of experts in pediatrics, infectious diseases,epidemiologists,health policy,and guideline methodology proposed eight key issues concerning influenza vaccination and antiviral use from a practice perspective. Through research question construction, evidence retrieval and synthesis, evidence appraisal and evidence-to-decision discussion, recommendations and implementation suggestions were formulated. This guideline is intended to provide guidance for pediatricians at different facility levels and healthcare providers engaged in vaccination services,and institutional professionals dealing with prevention and control of infectious diseases.

Polatuzumab Vedotin for Diffuse Large B-Cell Lymphoma: Innovation's Allure versus a Time-Honored Tradition

AbstractChemotherapy with R-CHOP (rituximab, cyclophosphamide, Adriamycin, vincristine, prednisolone) is the standard of care for patients with diffuse large B-cell lymphoma as the first-line therapy. The recent approval of polatuzumab as the first-line therapy after demonstration of its efficacy in the Polatuzumab Vedotin in Previously Untreated Diffuse Large B-Cell Lymphoma (POLARIX) trial is the first significant change in this treatment regimen over two decades. This concise appraisal of trial evidence and clinical context highlights the limited potential for a clinically significant benefit with the addition of polatuzumab to the first-line therapy for this common hematologic malignancy.

Current management of chronic kidney disease in type-2 diabetes-A tiered approach: An overview of the joint Association of British Clinical Diabetologists and UK Kidney association (ABCD-UKKA) guidelines.

A growing and significant number of people with diabetes develop chronic kidney disease (CKD). Diabetes-related CKD is a leading cause of end-stage kidney disease (ESKD) and people with diabetes and CKD have high morbidity and mortality, predominantly related to cardiovascular disease (CVD). Despite advances in care over the recent decades, most people with CKD and type 2 diabetes are likely to die of CVD before developing ESKD. Hyperglycaemia and hypertension are modifiable risk factors to prevent onset and progression of CKD and related CVD. People with type 2 diabetes often have dyslipidaemia and CKD per se is an independent risk factor for CVD, therefore people with CKD and type 2 diabetes require intensive lipid lowering to reduce burden of CVD. Recent clinical trials of people with type 2 diabetes and CKD have demonstrated a reduction in composite kidney end point events (significant decline in kidney function, need for kidney replacement therapy and kidney death) with sodium-glucose co-transporter-2 (SGLT-2) inhibitors, non-steroidal mineralocorticoid receptor antagonist finerenone and glucagon-like peptide 1 receptor agonists. The Association of British Clinical Diabetologists (ABCD) and UK Kidney Association (UKKA) Diabetic Kidney Disease Clinical Speciality Group have previously undertaken a narrative review and critical appraisal of the available evidence to inform clinical practice guidelines for the management of hyperglycaemia, hyperlipidaemia and hypertension in adults with type 2 diabetes and CKD. This 2024 abbreviatedupdated guidance summarises the recommendations and the implications for clinical practice for healthcare professionals who treat people with diabetes and CKD in primary, community and secondary care settings.

Re-appraising the evidence for the source, regulation and function of p53-family isoforms.

The p53 family of proteins evolved from a common ancestor into three separate genes encoding proteins that act as transcription factors with distinct cellular roles. Isoforms of each member that lack specific regions or domains are suggested to result from alternative transcription start sites, alternative splicing or alternative translation initiation, and have the potential to exponentially increase the functional repertoire of each gene. However, evidence supporting the presence of individual protein variants at functional levels is often limited and is inferred by mRNA detection using highly sensitive amplification techniques. We provide a critical appraisal of the current evidence for the origins, expression, functions and regulation of p53-family isoforms. We conclude that despite the wealth of publications, several putative isoforms remain poorly established. Future research with improved technical approaches and the generation of isoform-specific protein detection reagents is required to establish the physiological relevance of p53-family isoforms in health and disease. In addition, our analyses suggest that p53-family variants evolved partly through convergent rather than divergent evolution from the ancestral gene.

Decision Support Tool to Improve Decision-Making for HIV Pre-Exposure Prophylaxis (PrEP): Development Process and Alpha Testing.

African, Caribbean, and Black (Black) communities in Canada are disproportionately affected by the HIV epidemic. Pre-exposure prophylaxis (PrEP) is a highly effective option for the prevention of HIV. However, the use of PrEP for HIV prevention among eligible Black clients in Canada remains far below the thresholds necessary to achieve the goal of zero new HIV infections. In a recent study in Toronto, PrEP-eligible Black clients were found to have decisional conflict and unmet decisional needs, which affected the quality of their decision-making process regarding the initiation and adherence to PrEP. There is evidence that decision support tools (DSTs) can improve the quality of a decision, the quality of the decision-making process, the implementation or continuation of the chosen option, and the appropriate use of health services. Despite these benefits, there is currently no DST for PrEP-eligible Black clients being asked to consider PrEP for HIV prevention. Our study aimed to develop a DST to improve PrEP decision-making for Black clients and to evaluate the tool's acceptability and usability. We developed and evaluated the PrEP DST for Black patients using the 7-step process outlined in the Ottawa Decision Support Group Guideline for the development and evaluation of DST. To facilitate the implementation of the Ottawa Decision Support Group guideline, we assembled a multidisciplinary team of primary health care providers, researchers, community members with lived experiences, and digital content designers to serve as the steering committee. First, we assessed patients' and primary health care providers' views on decisional support needs, after which we determined the content, design, and distribution plan for the DST. Subsequently, we conducted evidence synthesis, reviews, and appraisal before developing the PrEP DST prototype. The final tool was reviewed by steering committee members for completeness before acceptability and usability testing with potential Black clients and PrEP providers. The web-based DST yielded 27 pages divided into 6 distinct sections. The six sections include (1) an introduction of the DST, (2) clarify your decision, (3) knowledge, (4) a value clarification exercise, (5) support system, and (6) next steps. Both Black clients and PrEP providers reported ease of task performance, general satisfaction, and usefulness of the tool to support decision-making for Black clients. Feedback on usability centered on the need to add a user guide to increase usability. All feedback was incorporated into the final tool. A PrEP DST for Black clients developed using a systematic process and a multidisciplinary steering committee was acceptable and usable by both Black clients and PrEP providers. Further study (eg, randomized controlled trials) may be needed to evaluate the efficacy of the PrEP DST.

National recommendations for the management of children and young people with IgA vasculitis: a best available evidence, group agreement-based approach

ObjectiveIgA vasculitis (IgAV) is the most frequently experienced subtype of vasculitis seen in children. Most children fully recover, however, complications including chronic kidney disease are recognised. The aim of this...

PubMed captures more fine-grained bibliographic data on scientific commentary than Web of Science: a comparative analysis

BackgroundResearch commentaries have the potential for evidence appraisal in emphasising, correcting, shaping and disseminating scientific knowledge.ObjectivesTo identify the appropriate bibliographic source for capturing commentary information, this study compares comment data...

Critical Appraisal of Evidence for DNP-Prepared Nurses.

This is the fourth article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making (EBDM). It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to https://links.lww.com/AJN/A133). This follow-up series on EBDM will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey. To access previous articles in this EBDM series, go to https://links.lww.com/AJN/A256.

Genotoxicity of radiofrequency electromagnetic fields on mammalian cells in vitro: A systematic review with narrative synthesis

BackgroundOver the last decades, great concern has been raised about possible adverse effects to human health due to exposures to radiofrequency electromagnetic fields (RF-EMF, 100 kHz – 300 GHz) emitted by wireless communication technologies. In 2011 the International Agency for Research on Cancer classified RF-EMF as possibly carcinogenic to humans, highlighting that the evidence was weak and far from conclusive. Updated systematic reviews of the scientific literature on this topic are lacking, especially for mechanistic studies. ObjectivesTo perform a systematic review of the scientific literature on genotoxic effects induced by RF-EMF in in vitro experimental models. The overall aim is to assess the confidence and level of evidence of the induced effects in mammalian cell cultures. MethodsFull details regarding the eligibility criteria, information sources, and methods developed to assess risk of bias in the included study, are reported in our published protocol (Romeo et al. 2021). The databases NCBI PubMed, Web of Science, and EMF-Portal were used as information sources (last searched on 31st December 2022). In developing the systematic review, we followed the guidelines provided by the National Toxicology Program-Office of Health Assessment and Translation (NTP-OHAT), adapted to the evaluation of in vitro studies. A narrative synthesis of the body of evidence was performed by tabulating data classified according to meaningful groups (endpoints) and sub-groups (exposure parameters). This report, abstract included, conforms to the PRISMA 2020 (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. ResultsOut of 7750 unique records identified, 159 articles were eligible for inclusion. From the extracted data, we identified 1111 experiments (defined as independent specific combinations of diverse biological and electromagnetic parameters). The large majority (80%) of experiments reviewed did not show statistically significant genotoxic effects of RF-EMF exposures, and most “positive” studies were rated as of moderate to low quality, with negative ratings in the key bias domains. A qualitative evidence appraisal was conducted at the endpoint level, and then integrated across endpoints. DiscussionTo the best of our knowledge, this is the first systematic review of the scientific literature on genotoxic effects in mammalian cell cultures in relation to RF-EMF exposure, which confirms and strengthens conclusions from previous syntheses of this specific topic thanks to the use of transparently reported methods, pre-defined inclusion criteria, and formal assessment of susceptibility to bias. Limitations of the evidence included were the frequent reporting of findings in graphical display only, and the large heterogeneity of experimental data, which precluded a meta-analysis. ConclusionsIn the assessment restricted to studies reporting a significant effect of the exposure on the outcome, we reached an overall assessment of “low” confidence in the level of evidence that RF-EMF induce genotoxic effects in mammalian cells However, 80% of experiments reviewed showed no effect of RF exposure on the large majority of endpoints, especially the irreversible ones, independently of the exposure features, level, and duration (moderate evidence of no effect). Therefore, we conclude that the analysis of the papers included in this review, although only qualitative, suggests that RF exposure does not increase the occurrence of genotoxic effects in vitro. Framework and fundingThis systematic review addresses one of the evidence streams considered in a larger systematic review of the scientific literature on the potential carcinogenicity of RF-EMF, performed by scientists from several Italian public research agencies. The project is supported by the Italian Workers’ Compensation Authority (INAIL) in the framework of the CRA with the Istituto Superiore di Sanità “BRiC 2018/06 – Scientific evidence on the carcinogenicity of electromagnetic fields”.

Implantable Cardioverter Defibrillators in Prevention of Sudden Cardiac Death in Kidney Transplant Recipients: A Case Series and an Appraisal of Current Evidence.

Background: Cardiovascular diseases, including sudden cardiac death (SCD), are the leading cause of mortality among kidney transplant recipients (KTRs). While implantable cardioverter defibrillators (ICDs) are established for SCD prevention in the general population, data on the benefits in patients with CKD is scarce and controversial, and there is no established general consensus on their use in this group of patients. Furthermore, data for KTRs are lacking. The aim of this study is to present our experience with ICDs in KTRs and evaluate the outcomes in this population. Methods: We retrospectively analyzed medical records of KTRs who received a kidney allograft between October 1973 and December 2023 and received ICDs for the prevention of SCD. Results: Of 2282 KTRs, 10 patients (0.44%) underwent an ICD implantation with an average age of 60.6 years at the time of implantation; 9 were male. Primary prevention of SCD was the most common indication, with only one patient receiving an ICD following sudden cardiac arrest. The female patient received an ICD while on dialysis, and the rest of the patients received ICDs in the posttransplant period with an average time of 9.1 years after KT. Kidney allograft function was reduced in all patients at the time of the ICD implantation with an average estimated glomerular filtration rate (eGFR) of 44 mL/min/1.73 m2. No ICD-related complications were recorded. Six patients are alive with an average follow-up of 5.2 years. Conclusions: ICD implantation in carefully selected KTRs may offer survival benefits and can be a valuable tool in preventing SCD. Larger studies are needed to confirm these findings and establish clear guidelines for ICD use in this specific population.

Using causal diagrams within the Grading of Recommendations, Assessment, Development and Evaluation framework to evaluate confounding adjustment in observational studies

Background and ObjectivesThe current Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system instructs appraisers to evaluate whether individual observational studies have sufficiently adjusted for confounding. However, it does not provide an explicit, transparent, or reproducible method for doing so. This article explores how implementing causal graphs into the GRADE framework can help appraisers and end-users of GRADE products to evaluate the adequacy of confounding control from observational studies. MethodsUsing modern epidemiological theory, we propose a system for incorporating causal diagrams into the GRADE process to assess confounding control. ResultsIntegrating causal graphs into the GRADE framework enables appraisers to provide a theoretically grounded rationale for their evaluations of confounding control in observational studies. Additionally, the inclusion of causal graphs in GRADE may assist appraisers in demonstrating evidence for their appraisals in other domains of quality of evidence beyond confounding control. To support practical application, a worked example is included in the supplemental material to guide users through this approach. ConclusionGRADE calls for the explicit and transparent appraisal of evidence in the process of evidence synthesis. Incorporating causal diagrams into the evaluation of confounding control in observational studies aligns with the core principles of the GRADE framework, providing a clear, theory-based method for the adequacy of confounding control in observational studies.

Maternal Care of Preterm Infants after Discharge from the Neonatal Intensive Care Unit: A Rapid Review

Abstract The maternal care of infants poses a unique challenge for mothers, especially after discharge from the hospital. This review focused on the literature on maternal care of preterm infants at home after discharge from the hospital’s Neonatal Intensive Care Unit (NICU). A comprehensive literature search was conducted using keywords relevant to the topic. PubMed and EBSCO essential databases were searched for studies published between 2017 and 2023 (six years). Out of the 2903 retrieved studies, 7 were eligible and included in the review. The quality of available evidence was assessed using the Johns Hopkins Nursing Evidence Appraisal Tool (JHNEAT) and the Critical Appraisal Skills Programme (CASP) checklist. This review found that exclusive breastfeeding rates for preterm infants at home varied from 27% to 76% (Pooled prevalence of 48%) in data extracted from the studies conducted in Ethiopia (Africa), Brazil (South America), USA (North America), Denmark, and Italy (Europe). The practice of kangaroo mother care (KMC) for temperature regulation ranged from 41% to 83% (Pooled prevalence of 63%) in data extracted from studies conducted in Ethiopia (Africa) and Denmark (Europe). The review concluded that the care provided by mothers at home after discharge from the NICU was inadequate. Maternal and child health services providers should develop social media platforms to educate and encourage mothers to sustain exclusive breastfeeding and KMC practices after leaving the NICU.

Benchmarking Human–AI collaboration for common evidence appraisal tools

Background and ObjectiveIt is unknown whether large language models (LLMs) may facilitate time- and resource-intensive text-related processes in evidence appraisal. The objective was to quantify the agreement of LLMs with human consensus in appraisal of scientific reporting (Preferred Reporting Items for Systematic reviews and Meta-Analyses [PRISMA]) and methodological rigor (A MeaSurement Tool to Assess systematic Reviews [AMSTAR]) of systematic reviews and design of clinical trials (PRagmatic Explanatory Continuum Indicator Summary 2 [PRECIS-2]) and to identify areas where collaboration between humans and artificial intelligence (AI) would outperform the traditional consensus process of human raters in efficiency. Study Design and SettingFive LLMs (Claude-3-Opus, Claude-2, GPT-4, GPT-3.5, Mixtral-8x22B) assessed 112 systematic reviews applying the PRISMA and AMSTAR criteria and 56 randomized controlled trials applying PRECIS-2. We quantified the agreement between human consensus and (1) individual human raters; (2) individual LLMs; (3) combined LLMs approach; (4) human–AI collaboration. Ratings were marked as deferred (undecided) in case of inconsistency between combined LLMs or between the human rater and the LLM. ResultsIndividual human rater accuracy was 89% for PRISMA and AMSTAR, and 75% for PRECIS-2. Individual LLM accuracy was ranging from 63% (GPT-3.5) to 70% (Claude-3-Opus) for PRISMA, 53% (GPT-3.5) to 74% (Claude-3-Opus) for AMSTAR, and 38% (GPT-4) to 55% (GPT-3.5) for PRECIS-2. Combined LLM ratings led to accuracies of 75%–88% for PRISMA (4%–74% deferred), 74%–89% for AMSTAR (6%–84% deferred), and 64%–79% for PRECIS-2 (29%–88% deferred). Human–AI collaboration resulted in the best accuracies from 89% to 96% for PRISMA (25/35% deferred), 91%–95% for AMSTAR (27/30% deferred), and 80%–86% for PRECIS-2 (76/71% deferred). ConclusionCurrent LLMs alone appraised evidence worse than humans. Human–AI collaboration may reduce workload for the second human rater for the assessment of reporting (PRISMA) and methodological rigor (AMSTAR) but not for complex tasks such as PRECIS-2.

Methodological components, structure and quality assessment tools for evidence summaries: a scoping review.

The objective of this review was to identify and map the available information related to the definition, structure, and core methodological components of evidence summaries, as well as to identify any indicators of quality. Evidence summaries offer a practical solution to overcoming some of the barriers present in evidence-based health care, such as lack of access to evidence at the point of care, and the knowledge and expertise to evaluate the quality and translate the evidence into clinical decision-making. However, lack of transparency in reporting and inconsistencies in the methodology of evidence summary development have previously been cited and pose problems for end-users (eg, clinicians, policymakers). Any English-language resource that described the methodological development or appraisal of an evidence summary was included. PubMed, Embase, and CINAHL (EBSCOhost) were systematically searched in November 2019, with no limits on the search. The search was updated in June 2021 and January 2023. Gray literature searches and pearling of references of included sources were also conducted at the same time as the database searches. All resources (ie, articles, papers, books, dissertations, reports, and websites) were eligible for inclusion in the review if they evaluated or described the development or appraisal of an evidence summary methodology within a point-of-care context and were published in English. Literature reviews (eg, systematic reviews, rapid reviews), including summaries of evidence on interventions or health care activities that either measure effects, a phenomena of interest, or where the objective was the development, description or evaluation of methods without a clear point-of-care target, were excluded from the review. A total of 76 resources (n=56 articles from databases and n=20 reports from gray literature sources) were included in the review. The most common type/name included critically appraised topic (n=18) and evidence summary (n=17). A total of 25 resources provided a definition of an evidence summary: commonalities included a clinical question; a structured, systematic literature search; a description of literature selection; and appraisal of evidence. Of these 25, 16 included descriptors such as brief, concise, rapid, short, succinct and snapshot. The reported methodological components closely reflected the definition results, with the most reported methodological components being a systematic, multi-database search, and critical appraisal. Evidence summary examples were mostly presented as narrative summaries and usually included a reference list, background or clinical context, and recommendations or implications for practice or policy. Four quality assessment tools and a systematic review of tools were included. The findings of this study highlight the wide variability in the definition, language, methodological components and structure used for point-of-care resources that met our definition of an evidence summary. This scoping review is one of the first steps aimed at improving the credibility and transparency of evidence summaries in evidence-based health care, with further research required to standardize the definitions and methodologies associated with point-of-care resources and accepted tools for quality assessment. A Chinese-language version of the abstract of this review is available at http://links.lww.com/SRX/A59, studies ineligible following full-text review http://links.lww.com/SRX/A60.

The Role of Furin and Its Therapeutic Potential in Cardiovascular Disease Risk.

Furin is an important proteolytic enzyme, converting several proteins from inactive precursors to their active forms. Recently, proteo-genomic analyses in European and East Asian populations suggested a causal association of furin with ischaemic heart disease, and there is growing interest in its role in cardiovascular disease (CVD) aetiology. In this narrative review, we present a critical appraisal of evidence from population studies to assess furin's role in CVD risk and potential as a drug target for CVD. Whilst most observational studies report positive associations between furin expression and CVD risk, some studies report opposing effects, which may reflect the complex biological roles of furin and its substrates. Genetic variation in FURIN is also associated with CVD and its risk factors. We found no evidence of current clinical development of furin as a drug target for CVD, although several phase 1 and 2 clinical trials of furin inhibitors as a type of cancer immunotherapy have been completed. The growing field of proteo-genomics in large-scale population studies may inform the future development of furin and other potential drug targets to improve the treatment and prevention of CVD.

KDIGO 2024 Clinical Practice Guideline for the management of lupus nephritis. Translated into Russian by E.V. Zakharova

The Kidney Disease: Improving Global Outcomes (KDIGO) 2024 Clinical Practice Guideline for the Management of Lupus Nephritis represents a focused update of the Lupus nephritis chapter from the KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. The aim is to assist clinicians caring for individuals with lupus nephritis. The update takes into consideration evidence from randomized controlled trials published since February 2022. As in 2021, the chapter follows the same template, providing guidance related to diagnosis, treatment, and special situations. Based on the evidence, this update is focused on guidance related to treatment of lupus nephritis. This guideline update followed an explicit process of evidence review and appraisal. Treatment approaches and guideline recommendations are based on systematic reviews of relevant studies, and appraisal of the strength of recommendations and certainty of the evidence following the “Grading of Recommendations Assessment, Development and Evaluation” (GRADE) approach. Limitations of the evidence are discussed and areas of future research are presented.

Does randomised evidence alter clinical practise? The react qualitative study

BackgroundIn 2015, the results of the ‘Small bites versus large bites for closure of abdominal midline incisions (STITCH) Trial’ were published in The Lancet. This demonstrated the superiority of small bite laparotomy closure over mass closure for the reduction of incisional hernias; despite this most surgeons have not changed their practice. Previous research has shown the time taken for the implementation of evidenced based practise within medicine takes an average of 17 years. This study aims to understand the reasons why surgeons have and have not changed their practice with regards to closure of midline laparotomy.MethodsSemi-structured interviews were completed with surgical consultants and registrars at a single institution in South West England. The interview topic guide was informed by a review of the published literature, which identified barriers to adopting evidence into surgical practice. Interview transcripts underwent thematic analysis with themes identified following discussions within the research team, exploring views on published data and clinical practise.ResultsNine interviews with general surgical and urological consultants as well as registrars in training were performed. Three themes were identified; ‘Trusting the Evidence & Critical Appraisal’, ‘Surgical Attitude to Risk’ and ‘Adopting Evidence in Practise’, that reflected barriers to the introduction of evidenced based practise to clinical work.ConclusionIdentification of the themes highlights possible areas for intervention to decrease the adoption time for evidence, for example from randomised controlled trials. The continued updating of clinical practise allows clinicians to provide best evidenced based care for patients and improve their outcomes.

Review of EmPATH Units for Behavioral Health Casualties in Prolonged Field Care Environments.

Psychiatric conditions are one of the leading non-battle injury diseases resulting in medical evacuation (MEDEVAC) from combat environments. The challenge of limited MEDEVAC capability necessitating prolonged field care in future large-scale combat operations must be addressed. Therefore, a robust program is needed to address frontline care of behavioral health (BH), maximizing service members returning to duty and minimizing MEDEVAC. This review summarizes the literature on the impacts of the Emergency Psychiatric Assessment, Treatment, and Healing (EmPATH) Unit program as a solution to the challenges of treating behavioral health in future wars. We conducted a systematic literature search and review, and a non-systematic literature critique. We then used the Johns Hopkins evidence appraisal tool to appraise the strength and quality of the evidence. The following electronic databases were utilized for the search: Google Scholar, Embase, CINAHL, and PubMed. Search terms included: included "EmPATH," "prolonged field care," and "operational," alone and combined. The literature review found that the EmPATH unit, a recently developed civilian hospital-based program, can work with higher acuity psychiatric crisis patients who would otherwise be admitted to an inpatient unit, showing promising results in avoiding the need for inpatient hospitalization. EmPATH units help decrease hospitalization rates, reduce restraints and violence, and shorten the patients' boarding time in a holding area. Such findings support the use of the EmPATH unit as a tactic for prolonged field care of psychiatric patients in a combat operational environment. This is the first literature review to consider EmPATH units for psychiatric prolonged field care based on its advantages demonstrated in the civilian sector. Studies have yet to be done on EmPATH units' usefulness in the military, showing a knowledge gap in current evidence supporting its suitability. Thus, this review recommends further studies of EmPATH units in military settings, especially prolonged field care environments.