Level Of Recommendation Research Articles

Current status of wet lab and cadaveric simulation in urological training: A systematic review.

We undertook a systematic review of the use of wet lab (animal and cadaveric) simulation models in urological training, with an aim to establishing a level of evidence (LoE) for studies and level of recommendation (LoR) for models, as well as evaluating types of validation. Medline, EMBASE, and Cochrane databases were searched for English-language studies using search terms including a combination of "surgery," "surgical training," and "medical education." These results were combined with "wet lab," "animal model," "cadaveric," and "in-vivo." Studies were then assigned a LoE and LoR if appropriate as per the education-modified Oxford Centre for Evidence-Based Medicine classification. A total of 43 articles met the inclusion criteria. There was a mean of 23.1 (±19.2) participants per study with a median of 20. Overall, the studies were largely of low quality, with 90.7% of studies being lower than LoE 2a (n=26 for LoE 2b and n=13 for LoE 3). The majority (72.1%, n=31) of studies were in animal models and 27.9% (n=12) were in cadaveric models. Simulation in urological education is becoming more prevalent in the literature, however, there is a focus on animal rather than cadaveric simulation, possibly due to cost and ethical considerations. Studies are also predominately of a low LoE; higher LoEs, especially randomized controlled studies, are needed.

Current status of simulation and training models in microsurgery: A systematic review

With the prolific uptake of simulation-based training courses, this systematic review aims to identify the available microsurgical simulation and training models, their status of validation, associated studies, and levels of evidence (LoE) for each training model, thereby establishing a level of recommendation (LoR). MEDLINE, Embase, and the Cochrane Library databases were searched for English language articles, describing microsurgery simulators and/or validation studies. All studies were assessed for LoE, and each model was subsequently awarded a LoR using a modified Oxford Centre for Evidence-Based Medicine classification, adapted for education, with 1 being the highest and 4 the lowest score. A total of 86 studies were identified describing 64 models and simulators ranging from bench models, cadaveric animal tissue, cadaveric human tissue, live animal models, virtual reality simulators, and training curricula. Of these, 49 simulators had at least one validation study. Models were assessed for face (n = 42), content (n = 31), construct (n = 25), transfer (n = 10), and concurrent validity (n = 1) by these studies. The most commonly identified modality was bench models (n = 28) followed by cadaveric animal tissue (n = 24). The cryopreserved rat aorta model received the highest LoR followed by chicken wing, chicken thigh and practice cardboard models. Microsurgery simulation is a growing field and increasing numbers of models are being produced. However, there are still only a few validation studies with a high LoE. It is therefore imperative that training models and/or programs are evaluated for validity and efficacy in order to allow utilization in microsurgical skills acquisition.

Editors' note: Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research

In their American Academy of Neurology (AAN) practice parameter, Giacino et al. provided a thorough review of the available evidence pertaining to the care of patients with impaired consciousness. The expert panel provided level of recommendations (LORs) regarding the discussion of long-term care needs, pain management strategies, and techniques for neuroprognostication in patients with disorders of consciousness. In response to these consensus recommendations, Phan et al. highlight 1 potential limitation of the LOR classification system that was used. Historically, the highest LOR (level A) was afforded only to recommendations based on 1 or more randomized clinical trials. However, this requirement was amended by the Institute of Medicine in 2011 as well as the 2011 AAN Clinical Guideline Practice Manual, as the authors emphasize in their response. After 2011, a level A recommendation was permitted as long as there was strong and consistent related evidence and inferences could be drawn. Therefore, a higher LOR could be assigned to recommendations with less explicit substantiation from large randomized clinical trials. By using this classification schema, some recommendations may be generalized to patients who are likely to benefit from such guidance. In their American Academy of Neurology (AAN) practice parameter, Giacino et al. provided a thorough review of the available evidence pertaining to the care of patients with impaired consciousness. The expert panel provided level of recommendations (LORs) regarding the discussion of long-term care needs, pain management strategies, and techniques for neuroprognostication in patients with disorders of consciousness. In response to these consensus recommendations, Phan et al. highlight 1 potential limitation of the LOR classification system that was used. Historically, the highest LOR (level A) was afforded only to recommendations based on 1 or more randomized clinical trials. However, this requirement was amended by the Institute of Medicine in 2011 as well as the 2011 AAN Clinical Guideline Practice Manual, as the authors emphasize in their response. After 2011, a level A recommendation was permitted as long as there was strong and consistent related evidence and inferences could be drawn. Therefore, a higher LOR could be assigned to recommendations with less explicit substantiation from large randomized clinical trials. By using this classification schema, some recommendations may be generalized to patients who are likely to benefit from such guidance.

Current Status of Simulation in Otolaryngology: A Systematic Review

Otolaryngology is a highly technical and demanding specialty and the requirements for surgical trainees to acquire proficiency remains challenging. Simulation has been purported to be an effective tool in assisting with this. The aim of this systematic review is to identify the available otolaryngology simulators, their status of validation, and evaluation the level of evidence behind each training model and thereby establish a level of recommendation. PubMed, ERIC, and Google Scholar databases were searched for articles that described otolaryngology simulators or training models between 1980 and April 2016. Any validation studies for simulators were also retrieved. Titles and abstracts were screened for relevance using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Level of evidence (LoE) and Level of recommendation (LoR) was awarded to each study and model, respectively. A total of 70 studies were identified describing 64 simulators. Out of these, at least 54 simulators had 1 validation study. Simulators for the ear and temporal bone surgery were the most common (n = 32), followed by laryngeal and throat (n = 20) and endoscopic sinus surgery (n = 12). Face validity was evaluated by 29 studies, 20 attempted to show construct, 20 assessed content, 20 transfer, and only 2 assessed concurrent validity. Of the validation assessments, 2 were classified as Level 1b, 10 Level 2a, and 48 Level 2b. No simulators received the highest LoR, but 8 simulators received a LoR of 2. Despite the lack of evidence in outcome studies and limited number of high-validity otolaryngology simulators, the role of simulation continues to grow across surgical specialties Hence, it is imperative that the simulators are of high validity and construct for trainees to practice and rehearse surgical skills to develop confidence.

Rapid confirmatory method for the determination of 11 nitroimidazoles in egg using liquid chromatography tandem mass spectrometry

A rapid confirmatory method has been developed and validated for the simultaneous identification, confirmation and quantitation of 11 nitroimidazoles in eggs by liquid chromatography tandem mass spectrometry (LC–MS/MS). The method is validated in accordance with Commission Decision 2002/657/EC and is capable of analysing metronidazole (MNZ), dimetridazole (DMZ), ronidazole (RNZ), ipronidazole (IPZ) and their hydroxy metabolites MNZ-OH, HMMNI (hydroxymethyl, methyl nitroimidazole), IPZ-OH. The method is also capable of analysing carnidazole (CRZ), ornidazole (ORZ), tinidazole (TNZ) and ternidazole (TRZ). MNZ, DMZ and RNZ have been assigned a recommended level (RL) of 3 μg kg −1 by the Community Reference Laboratory (CRL) in Berlin. The developed method described in this study is easily able to detect all the nitroimidazole compounds investigated at this level and below. Egg samples are extracted with acetonitrile, and NaCl is added to help remove matrix contaminants. The acetonitrile extract undergoes a liquid–liquid wash step with hexane; it is then evaporated and reconstituted in mobile phase. The reconstituted samples are analysed by liquid chromatography tandem mass spectrometry (LC–MS/MS). The decision limits (CCα) range from 0.33 to 1.26 μg kg −1 and the detection capabilities (CCβ), range from 0.56 to 2.15 μg kg −1. The results of the inter-assay study, which was performed by fortifying hen egg samples ( n = 18) on three separate days, show the accuracy calculated for the various analytes to range between 87.2 and 106.2%. The precision of the method, expressed as %CV values for the inter-assay variation of each analyte at the three levels of fortification (3, 4.5 and 6.0 μg kg −1), ranged between 3.7 and 11.3%. A Day 4 analysis was carried out to examine species variances in eggs from different birds such as duck and quail and investigating differences in various battery and free range hen eggs.

Development and validation of a rapid method for the determination and confirmation of 10 nitroimidazoles in animal plasma using liquid chromatography tandem mass spectrometry

A rapid LC–MS/MS method has been developed and validated for the simultaneous identification, confirmation and quantitation of 10 nitroimidazoles in plasma. The method validated in accordance with Commission Decision (CD) 2002/657/EC is capable of analysing for metronidazole (MNZ), dimetridazole (DMZ), ronidazole (RNZ), ipronidazole (IPZ) and their hydroxy metabolites MNZ-OH, HMMNI (hydroxymethyl, methyl nitroimidazole), IPZ-OH. The method is also capable of analysing carnidazole (CRZ), ornidazole (ORZ) and ternidazole (TRZ) which are rarely analysed by modern methods. MNZ, DMZ and RNZ have a recommended level (RL) of 3ngmL−1 which this method is easily able to detect for all the nitroimidazole compounds. Plasma samples are extracted with acetonitrile, and NaCl is added to help remove matrix contaminants. The acetonitrile extract undergoes a liquid–liquid wash step with hexane; it is then evaporated and reconstituted in mobile phase. The reconstituted samples are analysed by liquid chromatography tandem mass spectrometry (LC–MS/MS). The decision limits (CCα) range from 0.5 to 1.6ngmL−1 and the detection capabilities (CCβ), range from 0.8 to 2.6ngmL−1. The results of the inter-assay study, which was performed by fortifying bovine plasma samples (n=18) on three separate days, show the accuracy calculated for the various analytes range between 101% and 108%. The precision of the method, expressed as CV% values for the inter-assay variation of each analyte at the three levels of fortification (3, 4.5 and 6.0ngmL−1), ranged between 4.9% and 15.2%. A day 4 analysis was carried out to examine species variances in animals such as avian, ovine, porcine and equine.