Limits of Evidence-based Surgery

Is it feasible and ethical to randomize patients between surgery and non-surgical treatments for gastrointestinal cancers?

Background

In several settings in the treatment of gastrointestinal cancers, it is unclear if the addition of surgery to a multimodal treatment strategy, or in some circumstances its omission, lead to a better outcome for patients. In such situations of clinical equipoise, high-quality evidence from randomised-controlled trials is needed to decide which treatment approach is preferable.

Objective

In this article, we outline the importance of randomised trials comparing surgery with non-surgical therapies for specific scenarios in the treatment of gastrointestinal cancers. We explain the difficulties and solutions of designing these trials and recruiting patients in this context.

Methods

We performed a selective review based on a not systematic literature search in core databases, supplemented by browsing health information journals and citation searching. Only articles in English were selected. Based on this search, we discuss the results and methodological characteristics of several trials which randomised patients with gastrointestinal cancers between surgery and non-surgical treatments, highlighting their differences, advantages, and limitations.

Results and conclusions

Innovative and effective cancer treatment requires randomised trials, also comparing surgery and non-surgical treatments for defined scenarios in the treatment of gastrointestinal malignancies. Nevertheless, potential obstacles to designing and carrying out these trials must be recognised ahead of time to avoid problems before or during the trial.

ROBOCOP II (ROBOtic assisted versus conventional open partial nephrectomy) randomised, controlled feasibility trial: clinical trial protocol

INTRODUCTION

Randomised controlled trials comparing robotic-assisted partial nephrectomy (RAPN) and open PN (OPN) are lacking. Therefore, we aim to report the study protocol and a trial update for a randomised controlled feasibility trial comparing RAPN versus OPN for renal neoplasms.

METHODS AND ANALYSIS

The ROBOtic assisted versus conventional Open Partial nephrectomy II trial is designed as a single-centre, randomised, open-label, feasibility trial. Participation will be offered to patients with renal neoplasms and deemed feasible for both, OPN and RAPN. We aim to enrol 50 patients within 15 months using a 1:1 allocation ratio. The primary endpoint of the trial is feasibility of recruitment and will be successful if one third of eligible patients agree to participate. Secondary endpoints include perioperative results, health-related quality of life, inflammatory response as well as surgical ergonomics of the operating team. If the primary outcome, feasibility of recruitment, is successful, the secondary results of the trial will be used for planning a confirmative phase III trial.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the local institutional review board (Ethik-Kommission II at Heidelberg University: 2020-542N). Results will be made publicly available in peer-reviewed scientific journals and presented at appropriate congresses and social media.

TRIAL REGISTRATION NUMBER

NCT04534998.

Levels of evidence and journal impact factor in oral and maxillofacial surgery: a 15-year follow-up

This study was performed to assess changes over time in the quality of research in oral and maxillofacial surgery (OMS) by examining the level of evidence of published articles. A secondary aim was to determine the relationship of the journal impact factor to these levels of evidence. The four major OMS journals with an impact factor were assessed. Articles published in 2017 and 2018 were categorized based on their level of evidence, and their correlation with the 2019 journal impact factor was investigated using Spearman's rank correlation coefficient (rho). The total number of published articles increased by a factor of 2.4 over a 15-year period, from 932 in 2002-2003 to 2253 in 2017-2018. The percentage of articles increased by 1.0% for level I evidence, 3.4% for level II, 8.2% for level III, and 4.1% for level IV. Non-evidence articles reduced by 16.7%. All journals showed an increase in impact factor, and a significant correlation was noted between the proportion of published higher-level evidence articles and the impact factor over time (rho=0.811, P=0.001). It is concluded that OMS journals currently display a higher proportion of good quality articles leading to a better impact factor than 15 years ago.

Using Evidence for Hand Surgery: How to Practice Evidence-Based Hand Surgery Care

Each step of the evidence-based practice process is critical and requires clear understanding for accurate application. To practice evidence-based care, providers must acquire a specific skillset that facilitates translation of a patient problem into an answerable research question. Additional requirements are understanding of electronic databases, critical appraisal of the available evidence, and integration of the findings to generate a specific, individualized treatment plan. Although this process is demanding, evidence-based practice is essential in the delivery of optimal patient care.

Procedural Surgical RCTs in Daily Practice: Do Surgeons Adopt Or Is It Just a Waste of Time?

OBJECTIVE

To assess the adoption of recommendation from randomized clinical trials (RCTs) and investigate factors favoring or preventing adoption.

BACKGROUND

RCT are considered to be the cornerstone of evidence-based medicine by representing the highest level of evidence. As such, we expect RCT's recommendations to be followed rigorously in daily surgical practice.

METHODS

We performed a structured search for RCTs published in the medical and surgical literature from 2009 to 2013, allowing a minimum of 5-year follow-up to convincingly test implementation. We focused on comparative technical or procedural RCTs trials addressing the domains of general, colorectal, hepatobiliary, upper gastrointestinal and vascular surgery. In a second step we composed a survey of 29 questions among ESA members as well as collaborators from their institutions to investigate the adoption of surgical RCTs recommendation.

RESULTS

The survey based on 36 RCTs (median 5-yr citation index 85 (24-474), from 21 different countries, published in 15 high-ranked journals with a median impact factor of 3.3 (1.23-7.9) at the time of publication. Overall, less than half of the respondents (47%) appeared to adhere to the recommendations of a specific RCT within their field of expertise, even when included in formal guidelines. Adoption of a new surgical practice was favored by watching videos (46%) as well as assisting live operations (18%), while skepticism regarding the methodology of a surgical RCT (40%) appears to be the major reason to resist adoption.

CONCLUSION

In conclusion, surgical RCTs appear to have moderate impact on daily surgical practice. While RCTs are still accepted to provide the highest level of evidence, alternative methods of evaluating surgical innovations should also be explored.

Quality of surgical randomized controlled trials in hand surgery: a systematic review

We assessed the quantity, quality and trends of randomized controlled trials comparing hand surgical interventions. Study characteristics were collected for 125 randomized controlled trials comparing hand surgical interventions. The Jadad scale (0-5), which assesses methodological quality of trials, was calculated. Logistic regressions were conducted to determine associations with the Jadad score. The studies were published between 1981 and 2015, with an increase over time, most often in Journal of Hand Surgery (European). Mean study size was 68 patients. Mean Jadad score was 2.1, without improvement over time. Thirty percent conducted a power analysis and 8% an intention-to-treat analysis. Studies conducted in the United Kingdom and with smaller sample sizes, power analysis and intention-to-treat analysis were associated with a higher Jadad score. The quantity of trials has increased over time while methodological quality has remained low, indicating a need to improve quality of trials in hand surgery literature.

Trends in Disclosures of Industry Sponsorship

PURPOSE

To examine trends in the reporting of industry funding of oncology trials by primary therapeutic intervention studied: local, targeted, or nontargeted systemic.

METHODS AND MATERIALS

We reviewed oncologic trials published in 10 journals for the years 1994, 2004, and 2014 to determine the frequency of declarations of industry funding for cancer research. Logistic modeling was used to assess associations between reported industry funding and investigation characteristics, such as type of primary intervention, cancer site, study endpoint, number of participants, geographic location of corresponding author, journal impact factor, trial phase, and year of publication.

RESULTS

Reporting of industry funding increased over time (odds ratio [OR] 6.8; 95% confidence interval [CI] 3.82-12.35). Compared with systemic trials, those investigating local therapies were less likely to report industry funding (OR 0.08; 95% CI 0.14-0.15), whereas studies examining targeted interventions were more likely to report industry funding (OR 2.24; 95% CI 1.38-3.66). Studies investigating gynecologic (OR 0.37; 95% CI 0.15-0.88) and pediatric cancers (OR 0.08; 95% CI 0.02-0.27) were less likely to report funding by industry when compared with hematologic cancers. Phase 2 (OR 0.32, 95% CI 0.19-0.52) and phase 3 (OR 0.39, 95% CI 0.17-0.37) studies were less likely to report industry funding than phase 1 studies. Trials investigating interventions for metastatic disease (OR 2.55; 95% CI 1.73-3.79) were more likely to have reported industry funding compared with studies examining the primary/definitive disease setting.

CONCLUSION

Industry funding was reported in more than one-third of oncology trials examined in this study, and the proportion of trials reporting industry funding increased over time. The potential ramifications for these patterns of funding for the future direction of cancer research should be examined, especially given the disproportionate distribution of industry funding among therapeutic intentions, cancer types, and treatment modalities.

Attitudes, awareness and barriers regarding evidence-based orthopedic surgery between health professionals from a Brazilian Public Health System (SUS) hospital: Study of 400 patients

Background:

The fast-track concept refers to all phases of perioperative care: Preoperative, intraoperative, and postoperative strategies. Although most research has focused on adherence to medication, adherence also encompasses numerous health-related behaviors. The aim of this prospective study was to determine the attitudes and awareness among health professionals involved in the treatment of elderly patients with fractures of the femur and the results of 400 patients.

Methods:

The postoperative protocol acceleration was presented to various hospital departments through four seminars. Questionnaire with four ex-residents in the Department of Anesthesiology was conducted. Every 6 months, the results of project implementation to all departments were presented. It was considered adherence to the project when the professionals agreed with all the steps and routines of the project. Patients underwent spinal anesthesia with postoperative analgesia by lumbar plexus block.

Results:

All departments involved in the treatment of elderly patients’ adhered completely to the project and reported the importance of preanesthetic visit, the explanations of design, and reduction of fasting period. Just one anesthetist completely adhered to the project. No former resident of anesthesia joined the program. All parameters studied in 400 patients compared with the data before the project showed a reduction from 21.38% to 100%.

Conclusion:

Improving adherence requires a continuous and dynamic process. We can be inferred that the implementation of fast-track project Brazilian Public Health System (Sistema Único Saúde, SUS) costs decreased with elderly patients with hip fractures. The anesthesiologist was the major obstacle to deployment to all patients.

The Quality of Randomized Controlled Trials in Pediatric Orthopaedics: Are We Improving?

PURPOSE

The quality of randomized controlled trials (RCTs) in orthopaedics is a topic of considerable importance, as RCTs play a major role in guiding clinical practice. The quality of RCTs published between 1995 and 2005 has previously been documented. The purpose of the current study was to assess and describe the quality of pediatric orthopaedic RCTs published from 2005 to 2012, by identifying study characteristics associated with higher quality and outlining areas for improvement.

METHODS

A standardized literature search was used to identify pediatric orthopaedic RCTs published in 7 well-recognized journals between September 2005 and July 2012 inclusive. The Detsky Quality Assessment Scale and the CONSORT checklist for Non-Pharmacologic Trials were used to assess the quality of the RCTs. Scores for the Detsky and CONSORT were calculated by 2 independent blinded orthopaedic surgeon reviewers with epidemiologic training.

RESULTS

Forty RCTs were included in this analysis. The mean percentage score on the Detsky quality scale was 67%. Sixteen (40%) of the articles satisfied the threshold for a satisfactory level of methodological quality (Detsky >75%). Twenty-five (63%) of these studies were negative studies, concluding no difference between treatment arms. In 52% of the negative studies, an a priori sample size analysis was absent, and 28% were self-described as underpowered. In multiple variable regression analysis, only working with a statistician was significantly associated with higher Detsky percentage scores (P=0.01).

CONCLUSIONS

There is a trend for improving quality in pediatric orthopaedic RCTs. Compared with past reports, the mean Detsky score improved from 53% to 67%, and the proportion meeting an acceptable level of quality improved from 19% to 40%. One of the most concerning findings of this study was the lack of attention to sample size and power analysis, and the potential for underpowered studies. Ongoing efforts are necessary to improve the conduct and reporting of clinical trials in pediatric orthopaedics.

SIGNIFICANCE

Pediatric orthopaedic surgeons, JPO, and POSNA are working toward improving levels of quality in pediatric orthopaedic research. This paper highlights progress that has been made, and addresses some high-yield areas for future improvement.

Evidence-based surgery: The obstacles and solutions

Surgeons are often accused of lagging behind their medical colleagues in embracing evidence based medicine and utilizing new research tools to conducting high quality randomized controlled trials. Although there has been a noticeable improvement in the quantity and quality of high quality studies in surgical journals, the widespread practice of evidence based surgery is still poor. Unlike evidence based medicine, the practice of evidence based surgery is hampered by inherent problems and obstacles. This article reviews these difficulties and the limitations of randomized controlled trials in surgical practice. It also outlines some solutions that may help remedy this ongoing problem.

Evidence-based medicine in surgical education

Evidence-based medicine (EBM) is increasingly important for clinical surgery and for promotion of best practices into surgical decision making. Although barriers exist in the current surgical literature, for certain surgical scenarios, formal efforts to promote evidence-based surgery (EBS) into surgical education are helping to equip future surgeons with these important tools for optimizing patient care. As our evidence-base grows and standards of care evolve, incorporating EBM into everyday practice for trainees and staff surgeons remains an ongoing challenge.

Prospective head and neck cancer research: a four-decade bibliometric perspective

BACKGROUND

It is unknown whether changes in study sponsorship have affected the proportion of prospective research on surgery, radiotherapy, and pharmacotherapy for head and neck squamous cell carcinoma (HNSCC) being published over time.

PATIENTS AND METHODS

We examined prospective studies from PubMed, Ovid MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1980, 1985, 1990, 1995, 2000, 2005, and 2010. Chi-squared tests were used to identify significant associations between sponsorship and authorship, treatments within study protocols, and presentation of results, whereas time-based trends were analyzed using the Cochran-Armitage test.

RESULTS

Among 309 articles, industry (70, 22.7%) and the U.S. government (65, 21%) were the most common sponsors. There was a significant increase in the proportion of industry-sponsored research (p for trend = .013) and a decline in U.S. government-sponsored research (p for trend = .001) over time. The inclusion of surgery in treatment protocols declined over the past four decades (p for trend = .003). Protocols incorporating pharmacotherapy were more likely to have industry support than those without pharmacotherapy (p = .001), whereas protocols with radiotherapy (p = .003) or surgery (p = .002) were less likely to have industry support.

CONCLUSION

Industry is the predominant sponsor of prospective HNSCC research, with an emphasis on pharmacotherapy.

Time to rethink the role of the library in educating doctors: driving information literacy in the clinical environment

QUESTION

Can information literacy (IL) be embedded into the curriculum and clinical environment to facilitate patient care and lifelong learning?

SETTING

The Australian School of Advanced Medicine (ASAM) provides competence-based programs incorporating patient-centred care and lifelong learning. ASAM librarians use outcomes-based educational theory to embed and assess IL into ASAM's educational and clinical environments.

METHODS

A competence-based IL program was developed where learning outcomes were linked to current patients and assessed with checklists. Weekly case presentations included clinicians' literature search strategies, results, and conclusions. Librarians provided support to clinicians' literature searches and assessed their presentations using a checklist.

MAIN RESULTS

Outcome data showed clinicians' searching skills improved over time; however, advanced MEDLINE searching remained challenging for some. Recommendations are provided.

CONCLUSION

IL learning that takes place in context using measurable outcomes is more meaningful, is enduring, and likely contributes to patient care. Competence-based assessment drives learning in this environment.

Protocols in cleft lip and palate treatment: systematic review

Objectives. To find clinical decisions on cleft treatment based on randomized controlled trials (RCTs). Method. Searches were made in PubMed, Embase, and Cochrane Library on cleft lip and/or palate. From the 170 articles found in the searches, 28 were considered adequate to guide clinical practice. Results. A scarce number of RCTs were found approaching cleft treatment. The experimental clinical approaches analyzed in the 28 articles were infant orthopedics, rectal acetaminophen, palatal block with bupivacaine, infraorbital nerve block with bupivacaine, osteogenesis distraction, intravenous dexamethasone sodium phosphate, and alveoloplasty with bone morphogenetic protein-2 (BMP-2). Conclusions. Few randomized controlled trials were found approaching cleft treatment, and fewer related to surgical repair of this deformity. So there is a need for more multicenter collaborations, mainly on surgical area, to reduce the variety of treatment modalities and to ensure that the cleft patient receives an evidence-based clinical practice.

How to do clinical research in cranio-maxillo-facial surgery

INTRODUCTION

Not many randomised controlled trials are published in surgical journals, especially those on maxillo-facial surgery. There appears to be some uncertainty on how to perform such studies. Accordingly this paper offers some information on how to plan, pursue and publish a well conducted case-control study, or the more powerful randomised control trial.

RESULT

The main section describes how to define a relevant clinical question, and a research protocol, the way to implement the study, and it helps to find funding for such research. It also explains the various study designs, gives a very short introduction to statistics and on how to appraise the results achieved, and it advises on writing and submitting the resultant manuscript.

CONCLUSION

This paper offers a guide for young colleagues who wish to perform a study, write a paper and achieve publication in one of our leading speciality journals.

Limits to clinical trials in surgical areas

Randomized clinical trials are considered to be the gold standard of evidence-based medicine nowadays. However, it is important that we point out some limitations of randomized clinical trials relating to surgical interventions. There are limitations that affect the external and internal validity of many surgical study designs. Some limitations can be bypassed, but can make it more difficult for the study to be carried out. Other limitations cannot be bypassed. When it is intended to extrapolate the result of a randomized clinical trial, the premise is that the performed or to be performed intervention will be similar wherever applied and/or for every doctor using it. However, no matter how standardized the technique may be, the results are not similar for all surgeons, which implies a significant limitation to surgical randomized clinical trials concerning external validity. When considering the various limitations presented for performing surgical trials capable of generating scientific evidence within the patterns currently proposed in the evidence level classifications of medical publications, it is necessary to rethink whether those scientific evidence levels are similarly applicable to surgical works and to nonsurgical trials. We currently live in a time of supposed ''inferiority'' of surgical scientific works under the optics of the current quality criteria for a ''suitable'' clinical trial.

Evidence-based surgery: knowledge, attitudes, and perceived barriers among surgical trainees

OBJECTIVES

This study was conducted to assess the knowledge and attitude of surgical trainees toward evidence-based medicine (EBM) and their perceived barriers to its practice.

DESIGN

The McColl questionnaire and the BARRIERS scale were modified and incorporated into a single questionnaire, which was administered to all surgical trainees attending a Continuing Surgical Education meeting.

SETTING

Department of Surgery, Christian Medical College, Vellore, India.

PARTICIPANTS

One hundred ten surgical trainees from 22 medical colleges.

RESULTS

In all, 84.5% (93/110) trainees returned the questionnaire. The attitudes toward EBM were welcoming, although individual participants reported they welcomed EBM more than their colleagues did. Participants agreed that EBM was useful in everyday practice and that it improved patient care. About 50% of actual practice was considered evidence based. In all, 12.6% (10/89) of participants had received formal training in EBM, and 64.3% (54/84) of participants were aware of the Cochrane database of systemic reviews, but only 35.7% (30/84) read it regularly. Also, 67.8% (61/90) of respondents used protocols and guidelines developed by colleagues. However, 61.5% (56/91) of participants were interested in learning the skills of EBM. The terms absolute risk, relative risk, and clinical effectiveness were understood by >80% of respondents, whereas publication bias, confidence interval, and heterogeneity were poorly understood. The major barriers to practice of EBM were the inability to understand statistical analysis, inadequate facilities for implementation, lack of a single compiled source of literature, relevant literature not being readily available, and insufficient time on the job.

CONCLUSIONS

Surgical trainees have a positive attitude towards EBM and have some familiarity with the common terms used in EBM. There is a need to increase awareness of, and provide access to, available sources of medical literature. Formal training in EBM, as well as basic statistical analysis, should form a part of the surgical curriculum to foster an environment favorable to the practice of EBM.

"Evidence-based dentistry in oral surgery: could we do better?"

Evidence-based Dentistry (EBD), like Evidence-based Medicine (EBM), was born in order to seek the “best available research evidence” in the field of dentistry both in research and clinical routine.

But evidence is not clearly measurable in all fields of healthcare: in particular, while drug effect is rather independent from clinician’s characteristics, the effectiveness of surgical procedures is strictly related to surgeon’s expertise, which is difficult to quantify. The research problems of dentistry have a lot in common with other surgical fields, where at the moment the best therapeutic recommendations and guidelines originates from an integration of evidence-based medicine and data from consensus conferences.

To cope with these problems, new instruments have been developed, aimed at standardizing clinical procedures (CAD-CAM technology) and at integrating EBM achievements with the opinions of expert clinicians (GRADE System).

One thing we have to remember however: it is necessary to use the instruments developed by evidence-based medicine but is impossible to produce sound knowledge without considering clinical expertise and quality of surgical procedures simultaneously. Only in this way we will obtain an evidence-based dentistry both in dental research and clinical practice, which is up to third millennium standards.

“Evidence-Based Dentistry in Oral Surgery: Could We Do Better?”

Evidence-based Dentistry (EBD), like Evidence-based Medicine (EBM), was born in order to seek the “best available research evidence” in the field of dentistry both in research and clinical routine.

But evidence is not clearly measurable in all fields of healthcare: in particular, while drug effect is rather independent from clinician’s characteristics, the effectiveness of surgical procedures is strictly related to surgeon’s expertise, which is difficult to quantify. The research problems of dentistry have a lot in common with other surgical fields, where at the moment the best therapeutic recommendations and guidelines originates from an integration of evidence-based medicine and data from consensus conferences.

To cope with these problems, new instruments have been developed, aimed at standardizing clinical procedures (CAD-CAM technology) and at integrating EBM achievements with the opinions of expert clinicians (GRADE System).

One thing we have to remember however: it is necessary to use the instruments developed by evidence-based medicine but is impossible to produce sound knowledge without considering clinical expertise and quality of surgical procedures simultaneously. Only in this way we will obtain an evidence-based dentistry both in dental research and clinical practice, which is up to third millennium standards.

[Methodological problems of controlled clinical trials in surgical subspecialties]

Surgical subspecialties are handicapped in classical drug development considering professional and ethical solutions to questions in relation to introduction of new methods. The experts of invasive procedures are challenged significantly to comply with evidence based medicine and answer questions of the national health fund and/or health insurance companies, which are responsible for resource allocation. Sham operation is one of the ways to carry out controlled clinical trials. It had been pursued less frequently in the past, but we can see it as an important tool of invasive clinical trials nowadays. The contemplation about the applicability of sham operation contributes to understand other important issues in the development of invasive procedures.

Attitudes, awareness, and barriers regarding evidence-based surgery among surgeons and surgical nurses

Background

Evidence-based surgery (EBS) is stressed to increase efficiency and health care quality, but not all surgeons and surgical nurses use EBS in clinical practice. To define future tailor-made interventions to improve evidence-based behavior, the aim of this study was to determine the attitude and awareness among surgeons and surgical nurses as to the paradigm of EBS and the barriers experienced when practicing EBS.

Methods

In this cross-sectional study, surgeons and surgical nurses at a university hospital in Amsterdam were invited to complete the BARRIERS scale and McColl et al. questionnaire. An evidence quiz was composed for the surgeons.

Results

Response rates were 67% (29/43) for surgeons and 60% (73/122) for nurses. Attitudes toward EBS were positive. Among the surgeons, 90% were familiar with EBS terms, whereas only 40% of the nurses were. Common barriers for surgeons were conflicting results (79%, 23/29) and the methodologic inadequacy of research reports (73%, 21/29); and for nurses they were unawareness of EBS (67%, 49/73) and unclear reported research (59%, 43/73). Only about half of the convincing evidence presented in the quiz was actually applied.

Conclusions

Surgeons have a positive attitude toward EBS and are familiar with EBS terminology, but conflicting results and methodologic shortcomings of research reports are major barriers to practicing EBS. Continual confrontations with available evidence through frequent critical appraisal meetings or grand rounds and using more aggregate sources of evidence are advocated. Nurses can probably benefit from EBS training focusing on basic skills. Finally, collaboration is needed among surgeons and nurses with the same zest about EBS.

Failure of a meta-analysis on the role of elective surgery for left colonic diverticulitis in young patients

BACKGROUND

The timing of elective surgery of colonic diverticulitis in young patients remains controversial. The present meta-analysis aimed to answer the question whether these patients should be operated after the first attack or, more classically, after the second attack.

MATERIALS AND METHODS

Electronic databases were searched for papers reporting the results of surgery according to the strategies. Major endpoint was the performance of a colostomy (during unplanned surgery or for anastomotic dehiscence complicating elective surgery).

RESULTS

Fifteen papers were selected for potential inclusion in the meta-analysis. But, eventually, only three papers gave information about the timing of surgery. Pooling the data of these 3 studies showed that 160 patients underwent elective surgery after the first attack and only 5 patients underwent subsequent emergent surgery at the course of their disease. Hence, no meta-analysis could be performed.

CONCLUSION

Researchers should no longer attempt (like us) to answer this question by any meta-analysis. The failure of the present meta-analysis highlights the limitations of evidence-based surgery in some particular fields.

[Medical and ethical considerations of sham operation]

The absolute refusal of sham surgery as control in clinical trials can not be justified from professional, ethical point of view. Introduction of any new surgical treatment should be evidence based in the form of sufficient scientific approval to support a novel method. It has to be decided whether sham surgery or any other control modality could be an optimal baseline reference for a clinical trial. The feasibility and the ethical acceptability of sham surgery controlled clinical trials should be approved individually. At the risk evaluation of any (sham) surgery controlled clinical trial, we should contemplate the outcome of the opposite scenario as well; that is, the consequences of not pursuing a "lege artis" controlled clinical project to estimate the efficacy and safety of the invasive procedure. It is possible and obligatory to reconcile two basic medical goals: the treatment of the individual patient and the need of the society for proven, safe and effective treatments.

A quality assessment of randomized clinical trials in pediatric orthopaedics

The promotion and practice of evidence-based medicine necessitates a critical evaluation of medical literature, including the criterion standard of randomized clinical trials (RCTs). Recent studies have examined the quality of RCTs in various surgical specialties, but no study has focused on pediatric orthopaedics. The purpose of this study was to assess and describe the quality of RCTs published in the last 10 years in journals with high clinical impact in pediatric orthopaedics. All of the RCTs in pediatric orthopaedics published in 5 well-recognized journals between 1995 and 2005 were reviewed using the Detsky Quality Assessment Scale. The mean percentage score on the Detsky scale was 53% (95% confidence interval, 46%-60%). Only 7 (19%) of the articles satisfied the threshold for a satisfactory level of methodological quality (Detsky >75%). Most RCTs in pediatric orthopaedics that are published in well-recognized peer-reviewed journals demonstrate substantial deficiencies in methodological quality. Particular areas of weakness include inadequate rigor and reporting of randomization methods, use of inappropriate or poorly described outcome measures, inadequate description of inclusion and exclusion criteria, and inappropriate statistical analysis. Further efforts are necessary to improve the conduct and reporting of clinical trials in this field to avoid inadvertent misinformation of the clinical community.

The role of collegial interaction in continuing professional development

INTRODUCTION

Many physicians seek information from colleagues over other sources, highlighting the important role of interaction in continuing professional development (CPD). To guide the development of CPD opportunities, this study explored the nature of cancer-related questions faced by general surgeons, and how interaction with colleagues addressed those questions.

METHODS

This study involved thematic analysis of field notes collected through observation and transcripts of telephone interviews with 20 surgeons, two pathologists, one medical oncologist, and one radiation oncologist affiliated with six community hospitals participating in multidisciplinary cancer conferences by videoconference in one region of Ontario, Canada.

RESULTS

Six multidisciplinary cancer conferences (MCCs) were observed between April and September 2006, and 11 interviews were conducted between December 2006 and January 2007. Sharing of clinical experience made possible collective decision making for complex cancer cases. Physicians thought that collegial interaction improved awareness of current evidence, patient satisfaction with treatment plans, appropriate care delivery, and continuity. By comparing proposed treatment with that of the group and gaining exposure to decision making for more cases than they would see in their own practices, physicians developed clinical expertise that could be applied to future cases. Little collegial interaction occurred outside these organized sessions.

DISCUSSION

These findings highlight the role of formally coordinated collegial interaction as an important means of CPD for general surgeons. Investment may be required for infrastructure to support such efforts and for release of health professional time for participation. Further research is required to examine direct and indirect outcomes of collegial interaction.

Evidence-based medicine—from best research evidence to a better surgical practice and health care

BACKGROUND

The use of the terms evidence-based medicine (EBM) and healthcare (EBHC) has become commonplace in the medical as well as in the surgical literature. Using the best available evidence, however, is not yet a working routine among surgeons because of the large amount and complexity of published research and the lack of user-friendly tools and necessary skills for the use of research results.

DISCUSSION

This article encourages to formulate surgically relevant questions and to answer them on the basis of high-quality research, preferably by using systematic reviews which are based on the quality criteria of the Cochrane Collaboration.

CONCLUSIONS

As currently only 77 Cochrane reviews address surgical procedures; much work remains to be done to enlarge the number of high-quality and relevant reviews. Similarly, the number and quality of randomized controlled trials need to be increased in all surgical specialties.