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Can you see? No. Yeah, it's, it's a back button screen. Yes. All right. Okay. Thank you. Okay. As I was saying before penicillin was disposed more actually. Okay. Like I was saying, everything changed in the world of medicine with the discovery of antibiotics and everyone knew how antibiotics was discovered. But in 1928 because uh I mean, because of the research that penicillin, I mean that flaming was carrying on. Okay. If you look at one of the what one of the greatest scientists of all time said, it said that if we knew what we're doing, it would not be called research with it. And this brings me to the other things I always tell people about research. Research is about asking questions. Sometimes it is about asking the most stupid of all questions. What look to orders to be stupid and then you ask that question and then you work on it, for example, take new team, for example, Isaac Newton, it was reported to be uh sitting order an apple tree and then an apple and an apa's, it fell from the tree close to him. And he asked the question, why did that apple fall. I can imagine me when I was young asking my mom why an why an orange fell from a tree. And I'm sure just like any other traditional become mom would have given me the to slap was he took that? What a stupid question? But see what are stupid question broke to mankind. The stupid question brought us the law of gravity, um universal gravitation brought us the law, uh the three laws of meth nicks and things like that. So really as a researcher we need and as uh students of research orthopedic surgeons, we need to ask those simple questions and sometimes those questions are what take us onto the next grand. And that is where a bad instants side, we wouldn't do it if we actually know what we were doing and that is what research is all about. It's about you coasting on from the known into the unknown. Okay. So there are many definition of, I mean definitions of research we have this one which says is a research in common balance with past research for knowledge. Okay, I can remember there are one of my best examples of uh I mean, one of my best illustration of researches about somebody Emma is like a beach combat who is searching for the best shells on the beach and patiently 16 thousands of shells until it comes to the ones that I feel. Yeah, this is the best and that is basically what research is all about? This is search for knowledge, okay among Myriads of misinformation. Okay. This another one and I want us to mark that word careful investigation. And this is also can I mean, it's also buttressed in this one, a systematized efforts. Okay for somebody to be systematize is that things are already arranged into Catholic goodies, into a system and they are easy to follow and can be reproduced. So research in general tells you the outings are manipulated, okay. And that manipulation in the clinical settings called intervention, they are manipulated in order for you to come onto new insight, to have a new insight as to what you intend to do. Okay, manipulating things, manipulating, I mean intervening and things like that make me, I mean the immune, the step onto new diagnosis, new waste of treating patients' and new methods of uh surgery. And that is what research is all about. Okay, let's let's let's look at your world. Research again, re means to do again and again, as such is for you to look carefully. So in other word, research is a way of looking into something carefully over and over and over and over again. And that over and over and over again is captured in this. Okay. You are join me a conversation, something that's cattle a long time before you, you join it in order to improve our rooms. It with some of the most uh some of the most paradigm shifting theories in the world formulas in the works. He didn't just come on their own. They came because somebody has, has been working on that. Take Newton um M Newton's law of universal gravitation. It was built on Galileo's Galileo's work. Take Einstein's uh E Z go to entry squad. It was um in the law of relativity. It was built on Michelson and Morley's uh experiment of 18 81 and also what we, I mean, the the brand your motion uh we all learned when we were in school. So nothing that we're going to do now is going to be like, oh, this is a new thing. Nobody has ever done it before. No, most of the time we're just going to build on what others have done. Okay. And that is what the literature review actually does for you. Okay. So therefore before you do any research, something must have gone by me must have, I mean, some something must have been done on that thing before. Okay. Something was already known. Okay. And what you are doing is to add to the body of knowledge, what is already known so that you can make it forward. I mean, you can take it forward and for you to do that, you need to do what is called a review. Okay? And that is basically what we're known as um literature review. It is a literature review that gives you an idea of what has been done and how you can build on that so that you can move on. I mean, you can move forward. And one of the things I ask people to do when you're looking at literature, when you are reading, when you are researching the subject that you want to do is basically try and look at the limitations of the papers that you are reading many a time. It is what it is from that angle that you can move forward. So what are the objectives of research? Research basically can be an exploratory of formula tive research in which nobody I mean. So if you think things have been done before on that, let's use something as an example, COVID 19, when COVID 19 1st came in December of 2019, January of 2020 nobody knew a lot about it. So the first set of uh studies that were done were basically exploratory. Okay to look at this. What exactly are we looking at? What are we seeing? What is the nature of this? And that is what is called a Formula Torrey or exploratory research? Next is you want to define the characteristic of such a phenomenon and that is where description comes into me. Descriptive research comes into play. Oh, what is this? What are the characteristics? What kind of people does it affect? Which part of the country or what part of the world? Okay. What age group is the most common in that is descriptive research. Then you move on to explanatory research in this. Okay. So you've known what this disease really about its nature. Okay. It's characteristics. The next thing is you want to be able to, to, to explain some things on this. Okay. Why is it that we're having it? What makes it come soon? What's top six ward drugs will be effective in its treatment and things like that? And that is the explanatory okay or analytic analytical aspect. Then the Panoxyl of everything is of course when you test and echo test. So based on your on your previous studies, you know, have an insight and you now want to make a protest is to test it clearly okay about how this thing can we behave in future. Okay. So you put up and hypothesis oh COVID 19. Okay, COVID 19 is likely to be affected, adversely affected by sunlight, for example. Okay. And then you test your purchases by, by doing and hypothesis testing uh study. And basically that is those are the four main objectives of research, okay. And it is extremely important for us to know that without to research, we won't be where we are right now really? And the numbers of research actually increasing in leaps and bounds. Oh As I came across the paper that said that in the past 30 years, more people's have been produced than the previous uh the previous for and absentees, right? From 16 70 more people's have been produced okay in the past 30 years. And that is the kind of thing that we actually need to do. Despite all these things, we will see that research in Africa is still very, very low and very, very and very poor quality. So therefore, it is in put down for us as we are coming in as well as we, as we are coming into the medical profession, as we are joining the medical profession, we should be very much aware that research is extremely important and it's one of the ways that we can improve the health of our people. Okay, so when we're going to research, we should know that research is, there are good researches and there are bad researchers. Okay. Let's go into some of the evidence is in 2004. This paper was, was written by John P A uh United's and the title is what we've seen on what we are seeing on our screen. When most published research findings are forced. And this is one of the good politicians I picked up from that. People simulations show that for most study designs and settings, it is more likely for a research claim to be for us than true. Morava. For many current scientific field claimed research findings may even be simply accurate measures of the prevailing buyers. This paper which was published in 2040 today is the most downloaded people on PLOS medicine. Based on this paper, this the Ottawa's won't quite a lot of awards and he went on to write some other papers on equally paradigm shooting. Um Topic guys, another one contradict contradicted an initial stronger effects in highly cited clinical research. And see this uh this quotation from it says the rate of findings that have later been found to be wrong or exaggerated as been found to be 30% for the top most widely cited randomized controlled clinical trials in the world's IES quality medical journals for no randomized trials. That number rises to one has to meet assassination five out of six. Think about that again, the paper that the author used from which the auto picked the articles is criticizing uh at the four top most people. Um the topmost ranked paper in the world include including Jama New England Journal of Medicine and so on and finding that 30% for the top most widely cited. That means when is the top most based on its methodology, towers papers that have decided at least 1000 times? Okay. And the thing about those people is that the those papers were what most of the things we are doing now E P M and things like that like that, what they were based on and 30% of those papers okay were found later not to be very reliable if that can happen to such journals. I mean, article sitting in papers of I mean, I impact journals like that. Imagine what would be happening in um other papers especially nowadays that we have lots of junk Jonas all around the so called them predatory journals. Okay. And this is another one where most clinical research is not useful. Okay. I uh if you go to Google scholar and we look at profiles of autos, you will discover that close to about 50% of papers written by most autos are never ever cited. Close to 35% of them are never even read at all. Okay. So it is extremely important for us to realize this, that even though why the number of papers they are increased, I mean, being published are increasing exponentially. We should also remember that quite a lot of these papers and these articles are junks, they don't follow their, they don't follow laid down procedures. Okay. And uh if we are going to be going, I mean, if we are going to be dream research is we shoot be aware of this so that we follow lay down scientific principles whenever we try to do research is okay. Another important thing is that continent's also valley in their research output. Now, I looked at autre PT publications for papers and I came across the paper that since 2007, 31,000, 454 articles were published and only o point where I mean, when you are the ones from lower income country and the world, I mean, and the ones from, um, low to middle income countries that makes 2.8% just 2.8% of those articles were from low to meet, low to middle income country and low income countries. And remember that all of the, all countries in Africa are induced two categories. It just shows the scale of obstacles that we are when it comes to research is in Africa. Okay. Uh So we have this on Africa generates less than 1% of world's research. Okay. And here is another one that I got from the scoopers, okay? And it's looking at the total number of articles from some countries in Africa just I just elected from, I mean five. You can see Egypt there, Egypt, South Africa's uh South Africa are here while Nigeria is a and Ghana and um in Ghana and Kenya are done here. Now that looks good when you look at it, that is 36 36,000 articles from Egypt and and and South Africa and just above um 8000 for Nigeria and less than 5000 for Ghana and Kenya that was in the year 2020. Okay. But thank God since are improving in 1996 you can see how low everything is, but since I have exponentially increased since then, okay, just like the same way in the rest of the world. Now, when you look at the age index, average age index of countries. Okay, H index is a way way of uh estimating impact of articles produced in countries. You can see the H index of uh us is about is closer about 1.75 key. Okay, Brazil which is another low to middle income country in Latin America. You can see it there and you can see Nigeria and Ghana than here. Okay. So we have a long way to go. Okay When you look at another way to look at research qualities you to look at ours, ours that have been captured by countries. And here we can see this is Nobel Prize in Medicine and you can see that us a is there no country from Africa is there okay? So I did this thing just looking, did this research among uh um academic physicians in Nigeria, looking at what is the state of research among orthopedics in Nigeria. And when look at the, when you look at the academical put uh orthopedics compared to others, okay, you can see that we have here 29 main number of published papers, pediatric stops for the three main numbers and uh, orthopedic and surgery is done there. When you look at different specialties in surgery, we've just since surgery air and now when you look at different specialties in surgery, you can see here that oughta pedic is the thought I s but actually lags way behind both pediatric surgery and general surgery. When you look at the main number of papers by C I R than some other ones. Okay. And I also now try to look at what effects are the uh college from, with the consultant graduated the training college. Does he have any effect on the number of paper? The mean number of papers when someone asked when someone has a fellowship on both collect that MS West African College as well as a Nigerian College of Surgeons. The mean number of paper is 44 national. Uh someone who has national alone, the mean number is 30 and someone someone who has West African College alone, the mean number is 25 28. Okay. And those others means those who do not have any uh fellowship and good spine. It is important for us to see this because it shows that when you are well trained and I assume that those who have both colleges, they will receive better trained than those who are individual colleges alone. That means when you are were trained, you are more likely to produce more people going forward. Okay? I also look at effects of other things, okay. Like I look at what about academic requirement for academic publication? For example, for a university, definitely you need to be, I mean, you need uh your paper to be promoted. Okay. When academic, where you need the papers to be promoted, the mean number of paper was 40 when you don't need it in not mean number was 20. Okay. That's certainly means that. Well, obviously, and it is expected when it is needed, you must do it okay. Now what about motivation for publishing? You see that for most, the, the most common cited, um the reason is promotion where you need, I mean, because they need these papers for their promotion, therefore they are motivated to write, then some do some rights because they feel, I mean, they also feel that they want to contribute to knowledge, interest and others, but very important here that and it, it goes with that, I mean, it goes with other aspects of the human endeavors. When you want people to do things, make sure that the same DC that it is important by making it necessary people, some of the things the hold important in this case, it is promotional. Okay. So what are the barriers to publication include time, work times, workload. Funding is also idea and funding is especially important in West Africa because the West African uh subregion ask less access to funding than other parts of Africa. Okay, then these are so some of the other things that we are seeing there. So we know that those barriers have really impacted us in what way? Okay. For example, we look at the Nigerian Gin of or to pivot trauma and well, we know about this uh um evidence uh pyramid and we know that the most, the most critical of them all is the top there and that's a systematic review meta analysis as well as our CTS. Now, we look at uh the publications from Nigerian uh John off trauma since 2016, we look, we look at uh the categories of publication and you will see that almost all those categories, none of them actually falls among the first two levels of the evidence based the pyramid. All of them are there are low in the low evidence section of the pyramid. Okay. And that tells us a lot about the quality of publication that are coming from the Afrikaans of regions. Okay. When we look also at the past conferences, okay, we also noticed that most almost all the papers. In fact, 40% of the papers that were case series as 60% were cross, I mean cross sectional studies. No court's know case control, no randomized that was uh to conferences that we looked at their. Okay. So it's not looking so good. So what can we do about it? Okay. Um We are look at all these stakeholders who can help in improving oughta pedic research, government hospitals, training colleges, orthopedic associations, departments, two units in the hospitals, orthopedic surgeon journals. But for the purpose of this presentation, we are going to be focusing on individuals. Okay. So what can the individual do? Well, one of the most important thing is for you to train yourself and that is one of the reasons why I'm happy to be a part of this session and to be a part of what this association is trying to settle. Okay as I was discussing with, I mean, just before this and, and as you probably, I mean, all of you have discovered that when you look at our competence, I mean, the competence of um residents in Africa compared to residents in the western world. As far as research is concerned, we realize that we are not there at all. Okay, here in cereal, you have come in contact with at least two residents who came from the US to come and do their attachment. The eyes were new neurosurgical residents to preside. And the one they were able to get funding from the USC to come to Africa for their attachment. Then too, as part of that funding, they were required to actually uh submitting research proposal which they will carry out when they, when they're in Syria, New. So I supervise uh supervise them and I was impressed by the quality of their output, the quality of their knowledge of research and everything and what they were doing actually the quality of what they were producing approach. I mean, it's more than the quality of what many lecturer want uh lecturer, one in Nigeria, what they know. So it is important for us to train ourselves if you want to be actually uh a good in research. I remember in 1919 7, in 1996 when I just passed my part one and I was looking for what to do. Fortunately, I was sent for a one, a one week research methodology. I'm sorry, a computer appreciation training as a chief resident. Then that was my very first time of coming across a computer in my life. Okay. And uh now withstanding immediately, I saw what it was doing. I knew that was going to be the future of research or um academic in Nigeria, I mean in anywhere in the world then. Okay. And that now we standing that then it was mainly um uh M S dose rather than the graphical, the graphic user interface that we are now very familiar with them. To most of the things we were doing were on M S doors. But that now we stand there and knew where the world was going. In 1990 1998. I had to pony up three months salary to join what you call it uh cooperative in order for me to buy my first desk deck stop computer. Okay. Uh And since I then have not looked back when it comes to things like that. I'm saying this because sometimes, especially when we're in Africa, we need to be the determinant of our own future. We need to determine what we need to do and we need to go for it. We need to sacrifice for it and not look at the immediate uh logical it uh immediate issues that we're having. Don't look at your poor internet connection. Don't look at the poor electricity and things like that. Rather look beyond that and look to the future. And by the end of this a lecture and going to show us another pie voter moment that is coming on as far as research of indeed anything in the world is concerned. My last, my last slide is going to talk a little about that. Okay. So we need to train ourselves, okay. Uh Find a mentor is extremely important. Okay, then you need to identify sources of research topics. Okay. Get familiar with Pope Made Google scholar and other make uh data base is important to also attend conferences. Okay. Um Learn how to turn ideas into research. I have and I made a beautiful representation and is on Power Point on my uh on my website. And that topic deals with Tony ideas into research. Please look into that people. I think you'll find it useful and I think I also made it also uh uh youtube video presentation. Please check those websites, correct. And, and then also look for collaborators. Uh Only uh all the peoples are waiting. Uh I've only really liberating on my own. Uh That one was reviewed redo at okay. The other uh donating collaboration, collaborate with others to engender more. Okay. So this is extremely never sleep to see exactly related activity. I did uh uh the internet pop made for new and you read about statistics or you do something sad relatedness, okay. So how they have to use an auto pt courage? Okay. So let's look at all the uh pacification of medical and basically you have big released touch. But what we're seeing about basically is clinical research and epidemiological. Okay. Not also you have what is called primary reveals with where you are data by yourself. Research on data as on secondary data I've done in form of people that have been reading and I talk about systematic analysis and things like that. But for this purpose, we are going to look at clinical research and epidemiologic research and what approaches can be used. Okay, we want more information on this. The reference is done there. So clinical and all this point that the similarities, both both types of studies, of course their medical research whaling require that you have the sand method a logical basis. Okay. And in both of them, you collect your data and then you analyze those those datas and basically they use similar research methodologies as as we're going to see. But what are the differences? So we're going to look at the differences based on these various uh segments. So we are going to look when you take focus, for example, clinical studies deals with individuals, all a little group of individuals such as patient's in the world. I mean the hospitals and go whereas epidemiological studies deals with populations, we are talking about countries if sometimes the old world and reach okay. And the scope is for evaluating new treatments in orthopedics you want to use. I mean also want to use it to evaluate new procedures, new methodologies and things like that like that where a scope of epidemiological studies for to determine distribution and determinants of this this episode. Very sick. A lady uh exploring, I mean exploratory purposes. Okay. Settings of clinical studies are usually the cause of epidemiological studies are in the communities. Okay in the real world, so to speak. And usually the best type of uh clinical studies will need interventions. Interventions also happens in epidemiological studies but they are not off army as often because uh interventions in most epidemiological studies may not be ethically acceptable. Okay. The most liable method in clinic in the clinical studies rand randomized um proved clinical trials. Whereas the most like if I our cities are not done for epidemiological studies. So other form of interventional studies are the most reliable in epidemiological studies. Usually the duration is short with clinical studies and it's longer with epidemiological study. And in the same way, sample sizes are smaller in clinical studies and subjects involved in clinical studies are usually subjects with the disease is ok of your subjects that you feel are going to develop the disease is whereas in epidemiological studies both and in so in um clinical studies, you deal with particular diseases at any time just a specific disease. Whereas when you are talking about epidemiological studies, they deal with, they can involve early individuals and also they can involve many disease entities at a time. Okay. So what are the clinic? We are going to take clinical studies first? What are the types? And I will you choose the right study? Okay. Now let's go through this algorithm in, okay. How do you um how do you um categorize ically Castell this in general? Okay. The most important thing is whether the investigator is going to actually intervene. Is there an intervention? If there is an intervention, then it is an experimental study, for example. And we want to look at the uh the performance of a new way of fig sitting a fracture versus another another, I mean another five verses good standard. When you, when, when you do that, you are intervening. Okay. There's an intervention that's intervention is a new method that you are trying. Once you intervene such week, then it becomes an experimental study. When there's no intervention at all, then it is an observational study. Okay. Then the next thing is is they're random allocation. This random allocation is extremely important. Okay. In random allocation, it means that everybody in your study group have an equal chance as an equal chance or being allocated into your treatment arms. Okay. So if you truly, if you random, if there's random allocation, then it is called a randomized control trial if there is no random ization, it is called, it is a normal Romanus control trier. This is also what it's called. It's also referred to as a quesy experimental study. A sub cortex. Okay. Now, in the case of observational study, okay, there's a comparison group. Okay. There you are dealing with an ana analytical study. Okay. If there's no comparison group, there it is a descriptive study. If there's a comparison group and there's a direction direction means explore. What if somebody is exposed, you look for the outcome after exposure, okay, which means it's a close control study. But when you follow a group of it is a core study, those a direction, I mean it does at once with directions. Okay. And then a cross sectional study is one that has no direction and take it just at a point in time to get whatever you want. I mean to get to get your data. All right. So what are the scale? What is the scale of evidence for these groups of clinical research? So as you can see here, the top most level level one, the one with the highest trust is randomized control trials. Okay, we're not talking about systematically gives. Yeah. Okay. This is followed by the level to which is cool studies and a random randomized comparative studies. Now what this means is that well, if you have the well conducted randomized control trials, it is evidence for the effectiveness of that intervention. Okay. There's no, I mean, there's no if it is work control and satisfied all uh all, I mean, all expected, it takes all expected black, it's especially if it follows the lay down rules as something in uh quote and coo and, and, and cool um um guidelines, then you are sure that whatever is produced from that kind of study okay is based on objective evidence and they're both should be recommended The next level across studies and non Adam eyes Comparative studies or quasi experimental studies followed by case control studies. And then the last level of evidence is retrospective studies, non Comparative studies, case series and expert opinion. And most studies from Africa actually belongs to this with a few belonging to these ones and very very few belonging to this K. So let's take them and looking at how when you look at the studies, I look at their timeline, you will see that when it comes to our cities that are randomized control trials, they are usually prospective studies. But when you look at these controlled studies, usually they're retrospective studies, okay. A cross sectional studies are for the moment you get your you do your intervention, you collect your data now and now not into the future, we are asked for the other ones for our cities. Your exposure is now you collect your data in future. OK. For retrospective studies, data has been collected before you are now retrospectively looking at them. Okay for uh I mean, I mean, because of uh when it comes to reliability and acceptance, okay, usually prospective studies have performed aerated superior to any other form of studies. Okay. So what are random randomized clinical trier's? Like I said, the uh the uh the highest level of evidence of all clinical studies? Okay. And the most important thing is that the study randomly assigned participants, okay to either the treatment group or the control group. Okay. So when it is done, when such is done, what it means is that when participants are randomly assigned, it means that all the groups will appear will be equal based on all exposure. I mean, all criteria, I mean all like normal demographic criterias like sex, age and things like that. Okay. If you're an dramatization process is is uh is done correctly according to lay down CDO after your random ization, then you're, you expect that the groups will be identical as far as a common available such as age, sex and things like that are concerned. The India. After mention, it can be, for example, assessment of a new drug, a new assessment of the surgical or medical procedure, which is new or in the psychiatric and other response. You want to actually do an inter amoebi bura intervention. Okay. So there's another way to look at it, okay. So as it is determine if an intervention or a treatment is effective by randomly assigning the participants Okay. So and the implication of this is that whatever outcome you obtain can only be because of your intervention. Okay. So for example, you have two groups now that you, you want to perform, I mean, you want to test a new way of uh reducing shoulder of uh I mean, uh dislocation of the IP on. Okay. So as your patient's are coming, you are randomly assigning them into group A, which is the group that is going to have your new methodology tested and group B that will be using the good. Uh Okay. So at the end and then uh outcome measures which may look for example, work uh dislocation, what is, what is the functional outcome? You discovered that patient's in your treatment arm scored higher in all your outcome compared to your um a patient compared to a patient. On the only, the only way this could come about is because of your intervention because on every other parameter your patient uh uh the same in term of age. There's no, there's no significant difference between their mean age in terms of their activities. None in term of how, how they go about their daily activities, there's not. So if they are, if they are equal, when it comes to all those outcomes, if they're, if they're outcome is different, then that outcome and that difference in outcome can only be because of your new intervention and that is business. That is the underlying paradigm for randomized clinical tries. Okay. So what the advantages? Okay, they are the good standard everywhere, okay? Because of random random rand randomization, okay. Uh I uh is reduced when a so obvious in assessing does not know whether it person be, it cannot be buyers in the way he's going to assess the outcome. Okay. That is the business of double blinded means the patient himself does not know what has been done for him. And the best thing who is going to assess the patient at the end of the study also does not know the group to which the patient belongs. It is important that the patient does not know what has been done for him in order to account for passable effect. And we know that possible effect is extremely important in surgeon because the fact that you told the patient that you are going to operate on Neil and you perform the operation, that patient already has a huge load of expectation. And for some may actually uh feel that whether they are better than they were. And that's one of the reasons why you cannot randomize surgical operations against non surgical operations because of the issue of the passable effect. Okay. And finally, because of randomization, okay. Um Usually you can explicitly say that a certain condition is causing exercising is having a certain effect and that is what is called cause and effect or causal relationship. And that is one of the things that separate randomize controlled trial from every other studies because you can equip unequivocally say that this thing is causing that. Okay. But there are disadvantages, it can be expensive and time consuming, especially in surgery. It is not always visible or ethical to perform. We're going to look more into that. Okay. And finally, uh, what you are finding your small population of subjects may not be generalize a ble to the broader population. Okay. So now this is the main problem we have with carrying out our cities in surgery studies have shown that less than 5% of studies done. The surgery are our cities. And the main reason is because of the problem of carrying out class, a bulk controlled studies. Let's let's take a scenario you want to examine and we want to, to find out whether uh you want to compare two forms of managing. And so you want to compare a new form of surgery, OK to another, or you want to compare one surgical procedure to non surgical. I'm into classical now, for you to do classical surgery, that means you must take your patient through all the processes of doing surgery but will not carry out the effective intervention. So let's say, for example, you want to try uh atra scopic uh repair of meniscus against just non atra scopic prepare. Okay for you to do that, you will carry out, you will assign your patient's to treatment group. And then the, the control group and now in the other group, in order for you to account for the possible or the, the same effect of surgery. First, your patient must go through the same anesthesia two. You must make the same incision 30. You must place the patient in the same back slab. Okay. If you put in a soccer, you mommy, sorry, a suction, you must put those patient's in sanctions too. The only thing you will not do is to perform the surgery, okay. And it is extremely difficult for you to justify this ethically. And that's one of the reasons why our cities are very, very, very commonly done in surgery. The fact that it is difficult for you to perform sham surgery, okay, because the patient's will be faced with the same anesthetic, uh, the same anesthetic complications will be faced with the same, uh, word complications of uh, force operative infection. If you be faced with the same complications of non, non a link and things like, I mean, the lady leak and things like that and you cannot justify this. Now, if you now say okay, we won't use study, we will do all those ones, then your patient, we know that she never, he or she never had surgery and things like that. So it is extremely important to carry out sham surgery. And that's one of the reasons that, um, that's one of the problem of doing our cities in surgery Okay. So these are the things that all these are cities until random ization control group, blinding outcome measures and sample, uh, sample size. Okay. All right. And this shows us the timeline of uh how CTS you have your study population, you have the uh, and inclusion and exclusion criteria. All the other adaptations that you be, including your surgery. I mean, your, your study with patient. Are you going to exclude? And then you have your, uh and then from the Iraq A that you have your uh study subjects? Okay. And it is after that randomize, based on your random ization procedure in the intervention group and the control group in the intervention group will perform the intervention in the control group. Nothing is done. But they think they have done, they have done this because you would have performed sham surgery for them or a sham procedure. And then now look for your outcome measure and then you now compare your outcome measure. Okay. What is the, what is the odd ratio? What's relative risk and things like that? And that is how, you know, whether you're study, whether your intervention is better than the uh control. Okay. So under, like I've mentioned, there are, there are difficulty with our ct's in surgery. The first one is, of course you need a control group and I've already took talk about how difficult it is to perform sham surgery. Okay. Um, um, okay. Now all these ones they come under the problem with having a control, uh, group. Okay. In medical, in the medical field, for example, where you give a drug, it's easy for you to produce another drug. I mean, to produce a classical, that looks like the drug that we are giving. And when you give it to that patient patient thinks he has he or she has been given the same drug. But for you to perform a passable surgery or plausible procedure is extremely difficult. So it's difficult to eliminate the possible effects in uh a city surgery. Okay. The other problem is also the problem of blinding the surgeon. If I'm the one, if we are the surgeons you involved, we are involving your surgeons in those things. Ideally both the person doing the doing the procedure and the patient they should be blind or how do you blind the surgeons, how do you blind the surgeon um who is doing the sham surgery back is doing? I mean, he's doing, I mean, it's not doing a sham sham soldier, okay. So those are things that are involved with what you call it without city in surgery. Okay, then these are also some of the other effects when it comes to doing multi centered studies. Okay. You also know that uh individual surgical uh subjective skill as kill the surgeon is also important. Even the the patient's perception of how good your surgeon is is also important and these things cannot be uniph. Um it cannot be uniformly applied across multi centered uh I mean multi center, I mean across different centers in a multi centered our city. Okay. So these are these uh in a variability okay of surgical procedures and surgical teams makes performing some some surgery very, very difficult uh randomized clinical trial and randomized incurred trial. Okay. But thank God there are other ways. Okay. Bye, which you can arrive at your answers. It just depends on the kind of questions that you ask. Let's look at this supposed you have a patient, I'm a patient population okay. Who had uh open open, open reduction and internet fixation for frank angle fracture, ankle fracture dislocation. Okay. Now you have these four research questions. The first research question is is the patient's functional outcome better when treated by locked plate than by the city to what is the infection rate after the two fixation methods? Clearly what is the impact of diabetes on the infection rate at the ankle fixation for? What are the most common causes of ankle dislocation? These are full research questions. What research methods will you use to approach? Default them? Okay. No, the first research question is says is the patient's functional outcome better went to trade by locked plates down by DCP. Basically you do add a a randomized control trial or you do a non randomized control trial. Okay. The easier want to do would be a non randomized control trial in which you have your two clinical arms and then you assign your patient's to the two groups and then you do your surgery okay. On one and the other one, you do another thing and then you follow them up okay. And then using the ankle, ankle, uh, any of the functional outcomes, ankle measures, okay. You can now determine which one is better, okay. And of course, you can also measure objectively looking at time to full with very incidence of pain who's operative pain and auditions after your surgery. And then you compare the two. Okay. Now the second question says, what is infection rate after, after the two fixation methods? Basically, you can use cruel studies to follow your patient's of condition. Okay. So immediately your surgery, yeah, your study starts and then you begin to follow them on after and then you look at incidents of infections in the two groups and then you compare those uh incidences and that will be a cool study. Okay. Now, um what is the impact of diabetes on the infection rate after ankle fixation? Okay. For this one, you have to do a retest, retrospective case control study. In other word, you now go back into the patient's record and look at patient's with diabetes and patient's without the abilities. And now you look at the incidence of infection okay in the two groups. Okay? And now the same what percentage of those have infections are uh diabetes what percentage did not have uh diabetes? And then you look at the ratio among the two of them. And now you now you can now determine that well, uh do patient's with, with diabetes have increased all of developing infection after so after ankle fixation? Okay. And then what are the most common causes of ankle dislocation? That one is simple as soon as the patient is coming in, you take your history, you look at the mechanism of injury and then your frequency and things like that gives you because is of ankle dislocation. And that basically is a cross sectional study because it's taking, taking place at that time there and then, okay. So uh so we look at those other studies that we just mentioned that you can, you can use. And the first one is a poor study. Basically a poor study is an ob sufficient study. There's no intervention and it follows a group of individual inspired what court's comes from the English word for group of people. Okay. So when you see cohort study, it means you are studying a group of study, a group of people and then you are studying them over time. The other word for it is non ditan venous study. So you are starting your, your, your study at time. A and then you're starting at time be okay. And uh with this one, you can actually study, I mean, you can look for uh risk factors for example, in the example of ankle decision that we just talked about, we look for the risk of infection. Okay. We are, we are all aware of people saying uh the risk of cancer is smoking. The risk of uh breast cancer in patient's who are on the, who are on the uh what you call it, who are on who are smoking or who are uh contraceptively. So, so sue and the effect of physical activity. Uh I mean the risk of uh uh the effect of physical activity on the, on the myocardial infection. All these things are actually carried house most of the time as a result of uh what we call it. Court's studies. Okay. And the advantage is the advantage is, is that it can actually establish uh what you call it a connection between exposure and the outcome. When you follow a group of people who are initially hokey and then you divide them, introduce you work, exposure risk, who are, who have risk exposures and who did not have the risk and then you follow them over time. Then you can look at the proportion of patients who develop the disease that we're looking that the disease of interest in the two groups. So it helps you okay to determine the risk. Okay. Then the second thing is can examine multiple outcomes together. You can look at, for example, if somebody you can smoking, you can look for outcome of the breast cancer and breast cancer outcome of uh lung cancer outcome. Uh I mean, outcome of uh what you call it emphysema and other things, spoiling of fragile and cool. These are things you can look for simultaneously in the same group. Okay. All right. But it can be uh ex expensive and time consuming. Okay. And the other two is that you can lose a lot, a lot of your patient's over 10. For example, the Framingham studies that we read about when we're in community medicine, uh that study is now in his 58 year, they're about okay. You can carry out that area of study in Africa. Okay. So when you need a study that I need to prolong follow up time, you can actually lose a lot of your patient's to follow up. Okay. And then you can have a selection bias, okay. Um uh Then um the, then you have types can either be prospective or retrospective. The most common one is prospective. Okay, you look at the patient's and then we follow them over time. For example, the one we say that we're going to do for risk of infection, it has to be a prospective, okay. But sometimes you also do it retrospectively when you look at patient's who have the, who have the disease and then you look into their case files to see whether they've been exposed to uh to that in the past. And that can, that would be a retrospective cohort study, for example, the same group of patient that we're talking about, let's say that we didn't collect any data now. But in the future, we want to do a retrospective study. We now collect those data then and we're now looking back and looking at patient's who have, who are, who have developed infection. Okay. That will be a retrospective kind of port study, not as reliable as prospective one, but it does a person insights. Okay. So the second, the second k and the second type of study will be considering at a court study is case control study is also an observational study. Okay. And basically it compares two kinds, two groups of people, okay, a group which the outcome you are interested in another group without that outcome. For example, in our, in uh in uh the study we are talking about, we say well to look at whether which group of whether the diabetes as an effect on the outcome. I mean, on the on the incidence of infection in patient's who had only for ankle fracture. So basically, we look at all our patient's and then we go back into their case files and look at those who have diabetes and and those who do not have diabetes. Okay. So when you look at them, you now uh filter those two groups into those. I mean, once you look at those who have diabetes and those who do not have the diabetes, we can basically calculate the proportion of patient's with infection who has diabetes and the proportion of patient's without infection who have diabetes and compare those proportions. That is what is called all this ratio. Okay? And when when you look at your pulse ratio, if it is more than one, if it is better down than uh than one, then you can say that your group of interest is more likely to develop diaries as a greater also developing diaries than the control. Okay. Now, one of the most important aspect of case control study is that it can be used to investigate really very rare diseases and that is where course studies is poor. Now, let me explain that a little bit. Imagine that you have a disease that only occur one once in about one in about, let me see one million individual and then to maybe uh it happens only maybe very rarely even in those individuals. Now imagine that if it of course, in one in one million individuals for you to do a course studies, even if you want to just let's say your sample size in your court study when you calculate it is 50. Okay. That means you must follow up 52. I mean, you must, you must, you must have 50 individuals that have that disease. That means you must follow up at least 15 million people. Okay. That is one of the problem with cohort cohort studies when it is the very rare disease, it is difficult for you to do course studies. But because it will be very, very expensive for you to follow up. The like number of people can I mean that you will need for your sample. So in those instances, it is the the option is for you to do case control study. Okay. And these are the advantages okay. As you can see the the first one there is it can study real diseases and conditions, okay. And disadvantages is that you can only unlike course study, you can only study one outcome at the time. Okay. And of course you cannot establish position, only our cities can establish concessions. Okay. So the final one we are going to look at among the clinical studies are the cross sectional studies. Okay? Like I've said before, this is taking at a point in time and most of the studies you've come across from Africa, they're a cross sectional studies. Okay. For example, in the abode in the in in our sample, I'm in our example, the cross sectional study was looking at the incidence of causes of um in the prevalence of different causes of ankle fractures. For that. You just ask your patient's when they come in. What cause you're what what what why are you here? What were you doing? Where you happen then you know your cause and then that is it okay? Most of the time cross sectional studies are very useful for doing things like that. And they also used to in epidemiology and epidemiological studies as we're going to see. So this the more most important advantages, of course, sectional study and the reason why we do it a lot in Africa is they're very quick and inexpensive there to collect, I mean to conduct. Okay. And um it can also be used as a business for Qantas. In fact, many times they are the explore it three stage of many other form of studies that were about to do. Of course, it has a disadvantage is that like a case control. So you cannot talk about causality. Okay. And even the association that I talked about is not as effective as the one uh case control study. Also there's no temporary sequence. You can only see what happens at the point in time, you cannot see what happens subsequently or before that. Okay. So these are the different types of uh cross sectional studies. We have descriptive studies, okay, which does and that is the world's most common one we do around the just discuss uh privilege, the incidence of the Democratic uh demographic factors and other things in those diseases. Okay. Uh Yeah, I'm sure everyone is that be a nice time. I'm just a little concerned about his attention span. Uh Is that, do you think we, we can round up in the next 15 minutes so that we can take uh some questions we should Thank you. All right. Okay. So you look at analytic, the ecological uh which can be uh at the ecological level or individual level is still going to look at that one a little bit long as we proceed. Okay. So these are the key concentrations you need to take into. I mean, you need to look into in all clinical stories, your sample size must be adequate. Okay. And your measurements must both, both, I mean, your measurements must must must must be both village and reliable, valid means it is actually recording it has it is actually measuring what is expected to measure. Okay. So if you have uh for example, you want to measure uh you must use a measure in a measurement, I'm sorry, a measuring technique to actually measure your eyesight. Okay. You say stadiometer or something like that okay. And uh reliable means where you repeat your measurements. Okay. It measures the same thing. I mean if you go on a bedroom scale and uh now it measures 75 kg and another time it measures 80 kg, another time it measures 90 kg, that is an obviously a reliable measure. Okay. So validity and reliability are extremely important. And uh and of course, statistic analysis very, very important. Every statistics have their assumptions okay. The assumptions of uh almost uh I mean, the assumption that your data is is what we call it is um normally distributed. For example, before you can do parametric uh analysis, okay, the assumption of uh independence of observations and other things like that. So for you, before you use any statistics at all, you must look into that assumptions and be sure that you actually account for those assumptions before you can use your uh statistical analysis. Okay. So that dealt with clinical approaches and then they have epidemics epidemiological approach is this added various kinds of epidemiological approach is that you have the important thing you need to realize here is that like I mentioned in the earlier alias lives, compare lee epidemiology and clinical study is that some of the methodologies that I use. Okay. The cut across the two broad approaches, the only difference is that your sample size and your subjects varies. Okay. Cross sectional studies. For example, in eco ecological studies deals in population, your country, the old region, not individuals in the hospitals. Okay. The same thing with their core studies and their case control studies and those different kinds of studies, they also obey the same rules. The only difference this is on a vaster scale that compared to clinical studies. Okay. And the main importance of ecological study is that it describes the characteristics and distributions of diseases. Okay, like COVID 19 when he first came, a lot of ecological studies were done and that was when we knew that well, temperature, humidity and things like that affects COVID 19. That was when we learn about the way a manner express, okay. Our people behavior affect it spreads, those are ecological uh studies because he happens to identify not only the spread but also the risk factors that can um that can affect those ones as well as it help us also to look into the effectiveness of our interventions and if inform whether your intervention we're okay. Okay. So uh this is just a word on basic medical research in orthopedics are not going to go into that because most of the time it is actually does in the basic medical sciences and could that goes into it or you are working with laboratories or research institutes. But basically it is good for us to know what basic medical research in orthopedic can tills. And then there is a the guy's a what you call it. There's a reference down there for you. OK. My final thoughts on this object is that um in your quest to add to the world's body of orthopedic knowledge, the most important person is you and the decision you make. Ok? It is important for you to not to say you, you don't have enough time, you always have this enough time urinating is just you need to allocate enough time to your research activities. Like I mentioned before, never, never ever end a day without at least carrying out and a research related uh activity. Okay. So the future of research actually with the interwoven with artificial intelligence, I want to ask this question, how many of you listening a add of chat DPT before chat G B G P T? If you have not, you need to go and just open, open the link down there, the link down there and look into it because like I mentioned, I told you in 1996 when I came across a computer and I look at it and I, I had that feeling that, well, this is going to beat the future of research, future of academic. Okay, of course, it has, people have been using it in. Um, but that was the first time I was coming across it and I remember I, I came across, um, right up just two or three days ago. Okay. That told me that when that person came across computer, it was in 1977. It was a moment. I says, well, this is going to be a paradigm shift. Oh, poor me. A eye is giving me the same feeling research as we know it is going to change tremendously with open A I army with artificial intelligence. Writing is going to change tremendously. In fact, every, every aspect of academic medicine and clinical medicine is going to change with a trick Fisher intelligence. And the earlier you actually know what it is all about, the better for you. Please look, check into uh that, that link down there and uh they look and of course you can also ask even it wants to loving what it is all about is going to tell you about itself. Okay. And just going forward here is my website. Okay. Here you can get all these attic. I'm sorry, these presentations I've been talking about, they're all, they're close to about 80 presentations and other things. And then I also have a youtube channel which present as about 11 videos have not had time to increase Ambien us to the last six months because of my activities. But what you have there now, I mean, they would be a help to anyone of usually sleep. Okay. So thank you for listening. Thanks a lot pro uh I think it's been an absolutely fantastic success. Uh And thank you everyone for sticking around all through the session. Um I haven't seen any questions in the chat box. If anyone has a question, please uh feel free to mute and ask your questions. I think we can entertain a few questions. Mhm Does anyone have a question? Okay. Um A suspect you've uh you've succeeded in providing so much information that you probably need to take a step back and digest uh all of it. Um Like we did said in the in the program link, the video is the session is being recorded and against be provided uh as a culture of content. So people can have a look and go over this session again and um of the benefits of, you know, uh going about I think there's something perfect. Okay, so there's a question here. Let me get that quickly. Mhm Yeah, I think there there are lots of thank you. Thank you. Um So 11 of the question is, do you have any advice for our the house of second grade about conducting research? Would you like to respond to that approach? Okay. The easiest for you hours officer to go about conducting research is actually to find a mentor. Did mention it's one of the slides you will find a mentor. And the easiest mental to find is actually the uh the consultant in the achievement. Okay, if you finish your house job, I mean, if you if you did, if you did your medical school in the same hospital, you must have actually have one or two of your consultants, your lecturers that you admire for their research output on the way the teacher in the class or anything like that. Well, you can go ahead and actually uh as them. That's sad. Is there anything I can do uh regarding any of the things that you are doing any of the research is that you're currently working on? I want to be a part of it and other strong. So that's one way of doing it. The other way of bring it, which actually is possible is for you to actually collect data on your own. When you collect that data, then you approach your consultants or your senior registrar, some other people. This is what I have, please. How can aggravate with it? I remember that your first time. I actually um I uh started doing research when I was a resident, not as a house officer bosses, Boaz, a resident doctor. I just went ahead and collect all data on orthopedic uh orthopedic surgeon that was done in O U T X C right from its inception up to the time I was doing. And I remember that I actually asked one of the house officers to help me to collect those, those data from the lab. I'm sorry, from the third uh I mean from the um theater. OK. Up getting it and then approached matured in. This is what I uh please uh blue something about it by then, I was very naive as far as research is concerned. Uh I was more happened and everything and I think it worked up my paper, okay. But that people was causes do uh delay, sorry, you know, Bill chills. So these can uh go about. And then of course, the last thing around uh reading about research is reading around researches. I'm sure when you were in community medicine, you also have some um you have some some lectures uh research methodology and go over, go over there, going to youtube, listen to some of those things and slowly little by little develop your interest. And I'm going to tell you this the first time you see your name as the auto of the paper. It's going to be a game changer for you. If you have that inclination from that, from that day on, you will be hooked and that's all. Thank you. Thanks, bro. Um Okay, there's, there's a question about how to get access to the slides and recording. So after this session you receive, uh okay, and, and he may ask you to provide feedback and uh there will be a box to check as to whether or not you would like to have the party of content. So if you say yes to that, you, you provided a link as soon as we uploaded. Uh So I think uh probably just hang on for one more minute. Uh If there are no other questions, um we can bring the meeting uh to close, but I think he's done absolutely fantastic uh plastic session. Thank you uh pro for honoring the invites and providing this teaching a very high additional value. I can't see any other questions in the chart box. Um So once again, I'll thank everyone for your attendance. You receive a link athlete to provide feedback. As soon as the feedback is provided, you also receive a certificate of attendance.