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Ok, we'll live now whenever you're ready. Hi, good evening everyone. Um, my name is I'm one of the surgical registrars over at um Nottingham. Um, welcome to tonight's Morning Academy session looking at uh preparation for the FR CSE exam. And we've got some brilliant talks tonight from my colleague, Jared and Jared Leeds. Um our research for the Morning Academy, our past president, a um Alan Ascaris also here, he's now a consultant upper gi surgeon and we are joined later by John Shepherd. So once we run through all of these people will come and say hello to you themselves and they will give their talks as we go through. Um I have been tasked first of all to go fast and to try and talk to you about how you prepare for, you know, reading a paper necessarily. And that's basically the first talk is how do you do a critical appraisal of any paper that you get given during the exam? So it got me thinking about actually, let's go to the start, you know, what is critical appraisal? How do you perform this? Now? I don't know if I can move the slide along or? Ok. Good, excellent. So, without wanting to sound too controversial in the last few weeks, I'm sure most of you would have heard about a survey of data that was done by the Royal College of, er Physicians. Now, the result of this, which was presented at the emergency meeting seemed to suggest one thing but later on when the actual data was showed or shared, um, it actually told a whole different story And I suspect that is the important part of a critical appraisal. It's you can't just believe what has been shown. You, you can't just believe what you've been told or just the results or the data that you're looking at. So it's always important to be able to look at the things to critically appraise it and decide for yourself. If you think this information I'm receiving is actually worth what the paper is written on. Get to the next slide. So in critical appraisal and some people have defined it previously to suggest that it is systematically examining the research to show three things. Firstly, is it trustworthy? Can I believe the data I'm being told actually? Is it valid? Have they used the right methodology to come up to the conclusions that they seem to suggest? And now their results actually believable. And finally, is this information I'm receiving relevant in my clinical practice. And for every single study or every single paper that you read, these are the three things that you should be thinking about is the study valid. Have they used the right methodology are the results useful to me in my clinic practice? And finally, is the study information relevant to my clinical practice. Because one way or another, the exam will try and get you to assess this in your appraisal. Most of the things that you'd be doing during critical appraisal was to look for the biases and the biases will be there if you look for it well enough, you know, is there any evidence of selection bias? So if the study is not a randomized controlled trial, for example, how have they selected their patients? How did the patients enter the uh enter the study? Um who was doing the recruitment? Was there any blinding of the study? Did people know who was receiving what medication all of these will influence potentially the data? These are bits of devices that you're meant to be looking out for as you read or as you go through the paper. So if I take ut uh sorry. Yeah, if I take you to the academic station itself, you're supposed to get 30 minutes to read the paper and you read the paper, you get called in and you got 15 minutes to Viber that academic station is also tick sort of joined up with your special interest surgery. Basic basic principles. Viber, so it's 15 minutes for academic Viber and 15 minutes for your special interest. Um surgery, basic principles. And so I think you're offered a choice between which one you'd like to do. But I suspect if you spend 30 minutes reading the paper, the next thing to actually do will be to VR on the paper first. Ok. First of all, if you've got the paper, the first thing to know is what type of study am I dealing with? Knowing? The type of study is actually important because it helps you to decide what level of evidence the study has. Um in the hierarchy of evidence, Jared, can you move a screen for me? I don't think it's me. So, in the hierarchy of evidence, where does this sit, if you, if what you've been given is a meta analysis? That's great because you know, that I can believe or, you know, the conclusions of this are gonna be much more superior than if you were reading a cohort study or a case uh based study. And this is the main thing that you're meant to be looking at. What kind of study am I looking at? Knowing what kind of study you're looking at also has an, an advantage for every type of study that you can think of. There will be specific problems with them that you can al almost already guess or you can write these down because, you know, well, it's a cohort study or it's a case control study. So how did they pick their cases? These are problems with it. They are inherent problems with the type of study that you can prepare yourself for. So when by the time you get into the Viber you already have some answers for the examiners say the enhancing the quality of transparent health research equal to network has been quite important for the way we report uh scientific studies and these reporting guidelines are supposedly what every study should be doing. So most randomized controlled trials will report using the consort guidelines and most journals now will not accept a paper unless they can show that they've followed these reporting guidelines. Observational studies will use stroke, the systematic review will have prisma, there are others for case reports. And so you can literally go to the Equator network, have a look at the type of studies that they have available, look at the reporting guidelines. So you have an idea, at least of what type of principles should be used in reporting these studies. Now, if you look at the paper in front of you during your Viber, the way I look at it is I sort of divide it into two. The first stage where I'm looking at just the title cos the title should say what type of study it is. So if it's a randomized controlled trial, you already know from the title that this is gonna be a randomized controlled study. Then the next thing I would suggest to look at is the abstract. The abstract and I'll show you a picture of it can sometimes over promise and under deliver than you look at the aims and this should be a succin line that says this study was conducted to look at this. Now, the aim of the study is what you will come back to, to see whether the study achieved the aims it set out to do from the start, the methods tell you how they try to achieve this. So in the first stage alone, you have got an idea of what was being conducted. And since you've got 30 minutes to read this paper, I suspect the 1st 10 minutes should probably be spent doing this looking at the title, knowing what kind of study it is. Looking at a abstract, gives you a brief summary of the entire study. Um and then looking specifically at the angel and reading the introduction and then finding the methods. Once you finish this stage, that's when you move on to the next stage, which we should talk about in a, in a, in a second. OK. So if I gave an example of this title, next, go to the next slide. Yeah. So if I gave you at this particular study and I probably will use it a couple of times. Um And it clearly states that there's a randomized clinical trial of observation versus antibiotics treatment. So just by reading the study, you kind of know that this is gonna be a randomized clinical trial. What it hasn't told you though is, it's not said whether this was a single, uh blinded or double blinded trial. But at least we know it's a trial. We know that there's a, it's an intervention trial, they're doing observation. So, no antibiotics versus antibiotic treatment. And that already sets the scene of what you're looking for. And e even from the title, you probably get, it can get an idea of what you think the aim of this study is going to be because the next slide for you, please. Well, so the abstract ones, I was saying can sometimes they pros and under deliver and most people would, who have bought things online would probably attest to this. So reading the abstract might give you an idea of what the study is. But actually that gives you enough of a talking point because you can say, oh, well, looking at the abstract, this is what they said they had done. But actually when I looked at the full paper, what they did was entirely different to what they said in the abstract, please go to the next slide for me. So now if I move you on one more slide, please. Yeah. So if we come back, if we move on from the first page where we looked at the introduction um or the aims and the methods, now we wanna look at the results when you start looking at the results, one of the first few things that they tend to do or most papers will tend to attempt to do is tell you about the demographics of the population in a randomized controlled trial. This is actually quite important because what it's trying to do is trying to tell you if there are any systematic difference between their P patients that are being compared. So if you look in this particular slide and you can see that there is a no antibiotic group and there's an antibiotic group and between the two of them say on some the parameter like age. Well, there is no difference because the P value is non significant. But actually, if you look at previous divertic colitis, the P value is no point no two. So there is a difference between the antibodies and the, and the non antibiotic group on that particular variable. And, and these are the kind of things that you wanna look out for. So demographic probably is gonna be your table one. You wanna look at that first, you wanna get an idea, are the populations being compared similar or actually do they? Are they systematically different? OK. Then the results, I mean, these ones, we could, we, we don't want to really label the point by this point. We all know about peer values, we all know about confidence intervals. And there are several ways that the population sort of been compared and the choice of these tend to be based on what outcome is being compared, but also sometimes is dependent on the researcher. So you wanna look at why they have chosen what type of analysis they've done. Um You know, I've looked at a me meta analysis previously where people were looking at fixed effects versus random effects. So why has this investigator chosen a fixed effects meta analysis? Is that because by choosing a fixed effects meta analysis, your confidence intervals are narrow. So suddenly you can make something that perhaps was insignificant, significant. And those are the kind of little things that you're trying to pick up on to see. Oh why have they, have they done this? Why have they chosen this analysis? Why have they chosen relative risk? Why have they chosen odds ratio? Did one give them a significant result? And the other didn't? And these are the kind of things that you're trying to pick up on. Yeah. Now most of you would have come across this before and again, it's like it's an idea to try and remember, but you can't just believe the results just because they've gone through a peer review does not mean that the results that you've seen is true. So always have this in the back of your mind. Now, II kind of also wanna talk about the discussion. So you've gone through your first stage where second stage we've done results, we've done, you know, we've got an idea of what they actually found and you wanna look at the discussion and the discussion tells you two things, firstly is what they always describe what their study found. So where does their study results sit? But then they have to then compare it to what is already in the literature and that gives you a bit of background. So even if it's a topic that you've never met before, because you're reading the paper, you should then be able to pick up what elements in the discussion. And a and actually what else is known about this particular topic. But because you're in an exam and you're anticipating that you'll be given questions that asked you what are you gonna do differently? It's important to note the limitations and most studies will themselves tell you what their own limitations are. So, if you know what their limitations are and you come to be asked the question on, you know, well, how would you do this study differently? Well, I've read the paper, they already told me what their limitations are and you can use that to inform that particular question and finally the conclusion or what they say in their conclusion can be quite useful. Some people are very bold and make strong statements. Others might limit what conclusions they make based on, you know, what they find. So it's almost looking at it as saying, have they got bold statements or have they actually been a bit more circumspect? And a bit more restricted in terms of how they've presented this. You go to the next slide for me. So if I, if I look at the same sort of paper that I showed the type of, you know, you could almost summarize it by the time you've done your 20 minute talk and say, well, this was a randomized trial that was testing the effectiveness of no antibiotics versus antibiotics for simple or for uncomplicated divertic colitis. The patients were only eligible because if they had this and if they had a CT scan within 24 hours, um and actually that they included patients in stage one and uh one A and B where the abscesses were allowed to be up to the size of five centimeters. So again, that kind of gives it draws people's attention to what the study was about, what they were looking for, which patient population was being looked at. So, just looking at that, well, what was your population? Because patients were left sided, uncomplicated, acute diuretic colitis except uncomplicated for them includes abscesses up to five centimeters and that will become something that you can talk about. Well, the primary outcome was, you know, recovery after six months of follow up. And they used uh they reported a hazard ratio to show that there was no difference between the antibiotic and the no antibiotic groups. And that could be a quick summary of what study it was. And then if you go to the next slide, if you look at the list of limitations, you know, well, they had it was a multicenter. So the different centers recruited different number of people and different number of patients. And that suggested that there possibly could have been some level of selection bias. Um They said that patients who had recurrent diverticulitis were gonna be excluded. But actually, that was caveat if you had diverticulitis who was treated in the community, they didn't come to the hospital and didn't have a CT scan while you were counted as having first episode of divertic colitis. So again, that could introduce some confounding to your results. It, so all of these things were things that you could have literally just picked up just from the paper itself. All right. So I guess if I go back to the slide that we started off with, then there it's up with this. We suggest that that as your study found it, does this, this study add anything new to the area that I perhaps work in? What was the research question specifically being asked? So here, antibodies, no antibiotics. Is that something that would be relevant to our daily practice? Now, the study design that they chose was that appropriate is asking those kind of questions a random. That's the right way to go. But you would suggest, yeah, you know, the prevention trial, it would be useful to minimize bias by allocated patients to different treatment groups and seeing what their outcomes will be, the outcomes that they chose was irrelevant. Um You know, overall does the study attain its intention of comparing this and this, this reporting is, is this pragmatic, would this, um would this results help my patients? So if somebody came in and they had, you know, a H B1 ba uh diverticulitis with a small abscess, would I treat them with no antibiotic or would I be a little bit more cautious in this kind of population? And that's basically what you're trying to relay in your final exam. Now, this talk was meant to be just 20 minutes and in that 20 minutes, there's no way I could go through all of the different um, task checklist. So it's important that you perhaps spend some time to look at those. But hopefully this has given you a bit of a flavor of what to look out for during the exam. Um The last thing I was meant to mention was conflict of interest. I perhaps should mention that. Um So conflict of interest is always declared or should be declared by the authors. And again, that's one of the limitations that we probably shouldn't miss. Thank you so much, Jared back to you. Ok. Cool. See if I can work out how to get over to my one. Hi. Can everyone see this? And can you hear me? Yes, you can go ahead. Ok, great. Uh My name is Jed Volga. Um Many thanks for everyone who's registered for this webinar. Um Thank you very much, uh Mr Diamma. That was brilliant. So that was an excellent in depth view on how to critically praise a single paper. This is going to be a, a little bit different. Um So as I said, I'm a, I'm an SD five in surgery. I'm a research lead for a S TBI Mon Academy and I'm just finishing up a phd at Queen University of London in Trauma. I'm gonna present, uh you believe it or not? 26 landmark ETS papers and 26 trauma papers. As you can see, I'm going to be skipping the surface only. It'll be very superficial, but it's more of a signpost and a guide to tell you or to give you a flavor of what sort of papers that you could be looking at and you could be quoting in your, um, in your five exams. It's not exhaustive and I don't even touch anything related to colorectal upper gi breast or so on. So it's a whistle stop tour as they say. So first, eeg s first, uh the ne reports of which there, they've just published their eighth one is without a doubt landmark. Uh, piece of work. It guides a lot of our thinking in emergency laparotomy and it kind of provides a benchmark nationally for what we do. Um, and gives us important information about whether or not we're meeting certain standards like consultant anesthetist, um surgeons present uh CT scans done at certain times and so on. Um Next frailty. So the ELF study, the emergency laparotomy and frailty is, is definitely a landmark paper. It was a prospective multicenter observational study included 937 patients and found that 20% of these patients were frail, 90 day mortality was 20% and frailty was associated with increased risk of mortality, morbidity, length of hospital and ICU stay. And was they were all independent of age? Uh The Elf two study is coming up and it's looking at the N A group. So that's the group of patients who are, who were needed, needed a laparotomy but were too frail or too unfit to have one. And it's another important uh group of patients we need to look at to see what their outcomes are. And as of April 2024 data will be collected on these type of patients, the N A group in the NI A study as well. So look up for that next epidemiology and this is a shameless plug, but I was told that that this paper was, er, showed up in there for CS examination. So I wrote a paper a few years back, er, er, publishing analysis, surgery and we looked at 20 years of um, of essentially hospital episodes, statistics, data. But in Scotland, it's called something slightly different uh for all the emergency general surgery admissions and it gives us a good view of. Um basically the EDS admissions increased over time while operations decreased over time. There were some demographic changes as well, especially an increase in female admissions. Um overall mortality, reduced length of hospital stay reduced. But the proportion of patients being discharged to non home destinations increased over time. And then we looked at the same population but then linked them with death records for those who died. And it showed there had been a reduction in mortality, mortality over all but one year mortality for, uh, those who were 75 was 36%. And for those who comorbid the mortality rate at one year reduced from 75 down to 57%. So we care for a cohort of patients who are high risk of per admission death, not just perioperative death. Ok, small bowel obstruction. The NAS study published in 2017 by Matt Lee et al. Um, Multicentre audit of small bowel obstruction. 54% of, of admissions were due to adhesions. 19% from hernias, 10% from cancer. Uh, 24% had immediate surgery. Uh, 12 3rd trial, non operative management, which succeeded in two thirds of the time. But in one third of those who it didn't succeed, they needed an operation. And about half of those were within the first three days. Overall, three patients, 3% of patients were treated palliatively. Then there's the Lasso study by Salonen in 2019. It's a good trial. Um, it's basically lap versus, uh, open elys for those who needed, uh, treatment after basically failure of conservative treatment. After a few days, the primary outcome was length of stay and lap was 1.3 days shorter than the open group. So they concluded that laps. Kinesio lysis pro provides quicker recovery in selected patients with adhesive, small bowel obstruction. Ok. A lot of stuff has been published in appendicitis, but we'll go to the code, a study published in the New England Journal first in 2020. So this one showed that, um, compared antibiotics with appendicectomy. Primary outcome was 30 day BQ five D antibiotics were non in ergotic group. 30% had surgery within 90 days. I had patients with a appendicis at a higher risk of operation and complications in patients without an appendicis. Then there's the a, a Pak two study um by S OA in 2020 which is an RCT comparing CT proven un appendicitis who either received seven days of antibiotics orally or two days of IV, followed by five days of oral antibiotics. Their primary outcome was treatment, success and discharge from hospital without surgery and no recurrent appendicitis within a year. Basically, there was 70% success with oral, 74% with IV. Um and they failed to demonstrate noninferiority, but you can still see the failure, nearly 30% of antibiotics alone. There's been a lot of these studies. So in 2016 sen published a RRC. Well, a systematic literature review and meta analysis of five RCT s of non perforated antibiotics, sorry, appendicitis and versus appendicectomy within one year of treatment. Uh 23% had recurrent appendicitis. Uh A similar study was done by pop uh including nine RCT sa few years later. And it also showed a recurrence rate of 18%. And then the real life studies like the Rift Study group by Bangu et al um did a prospective Multicenter observational study of over 5000 patients presenting with regular fossil pain. So, not just ct proven just presented with, you know, as we see them in A&E and whatnot, women were two times more likely to have a negative appendicectomy than men. And they looked at all sorts of prediction scores and of 15, evaluated the best one was adult appendicitis score, but it only had a specificity of 63%. So this is a difficult diagnostic uh population. Ok. Diverticulitis. First, the diva study uh published in 2013 was an RCT comparing placebo to mesalamine or mesalamine plus uh a probiotic for CT confirmed diverticulitis. Primary outcome was global symptom score and both both mesalamine groups had lower symptoms than placebo. But with the, the addition of probiotic didn't really help and recurrence was similar across groups. Then there are some controversial studies including De Lala and Ladies Delallo was published by Cole in 2018. It was an RCT of laparoscopic lavage versus Hartmann's resection for Hinch grade three perforated diverticulitis. Uh The primary outcome was one or more further operations within two years. The lavage group had 45% reduced risk of requiring one or more operations within two years and fewer operations than the Hartmann's group. At two years, there were three of the lavage group and nine of the Hartman's group who still had a colostomy and they concluded that lap lavage was a better option than open resection and colostomy. However, there were a lot of concerns with this paper, um especially regarding selection bias. So the lady study um actually looked at just compared to her Hartman's, it was an R CT versus sigmoidectomy plus anastomosis plus or minus defunctioning IOST toy. It was also for 33 or four. So perforated diverticulus, perent or fecal tinnitus. Uh The primary outcome was 12 month stoma free survival with 95% in the anastomosis group and 72% in the Hartman's group. Um So it concluded that and physiologically stable immunocompetent patients who are less than 85 primary anastomosis actually had better outcome than harmless. Uh Sorry, that was the uh lady trial as well. So then we've got mesenteric ischemia. So there's a lot of interesting papers on this, but it's quite rare. So we're looking at the World Society of Emergency Surgery Guidelines in 2022. And here it is essentially, they tell us that the, the mortality rate is 50%. And it reminds us of four different types of M I. So the Mesenteric arterial embolus, the arterial thrombus, the non occlusive M I and then Mesenteric uh venous thrombosis and they give a nice treatment um and investigative guideline for us, but essentially get a CT angio resuscitate them. And if they're hemody dynamically abnormal, uh or certainly if they're peritonitic do laparotomy, otherwise you can consider laparoscopy or endovascular techniques with your vascular colleagues gallstone disease. So, an interesting study was published uh this last year and based on the group of Aberdeen, it was a sea gull study and it was an RCT for patients with uncomplicated symptomatic gallstone disease comparing either conservative management versus lack coy. The primary outcome was quality of life uh via sf 36 scores, uh focusing on the bodily pain scores. After 18 months, there was no difference between the, between arms and I actually concluded that conservative management is a legitimate alternative to LAO for symptomatic gallstone disease. So it could change practice in the future. What about cholecystitis we see on call? Uh There's been quite a few studies on this as well, but in the era of laparoscopic surgery, I'll focus on those. So there's LA and, and B Js 1998 which was early. Um an RCT comparing doing a lab quality within 24 hours or delayed 6 to 8 weeks, they found no difference in conversion rate to open, which is a 21 to 24%. But the early group had a longer operating time and a shorter hospital stay compared to the delayed group. So they thought that early lab co was safe and feasible. The next study by Johansen in Sweden was also RCT and they said early was within seven days and late or delayed within 6 to 8 weeks. They also saw no difference in conversion rate, operative time and complications. Um and they said length of stay was slightly shorter in the early versus the delayed group. So they also said that early LA is safe and feasible. Then Cola in India um did an RCT early being 24 hours late being uh 6 to 12 weeks. And they also found essentially the same things that um, no difference in conversion rate, operating time complications or POSTOP analgesia requirement. So they said it was early early left, it was safe and feasible, excuse me. And then finally, I got in an of surgery as of surgery 2013, er, based in Germany did an RCT again early versus late. Uh, but they found that morbidity was lower in the early group and length of stay was lower and total hospital costs was lower and the conservative uh sorry conversion rate was similar. So they concluded that early lab co should be the therapy of choice for suitable patients. What about the ones who aren't suitable? Well, the chocolate study came out recently by Len et al in Netherlands and there was an RCT comparing LAO versus perk drainage um in high risk patients. So a patty seven or more the trial actually completed early cos even though there weren't any additional deaths, that wasn't the problem. There were major complications. Um So 12% in the lap group with 65% in the per drainage group, uh 66% required an intervention in the perk drainage group compared to 12% in the lap group. Um And recurrent bili disease occurs in half of the perk drainage group compared to only 5% of the lap K group. Er and not length of stay was also much longer for the perk drainage group nine days versus five days for lap Coly. So they, they basically said that lap Coly compared with perk drainage er reduced the rate of major complications in high risk patients with acute cholecystitis. Ok. Hernias again, lots of good studies. But there is a good prospective observational real life data study published recently in B DS in 2020. Um 2022 rather called MS. So there's loads of variation in different types of hernias that they evaluated. Um but they gave us some distribution of different types, some presentation how they present. So, symptomatic, incarcerated, obstructive strangulated, whether we use mesh or suture repairs. Um and then kind of looked at this health utility index by treatment. So, surgical delayed surgical conservative or palliative. And I guess another key point is that the surgical site infection rate regardless of uh type of hernia was 14% at 90 days, which might be useful for patient consent pancreatitis. There's been a lot of research on antibiotics in pancreatitis. So, uh uh sorry, starting with uh Dellinger in 2007, did an RCT comparing patients with severe acute necrotizing pancreatitis and compared meropenem to placebo. So five days um within five days of symptoms and for 7 to 21 days, the primary endpoint was pancreatic infection. Within 42 days of randomization, there were no difference in infections, mortality or surgical intervention. Uh There are some other studies that showed a difference. So then devries et al put together this RCT, sorry, this uh systematic literature review and meta analysis and found something very interesting. I hadn't read in previous studies. Um Basically, they found that as the methodological qual quality of the studies improved the effect of antibiotics at reducing the risk of pancreatitis reduced um to nothing. So basically, they were saying that, you know, rubbish studies are showing there's effective antibiotics but good studies aren't. So maybe we shouldn't use antibiotics. And the 2019 World Society of Emergency Surgery guidelines for the management of severe acute pancreatitis have warned against the use of antibiotics prophylactically, but they do say we should use antibiotics if there is proven infection um in the in the pancreas and and they've suggested you can use procalcitonin or fine needle aspiration to work that out. OK. Take a breather. I know this is a whistle stop tour, but I'm gonna go through some trauma papers with you. Another one of my passions. So first off trauma assessment, everyone knows a TLS. It's been around since 1978 and it's really the standard of how we assess patients in trauma. So know the algorithm ABCD since then, a UK focused Nightline, uh which helps us with assessment and additional management, um which we should also know um how it works uh with specifically with rib fractures. I only show this because it's uh well conducted and well developed and validated study to for blunt injury for people with rib fractures after blunt injury. Um predictors were age number of rib fractures, underlying lung disease, use of preinjury injury, coagulants, oxygen sats and their C index was 0.96 in the final model. Um and it's widely used in practice. And then there's the study by um Joseph et al in Jama surgery 2014, which talked about elderly and trauma and it was a prospective observational study measuring the frailty index, which is something again, we can measure as part of assessment in trauma patients aged 65 years or older. 44% of these patients have frailty and frail patients were more likely to have complications or adverse drug disposition. Uh discharge disposition, sorry. Ok. Trauma systems why do we even have trauma systems? There was a paper in uh by mckenzie et al in 2006 and this is an observational study comparing designated trauma centers with hospitals which were not trauma centers but can cared for injured patients across 14 US states, patients er were had to be between the ages of 18 to 84 to be eligible and they used propensity scoring to match patients which was not great but oh, well, trauma centers saw reduced inpatient mortality, uh also reduced one year mortality which was significant between groups. Um So they uh concluded that differences in mortality were more pronounced in patients with more severe injuries as well. So they argued for regionalization of trauma care in the UK context. Moan et al in 2018. Um sh found an increase of uh 0.08 survivors per 100 patients per quarter. In other words, the introduction of trauma systems there between 2011 and 2012 in England led to an unexpected rise er in survivors, which is a good thing. And also uh prof co in London, looked at er observational cohort of data and worked out that as time has gone on in the last 10 years. There have been a lot of improvements in mortality because of or associated with multiple different uh different um implementations of, of new strategies from a trauma system perspective. And it also showed us the type or the mode of death. So, in the 1st 24 hours, uh sorry, in the first three hours, it's mostly exsanguination in tamponade in the 1st 24 hours. After that, it's usually exsanguination and traumatic brain injury. And after that, it's usually traumatic brain injury or multiorgan dysfunction syndrome. Um That is the cause of death. Ok, coagulopathy. We all know a lot about this, probably the landmark paper was published in 19 9 2003 rather uh by uh prof bro and J TX. Um It was a retrospective study of nine sorry, 18,867 patients median iss of 20 and 24% had coagulopathy. The key thing was that patients with an acute coagulopathy had a significantly higher mortality uh 46% versus 11% and the incidence of coagulopathy increased with increasing injury. This really was a landmark paper since then. There have been multiple other papers looking into coagulopathy, but a very good um review of all the different um things we know about to, to, to date has recently been published in Nature Primer by Ernst et al. Uh It shows us a little bit about uh whether or not patients are hypocoagulable or hypercoagulable um phenotypes and how that works as well as gives us a really practical um idea of how to treat patients, whether they have specific uh abnormalities in their visco atic hemostatic assays where when you do a teg or a ro 10. So how to basically fix it? Uh Also how can you predict it? So this is a paper by Za Perkins and others and thinking, well, if you know, sure we can treat gray, but what if we knew it was happening before it happened, then we can prevent it. And that was the premise behind that paper working out that you can predict coagulopathy with uh variables that are known very soon after injury such as uh injury patterns, physiology, and biochemistry. Ok. What about permissive hypotension? We always use this term or where did this come from? There's a paper by Bickel et al and uh supervised by um Kenneth Mattox in 1994 published in New England journal. This was a randomized controlled trial of penetrating torso injuries. And uh they were had to be hypertensive less than 90 they were either given IV crystalloid, which was the standard at the time versus delayed treatment. So they got a cannula but no fluid until they got to theater. And they found that there was 62% survival in the standard group and 70% in the delayed group. They also had a 30% complication in the standard group and a lower 23% in the delayed group. So they said that delay in aggressive fluid resuscitation, improved outcome in hypertensive penetrating trauma patients, hence permissive hypertension. Ok. Damage control is another concept that has sort of started back in the nineties. This was published by Rotondo from Pen. Um, in 1993 basically a retrospective study comparing definitive laparotomy where you do everything with damage control laparotomy or abbreviated surgery in severely injured patients. And they found that the damage control group had a 77% survival compared to 11% survival only in the definitive laparotomy group. Uh, all the damage controlled patients went to ICU and had their coagulopathy acidosis and hypothermia corrected before then having definitive surgery since then. Um there have been a lot of hype on, on this sort of thing. It was used a lot in camp bastion as well from a trauma perspective. But it also necessitates in some cases to have open abdomens, uh you know, to leave surgery and go to ICU with an open abdomen. So there's a good uh paper published last couple of years ago by Mahoney as an East um East guideline on open abdomen management guidelines and they recommend a use of fascial traction techniques which was associated with improved myofascial closure during index admission. The another concept in damage control is ribo. It's a recessive endovascular balloon occlusion of the aorta. Er, and there's a really good study just published last year in Jama where all UK, well, all English major trauma centers contributed patients, er, or many of them actually and found that basically, er, they used Baes statistics which was relatively novel and they found that using rebo uh uh in addition to standard major hemorrhage protocol care for those who had uh exsanguinating torso hemorrhage or presumed to have exsanguinating torso hemorrhage in the emergency department, uh was less likely to be helpful than just standard care alone um which was major hemorrhage protocol um treatment without the use of RIBO. So they concluded that so the study was actually stopped early because of um these abnormal results or, or bad results with RIBO essentially. And the suggestion was that Ribo and used in this setting in UK emergency departments is not currently recommended. OK, blood products. Uh First, there was the prompt study which is observational uh cohort 10 level one trauma centers in the states. In the first six hours, there were higher proportions of FF uh plasma to red cells and platelet to red cells led to a lower mortality. Um So those ratios of less than 1.2 or 1 to 2 rather were 3 to 4 times more likely to die than patients with ratios of 1 to 1. And uh that was done by Holcombe who did another study. But this time in RCT comparing 1 to 1 to 1 plasma platelets to red cells versus 1 to 1 to 2 ratio. And even though it didn't show any improved mortality at 24 hours or 30 days, more patients achieved hemostasis and there were fewer fewer he hemorrhagic deaths at 24 hours in the 10101 group. And that's just some of the data from that study. There is also a pamper study. So this was prehospital plasma used as resuscitation fluid by Sperry et al. Uh they compared pre hospital plasma to standard care. The primary outcome was 30 day mortality and it found that there was 23% mortality in the plasma group and 33% mortality in the standard care group. That was statistically significant. There was also a reduction in prothrombin time ratio. Um There was a similar combat study by Mo et al who used uh plasma versus normal saline in the prehospital resuscitation environment. And they found uh no benefit, no survival benefit of plasma compared to another recess food. And then most recently, there's a big study called cry cryostat by Davenport et al, published last year in Jama uh RCT multicenter of patients with evidence of active hemorrhage hypertensive less than 90 receiving at least one unit of red cells. They're comparing major hemorrhage protocol um versus major hemorrhage protocol. Uh plus three units of pooled try to precipitate given within the 1st 90 minutes. The primary outcome was mortality within 28 days and even though it showed no difference, er and there was no difference in thrombotic outcomes, there were some interesting findings in the subgroup analysis including that if you had already a low fibrinogen giving cryo may have helped if you already had a high fibrinogen giving cryo uh, may have increased mortality. Ok. What about TX A? So the crash two study is absolutely landmark. It was 274 hospitals in 40 different countries and each arm had over 10,000 patients a massive study. Um, and it compared, uh TX A versus placebo um, in patients at risk of bleeding within the and given within the first eight hours of injuries, they basically found that, uh, their primary outcome was 28 days mortality and they found that it was significant improvement if given T Xa within one hour or within 1 to 3 hours. Uh but not over three hours. There's also this study by RA in 2020 showing giving TX a prehospital within two hours to patients with moderate or severe TBI I compared to placebo. Um but the outcomes uh didn't differ, which was uh the primary outcome was extended. Glasgow outcome score stamp was a similar study looking at pre hospital TX A versus placebo in injured patients. Uh primary outcome was 30 day mortality and it was not significant different. But a POSTOP subanalysis showed uh of more shock patients and within one hour of injury, there was a survival benefit at 30 days. Then there's the patch trauma trial comparing TX A 1 g bullous and 1 g effusion to placebo for patients at risk of hemorrhage. But the primary outcome which is extended Glasgow outcome score at six months didn't differ. And you can see here, they're almost identical between TX A and placebo group and then slightly different. The eye tactic study was a very interesting study. RCT whether augmenting major hemorrhage protocol with either viscoelastic chemostatic assay guidance or conventional coagulation test guidance. And the primary outcome was they had to be alive and not have had a major transfusion or massive transfusion. Uh It didn't differ between groups uh nor did 28 day survival. But there were also some interesting um subgroup findings. OK. TBI, we've got the res study, decompressive craniectomy. Um So, in patients with um TBI and intra uh intracranial hypertension to try to have decompressive craniectomy versus standard care. Primary outcome was also Glasgow outcome score extended within six months and they found that surgery decreased the intracranial hypertension but reduced and reduced the length of stay but led to worse functional outcomes. And a similar study was published five years later, the rescue ICP study um where this is an RCT for patients with TBI and intracranial hypertension to have decompressive craniectomy versus medical care. And again, it was Glasgow outcome score extended at six months. And this one was interesting, it led to lower mortality but higher rate rates of vegetative state, severe disability uh from surgery than medical care. And the rates of moderate disability were quite similar. And also finally, they ordered study, this is done by PROF C uh which is an observational multicenter study showing that multiorgan dysfunction had a 22% mortality rate. Uh and 24% of these occurred within the first two days. There were three sort of multiorgan dysfunction syndrome types. There's an early resolving type which had a median of four days mortality of 14% and was associated with saline use. There was a delayed group with a median of 13 days mortality of 35% associated with TBI. And there was a prolonged recovery group with a median of 25 days mortality of 46% and was associated with shock. OK. That's me done. Um Thank you very much for listening and bearing with me. There was a lot of papers in there. Um Point is know your key papers, you can mention them for extra points during the Fr CS, but you'd also have to be prepared to defend them and critique them if you do mention them. So, thanks very much for listening and we'll move on to other speakers. Thank you very much. Uh I'm just gonna share my screen and hopefully you should be able to see that. So, II hope you can all see the presentation. Yes. Fantastic. Um Now, OK, good. Uh So my name is Alan Mascari and uh thank you very much for the Mohan Academy um for inviting me to uh to, to help out tonight and, and present some of the some of the work that's uh that's gone into a lot of the work that they've done in providing these webinars. So I congratulate them. We're going to uh given the uh very high brown cerebral talks. We've just heard mine's gonna be a little bit less. So it's gonna be more about uh how you utilize research uh knowledge or research data or your understanding of research and your answers. And I will talk a little bit about uh upper gi and H PB as well. But ultimately, as my colleagues have rightly said, it's not really about regurgitating a massive amount of knowledge regarding each data trial, the minutia nitty gritty, but it's really about understanding why research is important, why we use it, what the roles it plays in guidelines and learning to critically appraise it as Alfie quite rightly said. So we'll talk a little bit about why research is important and then talk about some key upper GI and HPV studies. Um Jared's uh done an absolutely momentous job of going through very uh in very detail. A lot of the studies of. So I will, I will not do the emergency general surgery stuff so much, but it's uh we're also spending a bit of time talking about factoring and research. You know, how do you name drop it in? How do you actually put it in because you don't want to just start off as just saying at the beginning of the answer being. Well, the question trial says this, it's going to be in the context of what you're saying. So you don't want to sound like you or just parrot, fashion quote, kind of wrote memorization, just regurgitating what you've read or what trial has said and we'll talk a little bit about that as well. So why is research important? Well, a lot of you kind of know, well, all of, you know, this as well, really, but there's very good evidence that actually enhances patient care involves our medical knowledge. Overall. It's better than any one person's opinion and, and supporting evidence based medicine and driving innovation and treatment care and treatments and patient care and influencing healthcare policies is important. It also ensures that we deliver the best most cost effective uh health care that we can to as many people as possible. And that often requires research, not just into what's more effective drug wise or treatment wise, but also it's cost effectiveness in terms of quality of life and financial costs as well and also builds patient trust in the sense that, you know, the days 2030 40 years ago where a consultant um or a GP in any subspecialty um said, oh this is what you should do and, and it was widely accepted. Now, the global population really has become more data aware and more evidence based aware and expect more. They don't want just your opinion. Yes, they want your opinion in the context of the guidelines and research. But they also want to know that you haven't just thought this up on your, on, on, on the way to, you know, to the car park from the car park to the clinic. OK. K AJ paper is an HP for the F RC. Now, as just very, very eloquently demonstrated there is loads of papers out there. However, you do not by any means need to know all of them. It's about the key ones, the key ones, I mean, upper gi itself can be separated into kind of upper gi in, in terms of gastric bariatrics and antireflux. And there's also of course HPV. Now, not so long ago when either the the two stations were combined. So if you were upper gi you were H PB as well, so you ended up um doing the other kind of sub as well and it was quite a mammoth task, cos each one of them themselves was quite, quite big, but now they've separated them, of course, upper gi there in, in upper gi cancer studies, there's a lot of them and I'll go through some of them uh in a little bit more detail. But for example, for esophageal cancer, um actually, before we proceed, I think it's important that we make it clear that even though we are saying that all these key landmark studies are important, they're really important in the context of the subspecialty you're doing. So if you're a breast trainee or a colorectal trainee, knowing the ins and outs of the cross, the magic, the time et cetera trial, you know, it is not going to be all that relevant, the general surgery of the E GS and the trauma stuff we all have to know and do so what jar presented is kind of applicable to pretty much every however, unless you're gonna be, unless it says upper gi on your badge as you walk in and you want to do an upper G be an upper gi specialist, you're not really going to be expected to know the details of the four study. And the same for all other specialties in bariatrics, a Swedish obesity trial or study rather that very convincingly demonstrated the efficacy of bariatric surgery in reducing morbidity mortality and general health. Er, and it was followed by a whole bunch of other kind of studies in terms of pitting one procedure against the other and of course, an antireflux in its motility in HPV. It's equally kind of colorful in terms of the number of trials. And this is, by the way, is by no means an exhaustive list. One of our colleagues in the chat just wrote, if it's possible to have a list of these studies. And II think that's an excellent idea. What we'll do is we'll put an Excel spreadsheet together, uh putting the subspecialties and the list of trials. Uh and I can't promise and we'll try and see if we can find the links to the papers as well if we can. Um, it'll take us a little while to put together. But I think it might be a useful tool uh, for us to send out to everyone, uh, for pancreatitis, uh prean aortic trials and so on for pancreatic cancer. Sorry. And we've already heard some of the pancreatitis ones from, uh, Gyro's presentation regarding emergency general surgery. So how do you go about preparing for every year of R CS? Well, you can just put in an Excel spreadsheet like I've just done there where, where you just put very base, but that can be quite time consuming. And I would only recommend that you do this with very key trials in your subspecialty area or the ones that are general to everyone so called trauma and E GSI certainly would recommend you if you're a colorectal trainee going and doing this for OG cancer and vice versa. However, I think a much better way irrespective of social specialty is to do it in a mind map. Now, I'm a very visual learner and so it makes sense to me, but some people may not like that, but you can create these mind maps and you can just find a diagram, essentially, you can create them on pen and paper, of course. But um there are kind of free software out there as well or some that are a bit more fancy that you can pay more for subscription fee. Obviously, you don't have to. But I think just having the trials or even the scenarios I found this kind of approach really, really useful when I was trying to kind of understand and remember the key trials. And all I did was really have three or four kind of reports. What was the recruitment published? What was it published in and what the arms were, what, what did they pit against, what, what they find, for example, the cross trial or before that really, the magic trial they recruited in almost these years published in new in general medicine and kind of chemotherapy and surgery together. So combined therapy versus surgery alone and there of course been a trial, nearly equal numbers in both arms and they found that combined therapy is better offers a better five year overall survival, 36 versus 23 which is very significant. So as a result of that, we started giving everyone chemotherapy and surgery now to a lot of P I trainees, it may seem absolutely crazy that there was a time where we didn't give people chemotherapy before we did surgery on them. But there really was. And this kind of set, obviously the scene that we should be giving combined therapy, not just surgery alone, then the cross trial also came and followed them and said, ok, what about if we give chemotherapy chemotherapy and also radiotherapy and surgery versus surgery alone? Again, equal numbers in each arm both um on, on both arms and surprise, surprise if the survival is better. So what do we do? Now, we give them chemotherapy surgery and radiotherapy rather than just the, the radiotherapy alone presuming that they are fit for it uh physiologically, and the patient is obviously consented to that. Then they came about with the advent of kind of laparoscopic surgery and minimally invasive techniques, especially robotic surgery. Now, there's been a time and neuro studies which essentially looked at. Ok. Traditionally, we've done open eye with livers, esophagectomies and, or thoracoabdominal, which um is, is great to watch and assist in and, and do parts of, but it's, it's pretty mutilating. There's a great big cut across from the, from the chest all the way down to the, essentially from your left, you know, arm just left armpit to, to the right. You know, it's a, it's a very big cut across, very painful uh crossing all the dermatomes that we asked not to usually in surgical er, treatment, but it does give you fantastic access uh to um to remove the tumor. And the time trial, for example, looked at uh open versus uh minimally invasive mo small, relatively small numbers. And they wanted to know is there a survival difference? And there was no survival difference if you cast your mind back from uh some time ago when laparoscopy was in infancy in colorectal surgery. For example, there was a real concern that colorectal laparoscopic colorectal surgeries, excuse me, was associated with a uh poorer outcome in terms of oncological outcome. But the, the subsequent trials demonstrated that wasn't the case. And the same thing has been done in, in og cancer surgery. There's no difference in survival and the chest infections and the peral complications mainly chest are, are less. Uh That's what the time trial should be. Mero also kind of did something similar thought instead of using minimally invasive, he used hybrid or by hybrid, would mean a laparoscopic abdominal approach and an open chest versus open, open alone. Uh And again, I found no difference in survival and less uh peroperative complications again in the chest. Now, one of the things that really changed practice uh not so long ago, actually, only a few years ago was the flot trial. Essentially, traditionally in the Magic and Cross have been using CF and CX chemotherapy. Uh in these kind of chemotherapy and surgery, arms or flot came along and said, well, what if you give them flot instead of that chemotherapy and flot survival was, was substantially better. So if you'd have flocks, you're 23% that's what a hazard ratio. 0.77 means essentially you are 23% more likely to survive. If there was a higher ratio, ie it was, if the hr the the hazard ratio was above one was means that you're more likely to die. So the flo group were less likely to die. Ok. So where can you find out about all these trials apart from, er, the fact that we're gonna send out a list. Er, well, there's loads of sources, of course, with PUBMED. Of course, you'll know systematic reviews and meta analyses are fantastic places to look because you get a, somebody's already done the hard work for you and, and, uh, given you a list, the revision books, of course, cracking Fr CS and so on will have them in as well. The other places really on the one is the World Health Organizations Cancer Registry, the N I Charles uh National Library of Medicine in the United States government uh medical database will have them and of course, Cochrane as well. Books, there's a couple of uh very good books um that have got lots of papers in there. Pretty much, all of them are included. The only thing about books to be to be mindful of is is that remember, excuse me, is that remember that books uh obviously time elapses, they get out of the dates and not all the trials, especially the ones that have been recently conducted for being there. There's one little G of a paper actually which um I came across uh in a little while ago actually was uh looking at and this is upper G IHP B. It's all the GI I'm afraid it doesn't contain breast but all the gastrointestinal kind of subspecialties of general surgery. It's got a lot of the key ones in there and you can look it up. That's the details and it will, it gives you nice tables and some summary of all the, the the trials as well. So it's quite useful paper that one to, to have it summarize a lot of it. OK. So research in, in, in, in the FR CS, OK? Now, it's very rare, in fact, almost never the way the examiner you sit down in a chair and the examiner says, welcome. This is your upper gi colorectal whatever trauma scenario, tell me about the crash two trial. That's not what the exam, that's not how it works. In fact, there's very few direct questions you will be asked regarding that unless you're doing really, really well and you're going into it and you've already mentioned it. It's not a partial fail, you don't fail because you don't know the ins and outs of the cross trial, the mirror trial or any of the other trials that you mentioned more commonly. It's, you've already done the scenario. You're already well into the scenario, the vast majority of course, being clinical and they say, OK, it's interesting you said that do you have any trials that backs up what you said or do you know of any data out there or do you have any studies? And that's your prompt to kind of go in with something now in a, in a in if you can really get your answer really refined you'd actually be able to offer that before they even set it. Uh, but so even though there isn't any direct questions, there isn't gonna be a quizzing of and even if you're part a, there isn't going to be a, um, or, or very rarely is there a question saying, tell me what this trial said. Unless there's something really, really massive like the Crest trial, res two trial. Uh, it's, but it's usually more helpful that it gives you more marks rather than, oh my God. I'm gonna be grilled about this trial of that trial. So remember an in depth knowledge of every single study that you've seen or even most of them or any of them really is not really required. But the ab ability to understand and the ability to understand complex districts, hierarchical regressions and all these other things is also not really required. What is required, however, is understanding of the key ie landmark studies, the practice changing ones, the ones they put in the guidelines, that kind of stuff. And that's why the guidelines are quite useful to um go through uh not just from a clinical perspective but from this perspective as well from an academic perspective for your station, academic stations. It's also absolutely vital and you don't have to have published a single paper although I recommend you do because it's part of your CCT requirements, but it's not, you don't have to have published a single case report to pass the F RC, it's really don't, but you do need to know how to interpret research. You need to know what the methodology is roughly about and, and a basic, and I do mean a basic understanding of statistics, you need to know your definition. So when they say what is an odds ratio, there shouldn't be any kind of um uh should be bang a right off the bat answer that you've practiced, but it sounds genuine. It sounds like it's your own words. It sounds like you understand it. So the best approach is really to incorporate these research data into your answers. Uh rather than expect that that somebody is going to say right? Tell me about how many was in each arm of the cross trial or something. OK. So research in Fr Cl, so this is gonna be we're gonna apply the research that we know the data that we know the trial information that we know about into our answers. And it's important to understand what kind of research matters applicable as Jared and Alpha both kind of alluded to in the talks know the recent evidence. As we mentioned, the guidelines are very important because they've already done the hard work for you. They've already put a two A or two B or, or whatever it is and they've already said that what the problems are and you know, all this trial recommends this. Therefore, we cautiously recommend it as well. However, in this scenario, they've already done that. So reading those kind of summary of the guidelines, I appreciate every guidelines are 70 pages. And again, you're not going to be able to read 600 guidelines in your exam. But having an understanding of the big uh guidelines are the key important ones for general surgery, emergency surgery and for your own subspecialty advice. You wanna do smart references and strategies, you don't wanna just overload them and just name drug trial after trial after trial, uh, saying, yeah, yeah, mirror time across stampede and just, that's not what it's about. It's about say, putting in the context of your answer, focus on the clinically relevant ones. So, for example, if you get a trauma scenario, as Jared said, the crash, two big massive international trial across several continents, tens of thousands of patients, that's an important study and they're very clearly demonstrating what they did, which we'll talk a little bit about, um, later as well. Be very specific and be honest, don't overreach if you don't know if you haven't heard of a trial or, um, they're unlikely to bring up any, uh, have you heard of this obscure trial? That's, um, that's got and equals 10 patients and that's not gonna be the case. And if it is, it certainly will not be something that you're gonna miss an ar of do not guess, practice your answers. And that goes for everything, not just the FRC S uh academic station, every single station. Because one thing, knowing the answer in your head and understanding it and it's quite a different matter, actually being able to vocalize it concisely intensively and with, with structure that is easy to understand and makes it look like that you're um put together the answer quite well. So we'll go through an example. So this is the kind of thing they will do uh in upper gi station, for example, let's say you walk in your up, your bad says upper jaw. But look, this could be easily colorectal breast HPV transplant, whatever it doesn't matter. So you walk in and, and you talk about a scenario they've given it to you and they say, oh yes. Uh This is a, a lower esophageal tumor. Oh Great. OK. Yes, a lower. What would you do? Oh MDT not. So you've done all of that stuff and then they say, OK, so you, you, the patient presuming the patient is fit for surgery. How would you approach? So what, what kind of operative technique do you undertake in your practice? Would you offer the minimally invasive subject? Something along the lines? Would you do this robotically or, or something along those lines to, to trigger a discussion? And then your answer you won't say in my practice, I would. And then the reason why I left a blank here is because in this kind of scenario, if we could really do any one of these, you could do open mo hybrid, there's no guideline, you have to do one or the other. OK. So there's no absolute way of doing it, but you need to be able to justify that. And that's based on experience your training, what your unit does, what you're used to the suitability of the, of the candidate or the appropriateness of the treatment for that candidate. So you can say, for example, and bear in mind, I'm using here, I am using the same kind of um trials argue both ways. So you can say, oh, I would do this open because in my practice, that's what I've been trained to do. I don't have any experience in in robots or laparoscopy or minimally invasive. And I'm aware that the mirror and time trials have said that there is a bit of difference since there's no difference in survival. So oncologically, patients going to be safe, whether I do an open procedure or a high predominantly invasive. I appreciate that there that some of the data in the in these two trials have demonstrated a slightly lower complication rate in the in, in my own hybrid group, particularly in, in terms of chest infections, POSTOP. However, you can justify it did not say yeah, the the the time and mirrors uh trial said that actually mean invasive is better for chest infections. Therefore, I'm only going to do hybrid or only do going to do uh robotic called M IO. But equally, you could argue the other way if you are a trainee who's upper gi who's been trained, how to do hybrid or M IO. You could say, well as I've been trained in this technique, not notice how I am al always putting the clinical thing first, not the trial says um laparoscopy good, open bad. Therefore, even though I didn't say that, but I, I'm obviously just laboring the point here. But notice how I'm always saying that in my experience in what in the training I've had because that's what they want, they want you to do the safe thing. But you can say, as I've been trained in a hybrid, a million, a million invasive eom and given that's what my unit does uh routinely and there is no oncological deficit. There's no, it's not inferior to open surgery and possible, potentially a better complication profile. I'm going to do it robotically or laparoscopically or hybrid. The same trials you can use for different answers. Eg Jared's already uh given us the uh the crash two trial, which is a very key one, as we've already mentioned, 23 year old male brought to away. So this could be a trauma scenario very easily or something along these lines came off a motorbike half an hour ago, they were around the corner from the hospital, came off the dual carriageway. So that should alert you that it's a high speed impact motorbike and they may throw in something, not wearing body armor, not wearing helmet, whatever. How would you assist the patient? Now, of course, you're not gonna go straight and say, well, um trial says given acid, that's the wrong answer. Um So remember you have to put the research in the context of the question, you're gonna do all the usual things. This is very serious life threat trauma team. As part of an MDT, we're going to simultaneously assess and resuscitate the patient as per the ATL S guidelines. So you see the phraseology I'm using to try and cut down the wording of what I'm using uh and save myself time and deliver it concisely. Then you can say, oh sure, the patient is ultimately after you've done everything else, you're gonna to ensure the patient is given 1 g or, or simultaneously as part of your resuscitation, 1 g of tram acid as per the crash two international study or trial, which demonstrated when given early within three hours TX A reduces all cause mortality. So that's the kind of way you want to deliver it. They may follow up with the research questions, especially if you're doing well. So if you've been asked for more in depth questions about the trials or studies um or the methodology or your statistics questions, just take a breath and relax, you're doing great. It means that you've already kind of got sixes and sevens and you're one bringing to the high seven points and high eight points. Uh it means cos you've really done well. So they're giving you increasingly more harder questions uh in the exam to see where they can push you to, to get you the maximum number of marks if they're asking you really, really easy questions. There was a five minute scenario and you're four minutes in and they're saying, OK, so after b what comes next, is it C Yeah, or what are you gonna do c with this trauma patient then, and then you should start sweating a bit. But if you, if you're getting to these hard questions, you're doing well. And they may also ask uh if you had unlimited funds. Uh How would you do the trial differently? Especially in academic station? They, they love asking that. So even across street trial, OK, if you had lost, if you had billions of pounds or whatever and tens of thousands or more patients, what would you do differently? And there are other things you can't and that's what the testing there is, the testing, your understanding of the methodology, what are the good things and what good things are? You, you, you think it could, it could be done a bit better or what are add-ons, what are extensions of trials that you could do? So we did a good trial here, you know, Creche one, then crash two. and, and then what could be crash three, you know what could be the add on to that, to further our knowledge. Um Now, the other thing is, uh, the way that they could also phrase is you mentioned in the trial. Can you tell us more details? What do you think were the issues with the study? Is there anything else the investigators could have done? Do you think a study is relevant to current practice? Would you change your practice? That's a very key one. The, an the answer unless it's an absolute big winner like the crash two, something like that, uh which gets incorporated into a guideline. The answer is usually cautious. You're not going to just completely give up your practice now and completely uh do open or M IO just because one trial of the other system in the academic station do not go into that exam without having practiced the definition of every single statistical or methodological term. In fact, every single definition of sepsis of what the uh of the at LSS, what is the definition of anything that, that you could potentially ask, you know, what is hypoxia, believe it or not? They will ask something like that, you know what hypoxia is? Go on then explain what hypoxia is. So you need to have a very clear term uh phrase one or two sentences. Ideally, the shorter, the better that can ci summarize it, know the levels of evidence. OK. There's Oxford, there's this, there's that there's about four or five different ones and they always change. It doesn't matter. You just need to pick one that you're comfortable with. They're not gonna say, tell me specifically about the Oxford classification. They're gonna say what levels of evidence do you know? And you can pick one. So there are several levels of evidence, uh, classifications, the one that I'm most familiar with is the, and I'll talk about it. Give a balanced opinion. Please don't trash papers. Um, because you can, you can walk in and, um, the person in front of your examiner could be one of the authors which absolutely happened to me. And, um, is, uh, some, is, is somebody who's not a million miles away from the A S GBI, er, president. Uh, let's just say, er, and it, and she was on the paper, there's a paper I had from my, uh, from my academic station. It was a good paper anyway. Of course, there are shortcomings like any paper. Um, and there's things that could be improved but don't go in there and say this is a rubbish paper. Uh, even if the, if the examiner isn't one of the authors because no paper is at all. Very few people. Papers are absolutely rubbish. Now, they may incidentally give you a paper that's not very good. Just cos it's published in the B Js and it'll almost certainly be a B Js paper, which is another which leads me on to the point that you should skim through all the abstracts from the B GS journal er in the last few months before you go in, you're not gonna change your life over it. OK? But equally, it's not garbage. You're gonna have to have balance, you simplified language. Say if you don't know most of the marks, believe it or not, you can be gained by summarizing and having an understanding of methodology. Um So I've kept it, uh I hope not too long but um that's it for me and um more than happy to take any uh questions uh regarding uh what we've talked about. Thank you so much, Doctor Scary. Um, we'll probably keep questions at the end if we can and do a bit of Q and A, er, Doctor Shepherd. Are you happy to share your slides or do you want me to? Oh, you're muted. OK. I'll try and share them. Um, I've got to share the entire screen, don't I? Is that the way to do it? Yes. OK. Um I share my and then I'll get my presentation up. Um, can you see the contents yet? No, not yet. No. OK. There should be a present now but uh third from the left on the bottom of the med screen. OK. And then it says sha entire screen. OK. I'll share now, I think I've got, it should be able to see me. Uh I can see you but I can't see your screen for some reason. Ok, it says I'm sharing but let me see. Um any thoughts um when it comes up with the option to share entire screen, you need to click the window that comes up. Sometimes it doesn't let you do that or you don't manage to initially, have you been able to do that? I have done that. Well, I feel like I've done that but maybe it hasn't worked. Um And then does it allow you to share content? And then that's when your screen isn't sharing? Sure. Entire screen, entire screen. I've clicked on that. Um And then I clicked share but it won't come up. Uh In which case, it's may be easier, Jared if you share if you've got it there because you've got not there. No problems, no problems at all. Ok. How's that look? Perfect. Thank you. Um So my name is Joe Shepherd. I have literally just TD in um general and colorectal surgery. Um I'm also uh honorary clinical, a Center for Trauma Sciences and part of the A S GBI trauma and research committees. Um And I'm gonna do my talk slightly differently to my predecessors. Um And that was a brilliant talk. I caught, um I wish I had a um system of success of preparing my papers as beautifully as that for the, um, FRCS. Um Mine was scribbled on card XS um with uh loads of um, random underlining and highlighters and whatever else on it. But, but yes, very nice system. And so I'm actually just gonna take you to, to through a couple of cases loosely based on scenarios I had but also real life scenarios. Talk through what I wish maybe some of my answers may have been like how I was questioned where you could maybe bring in some research into those particular scenarios um and take it from there really. Um And we'll see how it goes. Um So next day, please. So, um this is the first case. Um You've got a 35 year old female, she's recently been investigated by a GP for iron deficiency anemia, weight loss change of bowel habit, positive fit test of 85. She's waiting to be seen in the colorectal clinic. She's now sent into your surgical assessment unit um by the GP as she's feeling dizzy and very symptomatic and her late stage B came back as 65 last few days. She's had loose stools and abdominal pain and the GP is quite concerned that she's got an underlying gi pathology, we can move on. So what would you do? So, this is very much starting off with your basic answer. I would start by performing an at assessment of the patient to ensure there was no hemodynamic compromise, no active source of bleeding that she had good IV access. Once I was satisfied that she was hemodynamically stable, I would take a full history and examine the patient specifically I would look to be sourcing the potential cause for anemia. I would want to know if there was any change in bowel habits. Pepsi, and your abdominal pain, weight loss, et cetera, et cetera. So that's kind of how you would start. I would take a full set of bloods, including a venous gas cot and grit and save. So that's kind of your first premise and then you get some more information. So her heart rate is, observations are as shown she's had intermittent loose stools for six months. Colicky abdominal pain, she's lost about a stone weight the last two weeks, she's been very symptomatic, very fatigued, having dizzy spells. She's already been on oral iron by the GP abdominal examination, unremarkable, pr examination, unremarkable. And those are the blood tests that you get back. You've been on next slide. So how would you manage this patient? This will be the next question. What are you gonna do? So, um in the first instance, you'd say, well, given that she's got a symptomatic anemia, she's tachycardic. She's got an HB of 65. I would admit her and I would consider starting a blood transfusion, which would be, would have been my answer. Um Whilst um an iron transfusion is preferred in patients with iron deficiency anemia is the first line of correction. Um My rationale for giving her a transfusion is that she's tachycardic and, and, and very symptomatic and the M BSG iron deficiency anemia guidelines in 2021 suggest that that is an appropriate alternative in this sort of setting. Um I can also refer to the nice guidelines on blood transfusion and a, a threshold of low, lower than 70 would be um appropriate for restrict uh a restrictive transfusion policy. Um I would then go on to investigate the cause of her anemia next slide. So, um after you into blood, her heart rate comes down to 65 her systolic is normal. Moving on. So what investigations you would do next? So your options. So you could do a CT with IV contrast, you could do a CT, a mesenteric angiogram, could do an O GD, could do a colonoscopy. Um You'd assume you'd have done some urinalysis as well as part of your workup potentially. Um What would you do? And the question here is there's not necessarily the right answer. So I would be saying, well, if my patient is completely stable and there's no other source of bleeding and we've corrected her anemia in my hospital, the local guidelines for investigation of iron deficiency anemia um in a fit positive patient would be an OGD and a colonoscopy. However, um in this setting, I arrange a colonoscopy and I'm concerned that there may be something going on in the abdomen. Um given that she's had weight loss, I would therefore request a CT abdomen um and possibly an OGD as an inpatient. And I think that this is some, again, it's open for debate, but I think you can refer to your local policy, your, your local hospital policy. What would you do in your general practice? Next slide, please? So then you get shown a CT scan, please. Would you describe the CT scan to us? And again, again, you'd start off something like, well, this is a single slice CT scan um possibly in the porto venous phase. Although I'd like to see more images to clarify this um from the single slice. Um For example, I can see no obvious abnormality here and they will move you on from that and it's worth clarifying that. You know, this is a single slice CT. So you can only give the information that's presented to you at the time. Um The next slide. So she has a CT, it's normal, she has an OGD, it's normal. Her urinalysis is normal. She has a couple of units of blood. She feels much better. You arrange her to have an iron transfusion as per um uh uh I if she's seen any new guidelines, um her pain settles when you send her home. So would you routinely do an OGD and a colonoscopy in a 35 year old with iron deficiency anemia? This is one of the questions that I was asked. Um And I would say as per B SG guidelines, I would not routinely perform an O GD and colonoscopy in a 35 year old with iron deficiency anemia. Um This is because gi t malignancy is um not common. It is less common in this age group compared to other causes of anemia, which should be investigated first. However, given this patient has a positive fit test, change of bowel habit and weight loss symptoms, then an O GD and colonoscopy in my practice would be um justified in this case. And I would refer to relevant um guidelines to support this at next. Um So is fit testing specific for the colon or the whole GI T? This is another question that um came up as, as part of all my scenarios. Um And uh so again, how to answer this question? Well, fit Test is a measure of antibodies uh to measure the presence of um human hemoglobin in the stool. Um We know it's got an established role in investigation of colorectal malignancies and there is B SG and ACP joint publications um guidelines on the use of Fit in symptomatic patients who are suspect of colorectal cancer. However, to my knowledge, there is not much research as uh for using Fit Test as stratifying patients um for bleeding from other sources of the gut uh in terms of further investigation. Um although um from a a logical basis, there is no reason why you couldn't get a positive test from bleeding in the small bowel or the stomach next slide. So she goes home, she has AC DX screen which is negative. She has a colonoscopy that's negative and then she comes back to your clinic. She's just been booked back into your clinic. Next slide, what investigation are you gonna do next? So, next slide. So you arrange for her to have a capsule endoscopy and it shows a polyp somewhere in the proximal ilium. Can't exactly say where, but it looks like it's possibly in the proximal ilium. What are your differentials? Would you biopsy this lesion? How would you biopsy that lesion? So, um again, I um you think about how you would answer this and sometimes you might feel like you're on the spot. Um So obviously you want to think about adenocarcinoma, pro possibly a gist, maybe angiodysplasia, although they've seen a polyp. So may be less likely to be that. And I would be concerned that this patient with the history and her weight loss that this could be something sinister. And yes, I would like to biopsy it um next slide. So actually, um this patient that I've got in mind had an extended colonoscopy with a deep i intubation. They couldn't see the um polyp. Uh So they arranged for a small bowel enteroscopy. Um and you connect slightly. So two weeks later, you get a call from endoscopy when on call and she's got active bleeding from the proximal ilium, but they couldn't see the lesion, they tattooed, proximal distal to the bleeding point. Um What do you do next? Next slide. So what would you do? Um So my answer in this scenario would be I would admit the patient um she's he's actively bleeding. Um And I would consider a diagnostic laparoscopy and small bowel resection as it should have been tattooed in two places. Um So we should be able to resect the bowel next slide and final question, consent to your patient for the operation. So this is sort of how the flow of the might run. OK. I'm not gonna consent that you guys can practice that in Europe. So just to summarize on this one, there's a whole amount of evidence on iron deficiency anemia, fit testing, blood transfusion, the nice guidance on cancer recognition and referral and it's just worth having a little bit of an idea of some of them. We've spoken a lot about papers and, and briefly touched on guidelines. These are a really good source and if you are a colorectal trainee, you will definitely get questions on fit testing and colorectal cancer two week great referrals. So just make sure you're familiar with that. And actually the ACP GBI BSG one from 22 is really comprehensive because it summarizes a lot of the studies and trials because if you start looking at individual fit studies and trials, your mind will start to become slightly mushroom. There are a couple that I won't go into now that are um ones to think about there a nice fit trial that probably should be aware of recently and there was a couple of other papers, but they're all summarized in that specific guideline. So it's worth having a look at that. Um know your guidelines on iron deficiency anemia, they can be integrated into an emergency scenario or it may just be within, I think within your um classic colorectal um station. So, um but I think, you know, from a standard point of view, this is what I would refer to in the first instance for this kind of question. Um And again, so this is sort of how you might weave in or how I might have thought, I don't know if I did it that well, actually in the exam, but how I would have, you know, thoughts that you might weave in some of your research or some of the guidelines into your questions as per this, I would do this or my thinking of this or it's not unreasonable to do this because this guideline says this, you know, and if you're choosing between like an iron transfusion and a and a blood transfusion and a stable patient, as long as you have some sort of justification to why you're doing it. And you're aware that there is some guidelines, you know, you're not going to be um held back. And, and the other thing um to really echo is that if you really are getting questioned about research, you based your station essentially as far as passing is concerned. So, you know, um if you are getting direct questions, ok. So moving on next study. So you're working in an MTC? Um, it's got full trauma capabilities. Um You receive a call from the ED consultant that there's been a blunt trauma patient in recess. Uh They've in a motor vehicle collision. They have um been trauma team has been assembled. They've done a primary survey and you've been told, well, that's 90% heart rate's 90 blood pressure's 100 and 5/700. He's got an open tip fracture, but his neovascular state is intact and he's had a CT scan next. So you get a shown CT scan again. So this is an axial slice looks like it's in the arterial phase. It's showing fluid in the left um uh pleural cavity um and which would be consistent with the hemothorax. And I think I can see AAA rib fracture on there which looks severely displaced next slide. Ok. And this is another slice from that same patient. What can you see here again? It's a single slice, uh axial plane um arterial phase. And now it looks like I can see a contrast blush in the spleen there, which would be consistent with an active splenic injury. Next slide. So you get your radiologist report multiple left sided fractures, flail segment 5 to 7, left moderate hemothorax, uh grade four splint injury with a contrast flush next slide. So how would you prioritize your treatment for this patient? Um Again, they've sort of asked quite a specific question here. How would you prioritize your treatment for this patient? So, again, um as um Alan said, I would treat the patient according to at principles, given that the patient has 90% oxygen saturations with evidence of a hemothorax on the CT. Um I would ensure the patient is on oxygen has good IV access and I would prioritize insertion of a chest drain at this point. So this is your B point really. Um And that's really what they're kind of looking for. Have you out of all this information that we've presented to you. Um Have you picked up what the key thing are you sticking to your basic principles? And again, it's a TS principles. So it's not like you're having to wrap your brains for some in depth. Um you know, paper on this issue. It's, it's, you know, the basic stuff. Um Subsequently, I would reassess the patient. I am concerned that he is active bleeding from his spleen. Um And this would be my next priority. I would ensure the team are aware of the findings that blood has been taken. A group can say clotting, um full blood count and venous gas have been taken. I would ensure we have a rapid infuser present and that the blood bank were aware that we may need to activate the major home protocol depending on the patient's vital signs. Um I would contact IR or theaters um and I would ensure the patient had T Xa. Um um particularly as you've got very good evidence such as the crash two trial. And more recently, the patch trial that it may reduce mortality in this patient and you could leave it at that. They may as, as I said, prompt you further to say, uh you know, that's interesting, you've had that data uh that those trials and what, what are the pros and cons of them or they may move you on on this scenario. So moving up. So after sessions of chest drain, the saturations improve, 96% pulse remains 95 blood pressure's 100/70. His venous gas comes back. His base X is minus four, ph is 7.3. He's on a TX a infusion cos he's already had a grumpy hospital. What would you do next next slide, please? So this is something that I started to dig myself home. But again, as long as you can back up your answers and you can give a sensible answer and then then really it, it ends up being a debate. So um uh what I start saying, I am concerned that this patient has evidence about bleeding in this scan. He is currently maintaining his systolic BP of around 100. Although his base test shows that he is, has a degree of shock minus four, but it's not major, major shock, it's not more than minus six and having referred to the um world's general surgery guidelines and splenic injury. I would like to think that IR may be a sensible option for him because it could avoid an invasive laparotomy. He's currently just about um, hemodynamically holding his own. But I would be mindful of the fact that if there was a clinical deterioration, I would be taking the patient for an emergency laparotomy next slide. So, ok, you call the radiologist, it's gonna take 30 minutes to set up the IR suite. And in that time, the ed nurse repeats the observations. His BP has plummeted. His heart rate is tachycardic, feels clammy and pale. What would you do next next slide, please? So, um your patient is now unstable. Um I would initiate the major hemorrhage protocol and provide 1 to 1 resuscitation according to our local major hemorrhage protocol. If the scholastic assays were available, I would use these to guide subsequent resuscitation based on our local protocol. Um I would arrange for the patient to be transferred to theaters for an emergency laparotomy and you can feed on to some of the evidence for that. Um or they may ask you a little bit more explicitly. So, next slide. So what evidence are you aware of that would guide your major hemorrhage resuscitation? So things you can mention definitely your local major hemorrhage protocol. They all want to hear that you know what your local protocol is. That's the first thing the British Society of Hematology have guidelines on major hemorrhage. And that will be what a lot of your major hemorrhage protocol has been drawn from. You can talk about your blood products that I have mentioned the proper pamper combat that two trials. Um Again, you could summarize that and say there have been a number of multicentre trials that controlled trials, there have been some conflicting results as to the precise ratios that should be and whether there's a mortality benefit. But generally, the observational studies have shown an overall benefit to moving towards 1 to 1, for example. So, so you could do that and um um using the scholastic assays may be protocol in some hospitals. Um although exactly how best to utilize them is still under the current research um as per the IAC trial. So you could bring it next paragraph. Uh It like, sorry. So you take your patient to theater then other things to think of what is damage control surgery? What incision are you going to make? How would you remove the spleen? What are the complications of splenectomy? And um you might find that these are very quick fire questions that you get asked. Um If you can think about bringing in um uh some of the what is damage control surgery that you could bring in some of the paper there that um J had already mentioned if you wanted to, but really what they want is a clear definition. So, and this is the stuff that you want to rattle off quite quickly. Um And so I had a similar question to this, you know, how would you prepare your patient for theater? So I said, well, I nipple her knees, prep, drape. I would make sure we've done our food checklist and I would make my incision from the zip then to the pubic synthesis, full trauma laparotomy. And I got met with um um a full laparotomy to remove a spleen. You really need to do a whole incision to remove just a spleen. What's wrong with an upper midline, that poor patient. So, you know, be prepared to back your answer up. Well, in a damage control setting with an unstable patient. Uh you know, the, the, the the considered practice for this approach is this. But yes, I do understand that if you've got an isolated splenic injury, you may not be as invasive. So you can, you know, if you're being challenged like that, you know, as long as you can justify your answer, you'll be OK. The next um slide. So your patient is now on a high dependency unit, POSTOP extubated awake, um saturating 93% on 30% oxygen, very poor inspiratory effort. Chest X ray shows that hemothorax is a lot better got very displaced multiple rib fractures on the left hand side. That's perfect. So what is the significance of this? How are you going to manage this patient? So again, my concern is that this patient um may be at risk of developing hospital acquired pneumonia because of poor inspiratory effort. I would refer to our local protocol for the fra rib fracture management, um which may be different for an MTC versus a trauma unit. I would ensure the patient multimodal analgesia, they had saline nerves, chest physio And then I would want to do have some sort of assessment to see whether they may be suitable for a more invasive um analgesia such as a nerve block or an epidural. And I may um calculate a stumble score which would help me to stratify the patients. And there is now good evidence that the stumble score helps to stratify patients according to their likelihood to need more invasive um uh um analgesia methods. Um I would also consider whether the patient would be suitable for rib fracture fixation. Um And again, the um local trauma networks may have guidance for referral criteria such as multiple severely displaced fractures, such as requirement for invasive ventilation, such as bilateral fractures. Um But currently, there is a randomized controlled trial called the ORO trial, which is recruiting patients that may be able to give us answers as to who may be the best patient next slide. So again, um don't need to bring a huge amount of evidence into every answer that you give. But there are some that you could just naturally talk about as you answer your questions. Should the opportunity allow? I wouldn't fixate on it too much. But if you happen to be answering a question and you can think of the guideline that you're, that's informing your decision or the trial or the study, then I think it just gives you that extra confidence and that's sleep for. I think that's it really from my side. Mhm Brilliant. Uh Thank you much doctor. She um and all speakers. So I just wonder whether we can um uh field some of these questions. So I think Ria, are you gonna summarize some of the questions that have come in? Yes, they've actually been um answered Alan throughout. Um And the only question I think that was that perhaps you guys could give some input on is the last one by Kelly if you'd like to comment. So, Kelly says fantastic top so many helpful tips. Uh How do you decide which guidelines to go by? Nice B GS World Society of Emergency Surgery. What's the best approach if you know the evidence but forgot the name of the paper or study? Uh I'm gonna leave that to our guests who have written the Fr CS um Miss Shepherd and Mr Sky. Yeah, thank you. So the, the thing to remember is most of the guidelines are gonna be they're gonna say very similar things and the reason why they say s very similar things is because they're based on the same evidence. Um So you're not gonna, it'll be very difficult. Uh It'll be very unusual on the same topic to have the British Surgical A British Society of Gastroenterology guidelines, for example, in colorectal cancer, to say something completely the opposite to what nice or to what the American Society would say, or the European Society would say regarding fit. It would be very unusual because uh when there is a disagreement, it's usually when the evidence isn't so good either way and there is kind of cautious interpretation. So the guidelines are unlikely to say anything vastly different. Therefore, it doesn't really matter which one you use being in the UK, it's more likely we're gonna use more UK based ones. But honestly, if you compare um guidelines in terms of uh the content, there's actually next to no difference between them. It's just how well they're written and how well they're laid out and explained. So the actual meat, the, you know, the substance, the evidence is, is pretty much the same. So it doesn't really matter on, on a second note, I think, um if you've forgotten the evidence, sorry, I forgotten the name of the trial. So the evidence is more important. The fact that you're aware there is evidence that says give tranexamic acid and you just can't remember crash two. Although that was quite easy because it's a trauma one they called it crash two. Um, it doesn't really matter, you're not gonna get penalized, you're not going to, you will still get that mark because look, I'm really sorry, but the name of the trial has escaped me. But I know that there is in a randomized trial, there's evidence to demonstrate that 1 g of tranexamic acid is associated given early with a better survival outcome. That alone would be more than enough. And on, on the day you're nervous, you're human. They know that. Um so they're not going to, you know, that's not gonna be pass or fail. In fact, none of these are gonna be partial fails. But um they're not gonna penalize you because you don't remember her name. So don't worry too much about the name of trials if you can remember them. Great and they can just name drop them. I mean, ideally you want to mention this as Joan very nicely demonstrated in her talk. You uh you know, alongside it, she said she justified every reason she gave it reason and justification why she's doing it even when she's going against the guidelines, technically. And that's important. So if you can say I would do this because um it's my practice and I think sensible and it's what I've been trained to do. But also there's a guideline with evidence behind it that says I should do that if you can do that without them having to ask you what's the evidence for? What you're doing, then you're already kind of smoothly flying. Ok. Um Yes, I haven't got a lot more to add. I would just say, um I, if you want us a little bit more meet to the guidelines with the evidence. In usually society ones are a little bit better from my experience with B GS or the ACP guidelines will summarize the evidence a lot more succinctly and easy to read. I find that nice tends to give you this is what you should do. But then it, there's nothing more beyond that. So I find quite difficult to use it as a like it's nice to know that they're existing. But actually, I found the society guidelines just a little bit more informative when you're reading through it equally, there can be quite heavy documents sometimes. So maybe just read the bits that you think are relevant, you know, pick and choose a little bit. But I don't think it matters in an exam where, which guideline you're gonna use as long as you mention one of them. Mm uh Great. I mean, I have one question for both Miss Shepherd and Mr Ascari. So if you were to uh study again and write this again, uh what would you change with your strategy? And um not just the Fr CS as a whole, but more more your to the folks of this talking or the research aspect of it. Um Would you put more or less emphasis on certain things. I'm, I'm just coming out in a cold shiver just to be the thought of actually having to revise again. Um, no, look, the, the exam and you won't be those of you who haven't done the exam yet will not believe it because I, we didn't, and I don't know if Joanna did, um, when they say actually the amount of knowledge that you need to know isn't that v it's quite broad and there is. And in your self specialty, obviously, you expected to know to be a subspecialist, but it really isn't, you know, you must know every single, it's not, that's not what it's about. So getting involved, one thing I wouldn't do and that's what uh in, in some of the answers in the Q and A, I've been trying to, um emphasize is I wouldn't go and say, right, I've got 60 trials for colorectal, over 50 for upper gi or 45. Well, probably 100 and 45 for breasts. I had to learn them all. I wouldn't do that. What I would do is I would put it exactly how Joanna did it and she demonstrated that beautifully. She gave an answer, a clinical answer and then backed it up with reasoning. What's my reasoning for doing this? Well, my reasoning is in, in my local protocol, I efficiency use this and all the evidence suggests that I should give this because it associated with a better outcome from a good quality study. So I'll definitely do more of that, that kind of integrating my answers, plugging it in. I'm gonna do this and it always has to be, I, by the way, not, we could do this, but it has to be, I'm going in this scenario, I would do this because, and you've gotta give you a reasoning and not, and, and sometimes if there is no evidence, either way, that's how I've been trained to do and safe in my hands is a perfectly reasonable answer. So I would do more justification of my answers. And I would also plug in the research only as and when it's appropriate to back up that to support my position or to say like I as II think presented in the slide, say, look, I know the mirror trial or time trial says, meaningly invasive is great. You get less chest infections, but I have no idea how to do the thoracoscopy. Therefore, I'm gonna do open and open because that's safest and that's what my unit does. That's also perfectly acceptable. So just the justification part, I would do more in the terms of the research of the academic station. Again, I wouldn't give, I would practice, please practice your answers. Um It's one thing knowing it and I'm sure John will backing up on this. But you think, you know, all in your head and you do. But as soon as somebody asks, you give me a definition of sepsis. You're like, uh, and that was the, this was the appetizer. That was the opening sentence, you know. And so just having a practiced, um, kind of answer is that's in your own words, is very important. I don't know if Joanna, you want to add any, add any more to that. Yeah, I mean, I think, um, having somebody you can practice with who you feel safe with as well To an extent, you probably want a mixture of people, people who are gonna put you on the spot a bit and people who are, who you feel safe with. But like, I mean, with one of my friends that I practice with, she'd be like, OK, so what is the definition of sepsis? And I stumble things and she'll be like no jo word for word repeat after me, this is the definition of sepsis. So that by the time you come to set it, you've had somebody and it's very difficult to do that by yourself. You can sit there and try and pat it out in the mirror while you're walking around. I mean, I did do quite a lot of that because sometimes you are on your own and there's no one else. So I would just walk around my room and try and vocalize answers like a random person. But I think having someone to practice with helped me, you may not be in that privileged position where, you know, you've got someone doing at the same time exam as you. But if you can find someone, we did a couple of group sessions online and with it being online, that's quite easy to do as well. Because also through doing it with people, you'll find, you'll start to find the common scenarios between you and you'll start to practice the common scenarios. And then by the time you've done, go get to the exam, uh you practice, I think one thing that I wish I probably didn't get quite so caught up on is that you get this Fr CS Viber book and there's so many random scenarios. Oh my goodness. I, the last time I like learned about some random transplant, immunosuppression, whatever drug. And again, yes, there are theoretical things that random scenarios can come up in your exam. That's true. But actually the vast majority of my, my exam was the bog standard stuff that you saw day to day. So I wish I could go back and tell myself not to get so worked up about the, the what? Weird and wonderful that theoretically could come up, but generally doesn't accept the odd exception. So I'll just briefly out. So that's absolutely brilliant point actually because I mean, there's different books out there. I've got instrument by the way. But the cracking a book you, you open your chapter and, and I thought, oh my God, there's like 1000 breast trials. And I know remember each of those chapters is written for that subspecialist. OK. So you do not need to know all of those things. Of course, you need to know how to examine, you know, somebody comes in with a breast lump or whatever in your general surgical scenario. Even as a colorectal upper gi or transplant trainee, you'll, you'll, you may get that. Uh and, and you'll have to, you know, deal with that. That's fine. But remember each chapter is written specifically called our specialty. So you don't need to know that in depth. The only exceptions are critical care, academic station, general, general surgery, emergency surgery, you know, those kind of things that are core to everyone. You gotta know those, you gotta treat them like your own subspecialty, like it's a subspecialty thing. But outside of that, you really don't need to get bogged down in it with regards to doing it in teams. There's absolutely no way you can do it otherwise you have got to do it with people, especially the part B. Uh In fact, absolutely. The part B, all I would say is as well as at different levels of personality and people you're comfortable with and different kind of uh techniques and things also try and revise in diff with people in different sort of specialties to you, especially for the ones that are the core ones are critical care, general surgery, eeg S and trauma, do those with people. So if you're an upper, if you're a correct trainer, you get an upper gi and a breast training, uh, you know, and so on and don't make your groups too big. Um, CO2 people. Yeah, you just find three even better. Four, probably lax 567 and eight any more than that. It was very difficult and to kind of get a useful, uh, kind of any kind of real good practice out of. And also I would say, is pace yourself and make sure that you don't take anything personally because you all say silly things we all have and you will say things that you'll, you'll slip over words and so on. Just keep going. Uh Great. Um For the final question perhaps is Miss Payton asking um good resources, websites, highlighting key papers and evidence. What journal papers would you recommend practicing critical appraisal? Um and also ashamed this book for the S GBI Academy. We've got lots of good uh key papers and private practice sessions. So get in touch. I think probably we should put something together. Uh Alan, you mentioned it earlier. Um We should put something together maybe for the website, the A STB Morning Academy. Absolutely. I think II don't want to commit. You got, you got lots of work to do as well. I don't want to commit you to completely to speak on your behalf, but I think it would be a good idea if we as well as a list of key landmark studies, you know, the really big ones um uh in all the subspecialties including breast and so on Z 11 trial, those kind of things, we can just put a list together with some links as to where they can find the actual papers. And also we can put, put in some links on good um uh kind of websites and resources for, for how to do critical appraisal, how to look at trials. And also there are some reasonable videos out there as well on youtube as well. So some people have already, I mean, you, you, you anybody who has explains any kind of study in more than five minutes go in here because you'll be there forever. You want nice concise snappy. This is the key, take home message two arms and did this. So there's lots of resources out there. But yeah, we can put it together and send it out and put it on the website. That would be, that would be a good resource. Yep. And hopefully that answers uh some Singh's question, another webinar for Fr CS bre, there's nothing planned yet. Um Miss Singh. But um if we put some papers together for the website, that would be a start any other for anybody, I think I've just posted the CSP checklist. You need to know all of this in too much detail and especially you don't need to do it for every single type of study. But getting a broad overview, especially of things like randomized controlled trials because those are quite common and you could get that. And for cohort studies, I think at least do the cash checklist with those type two other studies because most of the things you need will cross over to what type of study is this. You know, what was the aims? Those things will always be very, very similar. So just do a couple of the c checklist and that should help you get started and don't get too bogged down as well. Because like, for example, for assessing a randomized control, there's, there's, there's a dozen ones for each one. You do not, please do not feel that you need to learn off by heart how to do each one you won. There's a Strobe checklist and there's three other counterparts by different organizations for an observational study. Um you know, the Prisma and these kind of terms you kind of need to know, but just pick one if they ask you, do they want to ask you, tell me about the gad scoring. That question will not come up. What they will say is even if it's an academic station, they'll say, what levels of evidence do you know? Or how do you know of any means to any validated tools to objectively assess a randomized trial and say, well, there are several ones I'm most familiar with gat for example, or this or Strobe or whatever and that's, that's, that's good enough. So stick to one and just be aware, there's more than one. If you're gonna use ca ca you're gonna use, just stick to one and that's it. Do not spend hours and days fretting about or knowing every single assessment tool. It is a waste of time, I think. Um what one of my um friends did was um, ask me to look at a paper, send it to her with like 15 minutes to prep and then ask questions. Um And that was uh like, you know, so if you, if you can find someone who maybe has done a little bit of research as well, who's prepared to do a paper. They, they're familiar with that, you don't know, then they can send that to you. And also even just in the vi of books, they give you a framework for how you, all that stuff is in there, like the, the different guidelines like in the little blurb there. And if you just write out like a few things, I think I just would write out introduction methods, plus and minus. Introduction plus and minus, like result, you know, uh conclusion, plus and minus. And the overall summary of the paper. If you've managed to get through that in the first few minutes with a few questions added on which one of your friends can throw at you, then that's, that's exactly what I did. I even now really when I'm President, I just get, get a, a four piece of paper and just put lying down in the middle of two columns or three columns rather. And I just put, you know, abstract introduction methods, um results, discussion, whatever. And I just put a plus box, the top column on the left and then right is the negative one or thing that could be improved. You're not gonna say negative one, you're gonna say think that could be improved. And then literally a couple of bullet points about each of those sections under plus each under minus and so on before you know it, after five minutes, you've got praise. That's it. Keep it simple. There's no kind of, you know, writing out in that 20 minutes or in that time, you've got to read the paper, do not spend there, you know, writing out entire paragraph, waste of time. You just want bullet points. So you go in there with a sheet of paper. So you've got a rough idea of what it is. You practice how you're gonna deliver it and you've got your plus column, your minus column go. Um Often the last paragraph of the introduction will give you your research question and then the first paragraph of your discussion will give you the main finding or the summary of the finding. And so if you start with those two bits, at least you can say, well, this paper was about this and this was its main finding and then you can go into, you know, and yeah, and, and, and the penultimate one, they'll give you some, you know, just before the end of the discussion, the penultimate usually the limitations, most good papers right there. So they've done a half a job for you. They've already said what the limitations are just put those in. Um, and then a add a couple of your own, you're done, you, you, you, you make it sound easy, but of course, you two have excelled and succeeded. So I'm honestly, isn't um It honestly do. That's what, you know, I mean, there was a really good question that was asked, you know, what would you do going back in time? Uh If you could ask, you know, if you could talk to yourself, this is exactly what I tell myself because you, you go in there, you know, leading up to it because it being built up because it, because it's such an important milestone in our careers for all of us with respect of our specialty. And there's so many other things going on in your life at that time. You know, you worry about training possible fellowships, maybe family and so on. It's such a key moment that it gets built up into a real super hype, which actually once if you've done the exam, you'll find it. It really wasn't. Um I'm not saying good, by the way, I'm not saying just relax and chill and don't do any work for it. No, but equally, you know, getting into a front thinking they're gonna, you know, this, they're gonna ask AOS questions. That's not what it's about. It really is more about practice, the more you get like, just literally pull out five or six abstracts from the B Js and they're gonna give you something usually very general, like very, very general surgical or even something that hasn't even got. It can be a health cost analysis about, you know, chlorhexidine or something. It could be something very, very general. And if you practice just getting that, you know, a piece of paper like that as Joanna just said, put a plus and minus and just doing four or five of them the first couple of times you do, it is gonna be brutally painful by the fifth or sixth. You'll, you'll, you'll just get a flow of it. It'll be a lot easier. It's just practice honestly. Well, it's been amazing, uh really appreciative of um Mister Shepherd and Mr Sky to give us your um precious time and your wisdom as well, having gone through all this. So I hope the listeners got something out of it and thank you very much, Mister Aa for telling us how to do uh a brilliant uh critical appraisal and yeah. Well, hope, I think this has been recorded and we'll definitely get something on the website as well. So, um please fill out feedback. It's in the chat there. We would really appreciate uh your feedback, letting us know how we could do this better. What would you like in the future? Um And what you like about it as well. So with that, I think we'll say thanks and get the bed.