Home
This site is intended for healthcare professionals
Advertisement

Research Skills Medical Student Journal Club - OCTOBER

Share
Advertisement
Advertisement
 
 
 

Summary

This on-demand teaching session gives medical professionals an in-depth understanding of the hierarchy of evidence, with a focus on the gold standards of meta analysis, systematic reviews, and randomized controlled trials. It explains real-world applications in medicine and the impact on clinical guidelines, along with methods to review and analyze scientific papers. The session even involves an interactive discussion about a paper on the integration of pharmacists in trauma response teams to improve pain relief delivery. Analyzing this paper using the CASP checklist, the instructor explains how such studies can spark department-wide discussions, elicit fresh research ideas, and potentially affect clinical practices. It's a must-attend session for those seeking to learn more about evidence-based medicine, study analysis, and the dynamic role of research within clinical practice.

Generated by MedBot

Description

Join Our Research Skills Medical Student Journal Club

Looking to sharpen your critical appraisal skills in a fun and supportive space? Our monthly journal club is the perfect place for you—no research experience required!

Theme of the Month: Randomized Controlled Trials

Session Plan:

  • 20-minute presentation by an academic foundation doctor
  • Paper presentation by tutor
  • Group discussion of the paper

This month’s paper:

Pharmacists in Trauma: A Randomized Controlled Trial of Emergency Medicine Pharmacists in Trauma Response Teams

ALL students welcome! Register in advance using the link in our bio!

linktr.ee/codeblueteaching

Learning objectives

  1. Understand and gain knowledge about the hierarchy of evidence, including meta analysis, systematic reviews and randomized control trials.
  2. Develop and enhance skills in analyzing medical research papers, with a focus on understanding how to effectively use the Critical Appraisal Skills Programme (CASP) checklist to determine the validity, methodology, results and impact of a study.
  3. Understand the basic structure and process of a Randomized Control Trial (RCT), including the process of assigning participants to different groups, and the concept of placebo vs. new treatment and standard of care vs. new treatment.
  4. Learn how to conduct a paper presentation for a medical journal club, focusing on how to summarize key points, stimulate discussion, and highlight relevant findings in the context of medical practice.
  5. Apply these analytical and presentation skills by dissecting, discussing and presenting the findings from a particular randomized controlled trial based on pharmacists' role in trauma response teams.
Generated by MedBot

Similar communities

View all

Similar events and on demand videos

Advertisement
 
 
 
                
                

Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

And see kind of if we can have discussions about that. Um And what you all think about the paper. So hopefully you've had a chance to read it. Um So does anyone know anything about the hierarchy of evidence? Um You can either kind of put in the chart or if you want to unmute and talk to me? So someone's part is the MET is a meta analysis at the top. Any any other comments that was fine. So it's not quite at the top, but it basically is. Um so this is the hierarchy of evidence. It basically goes from kind of um I wouldn't say poorest but um kind of the most basic um research analysis is all the way up to um the best that you can do and things that then go on to affect clinical practice and affect guidelines within medicine. Um So, meta analysis and systematic reviews are kind of gold standard um randomized controlled trials, which is what we're gonna talk about is gold standard for kind of a single um research question. And then you've got things like cohort studies and case control studies which are a lot fewer in numbers of participants, case reports and case series can be about one or two patients. Um And then you go all the way back down to kind of lab studies and starting off kind of right from the beginning. Um So a randomized controlled trial about just over half of you said that you feel like, you know what one is, does anyone want to kind of explain what, how they would tell a layperson what a randomized controlled trial is or involves? I promise I don't bite any takers. It's OK. Oh So um randomly assigning participants into a call control group group and a study group. Yeah, basically. So um it's a type of experimental design and like Mira, I hope that's how you say. It said um you basically assign participants of people usually randomly to one group or another. So it's a study or an experimental group and a control group. Um There's kind of two ways that this could be done so you can have a placebo versus a new treatment. So this is one um for example, you'd give her a sugar pill um versus an actual pill. And we're trying to see um whether um the new treatment is better than the placebo, you can do standard of care versus a new treatment. So, um this is quite often done in cancer research when we know that something works and works quite well. But we think that something might work a bit better So we randomly assign patients to the standard of care or the new treatment. So we know that they're receiving kind of good, adequate care either way. But we're hoping that one cohort does do a little bit better and then we can go on to change practice um with the placebo versus the new treatment. That's usually in cases where we don't have a current standard of treatment for something. So that can also be, um, quite relevant in cancer research. If we've got a cancer that we don't currently have a treatment for, um, then it would be that the standard of care would be that we can't do anything at present versus this new treatment that we're hoping can kind of radicalize that area of medicine and a randomized controlled trial produces the highest level of evidence that can go, go on to change practice. Um And this feeds in very well to kind of clinical guidelines. Um NHS England, nice, that sort of thing. So, um, there's a lot of methods for analyzing papers including randomized controlled trials, but one of the, um, most well known and the best ones out there is the casp checklist. Um, so casp do CASP do checklists for all types of studies. Um So they do a specific one for randomized controlled trials and basically, you look at four different things. So is the study designed valid for a randomized controlled trial? Um, so are they looking at a placebo versus standard of care or new, new drug or whatever, versus standard of care? Um Was the methodology um ok. Was it, did they explain what they were doing? Did it make sense? Does it sound as though you can reproduce this somewhere else? What were the results? Were they significant statistically or not? And were they clinically significant if they weren't statistically significant? And will the results actually help, like, have you done a study? Um And it's actually going to impact practice? Um or is it something that not a really kind of rare niche disease only affects maybe a handful of people across the world? It's probably not gonna help in that many instances. Um So we wanna know, is it actually gonna help locally and kind of, you know, across multiple sectors? And then if you're then gonna present a, a journal club which hopefully you will get a chance to do um as a medical student, um You would have analyzed your paper using CASP or a similar resource and then you'd present the salient points of the paper to the audience. So usually at a journal club, I'm not sure if anyone's been to one. Everyone will have read the paper in advanced and then you as the presenter will put the salient points down into a slide show or whatever form of presentation you prefer, present it to the room and it kind of um sparks discussion amongst colleagues. Um It can then bring about new, um, research ideas within departments. Um, they might think of audits that they can do to see if they're kind of doing as they should be doing within a certain area of medicine or surgery. Um, and that usually happens on a weekly basis in a lot of medical and surgical departments. Um, so I thought it would be quite good if I went on and presented, um, the paper that we shared. Um so that you could see how I would present at a journal club. Um this way as well, if you've not had a chance to read, um the article, this gives you a bit of a breakdown of what exactly um kind of the article went through and then we can have a discussion about it at the end to see whether you think it's a good paper, whether it's a good randomized control trial, um whether you think it's gonna impact practice, um what you think the limitations are and how you think it's, it can kind of be improved going forwards. Um So does anyone have any questions before I move on about anything that I've mentioned? I've had a no. So that's hopefully that you've all understanding it. I hope I'm not teaching you to um suck eggs too much. Um So the background to this, so this paper sorry was um the pharmacists in trauma. So it was a randomized controlled trial um of emergency medicine pharmacists in trauma response teams. So, um in the background kind of section, I always put a background section when I'm presenting at journal clubs, um just kind of to lay down what we already know, what are the basics that the papers telling us. Um, kind of give you an idea of, of what the paper is going to go on to discuss, especially if it's an area of medicine or surgery that you're not quite um in tune to. So we know that in the setting of trauma medicine appropriate and timely pain relief is important um for patient wellbeing, but it is often delayed, especially in the emergency department. And this could be due to a number of reasons. Some of the ones included in this paper were insufficient staffing, overcrowding. Um and the perception that pain is a minor priority in trauma patients, we know that the prompt relief of pain has significant benefits such as reduced stress response and reducing the length of stay for patients including admissions to ICU and reducing the development of chronic pain that then can become then can lead to chronic issues in the future. And historically, pharmacists are not part of the trauma response team, but there are is there is increasing evidence um that the involvement of pharmacists in these responses can lead to improved patient outcomes. So therefore, this trial was carried out to assess the effects of integrating pharmacists into a trauma response team in order to improve the delivery of pain relief, um, management and, and medication management. So then I'll always go on to discuss the methods, break them down. Papers are quite wordy. Um So this kind of breaks down the important points from the less important points. So this was an unblinded randomized controlled trial. It looked at early emergency department, pharmacy involvement in trauma call outs versus standard of care, which was not involving pharmacy. It was done at one major referral hospital in Victoria in Australia and patients were randomized when the pharmacists were available to attend. So they selected from an envelope in the Ed Department. Ed pharmacists were then able to facilitate rapid pain relief, decision making and prescribe it. So they were all prescribing pharmacists. Um And the primary outcome that this paper was looking at was the proportion of patients who received analgesia or pain relief within 30 minutes of arrival. And they classified arrival time as the time the patient was registered within the department. So there was, there was inclusion criteria um and quite a bit of it. So I've not documented that down, but the specific exclusion criteria was that patients couldn't have been transferred from another hospital. So any patients that were transferred from uh an alternate hospital in Victoria, for example, um weren't included and trauma which occurred more than six hours prior to arrival were also not included. And patients who were receiving continuous infusion of pain relief were not included either So our patients needed to not be on an infusion of pain relief when they arrived. So the results um which as salient to the primary outcome of this were that 100 and 19 patients were originally randomized, only 82 of them were actually analyzed and it took place from the 15th of July 21 to the 31st of January 22. So as I said, the primary outcome was the first dose of analgesia admitted within 30 minutes of arrival to the department. So this paper, well, this study found that 64% in the control arm had the pain relief within 30 minutes, but in the intervention arm, so the arm with the pharmacists involvement, 84% had the analgesia administered within 30 minutes. And this was statistically significant because the p value was less than naught point, naught five and the confidence interval didn't cross one. So it landed on one. So from 1 to 1.71 but it didn't cross one. So we know that this is statistically significant for this paper. Further results um just out of interest looked at the medium time of giving this analgesia. So in the control arm, the medium time was 30 it was 28 minutes um which is less than 30 minutes, which is what we wanted. But in the intervention arm, it was 20 minutes. So again, ap value of naught point, naught 25 shows that there is a statistical significance in this difference. So then I would always go on to discussions and conclusions. Sometimes I split these up into conclusions and then have a slide of discussions. If the papers kind of particularly um resonant to who I'm presenting it to discussions can go on for a while. Um But in this case, I've put them together. So what can be concluded from this paper? And what this paper did conclude was the early involvement of emergency department, pharmacists in trauma call outs did improve time um between patients getting analgesia. It also deli er improved the delivery of time, the analgesia. The results built on evidence that was done previously in America um that showed similar results and it also highlighted the need for all emergency department pharmacists to be able to prescribe because without that um the results of this could have been quite different. So there's quite a few limitations. Um Hopefully you picked up on a few of them. Um The biggest one was this was only performed in one center. So I don't know about you, but I'm thinking the population in Victoria in Australia is not the same as the population in Manchester in the UK. Um The sample size was quite small. So 87 was it patients isn't a lot at all um because it was only performed in one center, the results might not be reproducible in other emergency departments. And that's also the case in other emergency departments with less trauma trained pharmacists, there's also the risk of some selection bias. And that's because if you read a little bit more, um, deeply patients were actually only recruited midweek from Monday to Friday cos that was the working hours of the emergency department, pharmacists. So the pharmacist that stayed within the emergency department and didn't move, um, so you obviously get patients coming in on a weekend. Um, and this wasn't looked into and also the trial was unblinded. So we know that this can influence behavior and especially from clinicians who um are in the control arm of this study, who know that they're not getting a pharmacist. Um, were they behaving differently? Were they prescribing analgesia quicker than maybe they would have done if they weren't involved in this trial? It's hard to say. So then my thoughts which I always present or try to present at the end of a journal club would be that we need to have a bit more, um, research into this globally. So, is it, excuse me, is it an issue that happens in other countries? Is it an issue in other parts of Australia? Um Is any other or any other countries doing anything differently that isn't kind of standard of care across the world? Um And do we need to push for emergency department, trauma trained pharmacists to be a standard? Um, so not all ed departments have pharmacists that are competent with dealing with trauma. And we also don't have um a set number of pharmacists that are able to prescribe. So do we need to look into um kind of increasing numbers of prescribing pharmacists within the ed department and provide them with some training on them helping within trauma cases? So that was everything. Um and now would be the time in a journal club setting that the floor would be opened up to consultants, registrars, juniors. Um and any other members of the MDT to have a discussion about what they think of the paper, um whether they did any further reading around it, whether they found out anything that I didn't. So they might have looked at whether this was analyzed in another hospital in another part of Australia in another part of the world. Um So I don't know if anyone wants to be brave enough and unmute themselves and let me know what they thought about this paper. Um If not, um I'm happy to take any questions that you've got and I hope it was somewhat helpful. Um This isn't everything that you need to know about randomized controlled trials, but I felt at your stage, um It's kind of the salient points that are useful. Um And then you can just build on these as you attend more journal clubs as you read more papers and as you hopefully get involved in research, I've just got a question and kind of a discussion point as well. Just to start off. Um I was wondering if you could just quickly go over like what AP value means just because in case anyone's not really familiar, obviously, I know that just quickly, I know it's a bit of a complicated topic. But yeah, so in basic terms and it depends very much on what, in what context you're looking at AP value. Um But in this value with a confidence interval, it would be that the difference between that 64% and that 85% if I'm rounding them both um is statistically significant. So that's not ha that, that difference that we can see isn't due to chance. So if we were to carry this out somewhere else, we should ideally see the same type of difference because it's not happened just on a whim if that makes sense. Um And because the confidence interval doesn't cross one. So I don't know if my mouse is, you can see my mouse, but if this value was naught 0.97 and this value remained the same, it would cross the value of one. So we'd be less inclined that this actually was significant. Um But we can say that 90 of 95% chance that this isn't due to chance. OK, thank you. Um I did have something that I thought was kind of was interesting. Um I'd be interested to know what the kind of demographics of the people of the sort of subjects of the study was because II think it did mention about polypharmacy somewhere. But, um, in, in the, in the center that it was carried out in, I know, for example, in the UK, obviously, we have a lot of, typically a lot of people in a elderly people, there's a lot of polypharmacy and so it's a bit more managing their medications and the things to withdraw and all those things are a bit more complex compared to say, a cohort of like 3040 year olds where their input might be less important. So, I guess, I don't know if it said anywhere but I think that could be something that would, I mean, it may be in a bigger sample site if that could be controlled for a bit. Mhm. To see if, um, maybe, maybe, for example, they would be useful in certain demographics of people but less so others, um, where it would be more straightforward. But I definitely think that there seems to be value when you have these kind of really complex patients that come in for a trauma and they've got like a really, really long past medical history. They're on 20 different medications. Um, and the pharmacist is able to better manage that and what should be stopped, things to be started, the interactions and things like that was further evidence, further research into, um, into what kind of, what kind of patients are benefiting from this should, should take place ideally. Yeah, I agree. Um Yeah, I think um it's a good start, isn't it? But it's not kind of, it's not currently practice changing. Um So even though looking at that hierarchy of evidence, you would think that maybe the next, the next step up from this would be a practice changing movement. But I don't think based on this, that that would happen any time soon. I don't even think that would happen in Australia, but I think it gives us some idea that we're maybe not accounting for people's pain well enough in the emergency department and we need people who can purely look at medications while we're dealing with the, at e of a patient that's come in on the back of a road traffic accident because having been in A&E and seen kind of these type of trauma calls, it, it really isn't what we're thinking about as number one. We're, we're making sure that they're not bleeding out. We're making sure that if they've had a head injury, they're not, you know, bleeding internally, they've not got, um, you know, a blockage that's cau gonna cause a stroke or making sure they're not having a heart an MRI um, we're not, we should be thinking about paying more. Um, but it, it's, it's often not at the forefront, but if we can have a member of the team, that medication is the sole kind of purpose and making sure that everything is accounted for. I think it probably would make for a smoother sailing in the Ed Department for sure. Does anyone else have any, any things I'd like to raise or any questions? So someone's asked, do they usually use chi square tests? Um or other, it really depends. So it depends on the type of data that they've collected. Um How many kind of um patients data have been collected? What they're looking at as the primary outcome. So some will use Q squared, um some will use other types of statistical tests to work out ap value or equivalent. Um It really depends on, on that kind of primary outcome as to what they want, what, what they want to find. I sorry, that's a really vague answer. Um But there's a a huge variety of statistical tests. Um more too many to kind of get into tonight. Um But maybe a future session looking into the different statistical tests um cause it kind of, it's broken down into kind of what you're looking at and whether that particular statistical test will actually give you a value that is actually gonna be of any use um to you finding kind of the answer to your question. I plan on organizing like a like a sessions to do with like medical statistics for UK MLA and like break down a different test. So if that's something that you guys would be interested in, then let me know in the feedback form. Um, yeah, but, uh, any, any other points I think someone I should say thank you. Um, does anyone else have any comments they wanna make or questions? Oh, let's see. Mhm. I promise. I don't bite and I'll try and answer. It's nice to see people interested in research. I think it's interesting as well. Sorry. I'm now, I'm now speaking again. But, um, I think it's interesting that, um, cos for things like major trauma calls, like road traffic accidents, you kind of, it seems that like there would need to be someone there kind of all the time. Um, but like the whole, like, j, not just during the day because obviously, um, they would ii, if I was like, applying this to an NHS hospital, almost like an on call emergency pharmacist and how feasible that would be. It's interesting. Cos, I think pharmacists they don't, I know they work in the acute setting but typically they have like n 9 to 5 working hours. Um, and they, and whether that would be a job role that people, that people, that would realistically be something that people would volunteer for in this country that was all volunteer for, but that people would want to be trained in a kind of like on the pharmacy. Yeah, I don't know how realistic that is, but we've got, you've got some, lots of people commenting now. So, yeah, I think with, with her, with that it really probably is trust and hospital dependence. Um, because like you said, I think ideally there should be kind of a, if not a trauma related pharmacist, definitely an ed pharmacist. That's kind of more than one that's available 24 7. And for some hospitals that will be the case. Um, but for a lot of hospitals, like you say, it is a very 9 to 5 service and then you'll have your on call pharmacist. Um, and so it's possible that if this study was extended to, even, probably the evenings, midweek and weekend you would probably see a difference even in the intervention arm as to how quickly people are getting the pain relief in, in trauma calls purely out of not having kind of the staffing. Mm. Um, I think there's like three questions. So, are there any resources you would signpost to improve on how to best appreciate things being discussed in these articles or is it more of the more you read and see, the more you understand? Um, so it's a bit of both. I would say, um, I'm still not a whiz at research or how to interpret articles and I still have to go back to the books. Um, a lot of it is, the more you read, the more you ask questions, um, the more you understand. Um, but then you can feel like you have a handle on everything and then another paper will kind of come out and you'll read it and everything will, gosh, go out the window and you'll feel like you've forgotten everything you have to kind of start again. Um, there's usually, I don't know if this is the same for every university, but I know at my hospital anyway, um, there's usually, um, statisticians, that's what they're called that work in the library. Um, so if there's ever a paper that you read or if, if you ever want to kind of look more into medical statistics, the the best people to ask, um because they can kind of find examples and really kind of dumb it down, which is what I need, um kind of what things mean. Um And they can look at you at it with you via multiple papers so that you get a real understanding. Um But like a lot of things, it is kind of the, the more you read, the more you understand, um which is not, not very helpful. I do apologize. Um I do have a book, it's, it's upstairs. Um, so I can, um, send a picture to Clemmy and she can somehow, um maybe distribute it. Um, but a lot of the books in the library on kind of medical statistics, um or even kind of second hand off ebay or Amazon. Um It's usually like they're all usually quite good cos statistics is statistics. So there's only really one way to look at things. Um But I've, I have put my email as Well, on the last page I'll put it back on so that if you want to email me and I can find out the name of the book that I use. Um, and then, sorry, I'll scroll back up. I'm need to research what I read in the article that there was a relative risk of 1.3. Is this very relevant? Yes. So, um, I missed it out because I didn't know how much or how um little um people kind of understood. Um So the relative risk um is 1.3 for looking at um the primary outcome of how quickly pa like whether patients got analgesia within the first of 1st 30 minutes and that's related to the P value that I mentioned, that's less than naught point naught five. So it is statistically significant. Um I don't, I didn't mention it as well because I don't think relative risk is the best measure for this paper. Um But that's probably um beyond the scope of today. Um But it's basically just showing again that the primary outcome for this paper does show statistical significance, but you do have to take it with a bit of a pinch of salt because the population size is so small. Um And it was only done in one center in Victoria. Um And I don't know what the kind of trauma ed department so like and whether that's um you know, representative of the rest of the world. Um Would the medical route also include uh inhalation or oral as well to change the data? I'm not sure I understand the question. I don't know if you do tell me. Um Is it the type of analgesia maybe? Is that like like the question? Sorry, it's been a long day at work. So my brain isn't fully functioning. Yeah. So um I do, I do have to admit that I did only read this paper today because work's been that busy. Um But from what I can see in kind of the breakdown of um the difference, any differences between the control arm and the intervention arm and who got like how many of each got what it looks like. There was um morphine, fentaNYL and ketamine were the top three kind of painkillers. Um And then there was others used. Um I don't know what the protocol is in Australia, but we would give IV morphine here in an emergency setting. Um We don't like fentaNYL in the UK. So we probably wouldn't give that. So I think it is a mixture of different um routes of administration. Um So that's another thing to maybe look into because um you know how much ketamine have they given? And is it the equivalent dose to the the dose of morphine that they're giving to other patients? Do we need to standardize the type of analgesia that we're giving to these patients? And does that affect how quickly we can give things. Um, fentaNYL is not always quickly accessible in hospitals. So that might delay things. Um, I hope that answers your question. I think it's interesting as well. If there's differences in trends of what medications take longer to administer and algesia wise, for example, it's an oral giving. Like if maybe there's more delay in certain IV medications because, you know, it takes someone has to draw them up and administer them tablet, which you can kind of give to someone straight away. Absolutely. So, yeah, I think that's, could be something to look into as well. Um, if there, if it's dependent on how the, the route of the medication. Yeah, that's something that I didn't actually put down in the limitations, but it is a really good one. cause morphine, phentin ketamine all work differently and we'll all, um, work at different rates on different patients who are different weights, different genders, you know, um, different ages. Um, so, yeah, there's a lot, there's a lot of good things in, in this paper in this trial. And I think it's a step forward in the right direction, um, to optimize pain management cause it does make life easier when the patient gets to the ward. Um, and the pain has been kind of optimally controlled in the ed department, not just for trauma patients, but I think more needs to be done to look into this to make sure that it is kind of reproducible and representative of a much, much, much larger population for the patients. So I don't know if anyone has any other questions. Sorry, I was on mute when I just said that. Um I was just gonna w what, uh, ask if anyone else had any questions? Yeah. Um I need to contribute. If not, then we can leave it. But I'll just give a moment the case ones typing anything, I guess as a side note as well, I don't know whether you will study medicine and if you do what stage of your career you're in. Um But if any of you have applied to S FP um or thinking of applying and the interviews are similar to last year, um you, you do usually get given a paper or an abstract at least to read. Um So knowing kind of roughly how to have a go at analyzing it like we've done tonight. So, like you've seen me done and hopefully you'll be able to do going forwards can be really useful for that as long as you find it useful. Hopefully you have. Uh So just ask what is FF what is S FP? Oh, sorry. Um It's like, um so, um it's a the specialized foundation program within the UK. Um So, um there's kind of three routes, research, um, education and leadership. Um And you often have um an interview for it um with one of the stations that the interview being how well you can kind of critique a paper um or an abstract, should I say? Um regardless of which of those pathways you're applying to, I don't know if there's anything similar in other countries. Um But that's how it works in the UK. Um What do you think is the hardest part of understanding the paper? Is it the medical statistics? I think when you're starting out trying to understand any papers, the medical statistics takes the longest to get your head around. Um And it's took me a number of years to be able to feel confident in analyzing a paper or even partially confident. So I think that is one of the biggest things. Um I also think that if it's a topic that you're not interested in that can sometimes make it difficult to understand. Um I picked a top this paper because uh I felt like it would, everyone would kind of roughly understand what it was trying to get at. I read other papers in the past and got to the methods section and put it down and not read it again because it's about a topic that I don't find interested. Um And I, I'm never gonna kind of understand what it's looking at. Um I think starting off on more simple papers like this, some more simple ST like um trials, randomized controlled trials, um makes it easier and then cause some of them become really complex. Um Yeah, it, it's similar to what we said before. It does just take time and practice and asking people. Um Can you explain this? What does this mean? Um And then you do feel like you're a bit of a bug beer, but it, it helps when it comes down to analyzing papers in the future. Um I don't know if Nicholas is his question is for me or whether it's for the code blue people. Um So I'll just answer the next one for now. So is the resources for understanding medical statistics. So if anyone wants to um there's a lot of resources out there. Um Most of them are OK. Um If anyone wants to email me, um I'm happy to send um like um a title or a link to the book that I use. Um That seems to be reasonable. Um There's probably a lot of youtube videos out there as well and I'm sure um that clammy and Patty and the rest of the team will be able to put on more sessions looking into different types of medical statistics and helping you guys understand things um in response to um Nicholas's question. Um Yeah, sorry, that must just be an error in the feedback form. So if you just put, um we'll make a note of that when looking at the feedback that that wasn't a um an option. So just put any of them and we'll try and disregard that question this time. But yeah, sorry about that. Yeah, if there's no further questions. Oh yeah. If there's no further questions, then I shall, I guess we can leave it here. Oh, I think uh something about uh 10 days ago question. Um what are the best types of papers to use analyzed for a literature review? Um So in theory, you can use all types of papers and all types of kind of research to do a literature review because even the bad one, the bad ones um contribute to a good literature review. Um higher up the hierarchy of evidence, the better the work and and the more um kind of significant whether statistically or not it will be. Um So I would suggest if you do a literature review, you include more of kind of um papers on randomized controlled trials and that sort of gist. But if you were to include case reports and case reviews in small quantities, um that is still relevant. Um Yeah, hope that answers that question. Oh Someone's saying to host a session um on how to do audits that can definitely be arranged. Um That's good feedback. Thank you. Um Certificates will be provided. I'm just trying to double check how exactly to do it, but it can be, but uh we'll probably send them out after the session um rather than during it. So yes, they will be. I think that is everything. So about three times now. Oh yeah, that just answered. So they automatically will be automatically um added to your meal to your medical account. Oh, well, in that case, I assume that that that no one else has any questions. Um So with that, I think we'll leave it there for today. Thank you guys all for coming if you're still here. Um And thank you so much, Holly. Um It was really, really useful. I land loads. I don't know about anyone else. Um And you will have more sessions in the future. So thank you. Enjoy your thanks. Bye.