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The strength of a systematic review hinges in large part on the quality of evidence it appraises. Observational studies, including cohort studies and case series, are positioned lower on the hierarchy of evidence, with cohort studies typically higher than case series. The often subtle differences between these study designs may lead to misclassification and can impact the strength of recommendations derived from such data. This manuscript offers an approach to delineate the differences between cohort studies and case series and provides clinical examples of these subtleties. By providing a simple approach for distinguishing cohort studies from case series, this manuscript seeks to assist researchers performing systematic reviews., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

In evidence-based medicine frameworks, the highest level of evidence is derived from quantitative synthesis of double-masked, high-quality, randomly assigned controlled trials. Meta-analyses of randomly assigned controlled trials have demonstrated that screening mammography reduces breast cancer deaths. In the United States, every major guideline-producing organization has recommended screening mammography in average-risk women; however, there are controversies about age and frequency. Carefully controlled observational research studies and statistical modeling studies can address evidence gaps and inform evidence-based, contemporary screening practices. As breast imaging radiologists develop and evaluate existing and new screening tests and technologies, they will need to understand the key methodological considerations and scientific criteria used by policy makers and health service researchers to support dissemination and implementation of evidence-based screening tests. The Wilson and Jungner principles and the U.S. Preventive Services Task Force general analytic framework provide structured evaluations of the effectiveness of screening tests. Key considerations in both frameworks include public health significance, natural history of disease, cost-effectiveness, and characteristics of screening tests and treatments. Rigorous evaluation of screening tests using analytic frameworks can maximize the benefits of screening tests while reducing potential harms. The purpose of this article is to review key methodological considerations and analytic frameworks used to evaluate screening studies and develop evidence-based recommendations., (© Society of Breast Imaging 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Red blood cell (RBC) transfusions play an important role in supportive care in children and neonates with cancer. However, in current clinical practice, evidence-based recommendations are lacking on when to administer prophylactic RBC transfusions. To address this gap, a clinical practice guideline (CPG) was developed to systematically review the available evidence and provide recommendations for clinicians., Methods: A systematic literature review in three databases was conducted. The GRADE methodology was used to assess, extract, and summarize the evidence. A multidisciplinary panel of 21 professionals was assembled to ensure comprehensive expertise. If there was insufficient evidence in children with cancer, additional evidence was gathered in general pediatric or adult oncology guidelines, or the panel utilized shared expert opinion to develop a comprehensive CPG. Multiple in-person meetings were conducted to discuss evidence, complete evidence-to-decision frameworks, and formulate recommendations., Results: Four studies including 203 children with all types of cancer, met the inclusion criteria. The expert panel assessed all evidence and translated it into recommendations. In total, 47 recommendations were formulated regarding RBC transfusions in children and neonates with cancer. For instance, specific thresholds for prophylactic RBC transfusions were recommended for children and neonates with cancer who have sepsis, are on ECMO, or are undergoing radiotherapy., Conclusion: This clinical practice guideline presents evidence-based recommendations regarding RBC transfusions in children and neonates with cancer. By providing these recommendations, we aim to guide clinicians and contribute to improving outcomes for children and neonates with cancer., (© 2024. The Author(s).)

Since its inception, Health Technology Assessment (HTA) has typically determined the value of a technology by collecting information derived from randomized clinical trials (RCTs), in line with the principles of evidence-based medicine (EBM). However, data from RCTs did not constitute the sole source of information, as other types of evidence (such as primary qualitative research) have often been utilized. Recent advances in both generating and collecting other types of evidence are broadening the landscape of evidence, adding complexity to the discussion of "robustness of evidence." What are the consequences of these recent developments for the methodology and conduct of HTA, the HTA community, and its ethical commitments? The aim of this article is to explore some ethical challenges that are emerging in the current evolving evidence landscape, particularly changes in evidence generation and collection (e.g., diversification of data sources), and shifting standards of evidence in the field of HTA (e.g., increasing acceptability of evidence that is thought of as lower quality). Our conclusion is that deciding how to best maintain trustworthiness is common to all these issues.

The gut microbiome plays a vital role in the overall health of dogs and cats, particularly their gastrointestinal (GI) health. Imbalances in the gut microbiome, termed dysbiosis, are associated with a range of GI disorders, including diarrhoea and chronic enteropathy. Emerging evidence tentatively supports the therapeutic use of pre-, pro- and postbiotics (collectively called biotics) to restore gut homeostasis and manage these conditions, especially due to their potential antibiotic-sparing effects. This article explores their evidence-based use in the treatment of GI disorders in dogs and cats., (© 2024 British Veterinary Association.)

The clinical syndrome of intracranial hypotension refers to the symptoms caused by cerebrospinal fluid hypovolemia and is primarily characterized by postural headaches, but can be associated with a multitude of other neurological symptoms. Imaging plays a critical role in helping to establish a diagnosis of intracranial hypotension, localize the source of cerebrospinal fluid leak, and assist in directing targeted treatments. Using the best available evidence, this document provides diagnostic imaging recommendations for the workup of intracranial hypotension across various clinical presentations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

A variety of thoracic imaging modalities and techniques have been used to evaluate diseases of the trachea and central bronchi. This document evaluates evidence for the use of thoracic imaging in the evaluation of tracheobronchial disease, including clinically suspected tracheal or bronchial stenosis, tracheomalacia or bronchomalacia, and bronchiectasis. Appropriateness guidelines for initial imaging evaluation of tracheobronchial disease and for pretreatment planning or posttreatment evaluation are included. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

This document assesses the appropriateness of various imaging studies for acute penetrating trauma to the torso. Penetrating trauma most commonly occurs from gunshots and stabbings, although any object can impale the patient. Anatomic location, type of penetrating trauma, and hemodynamic status are among the many important factors when deciding upon if, what, and when imaging is needed to further evaluate the patient. Imaging plays a critical role in the management of these patients. CT, in particular, aids in identifying and predicting internal injuries based upon trajectory of the object. Clinical variants are distinguished by ballistic versus nonballistic injuries, hemodynamic status, and compartment of the body injured. Ballistic trauma trajectory is less predictable, and imaging recommendations are adjusted for this unpredictability. Excluded from this document are penetrating traumatic injuries to pediatric patients and specific recommendations when the genitourinary system is clinically suspected to be injured, the latter of which is more specifically discussed in other Appropriateness Criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are documented annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer documented journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer documented literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Endometriosis is a common condition impacting individuals assigned female at birth. Though incompletely understood, the disorder is caused by endometrial-like tissue located outside of the endometrial cavity, associated with inflammation and fibrosis. Clinical presentation is variable, ranging from asymptomatic to severe pelvic pain and infertility. Treatment is determined by the patient's individualized goals and can include medical therapies to temporize symptoms or definitive surgical excision. Imaging is used to help diagnose endometriosis and for treatment planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Acute elbow pain can be the result of traumatic and atraumatic processes. Pathologic processes include osseous, ligamentous, and tendinous etiologies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Thoracic back pain is a common site for inflammatory, neoplastic, metabolic, infectious, and degenerative conditions, and may be associated with significant disability and morbidity. Uncomplicated acute thoracic back pain and/or radiculopathy does not typically warrant imaging. Imaging may be considered in those patients who have persistent pain despite 6 weeks of conservative treatment. Early imaging may also be warranted in patients presenting with "red flag" history or symptoms, including those with a known or suspected history of cancer, infection, immunosuppression, or trauma; in myelopathic patients; or in those with a history of prior thoracic spine fusion. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Acute scrotum is a medical emergency that requires prompt accurate diagnosis to appropriately triage potentially surgical conditions. Numerous differential diagnoses with overlapping clinical presentations make this a diagnostic challenge. Ultrasound is the established first-line imaging modality for acute scrotal disease and can be used to diagnose most scrotal disorders promptly and with high accuracy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Infective endocarditis and infection of cardiac devices are conditions characterized by high morbidity and mortality, thus requiring a prompt diagnosis. Advanced imaging modalities are often required in the management of infectious endocarditis according to guidelines. The aim of this review is to collect and describe evidence-based knowledge about the diagnostic role and clinical usefulness of [ 18 F]FDG PET/CT in endocarditis and cardiac device infections based on published systematic reviews and meta-analyses on this topic and on recent guidelines. [ 18 F]FDG PET/CT is recommended only in selected cases. This imaging method has good diagnostic accuracy in detecting prosthetic valve endocarditis and cardiac device infection. Furthermore, it can identify extra-cardiac infectious foci changing the clinical management in a significant percentage of cases., (© 2024 Wiley Periodicals LLC.)

CT and MR enterography are cross-sectional imaging examinations used in the assessment of inflammatory bowel disease. Consistent reporting and standardized nomenclature are important for clear communication with referring clinicians. Enterography has not only been used to depict inflammation in the small bowel, but it has also been used to quantify disease activity, assess distribution of disease, and detect complications including penetrating disease. This article reviews cross-sectional imaging findings in inflammatory bowel disease, including the current literature focusing on small bowel Crohn's disease and ulcerative colitis, with evidence-based guidelines on appropriate protocols and imaging procedures., Competing Interests: Disclosures B. Dane receives speaker honorarium and research support from Siemens Healthineers, Germany. J. Kim has no conflict of interest to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

At its best, the practice of medicine involves careful integration of experience and evidence. Generating evidence to address controversies in radiology - and translating such evidence to practice - requires appropriate selection of methods, and an understanding of the strengths, shortcomings, and biases inherent to different research designs and analyses. Equipped with such knowledge, the radiologic community can ensure that both research and clinical practice in our discipline excels, and that those questions that will be the most critical to answer will be formulated for successful investigation in the years to come., Competing Interests: Disclosure P.V. Pandharipande was a member of the Association of University Radiologists – General Electric Radiology Research Academic Fellowship Board of Review (2022–2023); she has ended this responsibility. SKK receives royalties from Wolters Kluwer for unrelated work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Evidence-based decision-making is generally based on published evidence. Therefore, if the published evidence is biased, so will the decision-making. One possible bias is the "positive-results" publication bias. This study attempts to characterize this phenomenon in cataract therapy trials. Studies were categorized as "positive" if their results were congruent with the hypothesis and "negative" if not. Secondary outcomes included the influence of funding source and differences in publication metrics between "positive" and "negative" publications. The U.S. National Library of Medicine Clinical Trials database was reviewed for cataract trials, yielding 248 trials. Trials with less than 2 treatment arms, less than 5 participants, or insufficient reporting were excluded. Data were collected on intervention, treatment arms, funding type, publication rates, citation rate, and the impact factor/H-index of journals. Of the 132 trials included, there were 69 positive and 63 negative results. Publication rate for positive results (71%) was significantly greater than negative results (17%) ( P < .01), with no significant difference in the other publication metrics. In conclusion, "negative" result trials are published less frequently, but are equally valued, if published. There are implications for evidence-based medicine with these findings., (Copyright © 2024 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Introduction: The 2024 Australian evidence-based guideline for unexplained infertility provides clinicians with evidence-based recommendations for the optimal diagnostic workup for infertile couples to establish the diagnosis of unexplained infertility and optimal therapeutic approach to treat couples diagnosed with unexplained infertility in the Australian health care setting. The guideline recommendations were adapted for the Australian context from the rigorous, comprehensive European Society of Human Reproduction and Embryology (ESHRE) 2023 Evidence-based guideline: unexplained infertility, using the ADAPTE process and have been approved by the Australian National Health and Medical Research Council., Main Recommendations: The guideline includes 40 evidence-based recommendations, 21 practice points and three research recommendations addressing: definition - defining infertility and frequency of intercourse, infertility and age, female and male factor infertility; diagnosis - ovulation, ovarian reserve, tubal factor, uterine factor, laparoscopy, cervical/vaginal factor, male factor, additional testing for systemic conditions; and treatment - expectant management, active treatment, mechanical-surgical procedures, alternative therapeutic approaches, quality of life. CHANGES IN ASSESSMENT AND MANAGEMENT RESULTING FROM THE GUIDELINE: This guideline refines the definition of unexplained infertility and addresses basic diagnostic procedures for infertility assessment not considered in previous guidelines on unexplained infertility. For therapeutic approaches, consideration of evidence quality, efficacy, safety and, in the Australian setting, feasibility, acceptability, cost, implementation and ultimately recommendation strength were integrated across multidisciplinary expertise and consumer perspectives in adapting recommendations to the Australian context by using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework, which had not been used in past guidelines on unexplained infertility to formulate recommendations. The Australian process also included an established data integrity check to ensure evidence could be trusted to guide practice. Practice points were added and expanded to consider the Australian setting. No evidence-based recommendations were underpinned by high quality evidence, with most having low or very low quality evidence. In this context, research recommendations were made including those for the Australian context. The full guideline and technical report are publicly available online and can be accessed at https://www.monash.edu/medicine/mchri/infertility and are supported by extensive translation resources, including the free patient ASKFertility mobile application (https://www.askfertility.org/)., (© 2024 The Author(s). Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Introduction: The Australian-led 2023 International evidence-based guideline for the assessment and management of polycystic ovary syndrome was based on best available evidence, clinical expertise and consumer preference. It followed best practice, involved extensive evidence synthesis and applied relevant frameworks across evidence quality, feasibility, acceptability, cost and implementation. Thirty-nine societies and organisations covering 71 countries were engaged. The evidence in the assessment and management of polycystic ovary syndrome (PCOS) has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report, 52 systematic reviews and analyses (approximately 6000 pages) underpin 77 evidence-based and 54 consensus recommendations, with 123 practice points., Main Recommendations: Changes include: refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone levels as an alternative to ultrasound in adults only, and differentiation of adolescent and adult criteria; strengthening the recognition of broad features of PCOS including metabolic effects, cardiovascular disease, dermatological symptoms, sleep apnoea, a high prevalence of psychological features and a high risk of adverse pregnancy outcomes; emphasising the poorly recognised, diverse burden of disease, the vital need for greater health professional education, evidence-based patient information, improved models of care, shared decision making and research efforts to improve patient experience; maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and emphasising evidence-based medical therapy and cheaper and safer fertility management., Changes in Management as a Result of This Guideline: The 2023 guideline is approved by the National Health and Medical Research Council and provides clinicians and patients with clear advice on best practice in a common and neglected condition, based on the best available evidence, expert multidisciplinary input and consumer preferences. It provides vital, extensive patient and provider resources to enhance evidence-based care. The full guideline is available at www.monash.edu/medicine/mchri/pcos/guideline., (© 2024 The Author(s). Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Applying evidence-based veterinary medicine (EBVM) is considered a Day One competence for veterinary graduates. Furthermore, the increasing interest in the use of complementary and alternative (non-conventional) veterinary therapies (NCTs) must be grounded on EBVM principles. Few studies have mapped the teaching of EBVM and of NCTs and assessed their content. This study analyses the official curricula of six (out of eight) Portuguese veterinary schools in terms of EBVM and NCTs, using the self-evaluation documents submitted to the National Agency for Assessment and Accreditation of Higher Education (A3ES) (2014-2015). Results show that, with few exceptions, veterinary education in Portugal follows a traditional, clinically-driven approach to evidence, with concepts taught mostly from an empirical and experiential perspective instead of a systematic one. Core EBVM topics, such as placebo effect , methodological validity , PICO , cognitive bias , and systematic review are either absent or insufficiently covered. Moreover, the teaching of NCTs was found in three out of the six curricular programs, namely acupuncture, phytotherapy, homeopathy, traditional Chinese medicine, aromatherapy, Bach flower remedies, ayurveda, energetic healing (reiki) , and massage. We found no evidence that these therapies are being taught under the principles of EBVM. Taken together, these results highlight the need for more explicit and targeted teaching of EBVM-related topics, namely regarding the critical appraisal of scientific literature and the integration of best evidence into clinical decision-making. Results can also be useful to inform the accreditation process by the A3ES and by education quality assurance agencies in other jurisdictions.

Background: Austria is among the countries with the highest incidence and prevalence of osteoporotic fractures worldwide. Guidelines for the prevention and management of osteoporosis were first published in 2010 under the auspices of the then Federation of Austrian Social Security Institutions and updated in 2017. The present comprehensively updated guidelines of the Austrian Society for Bone and Mineral Research are aimed at physicians of all specialties as well as decision makers and institutions in the Austrian healthcare system. The aim of these guidelines is to strengthen and improve the quality of medical care of patients with osteoporosis and osteoporotic fractures in Austria., Methods: These evidence-based recommendations were compiled taking randomized controlled trials, systematic reviews and meta-analyses as well as European and international reference guidelines published before 1 June 2023 into consideration. The grading of recommendations used ("conditional" and "strong") are based on the strength of the evidence. The evidence levels used mutual conversions of SIGN (1++ to 3) to NOGG criteria (Ia to IV)., Results: The guidelines include all aspects associated with osteoporosis and osteoporotic fractures, such as secondary causes, prevention, diagnosis, estimation of the 10-year fracture risk using FRAX®, determination of Austria-specific FRAX®-based intervention thresholds, drug-based and non-drug-based treatment options and treatment monitoring. Recommendations for the office-based setting and decision makers and institutions in the Austrian healthcare system consider structured care models and options for osteoporosis-specific screening., Conclusion: The guidelines present comprehensive, evidence-based information and instructions for the treatment of osteoporosis. It is expected that the quality of medical care for patients with this clinical picture will be substantially improved at all levels of the Austrian healthcare system., (© 2024. The Author(s).)

Laparoscopic adrenalectomy is worldwide currently considered the gold standard technique for patients suffering from benign lesions. There has been an increasing number of robotic-assisted adrenalectomies in the last decade due to the systematic further development of minimally invasive surgery resulting in the implementation of robot-assisted surgery. Interestingly, the available studies show some perioperative advantages for robotic surgery but overall the current evidence is weak and there are economic aspects that are not negligible. Therefore, further high-quality studies about robotic-assisted adrenalectomy are mandatory to strengthen the current evidence., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Head-to-head (H2H) studies enable the direct comparison of several alternative therapeutic approaches and thus provide the evidence-based foundation for the relative position of one treatment as compared to others for a specific indication. These trials constitute an important addition to placebo-controlled clinical trials. Among the controlled clinical trials not performed by the pharmaceutical industry, there are a relevant number of H2H trials for connective tissue diseases (CTDs) and vasculitides, particularly for systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). This article encompasses a review of the H2H trials for CTDs and vasculitides and discusses their relevance for current treatment algorithms. For SLE the H2H trials were predominantly performed for the treatment of lupus nephritis, demonstrating the impact of low-dose cyclophosphamide and mycophenolate as well as azathioprine for maintenance therapy. In recent H2H trials rituximab could be established as induction and maintenance therapy for AAV, which has now been incorporated into current treatment guidelines. Further comparative trials will be necessary in order to select the most effective and safest treatment for every patient, in the sense of personalized medicine., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Head-to-head studies are important to select the optimal treatment in terms of efficacy and side effect profiles when several drugs are available., Aim of the Work: This article describes all studies comparing the use of disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis (RA) in head-to-head studies or in which a DMARD was at least included in an active comparison arm., Results: A total of 23 studies comparing DMARDs were identified. These included comparisons of Janus kinase (JAK) inhibitors with methotrexate and with adalimumab as well as the oral surveillance study., Discussion: There are already an exceptionally large number of head-to-head studies in RA, both for comparisons of efficacy and safety of DMARDs. Nevertheless, more such comparative studies are needed, for example to clarify whether adverse events of tofacitinib observed in the oral surveillance study are specific to the JAK 1/JAK 3 inhibitor or are a class effect of all JAK inhibitors., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The practice of medicine in recent years has emphasized the use of evidence-based clinical guidelines to help inform treatment decisions. Since its development in 2004, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach has offered a systematic process for reviewing and summarizing the certainty of evidence found in the medical literature regarding various treatment options. To develop truly patient-centered care guidelines, this appraisal of the certainty of evidence must be combined with an understanding of the balance between benefits and harms, patient preferences, equity, feasibility, cost-effectiveness, and policy implications. This review examines each of these domains in detail, exploring the process and benefits of developing relevant, patient-focused guidelines directly applicable to the practice of modern medicine., (Copyright © 2024 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

The use of atherectomy for peripheral vascular interventions (PVIs) has increased exponentially and reached 18% of all PVI in the United States. The theoretical benefit on extensive arterial calcification relies on the concept of plaque modification and removal instead of displacement, as with other endovascular techniques. To date, there are no prospective studies comparing the different atherectomy technologies (directional, rotational, orbital, and laser). Moreover, most related prospective comparative studies have a small number of patients, and larger studies are single arm in patients with relatively mild to moderate disease burden. While available literature shows lower dissection risk and reduced bailout stenting, the superiority of this technology compared to other endovascular techniques has yet to be proven. Despite the lack of level 1 evidence to support its superiority, the lucrative reimbursement fueled the overuse of this technology as first-line therapy, particularly in office-based laboratories and ambulatory surgery centers. The use of atherectomy ought to be selective and complementary to other endovascular technologies, and individualized patient-level decision-making based on the practitioner's preference and expertise is essential to selectively incorporate atherectomy in managing complex atherosclerotic lesions., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: PR is an associate editor at BMJ Evidence-Based Medicine.TCH is on the BMJ Evidence-Based Medicine Editorial Board.

Evidence-based medicine (EBM) is helpful for laypersons' decision-making. This study aimed to evaluate the effectiveness of e-learning materials on the essential components of EBM for laypersons. We conducted a web-based, open-label, randomized controlled trial with laypersons in Japan aged ≥20 years who used the internet. Participants were randomly assigned to the intervention group with the e-learning material and the control group with only the 'Introduction' section of the same material. The primary and secondary outcomes were the self-created acquirement test scores (responding correctly with confidence) immediately after using the material and after 4 weeks. A multiple linear regression analysis was conducted. Of the 122 participants, 62 were randomly assigned to the intervention group and 59 to the control group; finally, 59 and 58, respectively, were included in the full analysis set. The mean (standard deviation) of the acquirement test score immediately after learning was 14.11 and (3.11) and 11.07 (3.88) in the intervention and control groups, respectively, indicating statistical significance (multivariable P < 0.001). The secondary long-term outcome was also statistically significant. The results showed that the e-learning material was effective for laypersons in acquiring the essential components of EBM. The material may increase laypersons' confidence in appraising health information, which can be used in decision-making., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Over time, the focus of evidence-based acute pain medicine has shifted, from a focus on drugs and interventions (characterized by numbers needed to treat), to an appreciation of procedure-specific factors (characterized by guidelines and meta-analyses), and now anesthesiologists face the challenge to integrate our current approach with the concept of precision medicine. Psychometric and biopsychosocial markers can potentially guide clinicians on who may need more aggressive perioperative pain management, or who would respond particularly well to a given analgesic intervention. The challenge will be to identify an easily assessable set of parameters that will guide perioperative physicians in tailoring the analgesic strategy to procedure and patient., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Operative decision-making of tibial pilon fractures is still of great complexity. The AO Trauma Italy has investigated the trend in the management of this fractures among orthopedic surgeons in Italy. A literature-based survey focused on preoperative planning and surgical strategies has been submitted to all the participants and the results were discussed in an online webinar in light of the most recent literature with the aim to outline common treatment recommendations especially useful for young surgeons., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: Evidence-based medicine integrates clinical expertise, patient values and best research evidence in clinical decision-making. This study aimed to assess evidence-based medicine knowledge, attitudes, practices and associated factors among medical radiology technologists in Addis Ababa, Ethiopia., Methods: A cross-sectional study was conducted among 392 medical radiology technologists from May to August 2022 using a self-administered questionnaire. Bivariate and multivariate logistic regression identified factors associated with evidence-based medicine practice., Results: Most medical radiology technologists (57.7%) had moderate evidence-based medicine knowledge and 94.9% had favourable attitudes. However, 64.8% demonstrated poor evidence-based medicine practice. Factors significantly associated with better evidence-based medicine practice were moderate knowledge (AOR 1.949, 95% CI 1.155-3.291), good statistical understanding (AOR 1.824, 95% CI 1.135-2.930), sufficient time for evidence-based medicine (AOR 1.892, 95% CI 1.140-3.141), institutional support (AOR 2.093, 95% CI 1.271-3.440) and evidence-based medicine resource access (AOR 1.653, 95% CI 1.028-2.656)., Conclusion: Despite moderate knowledge and positive attitudes towards evidence-based medicine, most medical radiology technologists had suboptimal utilisation. Strategies to improve knowledge, ensure dedicated time, provide institutional support and resources could enhance evidence-based radiology practice., (© 2024 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.)

Background: Consumption of stimulant drugs, a heterogeneous group of addictive substances, has significantly increased in recent years with rising numbers of stimulant-associated intoxication and deaths., Objective: To provide an overview of recent scientific evidence of the diagnosis and treatment of stimulant use disorders., Material and Methods: A literature review of the neuropathology, clinical presentation, diagnostic criteria and evidence-based treatment for stimulant use disorders., Results: The chronic use of stimulant drugs is associated with significant physical (e.g., hypertension, tachycardia and dyspnoea) and psychological harm (e.g., dependence, psychotic disorders and affective disorders). Despite major advances in the research of the neuropathology of stimulant use disorder and the refinement of diagnostic criteria, the disorder still presents a challenge, not least because of the lack of effective treatments. There are currently no approved pharmacotherapeutic interventions for stimulant use disorder and meta-analyses show that the efficacy of behavioural interventions is low to moderate, similar to cognitive behavioural treatment., Conclusion: Despite growing insights into the neuropathology associated with stimulant use disorder, treatment remains a challenge. The lack of effective interventions makes it difficult to give clear recommendations for the clinical practice. Further scientific research is thus warranted., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

We respond to discussant comments on our paper "Twenty years of network meta-analysis: Continuing controversies and recent developments" (https://doi.org/10.1002/jrsm.1700) and raise some additional points for consideration, including: the way in which methodological guidance is generated; integration of the estimand framework with evidence synthesis; and implications of the European Joint Clinical Assessment. We ask: what properties are required of population adjustment methods to enable transparent and consistent decision-making? We also ask why individual patient data is not routinely made available to re-imbursement authorities and clinical guideline developers., (© 2024 The Author(s). Research Synthesis Methods published by John Wiley & Sons Ltd.)

The study of rare diseases has long been an area of challenge for medical researchers, with agonizingly slow movement towards improved understanding of pathophysiology and treatments compared with more common illnesses. The push towards evidence-based medicine (EBM), which prioritizes certain types of evidence over others, poses a particular issue when mapped onto rare diseases, which may not be feasibly investigated using the methodologies endorsed by EBM, due to a number of constraints. While other trial designs have been suggested to overcome these limitations (with varying success), perhaps the most recent and enthusiastically adopted is the application of artificial intelligence to rare disease data. This paper critically examines the pitfalls of EBM (and its trial design offshoots) as it pertains to rare diseases, exploring the current landscape of AI as a potential solution to these challenges. This discussion is also taken a step further, providing philosophical commentary on the weaknesses and dangers of AI algorithms applied to rare disease research. While not proposing a singular solution, this article does provide a thoughtful reminder that no 'one-size-fits-all' approach exists in the complex world of rare diseases. We must balance cautious optimism with critical evaluation of new research paradigms and technology, while at the same time not neglecting the ever-important aspect of patient values and preferences, which may be challenging to incorporate into computer-driven models., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

In view of a recent recommendation of the European Commission to conceptualize novel screening approaches for lung, gastric, and prostate cancer, Germany is also invoked to revise its prostate early detection program. This discussion article provides an overview of new findings on prostate cancer screening, which suggest an organized and risk-adapted screening approach. Based on the German risk-adapted screening trial PROBASE, together with recently published data on organized screening programs in Europe, model projects should be established to determine the specific modalities for a new organized and risk-adapted prostate cancer screening program., (© 2024. The Author(s).)

There is disparity in the healthcare sector between the extent of innovation in medical products (e. g., drugs) and healthcare structures. The reason is not a lack of ideas, concepts, or (quasi-) experimental studies on structural innovations. Instead, we argue that the slow implementation of structural innovations has created this disparity partly because evidence-based medicine (EBM) instruments are well suited to evaluate product innovations but less suited to evaluate structural innovations. This article argues that the unintentional interplay between EBM, which has changed significantly over time to become primarily theoretical, on the one hand, and caution and inertia in health policy, on the other, has resulted in structural conservatism. Structural conservatism is present when healthcare structures persistently and essentially resist innovation. We interpret this phenomenon as an unintended consequence of deliberate EBM action. Therefore, we propose a new assessment framework to respond to structural innovations in healthcare, centered on the differentiation between the theoretical best (possible) evidence, the practical best (possible) evidence, and the best available evidence., Competing Interests: Prof. Pfaff has received institutional funding for scientifically-initiated research from the G-BA/Innovation Fund and the Federal Ministry of Education and Research (BMBF). He chaired the expert advisory board of the Innovation Fund (G-BA/Federal Ministry of Health) and is on the scientific advisory board of the BGF Institute of the general local health insurance fund (AOK) and co-editor of the health report of the company health insurance funds (BKK).Prof. Schmitt reports institutional grants for investigator-initiated research from the German Federal Joint Committee, German Ministry of Health, German Ministry of Research, European Union, German Federal State of Saxony, Novartis, Sanofi, ALK, and Pfizer. He participated in advisory board meetings as a paid consultant for Sanofi, Lilly, and ALK. Prof. Schmitt serves the German Ministry of Health as a member of the German National Council for Health and Care., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Extramammary Paget disease is a rare cutaneous malignancy that most commonly affects the genitals, perianal area, and axilla of elderly patients. Delays in care often lead to high levels of disease burden for patients. Thus, evidence-based recommendations are paramount in mitigating morbidity and mortality for this unique patient population. This 2-part continuing medical education series provides a complete picture of extramammary Paget disease. Part 2 of this continuing medical education series focuses on the complex management of extramammary Paget disease including surgical and noninvasive therapies, as well as novel approaches for advanced disease., Competing Interests: Conflicts of interest Dr Rossi has no relevant conflicts of interest related to this article but has received grant funding from The Skin Cancer Foundation and the A. Ward Ford Memorial Grant, served on advisory board, as a consultant, given educational presentations for Almirall, Allergan Inc, Galderma Inc, Evolus Inc, Elekta, Biofrontera (Quantia), Merz Inc, Dynamed, Skinuvia, Perf-Action, Cutera, and LAM therapeutics, and holds equity in DAR companies. Dr Funt has received research support from AstraZenecaAstraZeneca, GenentechGenentech/RocheRoche, and Decibel Therapeutics, is a consultant/advisory board member for MerckMerck and BioNTech, and owns stock in Urogen, Allogene Therapeutics, Neogene Therapeutics, Kronos Bio, ByHeart, 76Bio, Vida Ventures, Ginkgo Bioworks, Doximity, and Inconovir. The other authors have no conflicts of interest to declare., (Copyright © 2024 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Task Force on 'Clinical Algorithms for Fracture Risk' commissioned by the American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee has recommended that FRAX® models in the US do not include adjustment for race and ethnicity. This position paper finds that an agnostic model would unfairly discriminate against the Black, Asian and Hispanic communities and recommends the retention of ethnic and race-specific FRAX models for the US, preferably with updated data on fracture and death hazards. In contrast, the use of intervention thresholds based on a fixed bone mineral density unfairly discriminates against the Black, Asian and Hispanic communities in the US. This position of the Working Group on Epidemiology and Quality of Life of the International Osteoporosis Foundation (IOF) is endorsed both by the IOF and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)., (© 2024. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Background: Elective lumbar fusions have received criticism for inappropriate utilization. Here, we use a novel Operative Value Index (OVI) to assess whether "indicated," evidence-based lumbar fusions are associated with increased value (outcomes per dollar spent)., Methods: This study is a retrospective analysis of a prospective observational cohort of 294 patients undergoing elective lumbar fusions at a single large academic institution. All patients were preoperatively evaluated by a panel of neurosurgeons for concordance with evidence-based medicine (EBM), determined through guidelines from the North American Spine Society. Oswestry Disability Index (ODI) scores were collected for all patients both preoperatively and at 6-months postoperatively. Time-driven activity-based costing was employed to determine both direct and indirect intraoperative costs. The OVI was defined as the percent improvement in ODI per $1000 spent intraoperatively. Generalized linear mixed model regression, adjusting for confounders, was performed to assess whether EBM-concordant surgeries were associated with higher OVI., Results: Of 294 elective lumbar fusions, 92.9% (n = 273) were EBM-concordant. The average total cost of an EBM-concordant lumbar fusion was $17,932 (supplies: $13,020; personnel: $4314), compared to $20,616 (supplies: $15,467; personnel: $4758) for an EBM-discordant fusion. Average OVI was 2.27 for a concordant fusion, compared to 0.11 for a discordant fusion. Generalized linear mixed model analysis revealed that EBM-concordant cases were associated with significantly higher OVI (β-coefficient 2.0, P < 0.001)., Conclusions: EBM-concordant fusions were associated with 2% greater improvement in ODI scores from baseline for every $1000 spent intraoperatively. Systematic methods for increasing guideline adherence for lumbar fusions could therefore improve value at scale., (Copyright © 2024 Elsevier Inc. All rights reserved.)

In clinical clerkship (CC), medical students can practice evidence-based medicine (EBM) with their assigned patients. Although CC can be a valuable opportunity for EBM education, the impact of EBM training, including long-term behavioral changes, remains unclear. One hundred and nine fourth- and fifth-year medical students undergoing CC at a medical school in Japan attended a workplace-based learning program for EBM during CC (WB-EBM), which included the practice of the five steps of EBM. The program's effect on the students' attitudes toward EBM in CC was assessed through questionnaires. A total of 88 medical students participated in the program. Responses to the questionnaire indicated high satisfaction with the WB-EBM program. The most common theme in students' clinical problems with their assigned patients was the choice of treatment, followed by its effect. Based on the responses in the post-survey for the long-term effects of the program, the frequency of problem formulation and article reading tended to increase in the 'within six months' group comprising 18 students who participated in the WB-EBM program, compared with the control group comprising 34 students who did not. Additionally, the ability to self-assess problem formulation was significantly higher, compared with the control group. However, among 52 students who participated in the WB-EBM program more than six months later, EBM-related behavioral habits in CC and self-assessments of the five steps of EBM were not significantly different from those in the control group. The WB-EBM program was acceptable for medical students in CC. It motivated them to formulate clinical questions and enhanced their critical thinking. Moreover, the WB-EBM program can improve habits and self-evaluations about EBM. However, as its effects may not last more than six months, it may need to be repeated across departments throughout CC to change behavior in EBM practice.