Scottish Intercollegiate Guidelines Network

Abstract Aim Successful completion of the MRCS examination is mandatory for progression into higher surgical (registrar) training in the UK. National selection for training programmes is a highly competitive process. Despite this, the ranking of applicants does not currently include MRCS performance scores. This offers a unique opportunity to compare two independent assessments of surgical trainees to establish whether MRCS performance can predict future surgical career outcomes and competitiveness in training. Method All UK candidates who attempted MRCS between 2007-2020 were matched to career outcome data using the GMC list of registered medical practitioners and anonymised (n = 2910). Chi-squared tests determined associations with first attempt MRCS pass/fail outcomes. Multinomial regression models were developed to establish the predictive power of success at MRCS in determining surgical specialty and training deanery choices. Results There was statistically significant variability in MRCS Part A pass rates, ranging from 55.1%-76.7% between surgical specialties (P=0.001) but no significant variability in Part B pass rates (P=0.655). There was significant variability in Part A and Part B pass rates between training deaneries (P=0.010 and P=0.036 respectively). Pass rates ranged from 59.9%-77.7% for Part A and 70.1%-85.0% for Part B between training deaneries. Those in more competitive specialties and training deaneries performed better in MRCS in terms of first attempt pass rate, scores and number of attempts taken to pass. Conclusions MRCS performance is an early predictor of surgical career choice and competitiveness. Trainees who perform well at MRCS are more likely to enter competitive surgical specialties and training deaneries.

We note the concerns expressed by Abdel Shaheed et al in their recent editorial ‘Drugs for Chronic Pain’.1 They expressed important anxieties about the availability of pharmacological options for GPs treating chronic pain, which will be restricted if the current draft National Institute for Health and Care Excellence (NICE) guideline is implemented.2 Their concerns include: As clinicians treating chronic pain, people living with chronic pain, and advisors on relevant national policy, we share these concerns, and add the following observations: 1. Lack of evidence of effectiveness at population level does not equate to lack of effectiveness for all individuals. As Andrew Moore …

Decisions in public health should be based on the best available evidence, reviewed and appraised using a rigorous and transparent methodology. The Project on a Framework for Rating Evidence in Public Health (PRECEPT) defined a methodology for evaluating and grading evidence in infectious disease epidemiology, prevention and control that takes different domains and question types into consideration. The methodology rates evidence in four domains: disease burden, risk factors, diagnostics and intervention. The framework guiding it has four steps going from overarching questions to an evidence statement. In step 1, approaches for identifying relevant key areas and developing specific questions to guide systematic evidence searches are described. In step 2, methodological guidance for conducting systematic reviews is provided; 15 study quality appraisal tools are proposed and an algorithm is given for matching a given study design with a tool. In step 3, a standardised evidence-grading scheme using the Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) methodology is provided, whereby findings are documented in evidence profiles. Step 4 consists of preparing a narrative evidence summary. Users of this framework should be able to evaluate and grade scientific evidence from the four domains in a transparent and reproducible way.

BackgroundClinical practice guidelines are typically written for healthcare providers but there is increasing interest in producing versions for the public, patients and carers. The main objective of this review is to identify and synthesise evidence of the public’s attitudes towards clinical practice guidelines and evidence-based recommendations written for providers or the public, together with their awareness of guidelines.MethodsWe included quantitative and qualitative studies of any design reporting on public, patient (and their carers) attitudes and awareness of guidelines written for providers or patients/public. We searched electronic databases including MEDLINE, PSYCHINFO, ERIC, ASSIA and the Cochrane Library from 2000 to 2012. We also searched relevant websites, reviewed citations and contacted experts in the field. At least two authors independently screened, abstracted data and assessed the quality of studies. We conducted a thematic analysis of first and second order themes and performed a separate narrative synthesis of patient and public awareness of guidelines.ResultsWe reviewed 5415 records and included 26 studies (10 qualitative studies, 13 cross sectional and 3 randomised controlled trials) involving 24 887 individuals. Studies were mostly good to fair quality. The thematic analysis resulted in four overarching themes: Applicability of guidelines; Purpose of guidelines for patient; Purpose of guidelines for health care system and physician; and Properties of guidelines. Overall, participants had mixed attitudes towards guidelines; some participants found them empowering but many saw them as a way of rationing care. Patients were also concerned that the information may not apply to their own health care situations. Awareness of guidelines ranged from 0-79%, with greater awareness in participants surveyed on national guideline websites.ConclusionThere are many factors, not only formatting, that may affect the uptake and use of guideline-derived material by the public. Producers need to make clear how the information is relevant to the reader and how it can be used to make healthcare improvements although there were problems with data quality. Awareness of guidelines is generally low and guideline producers cannot assume that the public has a more positive perception of their material than of alternative sources of health information.

We thank Gordon and Gordon for drawing our attention to the matter of declaration of competing interests in clinical guidelines,1 2 which …

Cancer is diagnosed in 1600 children each year in the United Kingdom, and for teenagers cancer is the leading cause of death after accidents (unintentional injury, including road traffic incidents). The five year survival rate has improved over recent decades, from 30% to 80%; this increased survival has led to a rapidly increasing population of adult survivors, with an estimated 33 000 childhood cancer survivors now living in the UK.1 These survivors have higher premature death rates than the general population and are at increased risk of a range of physical and psychosocial problems.2 Late effects of treatment may occur soon after the treatment ends or many years later. Healthcare practitioners need guidance about potential late effects and the lifelong needs of survivors of childhood cancer. This article summarises the most recently updated recommendations from SIGN.3 SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (figure⇓), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”), based on the clinical experience of the Guideline Development Group, is also indicated (as GPP). The group appraised the current evidence for new or completely revised sections on subsequent primary cancers, fertility, cardiac and bone health, and metabolic effects; for the remaining sections the group did not re-appraise the original supporting evidence. Fig 1 Explanation of SIGN grades of recommendations ### Subsequent primary cancers (all new recommendations)

The degree of disability and negative impact on quality of life caused by psoriasis and psoriatic arthritis are comparable to those of ischaemic heart disease, diabetes, depression, and cancer.1 Severe psoriasis and psoriatic arthritis are associated with an increased risk of conditions such as cardiovascular disease, diabetes, and depression.2 3 4 5 Psoriatic arthritis is underdiagnosed; about a fifth of patients with psoriasis also have psoriatic arthritis.6 The management of patients with both conditions may be particularly challenging and require close collaboration among several specialties. This article summarises the most recent recommendations from the Scottish Intercollegiate Guidelines Network (SIGN) on the diagnosis and management of psoriasis and psoriatic arthritis in adults.7 SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (fig 1⇓), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”), based on the clinical experience of the guideline development group, is also indicated (as GPP). Fig 1 Explanation of SIGN grades of recommendations ### Diagnosis and assessment in primary care

Despite the successful introduction of immunisation with meningococcal group C conjugate vaccine in 1999,1 invasive meningococcal disease continues to cause substantial morbidity and mortality.2 Most deaths occur in the first 24 hours, often before specialist care starts. The challenge therefore is to identify those patients who will progress rapidly from non-specific early presentation to life threatening disease.3 Major changes to the organisation of health care in the United Kingdom, particularly in the provision of resuscitation and paediatric intensive care, have been associated with dramatically improved outcomes over recent decades.4 5 However, lack of high quality evidence to inform changes in clinical practice has been a particular challenge in developing this evidence based guideline. This article summarises the most recent guidance from the Scottish Intercollegiate Guidelines Network (SIGN) on the management of invasive meningococcal disease in children and young people.6 SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (fig 1⇓), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”), based on the clinical experience of the guideline development group, is also indicated (as GPP). Fig 1 Explanation of SIGN grades of recommendations ### Signs and symptoms Invasive meningococcal disease has an early, non-specific stage with signs such as fever, lethargy, irritability, nausea, and poor feeding. These signs are commonly found in children with self limiting viral illnesses, so a confident differential diagnosis at an early stage is very difficult. Observational studies have associated leg pain, cold extremities, and abnormal skin colour with developing invasive meningococcal disease.7 This non-specific early stage commonly lasts for several hours before invasive meningococcal disease progresses rapidly to three general disease patterns8:

EDITOR—The Editor's choice of 27 November expressed concern about the readership of the BMJ among surgeons. A recent survey of the candidates who passed the intercollegiate specialty examination …