reported only when respondents had already committed themselves deeply to patients' treatment (Q4) or when patients had arranged a second opinion without informing them (Q5). Specialists who provided second opinions struggled with feelings of helplessness toward patients if their opinion was in accordance with the first opinion and they thus took away the patient's hope (Q6). Moreover, respondents struggled with patients' unwillingness to be referred back to the first specialist after the second opinion. To reduce patients' reluctance, they actively tried to restore trust in the first specialist (Q7, Q8). Respondents were hesitant to communicate minor discrepancies with the first opinion to patients, fearing this would harm the patients' trust in the referring specialist, their own relationship with their colleague, or both (Q9, Q10). When differences in opinion were conveyed bluntly between the 2 specialists involved, this resulted in tension or anger (Q11, Q12). After back-referral, most referring specialists perceived that the physician-patient relationship had strengthened. Especially when both opinions aligned, patients gained acceptance, certainty, and trust (Q13). Discussion | The second-opinion process is complex and places great demands on the communication skills of medical specialists because of the emotions involved, especially when the attitudes they wish to convey conflict with their true beliefs and emotions. The physicians must balance objectivity with diplomacy to avoid harming their relationship with their patient or colleague. Interpersonal sensitivities between physicians and patients or colleagues may be managed by explicitly ascertaining patients' motivations and expectations, both when conducting and referring patients for second opinions. Although respondents in this study may not have been fully open about their personal experiences (a potential limitation of this study), the range of emotions identified suggests that acceptable candor was achieved. Addressing the identified challenges in medical training may improve the second-opinion process and enhance collaboration among medical specialists. Our research indicates that although some physicians believe they are often unnecessary, second opinions can strengthen the physicianpatient relationship after back-referral. Future research incorporating subjective and objective outcomes of second opinions should further establish their value.

Our study found that trials that provided strong evidence for orthopaedic surgery guidelines were largely fragile, underpowered, and at risk of bias.

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ObjectiveIt has been estimated that much of health research may be wasted, resulting in billions of dollars in wasteful research spending worldwide each year. Given the increased use of randomized trials and their influence on medicine, one method to combat research waste is to conduct randomized clinical trials (RCTs) only when a systematic review (SR) suggests more data are needed or when no previous SRs are identified. Here, we analyzed RCTs to determine whether SRs were cited as justification for conducting a trial.MethodsWe analyzed phase III RCTs published between 2016 and 2018 in New England Journal of Medicine, Lancet, and JAMA. We performed duplicate and independent data extraction to ensure the accuracy and validity of our data. For each trial, we extracted whether SRs were cited as justification for conducting the clinical trial.ResultsWe examined 637 RCTs that cited 728 SRs. Overall, 38.1% (243/637) of RCTs cited an SR as either verbatim (6.9%, 44/637) or inferred (31.2%, 199/637) for trial justification. The 79 remaining RCTs cited SRs in other ways. Approximately, 49.5% (315/637) of RCTs did not cite a SR.ConclusionsLess than half of the analyzed clinical trials cited a SRs as the basis for undertaking the trial. We believe trialists should be required to present relevant SRs to an ethics or peer review committee demonstrating an unmet need prior to initiating a trial. Eliminating research waste is both a scientific and ethical responsibility.

Background and Aim: Endoscopic surveillance for dysplasia in Barrett's esophagus (BE) with random biopsies is the primary diagnostic tool for monitoring clinical progression into esophageal adenocarcinoma. As an alternative, narrow-band imaging (NBI) endoscopy offers targeted biopsies that can improve dysplasia detection. This study aimed to evaluate NBI-guided targeted biopsies' diagnostic accuracy for detecting dysplasia in patients undergoing endoscopic BE surveillance compared with the widely used Seattle protocol. Methods: Cochrane DTA Register, MEDLINE/PubMed, EMBASE, OpenGrey, and bibliographies of identified papers were searched until 2018. Two independent investigators resolved discrepancies by consensus, study selection, data extraction, and quality assessment. Data on sensitivity, specificity, and predictive values were pooled and analyzed using a random-effects model. Results: Of 9528 identified articles, six studies comprising 493 participants were eligible for quantitative synthesis. NBI-targeted biopsy showed high diagnostic accuracy in detection of dysplasia in BE with a sensitivity of 76% (95% confidence interval [CI]: 0.61-0.91), specificity of 99% (95% CI: 0.99-1.00), positive predictive value of 97% (95% CI: 0.96-0.99), and negative predictive value of 84% (95% CI: 0.69-0.99) for detection of all grades of dysplasia. The receiver-operating characteristic curve for NBI model performance was 0.8550 for detecting all dysplasia. Conclusion: Narrow-band imaging-guided biopsy demonstrated high diagnostic accuracy and might constitute a valid substitute for random biopsies during endoscopic surveillance for dysplasia in BE.