Intraoperative bacterial cultures fail to reliably predict the bacterial spectrum encountered during infectious complications after appendicitis.

Acute appendicitis is a common surgical emergency. Complicated appendicitis usually warrants perioperative antibiotic treatment in order to prevent infectious complications. Whether routine microbiological testing benefits the individual patient is a topic of debate. The goal of our study was to assess perioperative antibiotic prescriptions as well as the benefit of microbiological testing during the appendectomy as a predictor for bacteria encountered in infectious complications. This is a retrospective analysis of 1218 consecutive patients that underwent appendectomy at a tertiary referral center between 2014 and 2021. The patient charts were systematically analyzed regarding intraoperative outcome, microbiologic results, and postoperative infectious complications. 1218 patients were included in this study of which 768 were uncomplicated appendicitis (UA) and 450 were complicated appendicitis (CA). Microbiological testing was performed in 39.2% of UA cases (33.6% of which grew bacteria) compared to 74.9% of CA cases (78.6% positive cultures). The strongest individual predictors for SSI were gangrenous and perforated appendicitis. A total of 58 surgical-site infections developed, of which 49 were intra-abdominal fluid collections or abscesses. Thirty-two patients had revision surgery or CT-guided drainage for SSI. In the cases where microbiological testing was done both during the appendectomy and the SSI, 13/18 showed different bacteria on culture testing. The infectious outcome was favorable in 98.3%. While microbiological testing offers insights into resistance patterns, it is of little benefit for the individual patient, given the low predictive value for bacteria found during SSI. Achieving source control combined with empiric antibiotic coverage leads to favorable outcomes independent of culture results.

Prophylactic effect of retromuscular mesh placement during loop ileostomy closure on incisional hernia incidence-a multicentre randomised patient- and observer-blind trial (P.E.L.I.O.N trial).

BACKGROUND: Incisional hernia is a frequent complication following loop ileostomy reversal. Incisional hernias are associated with morbidity, loss of health-related quality of life and costs and warrant the investigation of prophylactic measures. Prophylactic mesh implantation at the time of surgical stoma reversal has shown to be a promising and safe method to prevent incisional hernias in this setting. However, the efficacy of this method has not yet been investigated in a large multicentre randomised-controlled trial (RCT) with adequate external validity. The P.E.L.I.O.N. trial will evaluate the efficacy of prophylactic mesh reinforcement after loop ileostomy closure in decreasing the rate of incisional hernia versus standard closure alone. METHODS: P.E.L.I.O.N. is a multicentre, patient- and observer-blind RCT. Patients undergoing loop ileostomy closure will undergo intraoperative 1:1 randomisation into either abdominal wall closure with a continuous slowly absorbable suture in small-stitch technique without mesh reinforcement (control group) or abdominal wall closure with an additional reinforcement with a retromuscular non-absorbable, macro-pore (pore size ≥ 1000 µm or effective porosity >0%) light-weight monofilament or mixed structure mesh. A total of 304 patients (152 per group) will need to be randomised in the study. Based on inclusion and exclusion criteria, 1,014 patients are expected to be screened for eligibility in order to recruit the necessary number of patients. The primary endpoint will be the frequency of incision hernias within 24 months according to the European Hernia Society definition. Secondary endpoints will be the frequency of surgical site occurrences (including surgical site infections, wound seromas and hematomas, and enterocutaneous fistulas), postoperative pain, the number of revision surgeries and health-related quality of life. Safety will be assessed by measuring postoperative complications ≥ grade 3 according to the Dindo-Clavien classification. DISCUSSION: Depending on the results of the P.E.L.I.O.N. trial, prophylactic mesh implantation could become the new standard for loop ileostomy reversal. TRIAL REGISTRATION: DRKS00027921, U1111-1273-4657.

Perioperative Antibiotics in Appendicitis-Do We Need to Adjust Therapy for the Elderly? A Matched Pair Analysis.

(1) Background: Perioperative Antibiotics for acute complicated appendicitis are a standard of care. While there are plenty of trials for pediatric patients, data for elderly patients are scarce. The goal of our study was to evaluate whether elderly patients carry more resistant bacteria and thus have less favorable outcomes after an appendectomy that may warrant intensified perioperative antibiotic treatment (2) We present a retrospective single-center matched pair (139 patients each) analysis of perioperative and microbiological outcomes of an elderly appendicitis cohort (i.e., older than 60 years) compared with a younger adult cohort (i.e., ≤60 years). Both groups were matched one for one according to gender, duration of symptoms, c-reactive protein at presentation and whether they presented with uncomplicated or complicated appendicitis. (3) Results: After matching, complicated appendicitis was present in 76.3% of both groups. Elderly patients more frequently received preoperative diagnostic CT (p < 0.001) than the young. Both operative strategy (laparoscopic appendectomy in 92.1% each) and duration of surgery (57 vs. 56 min) were equal in both groups. Postoperative antibiotics were prescribed in ~57% for a median of 3 days in both groups and antibiotic selection was similar. The incidence of surgical site infections was higher in the young (12.2% vs. 7.9%) yet not significant. There was no difference in culture positivity or bacterial spectrum and the elderly cohort did not present with increased resistant bacterial isolates. (4) Conclusions: While overall resistant bacterial strains were rare, perioperative outcomes between the young and the elderly did not differ and did neither warrant longer nor intensified antibiotic treatment.

Erratum: Prognostic relevance of high pretreatment CA125 levels in primary serous ovarian cancer.

[This corrects the article DOI: 10.3892/mco.2020.2170.].

Routine postoperative blood tests fail to reliably predict procedure-related complications after laparoscopic cholecystectomy.

PURPOSE: Laparoscopic cholecystectomy is a highly standardized surgical procedure with a low risk of complications. However, once complications develop, they can be life-threatening. The aim of this study was to evaluate the value of blood tests on postoperative day one regarding their potential to predict postoperative complications METHODS: A cohort study of 1706 consecutive cholecystectomies performed at a tertiary hospital and teaching facility over a 5-year period between 2014 and 2019. RESULTS: Patients that had open CCE or conversion CCE were excluded. One thousand five hundred eighty-six patients were included in the final analysis that received a laparoscopic cholecystectomy (CCE). One thousand five hundred twenty-three patients had blood tests on POD 1. Forty-one complications were detected including 14 bile leaks, 2 common bile duct injuries, 13 choledocholithiasis, 9 hematomas, and 2 active bleedings. Bilirubin was elevated in 351 patients on POD 1. A drop of more than 3 mg/dl of hemoglobin was reported in 39 patients. GPT was elevated 3 × above the upper limit in 102 patients. All three tests showed a low sensitivity and specificity in detecting postoperative complications. CONCLUSIONS: Early postoperative blood tests alone show a low specificity in detecting postoperative complications after laparoscopic CCE. Their main benefit appears to be the negative predictive value, when they are normal. Routine blood testing appears to be unnecessary and should be based on the intraoperative diagnosis and postoperative clinical findings.

Biochar from pyrolyzed Tibetan Yak dung as a novel additive in ensiling sweet sorghum: An alternate to the hazardous use of Yak dung as a fuel in the home.

Yak dung is used as fuel in Tibetan homes; however, this use is hazardous to health. An alternative use of the dung that would be profitable and offset the loss as a fuel would be very beneficial. Sweet sorghum silage with yak dung biochar as an additive was compared with a control silage with no additives and three silages with different commercial additives, namely Lactobacillus buchneri, Lactobacillus plantarum and Acremonium cellulase. Biochar-treated silage had a significantly greater concentration of water-soluble carbohydrates than the other silages (76 vs 12.4-45.8 g/kg DM) and a greater crude protein content (75.5 vs 61.4 g/kg DM), lactic acid concentration (40.7 vs 27.7 g/kg DM) and gross energy yield (17.8 vs 17.4 MJ/kg) than the control silage. Biochar-treated and control silages did not differ in in vitro digestibility and in total gas (507 vs 511 L/kg DM) and methane production (57.9 vs 57.1 L/kg DM). Biochar inhibited degradation of protein and water-soluble carbohydrates and enhanced lactic acid production, which improved storability of feed. It was concluded that yak dung biochar is an efficient, cost-effective ensiling additive. The profit could offset the loss of dung as fuel and improve the health of Tibetan people.

Urinary Tract Infections in Kidney Transplant Recipients-Is There a Need for Antibiotic Stewardship?

(1) Background: Urinary tract infections (UTI) are the most common infections after kidney transplantation. Given the risk of urosepsis and the potential threat to the graft, the threshold for treating UTI and asymptomatic bacteriuria with broad spectrum antibiotics is low. Historically fluoroquinolones were prescription favorites for patients that underwent kidney transplantation (KT). After the recent recommendation to avoid them in these patients, however, alternative treatment strategies need to be investigated (2) Methods: We retrospectively analyzed the charts of 207 consecutive adult kidney transplantations that were performed at the department of General, Visceral and Transplantation Surgery of the University Hospital of Tuebingen between January 2015 and August 2020. All charts were screened for the diagnosis and treatment of asymptomatic bacteriuria (ASB) and urinary tract infections (UTI) and the patients' clinical characteristics and outcomes were evaluated. (3) Results: Of the 207 patients, 68 patients suffered from urinary tract infections. Patients who developed UTI had worse graft function at discharge (p = 0.024) and at the 12 months follow-up (p < 0.001). The most commonly prescribed antibiotics were Ciprofloxacin and Piperacillin/Tazobactam. To both, bacterial resistance was more common in the study cohort than in the control group. (4) Conclusions: Urinary tract infections appear to be linked to worse graft functions. Thus, prevention and treatment should be accompanied by antibiotic stewardship teams.

Prognostic relevance of high pretreatment CA125 levels in primary serous ovarian cancer.

The objective of the present study was to analyze the prognostic relevance of pretreatment serum CA125 ≥500 U/ml and its role as a non-invasive factor for estimating optimal cytoreduction (≤1 cm) in primary serous ovarian cancer. Clinicopathological parameters and CA125 levels prior to primary cytoreductive surgery were retrospectively evaluated in all 261 consecutive patients with primary epithelial ovarian cancer from a single centre. Inclusion criteria were existing preoperative CA125 level, serous ovarian cancer and performed full primary treatment (surgery/platinum-based chemotherapy). A total of 136 patients met the criteria. Among them, 74 patients had CA125 ≥500 U/ml. The other 62 patients that met the aforementioned criteria and had CA125 <500 U/ml were defined as controls. The present study tested cut-off CA125 values to detect subgroups affecting prognosis. The goal was to evaluate patients with optimal cytoreduction (R≤1 cm). Univariate analyses were performed with PASW to identify clinicopathological parameters associated with the pretreatment CA125 level. For survival analyses, a cut-off-value of CA125 ≥500 U/ml was used to identify the association between preoperative CA125 levels, resection status and prognosis. To test significant differences between examined groups, Student's t-test and the Mann-Whitney test were used. P<0.05 was considered to indicate a statistically significant difference. Significantly worse prognosis in terms of overall survival (P=0.023) and progression-free survival (P=0.011) was detected in the CA125 ≥500 U/ml group of optimally cytoreduced patients compared with in the CA125 <500 U/ml group. The complete cytoreduction rate was higher in CA125 <500 U/ml (33.9%) vs. CA125 ≥500 U/ml (21.6%). A CA125 level >1,404 U/ml had a higher rate of suboptimal cytoreduction (32.4%) compared with lower CA125 levels. A pretreatment CA125 level ≥500 U/ml had significantly worse prognostic impact after optimal cytoreduction compared with CA125 <500 U/ml. The higher the CA125 level the higher the suboptimal cytoreduction rate. Patients with CA125 ≥500 U/ml may be candidates for an initial laparoscopic approach to specify resectability and to determine how to proceed. Overall, CA125 levels appear to be helpful in predicting suboptimal cytoreductive surgery for patients with primary ovarian cancer, but should be interpreted together with clinical and radiologic findings. This may improve defining the optimal treatment strategy in these patients.

Perioperative strategy and outcome in giant retroperitoneal dedifferentiated liposarcoma-results of a retrospective cohort study.

BACKGROUND AND OBJECTIVES: Retroperitoneal liposarcoma (RPLS) are common soft tissue sarcomas of adulthood. The aim of this study is to show resectability of even giant liposarcomas and to identify factors associated with recurrence and survival in primary retroperitoneal liposarcomas. METHODS: We retrospectively reviewed the records of patients with retroperitoneal liposarcoma. Seventy-seven patients met inclusion criteria. Out of these 10 patients with primary giant, dedifferentiated retroperitoneal liposarcomas were operated with en bloc compartment resection with intention of radical resection. Treatment consisted of neoadjuvant radiochemotherapy and surgical resection or surgical resection. RESULTS: In 6 patients, neoadjuvant radiochemotherapy was performed; 3 patients were treated with surgical resection alone and 1 patient received adjuvant chemotherapy. The median diameter of tumor size was 360 mm (300 to 440 mm). Operative outcome showed complete resection in all 10 patients. Local tumor free survival was in median 19 month. Tumor recurrence was seen in 3 of 4 patients (75%) without neoadjuvant radiochemotherapy, and in 2 of 6 patients (33%) after neoadjuvant radiochemotherapy in 2 years follow-up. CONCLUSION: Even in case of giant retroperitoneal liposarcoma, complete resection is possible and remains the principal treatment. The rate of recurrence was improved in patients with neoadjuvant radiochemotherapy.

Critical Thinking Skills of RNs: Exploring Demographic Determinants.

BACKGROUND: Previous studies of nurses' critical thinking skills that included demographic characteristics as determinants have been inconclusive. This study explored demographic determinants of critical thinking skills among nurses from public hospitals in Peninsular Malaysia. METHOD: This cross-sectional study included 549 nurses recruited via multistage cluster sampling. Nurses completed the demographic questionnaire and Health Sciences Reasoning Test (HSRT). RESULTS: The majority of respondents failed to demonstrate critical thinking skills with a mean overall HSRT score of 13.8 (SD = 3.4). Educational qualifications (p = .003) and clinical specialties (p = .022) were significantly related to nurses' critical thinking skills. Years of clinical experience, age, and job ranking were not significant CONCLUSION: The findings indicate a need to address the present curriculum in nursing education and to reinforce critical thinking skills in the nursing workforce. Future research on how nurses in Malaysia acquire critical thinking skills is needed. [J Contin Educ Nurs. 2020;51(3):109-117.].

[Value of laparoscopy in blunt and penetrating abdominal trauma-a systematic review]. / Wertigkeit der Laparoskopie beim penetrierenden und stumpfen Abdominaltrauma ­ ein systematisches Review.

BACKGROUND: The range of indications for laparoscopic procedures has been continuously widened in recent years. At the same time, however, the diagnostic and therapeutic role of laparoscopy in the management of blunt and penetrating abdominal trauma remains controversial. METHODS: A systematic literature search was carried out in PubMed from 2008 to 2019 on the use of laparoscopy in blunt and penetrating abdominal trauma. Studies were analyzed in terms of relevant operative and perioperative event rates (rate of missed injuries, conversion rate, postoperative complication rate). On the basis of this analysis, an algorithm for the use of laparoscopy in abdominal trauma was developed for clinical practice. RESULTS: A total of 15 full texts with 5869 patients were found. With a rate of 1.4%, laparoscopically missed injuries were very rare for both penetrating and blunt abdominal trauma. Of all trauma laparoscopies 29.3% were converted to open surgery (laparotomy). Among the non-converted laparoscopies 60.5% were therapeutic. Complications occurred after trauma laparoscopy in 8.6% of cases. CONCLUSION: By means of systematic laparoscopic exploration, missed injuries in abdominal trauma are extremely rare, so that concerns in this respect no longer seem justified. A large proportion of intra-abdominal injuries can be treated using laparoscopy or laparoscopically assisted procedures.

Associated abdominal injuries do not influence quality of care in pelvic fractures-a multicenter cohort study from the German Pelvic Registry.

Background: Pelvic fractures are rare but serious injuries. The influence of a concomitant abdominal trauma on the time point of surgery and the quality of care regarding quality of reduction or the clinical course in pelvic injuries has not been investigated yet. Methods: We retrospectively analyzed the prospective consecutive cohort from the multicenter German Pelvic Registry of the German Trauma Society in the years 2003-2017. Demographic, clinical, and operative parameters were recorded and compared for two groups (isolated pelvic fracture vs. combined abdominal/pelvic trauma). Results: 16.359 patients with pelvic injuries were treated during this period. 21.6% had a concomitant abdominal trauma. The mean age was 61.4 ± 23.5 years. Comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger (47.3 ± 22.0 vs. 70.5 ± 20.4 years; p < 0.001). Both, complication (21.9% vs. 9.9%; p < 0.001) and mortality (8.0% vs. 1.9%; p < 0.001) rates, were significantly higher.In the subgroup of acetabular fractures, the operation time was significantly longer in the group with the combined injury (198 ± 104 vs. 176 ± 81 min, p = 0.001). The grade of successful anatomic reduction of the acetabular fracture did not differ between the two groups. Conclusion: Patients with a pelvic injury have a concomitant abdominal trauma in about 20% of the cases. The clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. However, the quality of the reduction in the subgroup of acetabular fractures is not influenced by a concomitant abdominal injury. Trial registration: ClinicalTrials.gov, NCT03952026, Registered 16 May 2019, retrospectively registered.

[Quality of operative treatment of pelvic fractures is not influenced by an additional abdominal injury : A monocentric registry study]. / Die Qualität der operativen Versorgung von Beckenfrakturen wird durch eine zusätzliche Abdominalverletzung nicht beeinflusst : Eine monozentrische Registerstudie.

BACKGROUND: Pelvic fractures are rare but severe injuries. The influence of a concomitant abdominal trauma on the quality of care regarding operative parameters, such as reduction quality and the clinical course in pelvic injuries has not yet been sufficiently investigated. METHODS: This study retrospectively analyzed the prospective consecutive data of patients with pelvic injuries treated at the BG Trauma Center in Tübingen in the years 2003-2017. Demographic, clinical and operative parameters were recorded and compared between two groups (isolated pelvic fracture vs. combined abdominal/pelvic trauma). RESULTS: A total of 1848 patients with pelvic injuries were treated during this period and 18.6% had a concomitant abdominal trauma. The mean age was 62.3 ± 23.1 years. Comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger (46.3 ± 20.3 years vs. 70.6 ± 20.8 years; p < 0.001). Both the overall complication rate (31.2% vs. 9.4%; p < 0.001) and mortality (5.0% vs. 1.7%; p = 0.001) were significantly higher in the group with a combination of injuries. The time until definitive surgery of the pelvis was significantly longer in the group with combined injuries (6.0 ± 6.4 days vs. 4.5 ± 4.4 days; p = 0.002). The results of postoperative reduction did not differ between the two groups. CONCLUSION: Patients with a pelvic injuries have a concomitant abdominal trauma in approximately 20% of the cases. The clinical course is significantly prolonged in patients with a combined injury and morbidity and mortality rates are increased; however, the quality of the postoperative results is not influenced by a concomitant abdominal injury.

Biochar amendment improves alpine meadows growth and soil health in Tibetan plateau over a three year period.

Previous biochar research has primarily focused on agricultural annual cropping systems with very little attention given to highly fragile, complex and diverse natural alpine grassland ecosystems. The present study investigated the effect of biochar on the growth of alpine meadows and soil health. This study was conducted in the Qinghai Tibetan Plateau over a three year period to investigate the effect of three rice husk biochar application rates alone and combination with high and low NPK fertilizer dosages on alpine meadow productivity, soil microbial diversity as well as pH, carbon and nitrogen content at 0-10 cm and 10-20 cm depth. At the end of the 3rd year soil samples were analysed and assessed by combined analysis of variance. The results showed that biochar application in combination with nitrogen (N), phosphorus (P) and potassium (K) fertilizer had a significant increase in fresh and dry biomass during the second and third year of the study as compared to control and alone biochar application (p ≤ 0.05). Biochar alone and in combination with NPK fertilizer resulted in a significant increase in the soil pH and carbon contents of the soil. XPS results, the SEM imaging and EDS analysis of aged biochar demonstrated that the biochar has undergone complex changes over the 3 years as compared to fresh biochar. This research suggests that biochar has positive effect on alpine meadow growth and soil health and may be an effective tool for alpine meadow restoration.

Robotic Versus Laparoscopic Sigmoid Resection for Diverticular Disease: A Single-Center Experience of 106 Cases.

Background: Laparoscopic sigmoid resection is the surgical standard for the treatment of diverticulitis. Robotic sigmoid resection with the da Vinci Xi® platform may offer advantages over the laparoscopic approach. Materials and Methods: One hundred and six patients with uncomplicated, complicated, or recurrent diverticular disease underwent robotic (n = 60) or laparoscopic (n = 46) sigmoid resection at our institution between 2013 and 2018. Patient demographics and characteristics, perioperative measures, and complications were retrospectively analyzed. Results: There were no statistically significant differences between the robotic and laparoscopic group with regard to operative time (130 versus 118 minutes; P = .23), anastomotic leakage (6.7% versus 6.5%; P = 1.0), need for stoma (6.7% versus 4.3%; P = 1.0), conversion rate (1.7% versus 0%; P = .36), reoperation (8.3% versus 15.2%; P = .27), overall complications according to the Clavien-Dindo classification (30.0% versus 30.4%; P = .8), mortality (1.7% versus 0%; P = 1.0), and need for intravenous analgesics (3.0 versus 2.1 days; P = .21). The duration of postoperative ileus was significantly shorter in the robotic group (2.2 versus 2.8 days; P = .01). Conclusion: Robotic sigmoid resection for uncomplicated, complicated, or recurrent diverticular disease is a safe and feasible procedure. However, robotic sigmoid resection for diverticulitis is not associated with relevant clinical benefits for patients compared to laparoscopic resection except for a slightly shorter duration of postoperative ileus.

Surgical treatment of gastrointestinal stromal tumours combined with imatinib treatment: a retrospective cohort analysis.

BACKGROUND: Targeted therapies changed the treatment concepts of gastrointestinal stromal tumours significantly. As only possibility to cure surgical resection is the cornerstone of therapy. Thus it is necessary to find out which patients will benefit most regarding modality (neo- or adjuvant) and duration of chemotherapy. METHODS: In a retrospective cohort analysis the medical records of all consecutive patients treated in the department of general and visceral surgery of the university hospital Tübingen between 2004 and 2015 were investigated. Recurrence and survival outcomes were calculated using the Kaplan-Meier method. RESULTS: Tumor location of GIST was gastric in 32, small bowel in 14, rectum in 3 and extraintestinal in 3 patients. Median tumor size was 46 mm. Median mitotic index was 4 per 50 hpf. Resection was achieved R0 in 46 patients, R1 in 4 patients and R2 in 2 patients. Mean overall survival was 58.9 months (range, 46-73 months). Mean recurrence free survival was 45.6 months (range, 36-57 months). Mean overall survival was 58.9 months (range, 46-73 months). Risk factors for recurrence were tumor location and high mitotic index Ki-67. CONCLUSIONS: The prognosis of GIST after surgical resection is favourable. Survival prognosis are excellent. Analysis of KI-67 mitotic index predicted best oncologic outcome.

An integrated review of the correlation between critical thinking ability and clinical decision-making in nursing.

AIMS AND OBJECTIVES: To explore whether there is a correlation between critical thinking ability and clinical decision-making among nurses. BACKGROUND: Critical thinking is currently considered as an essential component of nurses' professional judgement and clinical decision-making. If confirmed, nursing curricula may be revised emphasising on critical thinking with the expectation to improve clinical decision-making and thus better health care. DESIGN: Integrated literature review. METHODS: The integrative review was carried out after a comprehensive literature search using electronic databases Ovid, EBESCO MEDLINE, EBESCO CINAHL, PROQuest and Internet search engine Google Scholar. Two hundred and 22 articles from January 1980 to end of 2015 were retrieved. All studies evaluating the relationship between critical thinking and clinical decision-making, published in English language with nurses or nursing students as the study population, were included. No qualitative studies were found investigating the relationship between critical thinking and clinical decision-making, while 10 quantitative studies met the inclusion criteria and were further evaluated using the Quality Assessment and Validity Tool. As a result, one study was excluded due to a low-quality score, with the remaining nine accepted for this review. RESULTS: Four of nine studies established a positive relationship between critical thinking and clinical decision-making. Another five studies did not demonstrate a significant correlation. The lack of refinement in studies' design and instrumentation were arguably the main reasons for the inconsistent results. CONCLUSIONS: Research studies yielded contradictory results as regard to the relationship between critical thinking and clinical decision-making; therefore, the evidence is not convincing. Future quantitative studies should have representative sample size, use critical thinking measurement tools related to the healthcare sector and evaluate the predisposition of test takers towards their willingness and ability to think. There is also a need for qualitative studies to provide a fresh approach in exploring the relationship between these variables uncovering currently unknown contributing factors. RELEVANCE TO CLINICAL PRACTICE: This review confirmed that evidence to support the existence of relationships between critical thinking and clinical decision-making is still unsubstantiated. Therefore, it serves as a call for nurse leaders and nursing academics to produce quality studies in order to firmly support or reject the hypothesis that there is a statistically significant correlation between critical thinking and clinical decision-making.