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Practical Pediatric
Urology
An Evidence-Based Approach
Prasad Godbole
Duncan T. Wilcox
Martin A. Koyle
Editors
123
Practical Pediatric Urology
Prasad Godbole • Duncan T. Wilcox
Martin A. Koyle
Editors
Practical Pediatric Urology

An Evidence-Based Approach
Editors
Prasad Godbole Duncan T. Wilcox
Department of Paediatric Surgery Division of Urology
Sheffield Children's Foundation Trust University of Colorado Division of Urology
Sheffield Aurora, CO
UK USA
Martin A. Koyle
Department of Surgery and IHPME
University of Toronto Paediatric Urology
The Hospital for Sick Children
Toronto, ON
Canada
ISBN 978-3-030-54019-7 ISBN 978-3-030-54020-3 (eBook)

https://doi.org/10.1007/978-3-030-54020-3
© Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
Paediatric Urology is one of the youngest surgical specialties and much of its devel-
opment has occurred during the era of evidence based medicine. By promoting
clinical and experimental research in Pediatric Urology, specialist societies such as
the Society for Pediatric Urology and European Society for Paediatric Urology have
played valuable roles in ensuring that the new specialty has been built on firm sci-
entific foundations. The establishment of the Journal of Pediatric Urology in 2005
was another influential landmark in Pediatric Urology's development as an evidence
based specialty.
Opportunities to attain the levels of evidence achieved in other areas of medical
research are inevitably more limited in a small volume surgical specialty such as
Pediatric Urology. With certain exceptions (such as the RIVUR, PRIVENT and
Swedish Reflux trials) it has proved very difficult to design and conduct prospective
randomised controlled trials with the statistical power required to meet the highest
levels of evidence based medicine. However, to some extent this deficiency is now
being addressed by systemic reviews and meta analyses of case—controlled clinical
studies. Other obstacles to high quality research include the difficulty in attracting
funding and the length of time before long term outcomes can be reliably evaluated
in adolescence or adulthood. Against this challenging background the editors and
contributors have set themselves a daunting task in seeking to define the scientific
evidence underpinning best practice in clinical Pediatric Urology.
The opening chapter sets the scene by providing an authoritative account of the
history and development of evidence based medicine. This is followed by chapters
on the development of evidence based guidelines, antibiotic usage and the role of
effective pain management: important topics which rarely feature in standard
Pediatric Urology textbooks. For the most part, Pediatric Urologists are practical
clinicians for whom evidence based medicine exists primarily to assist them in car-
ing for their young patients to the highest standards. With this in mind, most of this
excellent book is devoted to enabling Pediatric Urologists to adopt an evidence
based approach to the management of a wide range of practical problems encoun-
tered in their day to day clinical practice. This book will undoubtedly serve as a
valuable resource for trainees—particularly those preparing for examinations. In
addition it will provide established Pediatric Urologists with an opportunity to
v
vi Foreword
appraise their own specialist practice and decision—making in the context of the
latest published evidence. The editors and contributors have distilled a wealth of
valuable and clinically relevant evidence into this textbook and are to be com-
mended on their achievement.
David F. M. Thomas
Emeritus Consultant Paediatric Urologist
Leeds Teaching Hospitals & Professor of Paediatric Surgery
University of Leeds
Leeds, England
Preface
The world of pediatric urology is progressing at a rapid pace. With the advances in
pharmaceuticals, technologies and greater understanding of disease process, treat-
ment decisions can be based on evidence as opposed to anecdotal experience.
Furthermore increasing patient/parental awareness of pediatric urological condi-
tions mandate that the Pediatric Urologist discuss the various treatment options with
the patient and family to enable a shared decision making approach.
With this background, we are delighted to introduce this book ‘Practical Pediatric
Urology—An Evidence Based Approach’. The book is predominantly in a question
and answer scenario based format to enable higher order thinking and decision
making process. Wherever evidence is available, this has been cited in the discus-
sion. A small minority of chapters are descriptive in nature where the scenario based
format would not have been suitable.
This book would be of use to all Pediatric Urologists, Adult Urologists practising
Pediatric Urology, Pediatric Urology and Pediatric Surgery trainees as well as
Trainers. The book can also be used as a self assessment tool for preparation of
Board exams.
We would like to thank the outstanding and timely contributions from the authors.
A special thanks to Ms Madona Samuel, project coordinator for her periodic
prompting to ensure our consistent focus on the project and to Melissa Morton
Executive Editor at Springer for giving us the opportunity to publish this impor-
tant book.
Finally it goes without saying that we are grateful to our families for their
patience and support throughout this process.
Sheffield, UK Prasad Godbole

Aurora, CO Duncan T. Wilcox
Toronto, ON, Canada Martin A. Koyle
vii
Contents
1 The Evolution of Evidence Based Clinical Medicine�� 1

Paul Dimitri
2 Clinical Practice Guidelines: Choosing Wisely �� 17
Prasad Godbole
3 Antibiotic Stewardship in Pediatric Urology: Editorial Comment �� 23
Prasad Godbole, Duncan T. Wilcox, and Martin A. Koyle
4 Pain Management in Paediatric Urology�� 27
Judith Morgan
5 Antenatal Urology�� 39
Martin Kaefer
6 Office Paediatric Urology�� 55
Joana Dos Santos, Mandy Rickard, Armando J. Lorenzo,
and Martin A. Koyle
7 Neonatal Urological Emergencies�� 83
Martin Kaefer
8 Urinary Tract Infection in Infants and Children�� 101
Prasad Godbole
9 Upper Urinary Tract Obstruction�� 113
Mike O’Brien
10 Congenital Upper Tract Anomalies: Duplication,
Cystic Renal Dysplasia, Multicystic Dysplastic Kidney �� 247
David Chalmers
11 Practical Pediatric Urology: An Evidence Based
Approach—Vesicoureteral Reflux and Bladder Diverticulum�� 263
Jonathan Walker, Jacqueline Morin, Leslie Peard,
and Amanda F. Saltzman
12 Lower Urinary Tract Obstruction�� 277
Brian T. Caldwell
ix
x Contents
13 The Lower Urinary Tract�� 305

John M. Hutson
14 Hypospadias�� 319
Felicitas López Imizcoz, Elías Ramírez Velázquez, and
Imran Mushtaq
15 Bladder Exstrophy �� 333
Sébastien Faraj and Marc-David Leclair
16 Genitalia: Undescended Testis, Acute Scrotum, Buried Penis �� 347
Diboro Kanabolo and Mohan S. Gundeti
17 Inguinal Hernia, Hydrocele, Varicocele,
Spermatocele and Abdomino-Scrotal Hydrocele�� 365
Neetu Kumar and Imran Mushtaq
18 Urolithiasis�� 377
Sajid Sultan, Sadaf Aba Umer, and Bashir Ahmed
19 Urologic Tumors�� 405
Patrick J. Hensley and Amanda F. Saltzman
20 Pediatric Urologic Trauma�� 433
Carter Boyd, Elena Gibson, and Pankaj P. Dangle
21 Functional Voiding Disorders �� 451
Anka Nieuwhof-Leppink and Prasad Godbole
22 Neurogenic Bladder �� 469
Kyle O. Rove and Christopher S. Cooper
23 Disorders of Sex Development�� 487
Prasad Godbole and Neil Wright
24 Pediatric and Adolescent Gynecology�� 497
Veronica I. Alaniz
Index�� 513
The Evolution of Evidence Based Clinical
Medicine 1
Paul Dimitri
Learning Objective
• To understand the rationale and need for evidence based medicine for clinical
practice
• To recognise the hierarchies and systems designed to support the evaluation and
classification of clinical evidence
• To understand the challenges and controversies with current systems used in
evidence based medicine
1.1 Introduction
Evidence Based Medicine (EBM) proposed by David Sackett over a quarter of a

century ago is the integration of the best research evidence with clinical expertise
and patient values defined as ‘the conscientious, explicit and judicious use of cur-
rent best evidence in making decisions about the care of individual patients’ sup-
ported by ‘integrating individual clinical expertise with the best available external
clinical evidence from systematic research’ [1]. The concept of EBM was initiated
in 1981 when a group of clinical epidemiologists at McMaster University (Hamilton,
Ontario, Canada), led by David Sackett, published the first of a series of articles in
the Canadian Medical Association Journal based upon ‘critical appraisal’ providing
a framework for clinicians to use when appraising medical literature [1]. Subsequent
to this in 1985, Sackett and co-workers published ‘Clinical Epidemiology: a Basic
Science for Clinical Medicine’ based upon the critical appraisal of research
P. Dimitri (*)
Sheffield Children’s NHS Foundation Trust, Sheffield, UK
Sheffield Hallam University, Sheffield, UK
University of Sheffield, Sheffield, UK
e-mail: [email protected]
© Springer Nature Switzerland AG 2021 1

P. Godbole et al. (eds.), Practical Pediatric Urology,
https://doi.org/10.1007/978-3-030-54020-3_1
2 P. Dimitri
providing the foundations that have gone on to support the principles of EBM [2].
Whilst David Sackett is considered the father of EBM, it was not until nearly a
decade after the first principles of EBM were published that the term ‘evidence
based medicine’ was coined by Gordon Guyatt, the Program Director of Internal
Medicine and Professor of Epidemiology, Biostatistics, and Medicine at McMaster
University [3]. Sackett believed that the truth of medicine could only be identified
through randomised-controlled trials which eliminated the bias of clinical opinion
when conducted appropriately. Furthermore, Sackett distinguished the difference
between EBM and critical appraisal by defining the three principles of EBM (a)
consideration of the patient’s expectations; (b) clinical skills; and (c) the best evi-
dence available [4]. Thus whilst EBM is founded on robust clinical research evi-
dence, there is a recognition that practitioners have clinical expertise reflected in
effective and efficient diagnosis and incorporates the individual patients’ predica-
ments, rights, and preferences. In 1994 Sackett moved to Oxford, United Kingdom
where he worked as a clinician and Director of the Centre for Evidence-Based
Medicine. From here Sackett lectured widely across the UK and Europe on EBM. He
would begin his visits by doing a round on patients admitted the previous night with
young physicians and showing evidence based medicine in action. Junior doctors
learned how to challenge senior opinions encapsulated in expert based medicine
through evidence based medicine [5]. Based upon the growing support and recog-
nised need for EBM, in 1993 Iain Chalmers co-founded the Cochrane Centre which
has evolved to become an internationally renowned centre for the generation of
EBM. Thus the foundations of EBM had been laid to pave the way for an revolution
in interventional medical care, robust in quality, but subsequently open to challenge
from critics that believed that EBM had developed into an overly rigid system lim-
ited by generalisation.
1.2 The Evolution of Evidence Based Medicine
Over the subsequent decade the popularity and recognition for EBM grew exponen-
tially. In 1992, only two article titles included the term EBM; within 5 years, more
than 1000 articles had used the term EBM [6]. A survey in 2004 identified 24 dedi-
cated textbooks, nine academic journals, four computer programs, and 62 internet
portals all dedicated to the teaching and development of EBM [7]. Evidence based
medicine derives its roots from clinical epidemiology. Epidemiology and its meth-
ods of quantification, surveillance, and control have been traced back to social pro-
cesses in eighteenth and nineteenth-century Europe. Toward the middle of the
twentieth century doctors began to apply these tools to the evaluation of clinical
treatment of individual patients [6]. The new field of clinical epidemiology was
established in 1938 by John R Paul. In 1928, Paul joined the faculty of the Yale
School of Medicine as a Professor of Internal Medicine and subsequently held the
Position of Professor of Preventive Medicine from 1940 until his retirement. Paul
established the Yale Poliomyelitis Study Unit in 1931 together with James D. Trask.
It was through this work that the concept of ‘clinical epidemiology’ was established
1 The Evolution of Evidence Based Clinical Medicine 3
in which the path of disease outbreaks in small communities was directly studied.
The concepts of clinical epidemiology were furthered by Alvan Feinstein, Professor
of Medicine and Epidemiology at Yale University School of Medicine from 1969.
Feinstein introduced the use of statistical research methods into the quantification of
clinical practices and study of the medical decision-making process. In 1967
Feinstein challenged the traditional process of clinical decision making based upon
belief and experience in his publication ‘Clinical Judgement’ [8], followed shortly
by Archie Cochrane’s publication ‘Effectiveness and Efficiency’ describing the lack
of controlled trials supporting many practices that had previously been assumed to
be effective [9]. In 1968, The McMaster University was established in Canada. The
new medical school introduced an integrative curriculum called ‘problem-based
learning’ combining the study of basic sciences and clinical medicine using clinical
problems in a tutorship system. The McMaster Medical School established the
world’s first department of clinical epidemiology and biostatistics, which was
directed by David Sackett. The process of problem-based learning led by Sackett
was fundamental to the curriculum; Alvan Feinstein was invited as a visiting
Professor for the first 2 years of the programme to combine clinical epidemiology
with the process of problem-based learning. Thus a new approach to clinical epide-
miology arose combining the methods problem-based learning curriculum, practi-
cal clinical problem solving and the analysis of medical decision making. In 1978
they developed a series of short courses at McMaster University based upon the use
of clinical problems as the platform for enquiry and discussion. This approach was
described in the Departmental Clinical Epidemiology and Biostatistics Annual
report 1979; ‘these courses consider the critical assessment of clinical information
pertaining to the selection and interpretation of diagnostic tests, the study of etiol-
ogy and causation, the interpretation of investigation of the clinical course and natu-
ral history of human disease, the assessment of therapeutic claims and the
interpretation of studies of the quality of clinical care’. The approach adopted in
these courses demonstrated that what we now know as EBM was practiced prior to
its formal introduction into the medical literature. These courses were the catalyst
for the landmark series of publications in the Canadian Medical Association Journal
in 1981 [2] describing the methodological approaches to critical appraisal, culmi-
nating in Guyatt’s publication in 1992 in JAMA (Journal of the American Medical
Association) popularising the term ‘Evidence Based Medicine’ [10]. Guyatt stated
‘a new paradigm for medical practice is emerging. Evidence-based medicine de-
emphasises intuition, unsystematic clinical experience, and pathophysiologic ratio-
nale as sufficient grounds for clinical decision making and stresses the examination
of evidence from clinical research’, thus challenging past medical knowledge,
established medical literature and practice formed by consensus and expertise based
upon knowledge derived from clinical research, epidemiology, statistics and bioin-
formatics. However, to ensure the that the principles of EBM carried credibility and
authority from consensus, this and other subsequent publications were written by an
anonymous Evidence-Based Medicine Working Group to ensure the greatest
impact. JAMA under the editorial authority of Drummond Rennie became one of
the first and principle proponents of EBM; of 22 articles on EBM published in the
4 P. Dimitri
first 3 years, 12 were published by JAMA with a further 32 published over the pro-
ceeding 8 years [6]. The terminology ‘evidence-based’ had been previously used by
David Eddy in the study of population policies from 1987 and subsequently pub-
lished in 1990 in JAMA, describing evidence-based guidelines and policies stating
that policy must be consistent with and supported by evidence [11, 12].
EBM is an approach to medical practice intended to optimise decision-making
by emphasising the use of evidence from well-designed research rather than the
beliefs of practitioners. The process of EBM adopts an epistemological and prag-
matic approach dictating that the strongest recommendations in clinical practice are
founded on robust clinical research approaches that include meta-analyses, system-
atic reviews, and randomised controlled trials. Conversely, recommendations
founded upon less robust research approaches (albeit well-recognised) such as the
case-control study result in clinical recommendations that are regarded as less
robust. Whilst the original framework of EBM was designed to improve the deci-
sion making process by clinicians for individual or groups of patients, the principles
of EBM have extended towards establishing guidelines, health service administra-
tion and policy known as evidence based policy and evidence based practice. More
recently there has been a recognition that clinical ‘interpretation’ of research and
clinical ‘judgement’ may also influence decisions on individual patients or small
groups of patients whereas policies applied to large populations need to be founded
on a robust evidence base that demonstrates effectiveness. Thus a modified defini-
tion of EBM embodies these two approaches—evidence-based medicine is a set of
principles and methods intended to ensure that to the greatest extent possible, medi-
cal decisions, guidelines, and other types of policies are based on and consistent
with good evidence of effectiveness and benefit [13]. Following the implementation
of the National Institute of Clinical Evidence (NICE) in the UK in 1999, there was
a recognition that evidence should be classified according on rigour of its experi-
mental design, and the strength of a recommendation should depend on the strength
of the evidence.
1.3 Methodological Approach to Evidence

A
Based Medicine
1.3.1 Reviewing the Evidence
Fundamental to the process of defining an evidence-base, is the ‘systematic review’

which was established to evaluate the available and combined evidence in order to
provide a robust and balanced approach. There are a number of programmes estab-
lished to conduct and present systematic reviews. The Cochrane Collaboration
established in 1993 was founded on 10 principles to provide the most robust evi-
dence; collaboration, enthusiasm, avoiding duplication, minimising bias, keeping
up to date, relevance, promoting access, quality, continuity and world wide partici-
pation [14]. The founders of the Cochrane Collaboration, Iain Chalmers, Tom
Chalmers and Murray Enkin attributed the name to Archie Cochrane who had
conducted his first trial whilst imprisoned during World War II defining the princi-
ples of the randomised-control trial. Through later work Cochrane demonstrated the
value of epidemiological studies and the threat of bias [15]. Cochrane’s most influ-
ential mark on healthcare was his 1971 publication, ‘Effectiveness and Efficiency’
strongly criticising the lack of reliable evidence behind many of the commonly
accepted healthcare interventions at the time, highlighting the need for evidence in
medicine [9]. His call for a collection of systematic reviews led to the creation of
The Cochrane Collaboration. The framework for the Cochrane Collaboration came
from preceding work by Iain Chalmers and Enkin through their development of the
Oxford Database of Perinatal Trials [16]. Through their work in this field, Chalmers
and Enkin uncovered practices that were unsupported by evidence and in some
cases dangerous, thus acting as a catalyst for adopting the same approach to estab-
lish and evidence base across all medical specialities.
The Cochrane Collaboration has grown into a global independent network of
researchers, professionals, patients, carers and people interested in health from 130
countries with a vision to ‘to improve health by promoting the production, under-
standing and use of high quality research evidence by patients, healthcare profes-
sionals and those who organise and fund our healthcare services’ (uk.cochrane.org).
The Cochrane Library now provides a comprehensive resource of medical evidence
for clinicians and researchers across the globe. The aim of the Cochrane Library is
to prepare, maintain, and promote the accessibility of systematic reviews of the
effects of healthcare interventions. It contains four databases: the Cochrane Database
of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of
Effectiveness (DARE), the Cochrane Controlled Trials Register (CCTR), and the
Cochrane Review Methodology Database (CRMD) [17].
1.3.2 Categorising the Quality of Evidence
The utilisation of EBM in different healthcare settings is underpinned by the quality

of evidence available. Different aspects of EBM including evidence-based policy
and evidence-based practice require a certain quality of evidence to inform practice.
Evidence ranges from meta-analyses, systemic review and appropriately powered
blinded randomised-control trials, to expert consensus opinion and case reports; the
inclusion of expert consensus is controversial as it is not felt to represent empirical
evidence. Categorising EBM is derived from the freedom from bias inherent in the
process by which the evidence was derived. There are many examples derived from
organisations that categorise EBM according to the quality of evidence. In 1989
Sackett provided a pragmatic classification of evidence quality based upon trial
design using antithrombotic agents as described in Table 1.1 [18].
An adapted approach to the earlier classifications is the well-established
‘Evidence Pyramid’ (Fig. 1.1) which divides the evidence level pragmatically into
study level data and subject level data based upon trial design. The pyramid priori-
tises randomised control trials due to the ability to provide high levels of internal
validity supporting causal inferences and minimising bias due to selection,
6 P. Dimitri
Table 1.1 1989 classifica- Level Type of evidence

tion of evidence based upon I Large RCTs with clear cut results
trial design
II Small RCTs with unclear results
III Cohort and case-control studies
IV Historical cohort or case-control studies
V Case series, studies with no controls
Systematic review and

meta-analysis
Randomised control trial

e
nc
ide
ev
Case-controlled clinical study

of
ty
ali
Qu
Cohort studies
Case Series/Case Report
Expert opinion
Fig. 1.1 Pyramid of evidence
measurement and confounding. As randomised control trials proliferated the use of

systematic review and meta-analyses were established as means of reviewing the
outputs of multiple trials.
Early evidence hierarchies were initially developed primarily to help clinicians
appraise the quality of evidence for therapeutic effects. The Oxford Centre for
Evidence Based Medicine (CEBM) is a not-for-profit organisation dedicated to the
practice, teaching and dissemination of high quality evidence based medicine to
improve healthcare in everyday clinical practice. Recognising the need to expand
the evidence hierarchy to consider evidence related to the area it is being applied
to, the Oxford CEBM released the first iteration of their guidelines in 2000 based
upon evidence relating to prognosis, diagnosis, treatment benefits, treatment
harms, economic decision analysis and screening; these levels were revised in
2011 (Table 1.2).
The type of evidence required is determined by the area in which the question is
being asked. Thus evidence for treatment, and prognosis will be depend on studies
that use relevant methodologies. For example, a randomised control trial may not be
used to determine prognosis and so the highest level of evidence (type 1) may be
based upon a systematic review of cohort studies. This is because prognosis may be
determined by the impact of not providing introducing an intervention compared to
the use of an intervention. Thus well powered prospective cohort analyses or sys-
tematic reviews would provide the best evidence (Table 1.2). The Oxford CEBM
state ‘The levels are not intended to provide you with a definitive judgment about the
quality of evidence. There will inevitably be cases where ‘lower level’ evidence—say
from an observational study with a dramatic effect—will provide stronger evidence
than a ‘higher level’ study—say a systematic review of few studies leading to an
inconclusive result’. Moreover, the Oxford CEBM website states that the levels
have not been established to provide a recommendation and will not determine
whether the correct question is being answered. The following questions need to be
considered to determine a recommendations [19].
1. Do you have good reason to believe that your patient is sufficiently similar to the
patients in the studies you have examined? Information about the size of the
Table 1.2 Oxford Centre for evidence-based medicine 2011 levels of evidence [19]
Step 1 Step 2 Step 3 Step 4 Step 5
Question (Level 1a) (Level 2a) (Level 3a) (Level 4a) (Level 5)
How Local and Systematic Local Case-seriesb n/a
common is current review of non-random
the random surveys that sampleb
problem? sample allow matching
surveys (or to local
censuses) circumstancesb
Is this Systematic Individual Non- Case-control Mechanism-
diagnostic review of cross sectional consecutive studies, or based
or cross studies with studies, or “poor or reasoning
monitoring sectional consistently studies non-
test studies with applied without independent”
accurate? consistently reference consistently reference
(Diagnosis) applied standard and applied standardb
reference blinding reference
standard and standardsb
blinding
What will Systematic Inception Cohort study Case-series n/a
happen if review of cohort studies or control or case-
we do not inception arm of control
add a cohort studies randomized studies, or
therapy? triala poor quality
(Prognosis) prognostic
cohort studyb
Does this Systematic Randomised Non- Case-series, Mechanism-
intervention review of trial or randomized case-control based
help? randomized observational controlled studies, or reasoning
(Treatment trials or study with cohort/ historically
Benefits) n-of-1 trials dramatic effect follow-up controlled
studyb studiesb
(continued)
8 P. Dimitri
Table 1.2 (continued)

Step 1 Step 2 Step 3 Step 4 Step 5
Question (Level 1a) (Level 2a) (Level 3a) (Level 4a) (Level 5)
What are Systematic Individual Non- Case-series, Mechanism-
the review of randomized randomized case-control, based
COMMON randomized trial or controlled or reasoning
harms? trials, (exceptionally) cohort/ historically
(Treatment systematic observational follow-up controlled
Harms) review of study with study studiesb
nested dramatic effect (post-
case-control marketing
studies, n-of-1 surveillance)
trial with the provided
patient you there are
are raising the sufficient
question numbers to
about, or rule out a
observational common
study with harm. (For
dramatic long-term
effect harms the
duration of
follow-up
must be
sufficient)b
What are Systematic Randomized
the RARE review of trial or
harms? randomized (exceptionally)
(Treatment trials or observational
Harms) n-of-1 trial study with
dramatic effect
Is this (early Systematic Randomized Non- Case-series, Mechanism-
detection) review of trial randomized case-control, based
test randomized controlled or reasoning
worthwhile? trials cohort/ historically
(Screening) follow-up controlled
studyb studiesb
a
Level may be graded down on the basis of study quality, imprecision, indirectness (study PICO),
because of inconsistency between studies, or because the absolute effect size is very small; Level
may be graded up of here is a large or very effect size
b
As always, a systematic review is generally better than an individual study
variance of the treatment effects is often helpful here: the larger the variance the
greater concern that the treatment might not be useful for an individual.
2. Does the treatment have a clinically relevant benefit that outweighs the harms? It
is important to review which outcomes are improved, as a statistically significant
difference (e.g. systolic blood pressure falling by 1 mmHg) may be clinically
irrelevant in a specific case. Moreover, any benefit must outweigh the harms.
Such decisions will inevitably involve patients’ value judgments, so discussion
with the patient about their views and circumstances is vital
3. Is another treatment better? Another therapy could be ‘better’ with respect to

both the desired beneficial and adverse events, or another therapy may simply
have a different benefit/harm profile (but be perceived to be more favourable by
some people). A systematic review might suggest that surgery is the best treat-
ment for back pain, but if exercise therapy is useful, this might be a more accept-
able to the patient than risking surgery as a first option.
4. Are the patient’s values and circumstances compatible with the treatment? If a
patient’s religious beliefs prevent them from agreeing to blood transfusions,
knowledge about the benefits and harms of blood transfusions is of no interest to
them. Such decisions pervade medical practice, including oncology, where shar-
ing decision making in terms of the dose of radiation for men opting for radio-
therapy for prostate cancer is routine
Other frameworks and tools exist for the assessment of evidence. The PRISMA
statement is a checklist and flow diagram to help systematic review and meta-
analyses authors assess and report on the benefits and harms of a healthcare inter-
vention. The Scottish Intercollegiate Guidelines Network (SIGN) Methodology
provides checklists to appraise studies and develop guidelines for healthcare inter-
ventions. The CONsolidated Standards of Reporting Trials (CONSORT) is an
evidence-based tool to help researchers, editors and readers assess the quality of the
reports of trials and the PEDro scale considers two aspects of trial quality, namely
internal validity of the trial and the value of the statistical information.
1.3.3 Grading
Another approach to the evaluation of clinical evidence was proposed in 2000, by

the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) working group providing a transparent and reproducible framework for
assessment [20–22]. It is the most widely adopted tool for grading the quality of
evidence and for making recommendations, with over 100 organisations worldwide
officially endorsing GRADE. It requires users of GRADE assessing the quality of
evidence, usually as part of a systematic review, to consider the impact of different
factors based upon their confidence in the results. A stepwise process is employed
by which the assessors determine the clinical question, the applicable population
and the relevant outcome measures. Systemic reviews are scored accordingly:
• Risk of bias: Is a judgement made on the basis of the chance that bias in included
studies has influenced the estimate of effect?
• Imprecision: Is a judgement made on the basis of the chance that the observed
estimate of effect could change completely?
• Indirectness: Is a judgement made on the basis of the differences in characteris-
tics of how the study was conducted and how the results are actually going to be
applied?
10 P. Dimitri
• Inconsistency: Is a judgement made on the basis of the variability of results

across the included studies?
• Publication bias: Is a judgement made on the basis of the question whether all the
research evidence has been taken to account?
Objective tools may be used to assess each of the domains. For example, tools
exist for assessing the risk of bias in randomised and non-randomised trials [23–25].
The GRADE approach to rating imprecision focuses on the 95% confidence interval
around the best estimate of the absolute effect. Thus, certainty is lower if the clinical
decision is likely to be different if the true effect was at the upper versus the lower
end of the confidence interval. Indirectness is dictated by the population studied
assessing whether the population studied is different from those for whom the rec-
ommendation applies or the outcomes studied are different for those which are
required.
The GRADE system also provides a framework for assessing observational stud-
ies but conversely utilises a positive approach to assessing the quality of the
evidence.
• Large effect: This is when methodologically strong studies show that the
observed effect is so large that the probability of it changing completely is
less likely.
• Plausible confounding would change the effect: This is when despite the pres-
ence of a possible confounding factor which is expected to reduce the observed
effect, the effect estimate is still significant
• Dose response gradient: This is when the intervention used becomes more effec-
tive with increasing dose.
Following the assessment of the quality of evidence derived from systemic

reviews and other methodological approaches, the GRADE system moves to a sec-
ond stage relating to the strength of recommendation (certainty) which will act to
inform guidelines, policy and may also act as a determinant for further research [26].
• High Quality Evidence: The authors are very confident that the estimate that is
presented lies very close to the true value.
• Moderate Quality Evidence: The authors are confident that the presented esti-
mate lies close to the true value, but it is also possible that it may be substantially
different.
• Low Quality Evidence: The authors are not confident in the effect estimate and
the true value may be substantially different.
• Very low quality Evidence: The authors do not have any confidence in the esti-
mate and it is likely that the true value is substantially different from it.
Evidence-based medicine approaches also objectively evaluate the quality of

clinical research by critically assessing techniques reported by researchers in their
publications. Consideration is given to trial design by which high-quality studies
Table 1.3 Cochrane’s table of evidence to guide evaluations of the internal and external valid-
ity—(efficacy, effectiveness and cost-effectiveness) of medical intervention [9, 19]
Type of
evidence Question Description
Efficacy Can it work? Extent to which an intervention does more good than
harm under ideal circumstances
Effectiveness Does it work in Extent to which an intervention does more good than
practice? harm under usual circumstances
Cost- Is it worth it? The effect of an intervention in relation to the resources
effectiveness
have clearly defined eligibility criteria and have minimal missing data. Some studies
may only be applicable to narrowly defined patient populations and may not be
generalisable in other clinical contexts. Studies also have to be sufficiently powered
to ensure that the number of patients studied is sufficient to determine a difference
between interventions and also need to run over a sufficient period of time to ensure
sustainable change. Randomised placebo controlled trials are considered the gold
standard in this respect providing they are sufficiently powered and have minimised
missing data points.
As early as 1972, Cochrane proposed a simple framework for evaluating medical
care that could be applied to treatment and policy in current-day medical practice
[9]. The questions posed test the internal and external validity of an intervention
(Table 1.3).
The fundamental importance in this approach lies in the extent to which the pro-
cess focusses on the external validity accounting for the application of an interven-
tion in clinical practice and the resulting financial impact.
1.4 Challenges to Evidence Based Medicine
Evidence Based Medicine has clearly revolutionised the practice of medicine, the
choice of investigations and treatments and has challenged therapies which had pre-
viously been built on limited evidence and opinion, but had gone unchallenged due
to the hierarchical constraints of the medical profession. However, there has been
criticism about inherent weaknesses of EBM. Some have suggested there is an over-
reliance on data gathering that ignores experience and clinical acumen, and data
which may not have formed part of the clinical trial process, and does not ade-
quately account for personalised medicine and the individual holistic needs of the
patient. Thus, EBM does not seek to extend to more recent advances in stratified
medicine. Others have argued that the hierarchical approach to EBM places the
findings from basic science at a much lower level thus belittling the importance of
basic science in providing a means of understanding pathophysiological mecha-
nisms, providing a framework and justification for clinical interventions and an
explanation for inter-patient variability [27, 28]. Furthermore, EBM has been
regarded as overly generalisable, considering the treatment effect to large
12 P. Dimitri
populations, but not accounting for the severity of a disease, whereby a treatment
may offer significant effect to those who are seriously affected compared to little or
no impact for those who are mildly affected by the same condition. Thus within
analyses, sub-stratification of patient cohorts may overcome this issue. Although a
doyenne of EBM, Feinstein also argued that some of the greatest medical discover-
ies, for example the discovery of insulin and its use in diabetic ketoacidoisis have
come about from single trials and would not stand up to the rigours of evidence
based medicine [29]. Feinstein argued that there was too much emphasis placed
upon the randomised-control trial and the process simply tests one treatment against
another, with additional acumen needed to treat a patient in relation to presentation
and severity of symptoms. Thus there is a concern that practice that does not con-
form to EBM is marginalised as a consequence. EBM is also restricted in its use for
the defined patient population and does not consider alternative patient groups using
the same therapies and interventions. Evidence defined by the RCT should also be
challenged by observational and cohort studies in which supported treatments may
lead to adverse effects in certain patient populations. Meta-analyses often include
highly heterogeneous studies and ascribe conflicting results to random variability,
whereas different outcomes may reflect different patient populations, enrolment and
protocol characteristics [30]. Richardson and Doster proposed three dimensions in
the process of evidence-based decision making: baseline risk of poor outcomes
from an index disorder without treatment, responsiveness to the treatment option
and vulnerability to the adverse effects of treatment; whereas EBM is focused on the
potential therapeutic benefits it does not usually account for the patient inter-vari-
ability in the latter two dimensions [31].
The GRADE approach described earlier attempts to overcome some of these
challenges by defining a system that provides a ‘quality control’ for evidence such
that powerful observational studies for example may be upgraded due to the dra-
matic observed effect. The use of meta-analyses and systematic reviews as a gold
standard are also scrutinised by GRADE for their inherent weaknesses. Heterogeneity
(clinical, methodological or statistical) has been recognised as an inherent limita-
tion of meta-analyses [32]. Different methodological and statistical approaches
used in systematic reviews can also lead to different outcomes [33]. To this extent
some have suggested that the approach to the evidence based pyramid should be
adapted to incorporate a more rational approach to the assessment of evidence and
with the use of systematic reviews at all levels of the evidence pyramid to determine
the quality of the evidence [34]. Others have argued that the rigidity of the
randomised-control trial has allowed an exploitation through selective reporting,
exaggeration of benefits and the misinterpretation of evidence [35, 36]. Greenhalgh
and colleagues state that through ‘overpowering trials to ensure that small differ-
ences will be statistically significant, setting inclusion criteria to select those most
likely to respond to treatment, manipulating the dose of both intervention and con-
trol drugs, using surrogate endpoints, and selectively publishing positive studies,
industry may manage to publish its outputs as unbiassed in high-ranking peer-
reviewed journals’ [37]. Fundamentally and most importantly, whilst Sackett
believed that the predicament of the patient formed part of the process of EBM, the
rigidity of the system has resulted in a paradigm shift away from this principle.
Some believe that EBM provides an oversimplified and reductionistic view of treat-
ment, failing to interpret the motivation of the patient, the value of clinical interac-
tion, co-morbidities, poly- pharmacy, expectations, environment and other
confounding and influential variables and demand a return to ‘real evidence based
medicine’ [37]. Others recognise that published evidence should also be presented
in a way that is readable and usable for patients and professionals [38].
1.5 Conclusion
Since the foundations of evidence based medicine were introduced by David

Sackett and colleagues in 1981 and the concept defined a decade later by Gordon
Guyatt, EBM has provided a revolutionary framework defining medical interven-
tions that challenged conventions of opinion-based medical practices based upon
experience and position. Medical guidelines, policy and practice were founded by
the evidence defined by research with frameworks subsequently applied that pro-
vided a means of defining the quality of the research and a system (GRADE) that
assessed the quality of the research output and the ability to apply the evidence to
clinical practice. Well established organisations now exist to systematically assess
research evidence to provide an evidence-based resource for clinicians and
researchers. Despite the recognised impact of evidence based-medicine, in the rap-
idly advancing era of personalised and stratified medicine, and the established role
that basic science research plays in understanding the pathophysiology of disease
and the impact of therapeutic intervention, the value of EBM has been questioned.
In current day medical practice, many now recognise the need to balance the value
of EBM with other methodological approaches to define future healthcare and
interventions for patients.
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Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol.
2011;64(4):383–94.
23. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane
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scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa:
Ottawa Hospital Research Institute; 2011. Oxford. Asp; 2011
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a tool for assessing risk of bias in non-randomised studies of interventions. BMJ (Clinical
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Clinical Practice Guidelines: Choosing
Wisely 2
Prasad Godbole
Learning Objectives
• To understand the process of developing guidelines
• To understand the process of critically reviewing guidelines
• To understand how/which guidelines should be implemented
2.1 Introduction
As Paediatric Urologists or in fact as clinicians in any discipline, we come across a

vast array of guidelines from which to choose. The ultimate aim of clinical guidelines
is to offer the clinicians an evidence based patient focused resource to improve patient
outcomes, maintain patient safety and provide the most cost effective treatments.
Guidelines can be found nationally, regionally or locally. Most local guidelines are
adopted from existing guidelines but tailored for local use. With the vast array of
guidelines available it can be a daunting task to determine which guidelines to choose
from for patient management as not all guidelines are consistent and may differ widely
in their content and recommendations. This chapter will focus on how guidelines are
developed and how end users—the clinicians can determine which guidelines have
been developed in a robust fashion to use with the highest level of evidence.
2.1.1 Clinical Guideline Development
There are several key steps when developing guidelines. These are:
1. Identify an area in which to develop the guidelines
P. Godbole (*)
Department of Paediatric Surgery, Sheffield Children’s NHS Foundation Trust, Sheffield, UK
e-mail: [email protected]
© Springer Nature Switzerland AG 2021 17

P. Godbole et al. (eds.), Practical Pediatric Urology,
https://doi.org/10.1007/978-3-030-54020-3_2
18 P. Godbole
2. Establish a core guideline developmental group

3. Agree on guideline appraisal process
4. Assess existing guidelines for quality and clinical content
5. Decision to adopt or adapt guideline
6. External peer review of the guideline
7. Endorsement and ratification at local level
8. Local adoption
9. Periodic Review of the guideline
2.2 Identifying an Area in Which to Develop Guidelines
The key consideration is to develop a guideline for areas which may be prevalent in
the local population or which will have improved outcomes for a maximum number
of patients. This could be areas such as urinary tract infections in children, congeni-
tal obstructive uropathies, urinary tract calculi, nocturnal enuresis to name a few.
2.3 Establish a Core Guideline Developmental Group
Once an area has been established, all stakeholders including patients/carers should
be involved in the guideline development process. For urinary tract infections this
may include pediatricians, Paediatric urologists, general practitioners, nursing staff,
microbiologists, parents of infants and young children and older children. In essence
any stakeholder who may provide a clinical service for or who may benefit from the
area that the guideline is designed for should be included.
2.4 Agree on a Guideline Appraisal Process
How can one determine whether a guideline is sufficiently rigorously developed to

adopt? The guideline development group therefore needs to agree on how the guide-
lines will be appraised. The AGREE instrument is one such appraisal methodology
and is shown below
2.5 Assessing Existing Guidelines
The initial chapters on Evidence Based Medicine already highlights the levels of
evidence and the hierarchy of evidence. As clinical guidelines are outcome focused
and are aimed to be cost effective, the following levels of evidence and their impli-
cation for clinical decision making may be used to assess existing guidelines. A
strategy to retrieve guidelines has to be agreed eg. Search terms, language/s, data-
bases etc.
2 Clinical Practice Guidelines: Choosing Wisely 19
Levels of evidence for therapeutic studies
Level Type of evidence

1A Systematic review (with homogeneity) of RCTs
1B Individual RCT (with narrow confidence intervals)
1C All or none study
2A Systematic review (with homogeneity) of cohort studies
2B Individual Cohort study (including low quality RCT, e.g. <80% follow-up)
2C “Outcomes” research; Ecological studies
3A Systematic review (with homogeneity) of case-control studies
3B Individual Case-control study
4 Case series (and poor quality cohort and case-control study
5 Expert opinion without explicit critical appraisal or based on physiology bench
research or “first principles”
a
From the Centre for Evidence-Based Medicine, http://www.cebm.net
Grade practice recommendations
Grade Descriptor Qualifying evidence Implications for practice

A Strong Level I evidence or Clinicians should follow a strong
recommendation consistent findings recommendation unless a clear and
from multiple studies compelling rationale for an alternative
of levels II, III, or IV approach is present
B Recommendation Levels II, III, or IV Generally, clinicians should follow a
evidence and findings recommendation but should remain
are generally alert to new information and sensitive
consistent to patient preferences
C Option Levels II, III, or IV Clinicians should be flexible in their
evidence, but findings decision-making regarding appropriate
are inconsistent practice, although they may set bounds
on alternatives; patient preference
should have a substantial influencing
role
D Option Level V evidence:little Clinicians should consider all options
or no systematic in their decision making and be alert to
empirical evidence new published evidence that clarifies
the balance of benefit versus harm;
patient preference should have a
substantial influencing role
From the American Society of Plastic Surgeons. Evidence-based clinical practice guidelines.
Available at: http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advo-
cacy/Health_Policy_Resources/Evidence-based_GuidelinesPractice_Parameters/Description_
and_Development_of_Evidence-
While the agree criteria may be used to determine the quality of the guideline, a
quick screening process that has been advocated is to determine the rigor of devel-
opment (number 7 of the AGREE criteria). Furthermore, the guideline should be
current. The content of the guideline also must be considered. Where more than one
guideline is being considered, a comparison between guidelines, recommendations
20 P. Godbole
and levels of evidence may result in evolution of a guideline incorporating recom-

mendations from more than one guideline.
2.6 Decision to Adapt or Adopt a Guideline
Once the process above is completed, a decision must be made by the guideline
development group as to the robustness of the guideline for local use. The guideline
may be used un modified or may need to be adapted for local use but maintaining
the key principles within the guideline.
2.7 External Peer Review
If a decision is made to adopt a guideline, the guideline should be sent to a specialist

in that field for peer review of the applicability of the guideline for local use. In
some instances when local guidelines are being developed without reference to
national/international guidelines, the peer reviewer may be a senior clinician within
the speciality. For example a guideline on the management of Transanal irrigation
or on insertion of catheters may be developed by specialist urology nurses and
reviewed by a Paediatric Urologist.
2.7.1 Endorsement and Ratification at Local Level
Once peer reviewed, the guideline has to pass through a formal process of ratifica-
tion usually via a committee that approves the guideline for local use. In the authors’
institution, this is the Clinical Audit and Effectiveness Committee. Guidelines for
approval are sent out in advance of the meeting and discussed in the meeting prior
to approval.
2.8 Local Adoption
Once approved, the guidelines are adopted for local use. Guidelines are reviewed at
periodic intervals of 2–3 years with updates.
2.9 Conformity to Guideline Adherence
While the process above describes best practice in developing guidelines and how
to determine which guidelines are robust, getting clinicians to adhere to the guide-
lines can be a different matter. In the past, surgical training was more paternalistic
in that the ‘doctor was always right’ and training was more experience based rather
2 Clinical Practice Guidelines: Choosing Wisely 21
than evidence based. In such scenarios, changing mindset of individuals can be a

daunting task. So imagine a scenario where a guideline is developed in a robust
fashion using the AGREE tool and the surgeon does not adhere to the guideline.
How can that be reversed?
In many organisations and indeed nationally there are specific standards that
need to be met in terms of guideline adherence. In England for example the National
Institute for Health and Clinical Excellence (NICE) publishes monthly requests for
information regarding guidelines adherence and new technology appraisals.
Individual organisations are expected to provide a baseline assessment of adherence
to the guideline (Urinary tract infection is a good example) or provide deviation
statements with rationale for the deviation from the guideline. These baseline
assessments are required to be updated every 2 years. In many instances individual
organisations may face a financial penalty for not providing these reports. As a
result at local level, organisations have mechanisms in place led by clinicians to
ensure this information is collected in a prompt manner.
Guidelines are developed to ensure standardised care and best possible clinical
outcomes. Hence audit of outcomes are also important in ensuring adherence to
guidelines. If outcomes are poorer than expected than a review of the guideline or
adherence to the same by clinicians should be triggered.
2.10 Conclusion
It is important for clinicians to understand the process of guideline development.

Wherever possible guidelines that are developed using the highest level of evidence
should be considered for local use. These guidelines may be tailored for local use
and must be reviewed periodically to incorporate any new evidence that may be
available. Regulatory oversight and audit of outcomes are useful tools to ensure
guidelines are being followed.
Appendix: Domains of AGREE II Appraisal Instrument
Scope and purpose

1. The overall objective(s) of the guideline is (are) specifically described
2. The health question(s) covered by the guideline is (are) specifically described
3. The population (patients and public) to whom the guideline is meant to apply is specifically
described
Stakeholder involvement
4. The guideline development group includes individuals from all the relevant professional
groups
5. The views and preferences of the target population (patients, public, etc.) have been sought
6. The target users of the guideline are clearly defined
Another random document with
no related content on Scribd:
The Rebels for a while concealed their loss, but ’tis now generally
allowed they had at least ten or twelve killed, several of these
French, but all common men. It is indeed generally believed that one
of them was a French Officer, as he was put in a grave by himself
with several Popish Ceremonies, though not certain. But the Rebels
still refuse that it was an Officer. They had also a good many
wounded, among whom was Mr Gordon of Birkenbuss, a gentleman
of a small estate, very dangerously.
The McLeods again had only five killed dead on the spot, which
was well known, as their bodies were left exposed for some days or
they allowed them to be buried. One also died of his wounds in the
retreat, as did another that was taken prisoner, but they were all
common men. About thirty were taken prisoners (many of which
were wounded) including ten or twelve Humlys (Colones)[362] that
they had picked up. Among the prisoners were Mr. Gordon, Ardvach,
Lieutenant of Culkairn’s Company, Mr. Chalmers, Principal of the
King’s College, and Mr. Forbes of Echt; McLeod’s own piper,
McGrimman,[363] happened also to be taken, and the piper is always
looked on as a person of importance in a Highland Chief’s retinue,
but McGrimman especially was a respectable person being
esteemed the best piper in the Highlands, having had most of the
Clan pipers as his scholars, and being looked on by them as a kind
of chief, and the veneration they had for him appeared when he was
carried prisoner to their army at Stirling, for it is said not a Highland
piper would play a tune till McGrimman was allowed to be on his
parole, and he himself behaved with so much state that he would
play to none of them till their prince himself desired him. Mr.
Maitland, Pitrichy, escaped to Keithhall, the house of the Earl of
Kintore, the night of the engagement, where he concealed himself all
next day, but unluckily venturing to show himself to Petry, the Sherriff
Depute, who intruded himself that night on the Earl, and Mr.
Maitland, and he squabbling over drink, Petry not only in violation of
the laws of hospitality, and of many obligations he was under to the
Earl of Kintore, but also of his own promise to the contrary, basely
went off next morning and sent a party of the Rebels who seized
him.
The Rebels do not venture to pursue
The McLeods passed the Ury about a quarter of a mile from the
town and refreshed themselves at Rayne and Strathboggy, but
stopped not a night till they got over Spey, where McLeod waited the
coming up of such of his men as had gone other roads, and
continued guarding the passes for some while after. But the Rebels
were so apprehensive what might be the consequences when for
ought they knew, they were joined by the Monroes, etc., that they
would not venture to pursue them over the Ury. McLeod lost most of
his baggage, but the greater part came not into the Rebels custody
but was secreted and pilfered by the townsfolks.
Mr. Horn stress’d
As the Rebels were informed of Mr. Horn’s design of joining the
McLeods, they were exceeding keen in their resentment against him,
and immediately sent a party to seize him, but he luckily had gone
out of the way. The party lived a good while at his house at free
quarters and made very free with everything, demanding the arms
he had made, and the Cess Levy money, but Mr. Horn had left
positive orders though they should burn the house to give them
neither, and as their Officers had by this time got pretty certain
information that their affairs were wrong in England and their Prince
retreating, they did not choose in these circumstances to do such a
shocking thing. And it was certainly a lucky thing that they got this
intelligence to calm them after the flush of their Inverury victory, or
then the Fire Order had undoubtedly been put in execution in these
counties.
Quartering for Levy Money
The towns of Aberdeen having now no relief were obliged to pay
their Quota of Levy money, that of the New town amounted to about
£500 Sterling. A party of the Clan Chattan (Mclntoshes, Shaws and
McGilavrys) under McGilavry of Dunmaglass, being now come up
from Dundee to support their friends in Aberdeen in case of a
straight, these for the greater terror were employed as far as
possible for quartering in the gentlemen’s houses in the country for
the Levy money. But the Rebels finding it would take longer time to
get people forced to give the whole of their exorbitant demands than
they could bestow, as they foresaw that in a week or so they must
march to reinforce their friends in the South, they were therefore
willing to compound the matter and take half in hand, and a bill for
the other half payable at Candlemass, and in this way they gathered
in a good deal of money. But still there were several gentlemen
stood out for a good while under all the hardships they imposed,
especially Mr. Leith of Freefield (whom they also kept a while
Prisoner), Mr. Patan of Grandsam, and Mr. Burnet of Kemnay. Mr.
Burnet’s zeal for our constitution, and the endeavours he used to
awaken the British spirit among his neighbours, had rendered him
excessively obnoxious to the Rebels, they hunted him for some
weeks from place to place, to seize him, but he at length got to
Edinburgh, where he was obliged to stay till his Royal Highness
marched for Aberdeen.
Rebels called up
The resolute delays of some few gentlemen, and the great
number they had to quarter upon, made it impracticable for the
Rebels to collect their Levy money from much more than one half of
these counties, before they were called up and obliged to march and
reinforce their friends in the South, so that almost all Buchan, and
most of the more remote estates in both Banff and Aberdeenshire
escaped at this time.
Elsick’s Men, and McGregors come to Aberdeen
Soon after Lord Lewis marched up with the whole of the Rebels
from this country, there arrived a Spanish ship at Peterhead with
arms and money, which brought a party of Elsick’s[364] men from the
Mearns to possess Aberdeen and bring up this loading; but they
being looked on as weak, a party of the McGregors joined them.
None of these parties however ventured to the country but only while
they were bringing up their cargo from Peterhead. Lord Lewis had
been abundantly arbitrary in his Government, Horses and Arms had
been everywhere seized throughout the counties, under the pretence
of searching for arms; in houses both in town and country many
things had been pilfered with impunity, and he himself treated
everybody with a great deal of insolence, but all this was but a jest in
comparison with these McGregors. They went to people’s houses
through the town and always behaved so very rudely as to make
them forced to give them money to go away. They would stop
gentlemen on the streets openly, and either take their silver buckles
and buttons from them, or oblige them to give so much to redeem
them. Without the least provocation they would beat and abuse
people; and whenever they took it into their heads to enquire about
any gentlemen’s principles they met with, they came up with their
broadswords drawn and asked what King they were for? If they
hesitated the least in answering ‘King James,’ they were sure of a
slap, and never got away till they sat down on their knees and swore
to the Pretender, and cursed King George in any terms the ruffians
pleased. But happily they soon went off with the arms and left
Elsick’s men only to guard the town. These continued mostly till the
retreat of their army and behaved pretty civilly; indeed though they
had inclined to do otherwise, yet the town’s people not being under
so much restraint as formerly, began to show themselves so keenly,
that they made them glad to be peaceable, for fear of their being
mobbed.
Rebels retreat from Stirling
The whole Rebel Army, except the Clans that went the Highland
road with their Prince, passed through Aberdeenshire on their retreat
from Stirling. They marched in two columns (the clans making a
third), Lord Lewis Gordon’s men, the Deeside men, Glenbucket’s
men and some other body’s forming one column and marching in the
high road to Strathboggy. The rest of their army formed another
column and marched with such baggages as they had got off from
Stirling, or the Clans had left them, through the town of Aberdeen.
They were commanded by Lord George Murray and consisted
mostly of the Athole Brigade, French, Lord Ogilvies men,[365]
Cromarty’s, Kilmarnock’s, Kelly’s,[366] Elsick’s, Lifeguards, Hussars,
and all their other Lowland Corps. They stayed but short while in
Aberdeen and so had not great opportunity of doing much mischief,
though they seemed not at all averse to do it. For the ill situation of
their affairs and their marching in such cold stormy weather, put
them in a great fret. They threatened dreadful things against they
should return Conquerors, particularly against the Clergy of the
Church of Scotland, on which subject none was more violent than
Lord John Drummond, who once and again proposed the hanging of
some of them for examples; and indeed the Clergy were so sensible
of their danger, that if the Duke had been obliged to retreat again,
most of them had resolved to prepare to leave the country. They
divided at Aberdeen and marched to Spey, some by Old Meldrum
and Banff and some by Inverury and Strathboggy. At Speyside they
all joined and met there with the other column. There was a good
deal of pilfering by their stragglers in this march, but when the
country people had the resolution to oppose them, they behaved
very cowardly. The minister of Clate[367] in particular and a few of his
parishioners unarmed, took the guns and bayonets from two
Strathboggy men who fired on the people for finding fault with their
robbing a dyeing woman of her bedclothes.
Hussars and Stonnywood’s men left in Aberdeen
Stonnywood’s men though they had marched so far in the
Highroad, yet came off from the rest of their corps and marched
down by Deeside to Aberdeen, where they remained after the main
body had left it, along with the Hussars under one Colonel Baggot,
[368] a French Officer, and a very rough sort of man and so
exceeding well fitted to command the Banditti of which that Corps
was composed, and to distress a country. The Lord Lieutenant was
along with their Prince, so Lonmay, the Depute Governor, had the
chief direction, though both he and Stonnywood pretended that most
of the extravagant things done by the Hussars, was owing to Baggot.
They immediately fell to work to collect the remains of the Levy
money. And now they had a new contrivance to force it. These
fellows, the Hussars, went galloping about, and seized the
gentlemen that were refractory, or their factor, or then the principal
tenants, if none of the former could be found, and brought them in
prisoners to Stonnywood and Baggot, the last of whom was sure to
use them very roughly. But most of the gentlemen absconded, and
some of the few they got stood out against all their bad usage, as
particularly Mr. Innes, Factor to the Earl of Kintore. The Tenants
which they seized had not the money to give so they were obliged at
length to let them go and made but very little of this method. The
Hussars were vastly rude and expensive wherever they went, and
failed not to pick up any horses as they come along that were
remaining. But for all their roughness, people that would venture to
stand their ground, would sometimes get the better of them. One
instance of which was at New Dear when two of them armed with
pistols were taking a gentleman’s horse and money, the minister of
the place[369] being only with the gentleman, and both of them only
with staves in their hands; the minister first knocked down one of the
fellows and the gentleman the other, and disarmed them both and
set them off.
Some of Fitzjames Dragoons land
The Saturday before his Royal Highness came to town, a French
ship landed some of the Dragoons of Fitzjames’ Regiment at
Aberdeen with their riding furniture.[370] There had come afore about
the same time another French ship with the money for the
Pretender’s use, but the Master thought it dangerous to land it at
Aberdeen as the Duke was so near, and so sailed about for
Peterhead where it was received by Lonmay.[371] Fitzjames’
Dragoons marched off next day, as did also Stonnywood and his
men with the Hussars, and thus the town of Aberdeen at length got
free of the Rebel Government, after it had been about five months
subject to it.
Duke of Cumberland comes to Aberdeen
The Tuesday thereafter General Bland arrived in town with the
van of the Army under the Duke of Cumberland, and his Royal
Highness on the Thursday thereafter. The Burgesses lined the
streets all the way from the Duke’s entry into the town to his
lodgings. He was immediately waited on by the nobility and gentry of
town and county, and next day by the Colleges and Clergy who had
assembled in a Synod pro re nata and had all the honour to kiss his
hand. Mr. Osborne, Principal of the Marischal College, made a short
congratulary speech to his Highness in name of the colleges, as did
Mr. Theodore Gordon, Moderator of the Synod in name of the
Clergy, and both had gracious returns.
More of Fitzjames’ Dragoons land in Buchan
Soon after this another of the Transports with Fitzjames’
Dragoons having got information on the coast, of the Duke’s being at
Aberdeen, landed in Buchan[372] and then very narrowly escaped
from the Duke’s Picquets who were ordered out to intercept them.
Lord Ancrum[373] marches to Curgaff
As to Lord Ancrum’s expedition to Curgaff, a house belonging to
Forbes of Skeleter in Strathdon (vid. London Gazette, March 11th),
Glenbucket was then with a few men within a few miles of Strathdon.
But his numbers were greatly magnified, and his being actually at
hand was so artfully insinuated to a minister’s wife in the
neighbourhood, that with the honestest intention in the world, she
gave a false alarm which made his Lordship in such a hurry that
though he destroyed the powder, yet he only scattered the ball,
broke a few of the arms, and carried off a very few, the rest falling all
into the hands of the country people. And yet one might imagine that,
as his dragoons were not to gallop off and leave the Foot, there had
been no miss in making them dismount and walk for a few miles and
loading their horses with the Arms, till they should come to some
place where country horses might have been got.
Bland[374] at Old Meldrum
When part of the army under General Bland advanced to Old
Meldrum, Barrels and Price’s under Lieutenant Rich[375] lay at
Inverury which is on the ordinary Post Road to Strathboggy (where
about 3000 of the Rebels under Roy Stuart were with the Hussars)
and about 100 Grants that came to escort their Laird to
Aberdeen[376] formed an advance guard on this road, as the
Campbells did from Old Meldrum, where they were very alert and
watchful, so that the Rebels never once offered to disturb either the
Generals or Lieut. Rich’s Quarters. And indeed if they had, all
possible care was taken to give them a warm reception. There was a
bridge of boats thrown over the Ury on the road from Inverury to Old
Meldrum, and a Guard midway betwixt the two Garrisons who could
observe a blaze in the night time at either of them or anything
happening extraordinary, and by a blaze could give information of it
to the other, and the Light Horse, too, were quartered betwixt so as
to form a line of communication.
Rebels attempt to surprise the Grants
The night before General Bland marched for Strathboggy, the
Grants came first to the Kirk Town of Clate, which is about six miles
south of Strathboggy and off from the high road to Aberdeen. As
there were many disaffected people thereabouts, the Rebels at
Huntly had notice of it that night, though it was late before they came
there, and they immediately formed a scheme of surprising him next
morning. But Grant, suspecting such a thing might be done, wisely
advanced a mile further the same night to Castle Forbes, a house
belonging to Lord Forbes, and by the strength of its old walls alone
not easily to be taken without cannon, so that next morning when the
Rebels under Roy Stuart missed them at Clate, they returned without
meddling with the Castle.
Bland marches to Huntly
Meantime General Bland had kept his orders for marching that
morning so very closely that the Rebels had not got the least
intelligence of it. The two corps from Inverury and Old Meldrum met
at Rayne, and had it not been for a small accident, had intercepted
the Rebels who were on the Clate Expedition and got to Strathboggy
before them. For they, dreaming of no such thing, breakfasted very
leisurely at Clate and stopped also at a public house betwixt it and
Huntly. There was an exceeding great fog on the Hill of the Foudline,
so that some senseless, idle people that were running up before the
army, imagined that a plough that was going in the midst among
some houses on the side of the hill, was a party of men; on which
they gave the alarm that the Rebels were at hand, this was
immediately forwarded by the liger Ladys[377] with a deal of
consternation, so that some people of better sense gave credit to it
and came up to the General with this false alarm. Whatever might be
in it, he judged it safest for the men to halt and form, while proper
persons were sent up to see what the matter was, who soon found
out the mistake. But this trifle occasioned a stop for near half an hour
or three quarters, and the Rebels were scarce so long in
Strathboggy before the General came there.
The Enemy knew nothing of them till they came within sight of
Strathboggy. They had but just come there, and ordered dinner, but
they thought proper to leave it in a great hurry on Bland’s approach.
Their Hussars and some gentlemen on horseback brought up the
rear. Among these last, was Hunter of Burnside,[378] who for a good
way kept within speech of the party under Major Crawford and the
volunteers that pursued them; but managed his horse with so much
dexterity, turning so oft and so nimbly, that they could not aim at him
rightly; at length one of the Campbells shot so near him as made him
start aside and gallop off, and as the forces took him for Roy Stuart,
this gave occasion to the story of that gentleman being either killed
or wounded. The soldiers were incensed, and not unjustly with a
notion that Strathboggy was extremely disaffected: coming in to it
therefore under this impression after a long march in a bitter bad
rainy day, it was no surprise that they used some freedom with a few
peoples houses, who, conscious of their own demerit, had locked
their doors and run off, leaving nobody to care for the soldiers that
were to quarter in them.
Captain Campbell surprised at Keith[379]
Next day the General sent up seventy Campbells, and 30 Light
Horse to Keith, a little town six miles from Huntly, and half way
betwixt it and Fochabers where the Rebels had retired. One
Alexander Campbell, a Lieutenant, had the command, who had been
all along very alert on the advanced guard and had met with no
check, though oft in as dangerous a situation, but next night had the
misfortune to have his party surprised. This was chiefly owing to the
dissaffection of the inhabitants, who conducted the Rebels at dead of
night, not by any set road, but through the fields so as not to meet
with the Patroles, and then having fetched a compass about, and
entering the town on the south, by the way from Huntly, were
mistaken by the Sentrys, to whose calls they answered in a friendly
way, for a reinforcement they had some expectation of. The Guard
was conveniently posted in the Church and church yard which was
very fencible, and the Lieutenant, who had not thrown off his clothes,
on the first alarm ran out and fought his way into them, and behaved
very gallantly with his guard for a while. But the rest of his men,
being mostly all taken asleep, and having himself received several
wounds, he was at last obliged to surrender. The enemy suffered
considerably, but carried off their slain, so that their numbers were
not known. The Lieutenant was left a while with only one Sentry to
guard him, on which he very resolutely grappled with him, disarmed
him and got off; but being retarded by his wounds he was soon
retaken and then they hashed him miserably and left him for dead;
yet he afterwards recovered.
Popish and Nonjurant Meetings destroyed
His Royal Highness on coming to Aberdeen immediately stopped
all the Nonjurant Ministers, and soon after ordered their Meeting
Houses and the Mass Houses to be destroyed, which was
accordingly executed both in town and country as the Army marched
along, and indeed none were surprised at this piece of discipline, as
these houses were not only illegal, but had in fact proved such
Nurseries of Rebellion. The Priests had mostly gone off, and such as
could be got were seized and confined, but neither ministers nor
people of the Nonjurants met with any other disturbance unless they
were otherways concerned in the Rebellion. The Army also had
orders to seize the Corn, Horses, and cattle and Arms belonging to
those in the Rebellion, but to touch none of their other effects, and
the generality of the Rebels had foreseen this and either sold or sent
off these things, so that there were but few that suffered much in this
way. If any parties of soldiers used further freedom in these houses,
which was not oft, the Duke, on complaint made, not only obliged the
Officers to be at pains to recover the plundered effects from the
soldiers, but generally gave a compliment himself to make up the
loss; as particularly to Mrs. Gordon, Cupbairdy,[380] he ordered £100
Sterling. His protections were easily obtained till a piece of the
Rebels extravagance not only made this more difficult, but also
obliged his Royal Highness to recall some protections he had
granted, and gave up some houses to be plundered.
Cullon House plundered by the Rebels
The Earl of Findlater was at Aberdeen attending his Royal
Highness, when his factor gave him notice that the Rebels who were
thereabouts had intimated, that if the Cess and Levy money for his
Lordships Estate was not paid against such a day, his house at
Cullon would peremptorily be plundered. This intimation the Earl
showed to his Royal Highness, who ordered him in return to certify
them that if they took such a step, it would oblige him to alter his
conduct, recall his protections and give up their houses to be
plundered. Notwithstanding this threat, the Rebels actually pillaged
Cullon House[381] at the time appointed, and his Royal Highness
was in consequence obliged to withdraw his protections from Lady
Gordon of Park,[380] and Lady Dunbar of Durn,[380] for their houses;
and indeed the last of these suffered considerably, but most of the
effects were carried off from Park that were of any value.
Thornton Disgusted
The famous Squire Thornton[382] who had raised the Yorkshire
Company, his Lieutenant Mr. Crofts, and Ensign Mr. Symson,
Minister at Fala (who had been both taken prisoners at Falkirk), had
come as volunteers with the Army to Aberdeen, though they had
never met with very civil usage from the regular officers who seemed
not at all to affect volunteers. When Pultney’s Regiment was ordered
from Old Meldrum to Buchan on a command one day, these
gentlemen who declined no fatigue, and had usually joined that
corps, marched along. But coming the first night to a little village
called Ellon, the Quarter Master would not assign Quarters to the
volunteers as Officers, and none of the Officers would give orders for
it, which and some other things of this kind effectually disgusted
them, so that they immediately left the army and returned home. His
Royal Highness in order to preserve the town of Aberdeen from any
surprise after he should leave it caused fortify Gordon’s Hospital and
placed a garrison in it under Captain Crosby, and in honour of the
Duke it was called Fort Cumberland.
Duke marches from Aberdeen on Foot
When the Duke marched from Aberdeen[383] he endeared
himself exceedingly to the soldiers (if it was possible to increase their
affection for him) by walking most of the way with them on foot,
generally using one of the soldiers Tenttrees for a staff and never
going a yard out of the way for a bridge or any burn they met with,
but wading through at the nearest.
On a long march of near 20 miles from Old Meldrum to Banff the
following little accident much delighted the spectators. A soldiers
wife carrying a young child, grew quite faint and entreated her
husband, who was near with the Duke, to carry the child for a little
way; the fellow said he could not as he was burdened with his arms.
The Duke overheard, took the soldier’s gun and carried it himself for
some way and ordered him to ease the poor woman of the child for a
while.
Rebels not expecting his March
The Duke being stopped so long at Aberdeen, made his march at
length as great a surprise on the Rebels as if he had not halted a
day, for by this time they were grown very secure. The Duke of
Perth, Lord John Drummond, Roy Stuart, etc., were all lodged in the
minister’s house of Speymouth, and had more than 2000 men along
with them. They were sitting very securely after breakfast, when a
country man came over the River in great haste and told them that
the Enzie was all in a ‘vermine of Red Quites.’[384] But they were so
averse to believe it, that when they ran to an eminence and
observed them at a great distance they swore it was only muck
heaps: the man said it might be so, but he never saw Muck heaps
moving before. And after they were convinced it was a body of men,
still they would only have it to be some of Bland’s parties, till their
Hussars, whom they had sent over to reconnoitre, returned and
assured them the whole Army under his Royal Highness was coming
up.
Duke crosses the Spey
As to the Duke’s passing the Spey (vid. London Gazette, April
19th):—The Soldiers had got a notion that all on the other side Spey
were rank Rebels, and so immediately seized a number of the sheep
and other cattle as soon as they got over. But as the case was quite
otherways and the people of that Parish had been longing for the
Army as their deliverers, on the minister’s representing this, and
what had happened, to his Royal Highness, he immediately ordered
all to be restored that could be got unkilled, and gave the minister
£50 Ster. to divide among the people for their loss, and if that did not
do it directed him to demand whatever would, and it should be
ordered. His Royal Highness took up his quarters in the minister’s,
where the Duke of Perth, etc., had been but a few hours before.
Aberdeen Militia
Immediately after the Duke’s leaving Aberdeen the two towns
raised several companies of Militia to prevent their meeting with
disturbance from any flying parties. His Royal Highness named their
Officers and gave them authority to act. He also named twelve
Governors to have the direction of the N. Town, till they should be
allowed to choose regular Magistrates. There was also a proposal
for raising a County Militia, but the Duke’s victory at Culloden made it
to be dropped as useless.
Ancrum, Commander in Chief
The Earl of Ancrum came to Aberdeen soon after the defeat of
the Rebels as Commander in chief between Tey and Spey. Mark
Kerr’s Dragoons were along the coast, Fleeming’s Regiment at
Aberdeen, and garrisons detached from it to several places on
Deeside, and Loudon’s under Major McKenzie at Strathboggy, with
garrisons at Glenbucket, etc.
Houses burnt and plundered
Parties were immediately sent out through the country in search
of Rebels, with orders also to plunder and burn their houses.[385]
This severe order was not at all agreeable to Friends of the
Government, who could in no shape relish Military execution,
especially after the enemy was so effectually subdued. But it was not
universally executed; most of the Rebel Gentlemen’s houses on
Deeside were plundered, and some burnt, but these last were
houses of little value and really no considerable loss to the
proprietors. There was very little plundered in Buchan, some things
only picked up by the soldiers in their searches unknown to the
Officers. No Gentlemen’s houses were burnt, and only one or two
farmers’ by a worthless fellow not concerned with the army, who by
mighty pretences of zeal, had been employed by Ancrum to go with
five or six of Loudon’s Regiment, in quest of Rebels. There were no
houses burnt or plundered in or about the towns of Aberdeen; but a
Tenant’s house in the land of Stonnywood, who had been very
insolent. Glenbucket’s house was burnt in Strathdawn, as were also
a tenant’s house or two about Strathboggy.
Order for Arms
Lord Ancrum’s orders for bringing in of arms were very
extraordinary, and indeed cannot be better exposed than by giving
them and Lord Loudon’s in the same place, vid. Scots Mag. for July,
p. 339.[386]
Ill Conduct of the Soldiers
Most of the Officers of Fleeming’s Regiment were but young men,
and did not at all behave in an agreeable manner. They seemed too
much to look on the Army as a community of separate interests from
that of the Nation, and it was the common axiom of those even in
highest command in Aberdeen, that no laws but the Military were to
be regarded. They took it in their heads to despise all in civil
capacity, and especially as much as possible to thwart the
Governors of the town in every thing. They had no manner of
confidence either in the gentlemen of town or country, not even in
those who had merited so well for their zeal for the Establishment;
such as Mr. Middleton of Seaton, Mr. Burnet of Kemnay, etc., nay,
some of them were on many occasions ill used by them. The Clergy
of the Church of Scotland, for as much as they courted and
applauded them in time of danger, were now their common subject
for ridicule; and a deal of spleen was shown against them, that it
should be thought they had in the least merited well of their country,
and thus should have a title to some regard as well as the Military,
and not the least pendicle of the Army, a Commissary of foraging
Clerks, etc., but would have more regard paid to their representative
than any Clergyman.
People Disgusted
Such was the injudicious conduct of the Lord Ancrum and most of
the officers of this Corps, which soon raised great disgust and
heartburning. The Officers only, associated with one another, were
seldom troubled with any advice from anybody of consequence
acquainted with the country; or if they were, were sure to slight it.
This gave infinite satisfaction to the Jacobites who rejoiced in these
dissensions. It was this mutual disgust which on the one hand
provoked the soldiers in so riotous a manner to break almost the
whole windows in the town for not being illuminated on the first of
August,[387] when the towns people had no reason to think
Illuminations would be expected of them; and on the other hand
provoked the townsfolks to resent it so highly, for had there been a
good understanding betwixt the Corps and them, such an outrage
would probably not have been committed, or if some illegal things
had been done they’d as probably have been overlooked, or at least
easily atoned for.
Immediately after this, Ancrum was removed and Lord
Sempile[388] succeeded him.
A TRUE ACCOUNT OF MR. JOHN
DANIEL’S PROGRESS WITH PRINCE
CHARLES EDWARD IN THE YEARS
1745 AND 1746 WRITTEN BY
HIMSELF
The manuscript preserved at Drummond Castle from which this
Narrative is printed bears the following docquet:—
This is to certify, that I believe the aforegoing Narrative
to be a correct Copy of the Original, written by my late
Friend, Captain John Daniel, which I have frequently seen
and read, and conversed with him, on the subject of its
contents: more particularly as to the facts of the Duke of
Perth’s death, on his passage from Scotland to France, on
board the ship in which the said Captain Daniel was also a
passenger. To which conversations, I can conscientiously
depose if required.
Witness my hand at Exmouth Devon. This 25th day of
September 1830.
R. B. Gibson.
Signed in the presence of
Herbert Mends Gibson,
Atty. at Law.
[Note.—The notes in this narrative which are indicated

by asterisks are written on the Drummond Castle
manuscript in a later hand.]
A TRUE ACCOUNT OF MR. JOHN
DANIEL’S PROGRESS WITH PRINCE
CHARLES
As Fortune, or rather Providence, has screened, conducted and
brought me safe out of so many miseries and dangers; gratitude
obliges me to be ever-thankful to that Omniscient Power, by whose
particular bounty and goodness I now live, and survive a Cause,
which, though it be now a little sunk, will, I doubt not, one day or
other, rise again, and shine forth in its true colours, make its Hero
famous to after-ages, and the Actors esteemed and their memory
venerable. But since it is not permitted to pry into futurity, we may at
least take a retrospective view of our own or others’ actions, and
draw from them what may amuse, instruct or benefit human Society,
and by that means fulfill in some measure the end for which we were
sent into this world. Conceiving it therefore to be the best method of
shewing my gratitude to Divine Providence, I shall give a short but
true account of what happened to me during the time I had the
honour of being a soldier under the banner of a most beloved Prince;
hoping that the indulgent reader, whom curiosity may induce to
peruse the following pages, will pardon the simplicity and
ruggedness of my style, which, I am afraid, will be the more strikingly
conspicuous, as, in order to preserve the thread of my History
unbroken, I have occasionally been obliged to interweave with my
narrative some extracts from the Memoirs of another, whose
excellence totally eclipses my humble attempt.
The lessons of loyalty, which had been instilled into me from my
infant years, had made a deep and indelible impression upon my
mind; and as I advanced towards maturity, and my reasoning
faculties were developed, I became so firmly convinced of the
solidity of the principles which I had been taught, that, when arrived
at the age of Twenty-two, I resolved never to deviate from them, but
to act to the best of my power the part of a good and faithful subject,
notwithstanding the customs of an unhappy kingdom to the contrary.
Nor was it long before an opportunity presented itself of proving my
fidelity to my lawful Sovereign; viz., when the Prince entered
triumphantly into Lancashire on the 24th of November 1745,[389]
attended by about four thousand armed men. The first time I saw this
loyal army was betwixt Lancaster and Garstang; the brave Prince
marching on foot at their head like a Cyrus or a Trojan Hero, drawing
admiration and love from all those who beheld him, raising their long-
dejected hearts, and solacing their minds with the happy prospect of
another Golden Age. Struck with this charming sight and seeming
invitation ‘Leave your nets and follow me,’ I felt a paternal ardor
pervade my veins, and having before my eyes the admonition ‘Serve
God and then your King,’ I immediately became one of his followers.
How, and in what manner, I am now going to relate.
The brave and illustrious Duke of Perth (whose merits it would
require the pen of an angel properly to celebrate, being a true
epitomé of all that is good) halting to refresh himself at a Public-
House upon the road, where with some friends of mine I then
happened to be; His Grace, being truly zealous in the cause, asked
of them the disposition of the place and people. They replied, that
they believed it to be much in the Prince’s favour. After some
conversation on one thing and another, the Duke did me the honour
to invite me to join; which request being nowise contrary to my
inclination, I immediately answered His Grace, that I was exceeding
willing to do anything that lay in my power for promoting the Prince’s
interests, in any situation he might judge most proper. Upon this, the
Duke honoured me with a most sincere promise of his particular
patronage; and not a little proud I was of acquiring such a friend on
my first joining the Prince’s army, in which I had not before a single
acquaintance. After some questions, the Duke desired me to get in
readiness and to meet him on horse-back at Garstang; which in
about two or three hours I accordingly did. The army being then in
full march for Preston, the Duke desired me to go with forty men
round that part of the country which I best knew; which forty men
being accordingly put under my command, I went to Eccleston and
Singleton in the Fyld Country, where I delivered some commissions,
and caused the King to be proclaimed, the bailiffs, constables and
burgesses of the place attending at the ceremony. I dispersed
several of the Prince’s Manifestoes; and Exhortations were made, in
order to shew the people the misery and oppressions of tyranny and
usurpation, which like oxen yoked down to the plough, they seem to
labour under; and calling upon them to rise up and, like lions to
shake off the infamous yoke which too long had galled the necks of
free-born Englishmen;—to assert their liberties honourably both
before God and Man, and to prove to the world, that they remained
true English hearts, equal to their fore-fathers’, who once had given
laws to foreign States;—to exert their liberties under a Prince, who
was come for their sakes, and for their sakes only, and with their
concurrence would make them most happy. But alas!
notwithstanding all our proposals and exhortations, few of them
consented to join the Prince’s army. Therefore, having assembled
those who did come in, orders were given for them to give up all their
arms; which being reluctantly complied with, search was made in
several houses, where we found a few; and amongst the rest we
entered the house of an honest Quaker, whom I had seen about ten
days before at a Public-house, where he accidentally came in whilst I
was there, bringing with him a gun and a pair of pistols, which he
had bought. Calling for his pot of ale, he began to harangue the host
and the others present, telling what an honest man the Justice of the
Parish said he was, and that he could keep all the Papists quiet. And
with these, said he (meaning the pistols) I can bid defiance to half a
hundred of Rebels. I then heard him with great pleasure, thinking I
should have the satisfaction of trying the honest Quaker’s courage;
which accordingly happened. For, meeting with him at his own
house, I demanded of him, if he had any arms. Not knowing me
directly, he said he had none, and that he was not a man of blood.
Vexed at this evasive answer, I replied: ‘Hark thee, my honest friend,
since nothing but an action with thy own weapons will get thy arms
from thee, rememberest thou in such a place to have boasted much
of thy courage, with a gun and a pair of pistols?’ At which being
much struck and hanging down his head he seemed greatly terrified.
‘How now,’ said I, ‘honest Friend, thou that wast so lately so pot-

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Practical Pediatric Urology: An

Evidence-Based Approach 1st Edition

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Practical Pediatric Urology

ISBN 978-3-030-54019-7 ISBN 978-3-030-54020-3 (eBook)

© Springer Nature Switzerland AG 2021

Sheffield, UK Prasad Godbole

1 The Evolution of Evidence Based Clinical Medicine������������������������������ 1

13 The Lower Urinary Tract�������������������������������������������������������������������������� 305

Evidence Based Medicine (EBM) proposed by David Sackett over a quarter of a

© Springer Nature Switzerland AG 2021 1

1.2 The Evolution of Evidence Based Medicine

1.3  Methodological Approach to Evidence

1.3.1 Reviewing the Evidence

Fundamental to the process of defining an evidence-base, is the ‘systematic review’

1.3.2 Categorising the Quality of Evidence

The utilisation of EBM in different healthcare settings is underpinned by the quality

Table 1.1 1989 classifica- Level Type of evidence

Systematic review and

Randomised control trial

Case-controlled clinical study

Case Series/Case Report

Fig. 1.1 Pyramid of evidence

measurement and confounding. As randomised control trials proliferated the use of

Table 1.2 (continued)

3. Is another treatment better? Another therapy could be ‘better’ with respect to

Another approach to the evaluation of clinical evidence was proposed in 2000, by

• Inconsistency: Is a judgement made on the basis of the variability of results

Following the assessment of the quality of evidence derived from systemic

Evidence-based medicine approaches also objectively evaluate the quality of

1.4 Challenges to Evidence Based Medicine

Since the foundations of evidence based medicine were introduced by David

10. Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to

As Paediatric Urologists or in fact as clinicians in any discipline, we come across a

2.1.1 Clinical Guideline Development

1. Identify an area in which to develop the guidelines

© Springer Nature Switzerland AG 2021 17

2. Establish a core guideline developmental group

2.2 Identifying an Area in Which to Develop Guidelines

2.3 Establish a Core Guideline Developmental Group

2.4 Agree on a Guideline Appraisal Process

How can one determine whether a guideline is sufficiently rigorously developed to

2.5 Assessing Existing Guidelines

Levels of evidence for therapeutic studies

Level Type of evidence

Grade practice recommendations

Grade Descriptor Qualifying evidence Implications for practice

and levels of evidence may result in evolution of a guideline incorporating recom-

2.6 Decision to Adapt or Adopt a Guideline

2.7 External Peer Review

If a decision is made to adopt a guideline, the guideline should be sent to a specialist

2.7.1 Endorsement and Ratification at Local Level

Sheffield, UK Prasad Godbole

1 The Evolution of Evidence Based Clinical Medicine�� 1

13 The Lower Urinary Tract�� 305

1.2 The Evolution of Evidence Based Medicine

1.3 Methodological Approach to Evidence

1.3.1 Reviewing the Evidence

1.3.2 Categorising the Quality of Evidence

1.4 Challenges to Evidence Based Medicine

2.1.1 Clinical Guideline Development

2.2 Identifying an Area in Which to Develop Guidelines

2.3 Establish a Core Guideline Developmental Group

2.4 Agree on a Guideline Appraisal Process

2.5 Assessing Existing Guidelines

2.6 Decision to Adapt or Adopt a Guideline

2.7 External Peer Review

2.7.1 Endorsement and Ratification at Local Level

2.8 Local Adoption

2.9 Conformity to Guideline Adherence

Appendix: Domains of AGREE II Appraisal Instrument