Effectiveness of preoxygenation strategies: a systematic review and network meta-analysis.

BACKGROUND: Preoxygenation is universally recommended before induction of general anaesthesia to prolong safe apnoea time. The optimal technique for preoxygenation is unclear. We conducted a systematic review to determine the preoxygenation technique associated with the greatest effectiveness in adult patients having general anaesthesia. METHODS: We searched six databases for randomised controlled trials of patients aged ≥16 yr, receiving general anaesthesia in any setting and comparing different preoxygenation techniques and methods. Our primary effectiveness outcome was safe apnoea time, and secondary outcomes included incidence of arterial oxygen desaturation; lowest SpO2 during airway management; time to end-tidal oxygen concentration of 90%; and [Formula: see text] and [Formula: see text] at the end of preoxygenation. We assessed the quality of evidence according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) recommendations. RESULTS: We included 52 studies of 3914 patients. High-flow nasal oxygen with patients in a head-up position was most likely to be associated with a prolonged safe apnoea time when compared with other strategies, with a mean difference (95% credible interval) of 291 (138-456) s and 203 (79-343) s compared with preoxygenation with a facemask in the supine and head-up positions, respectively. Subgroup analysis of studies without apnoeic oxygenation also showed high-flow nasal oxygen in the head-up position as the highest ranked technique, with a statistically significantly delayed mean difference (95% credible interval) safe apnoea time compared with facemask in supine and head-up positions of 222 (63-378) s and 139 (15-262) s, respectively. High-flow nasal oxygen was also the highest ranked technique for increased [Formula: see text] at the end of preoxygenation. However, the incidence of arterial desaturation was less likely to occur when a facemask with pressure support was used compared with other techniques, and [Formula: see text] was most likely to be lowest when preoxygenation took place with patients deep breathing in a supine position. CONCLUSIONS: Preoxygenation of adults before induction of general anaesthesia was most effective in terms of safe apnoea time when performed with high-flow nasal oxygen with patients in the head-up position in comparison with facemask alone. Also, high-flow nasal oxygen in the head-up position is likely to be the most effective technique to prolong safe apnoea time among those evaluated. Clinicians should consider this technique and patient position in routine practice. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42022326046.

Does the type of lower extremity fracture affect long-term opioid usage? A meta-analysis.

INTRODUCTION:  Patients recovering from musculoskeletal trauma have a heightened risk of opioid dependence and misuse, as these medications are typically required for pain management. The purpose of this meta-analysis was to examine the association between fracture type and chronic opioid use following fracture fixation in patients who sustain lower extremity trauma. MATERIALS AND METHODS: A meta-analysis was performed using PubMed and Web of Science to identify articles reporting chronic opioid use in patients recovering from surgery for lower extremity fractures. 732 articles were identified using keyword and MeSH search functions, and 9 met selection criteria. Studies were included in the final analysis if they reported the number of patients who remained on opioids 6 months after surgery for a specific lower extremity fracture (chronic usage). Logistic regressions and descriptive analyses were performed to determine the rate of chronic opioid use within each fracture type and if age, year, country of origin of study, or pre-admission opioid use influenced chronic opioid use following surgery. RESULTS: Bicondylar and unicondylar tibial-plateau fractures had the largest percentage of patients that become chronic opioid users (29.7-35.2%), followed by hip (27.8%), ankle (19.7%), femoral-shaft (18.5%), pilon (17.2%), tibial-shaft (13.8%), and simple ankle fractures (2.8-4.7%).Most opioid-naive samples had significantly lower rates of chronic opioid use after surgery (2-9%, 95% CI) when compared to samples that allowed pre-admission opioid use (13-50%, 95% CI). There were no significant associations between post-operative chronic opioid use and age, year, or country of origin of study. CONCLUSIONS:  Patients with lower extremity fractures have substantial risk of becoming chronic opioid users. Even the lowest rates of chronic opioid use identified in this meta-analysis are higher than those in the general population. It is important that orthopedic surgeons tailor pain-management protocols to decrease opioid usage after lower extremity trauma.

Preventing controlled substance diversion in perioperative settings: a narrative review.

PURPOSE: Diversion of controlled substances in the perioperative setting is an ongoing challenge, with consequences for patients, anesthesiologists, perioperative staff, and health care facilities alike. Perioperative environments are at high risk for diversion, since controlled substances are frequently handled in these settings, with varying levels of oversight. In this narrative review, we summarize strategies for preventing diversion of controlled substances in perioperative settings (i.e., operating rooms, endoscopy suites, and postanesthesia recovery units). SOURCE: We performed a targeted literature search in PubMed MEDLINE, Embase, Scopus, Web of Science, the Cochrane Register of Controlled trials, and the Cochrane Database of Systematic Reviews, as well as a manual search for additional references. We used terminology related to drug diversion, drug abuse, anesthesiologists, pharmacists, physicians, operating room personnel, and controlled substances. PRINCIPAL FINDINGS: Many strategies have been described for preventing diversion in perioperative settings, and these are broadly categorized into: education, distribution, auditing, or provider screening. Some of these approaches may be time- and resource-intensive. There is limited evidence to inform anesthesia departments' choice of which strategies to adopt. CONCLUSION: Although awareness of perioperative controlled substance diversion has been improving, there are too few data to suggest an optimal approach. Anesthesia departments will need to work collaboratively with hospital pharmacies and actively select strategies that are reasonable given local resources.

RéSUMé: OBJECTIF: Le détournement des substances contrôlées en milieu périopératoire constitue un défi permanent qui a des conséquences pour la patientèle, les anesthésiologistes, le personnel périopératoire et les établissements de soins de santé. Les environnements périopératoires courent un risque élevé de détournement, car les substances contrôlées sont fréquemment manipulées dans ces milieux, avec divers niveaux de surveillance. Dans ce compte rendu narratif, nous résumons les stratégies de prévention du détournement des substances contrôlées dans les milieux périopératoires (c.-à-d. salles d'opération, salles d'endoscopie et salles de réveil). SOURCES: Nous avons réalisé une recherche documentaire ciblée dans les bases de données PubMed, MEDLINE, Embase, Scopus, Web of Science, le registre Cochrane des essais contrôlés et la base de données Cochrane des revues systématiques, ainsi qu'une recherche manuelle de références supplémentaires. Nous avons utilisé une terminologie liée au détournement de médicaments, à l'abus de substances, aux anesthésiologistes, aux pharmacien·nes, aux médecins, au personnel de salle d'opération et aux substances contrôlées. CONSTATATIONS PRINCIPALES: De nombreuses stratégies ont été décrites pour prévenir le détournement dans les milieux périopératoires, et celles-ci sont généralement classées en éducation, distribution, audit ou dépistage des fournisseurs et fournisseuses de soin. Certaines de ces approches peuvent exiger beaucoup de temps et de ressources. Il existe peu de données probantes pour éclairer le choix des départements d'anesthésie quant aux stratégies à adopter. CONCLUSION: Bien que la sensibilisation au détournement périopératoire de substances contrôlées se soit améliorée, il y a trop peu de données pour suggérer une approche optimale. Les départements d'anesthésie devront travailler en collaboration avec les pharmacies hospitalières et choisir activement des stratégies raisonnables qui tiennent compte des ressources locales.

Healthcare delivery gaps in pain management within the first 3 months after discharge from inpatient noncardiac surgeries: a scoping review.

BACKGROUND: Poor pain control during the postoperative period has negative implications for recovery, and is a critical risk factor for development of persistent postsurgical pain. The aim of this scoping review is to identify gaps in healthcare delivery that patients undergoing inpatient noncardiac surgeries experience in pain management while recovering at home. METHODS: Searches were conducted by a medical librarian in PubMed, MEDLINE, EMBASE, EBSCO CINAHL, Web of Science, and Cochrane Database of Systematic Reviews for articles published between 2016 and 2022. Inclusion criteria were adults (≥18 yr), English language, inpatient noncardiac surgery, and included at least one gap in care for acute and/or persistent pain management after surgery within the first 3 months of recovery at home. Two reviewers independently screened articles for inclusion and extracted data. Quotations from each article related to gaps in care were synthesised using thematic analysis. RESULTS: There were 4794 results from databases and grey literature, of which 38 articles met inclusion criteria. From these, 23 gaps were extracted, encompassing all six domains of healthcare delivery (capacity, organisational structure, finances, patients, care processes and infrastructure, and culture). Identified gaps were synthesised into five overarching themes: education (22 studies), provision of continuity of care (21 studies), individualised management (10 studies), support for specific populations (11 studies), and research and knowledge translation (10 studies). CONCLUSIONS: This scoping review identified health delivery gaps during a critical period in postoperative pain management. These gaps represent potential targets for quality improvement and future research to improve perioperative care and longer-term patient-centred outcomes. SCOPING REVIEW PROTOCOL: Open Science Framework (https://osf.io/cq5m6/).

A systematic review of patient-reported outcome measures used in maternal postpartum anxiety.

OBJECTIVE: This study aimed to conduct a systematic review and to evaluate the psychometric measurement properties of instruments for postpartum anxiety using the Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines to identify the best available patient-reported outcome measure. DATA SOURCES: We searched 4 databases (CINAHL, Embase, PubMed, and Web of Science in July 2022) and included studies that evaluated at least 1 psychometric measurement property of a patient-reported outcome measurement instrument. The protocol was registered with the International Prospective Register for Systematic Reviews under identifier CRD42021260004 and followed the Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines for systematic reviews. STUDY ELIGIBILITY: Studies eligible for inclusion were those that assessed the performance of a patient-reported outcome measure for screening for postpartum anxiety. We included studies in which the instruments were subjected to some form of psychometric property assessment in the postpartum maternal population, consisted of at least 2 questions, and were not subscales. METHODS: This systematic review used the Consensus-Based Standards for the Selection of Health Measurement Instruments and the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify the best patient-reported outcome measurement instrument for examining postpartum anxiety. A risk of bias assessment was performed, and a modified GRADE approach was used to assess the level of evidence with recommendations being made for the overall quality of each instrument. RESULTS: A total of 28 studies evaluating 13 instruments in 10,570 patients were included. Content validity was sufficient in 9 with 5 instruments receiving a class A recommendation (recommended for use). The Postpartum Specific Anxiety Scale, Postpartum Specific Anxiety Scale Research Short Form, Postpartum Specific Anxiety Scale Research Short Form Covid, Postpartum Specific Anxiety Scale-Persian, and the State-Trait Anxiety Inventory demonstrated adequate content validity and sufficient internal consistency. Nine instruments received a recommendation of class B (further research required). No instrument received a class C recommendation (not recommended for use). CONCLUSION: Five instruments received a class A recommendation, all with limitations, such as not being specific to the postpartum population, not assessing all domains, lacking generalizability, or evaluation of cross-cultural validity. There is currently no freely available instrument that assess all domains of postpartum anxiety. Future studies are needed to determine the optimum current instrument or to develop and validate a more specific measure for maternal postpartum anxiety.

Virtual Reference at Health Sciences Libraries in the Time of COVID-19.

Virtual reference services have become a staple in many libraries, but these services reached a new level of importance when in-person reference shut down in response to COVID-19. This descriptive study aims to discover how health sciences librarians utilized virtual reference services in response to the pandemic. A survey was developed and distributed to health sciences librarians. The survey addressed the status of virtual reference services before and during the COVID-19 pandemic as well as any changes that are seen as libraries reopen. Virtual reference shifted heavily to video conferencing during the pandemic both for librarians at home and those remaining onsite.

Pharmacological agents for prevention of pruritus in women undergoing Caesarean delivery with neuraxial morphine: a systematic review and Bayesian network meta-analysis.

BACKGROUND: Neuraxial opioids provide effective analgesia for Caesarean delivery, however, pruritus can be a troubling side-effect. Effective agents to prevent pruritus are needed. Our objective was to perform an updated systematic review and network meta-analysis to provide clinicians with a comparison of relative efficacy of available interventions to reduce the incidence of pruritus, induced by either intrathecal or epidural single-shot morphine, in women undergoing Caesarean delivery. METHODS: Databases systematically searched (up to January 2022) included PubMed MEDLINE, Web of Science, EBSCO CINAHL, Embase, LILACS, and two Cochrane databases. We included randomised, controlled trials involving adult female patients undergoing Caesarean delivery. We pooled trials comparing interventions used for preventing pruritus after Caesarean delivery and performed a Bayesian model network meta-analysis. RESULTS: The final primary network included data from comparisons of 14 distinct interventions (including placebo) used to reduce the incidence of pruritus in 6185 participants. We judged five interventions to be 'definitely superior' to placebo: propofol, opioid agonist-antagonists (neuraxial), opioid antagonists, opioid agonist-antagonists (systemic), and serotonin antagonists. For the network evaluating the incidence of severe pruritus (warranting additional therapeutic treatment of pruritus), data were available for 14 interventions (including placebo) in 4489 patients. For this outcome, we judged three interventions to be 'definitely superior' to placebo: dopamine antagonists (neuraxial) and systemic and neuraxial opioid agonist-antagonists. CONCLUSION: Our analysis found several interventions to be effective in reducing the incidence of pruritus. Although sub-hypnotic doses of propofol appear to have an antipruritic effect, replication of this finding and further investigation of optimal dosing are warranted. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42022367058).

Comparison of different nonsteroidal anti-inflammatory drugs for cesarean section: a systematic review and network meta-analysis.

BACKGROUND: Cesarean section is associated with moderate to severe pain and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly employed. The optimal NSAID, however, has not been elucidated. In this network meta-analysis and systematic review, we compared the influence of control and individual NSAIDs on the indices of analgesia, side effects, and quality of recovery. METHODS: CDSR, CINAHL, CRCT, Embase, LILACS, PubMed, and Web of Science were searched for randomized controlled trials comparing a specific NSAID to either control or another NSAID in elective or emergency cesarean section under general or neuraxial anesthesia. Network plots and league tables were constructed, and the quality of evidence was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis. RESULTS: We included 47 trials. Cumulative intravenous morphine equivalent consumption at 24 h, the primary outcome, was examined in 1,228 patients and 18 trials, and control was found to be inferior to diclofenac, indomethacin, ketorolac, and tenoxicam (very low quality evidence owing to serious limitations, imprecision, and publication bias). Indomethacin was superior to celecoxib for pain score at rest at 8-12 h and celecoxib + parecoxib, diclofenac, and ketorolac for pain score on movement at 48 h. In regard to the need for and time to rescue analgesia COX-2 inhibitors such as celecoxib were inferior to other NSAIDs. CONCLUSIONS: Our review suggests the presence of minimal differences among the NSAIDs studied. Nonselective NSAIDs may be more effective than selective NSAIDs, and some NSAIDs such as indomethacin might be preferable to other NSAIDs.

Research Collaborations Among Health Sciences Librarians.

Librarians collaborate in their positions daily to assist patrons with their needs. Many of these interactions are brief with collaborations quickly forming and then being dissolved as librarians provide for the needs of their patrons. Collaborations allow librarians to advance the purposes of the library and reach out and assist the institution. Unlike these brief daily interactions, research collaborations require librarians to make long-term commitments to projects. How can we ensure that these collaborations are successful? Study of research collaborations can assist librarians in determining how to build and maintain research collaborations and avoid or overcome conflicts and barriers. Finding others with similar interests, maintaining communication through multiple channels, and basic project management skills are key to successful research collaborations.

Education and Experiences of Antenatal Breast Milk Expression: A Systematic Review.

Background: Breastfeeding rates have stagnated recently despite recommendations to breastfeed until age 2 years. Antenatal breast milk expression (ABME) is a method used to prepare the breast for breastfeeding. However, there is limited evidence available on the benefits, risks, and impact of ABME on maternal-infant breastfeeding dyads. Methods: This review identified and summarized studies on women who engaged in ABME and their personal experiences. Databases searched included PubMed MEDLINE, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and EMBASE. Initially, abstracts and titles were reviewed, and then, full-text studies were screened for inclusion by two blinded authors. Two authors assessed the quality of the studies using a standardized tool, two authors completed data extraction, and one author completed data harmonization into tables. Results: A total of 1,410 studies were identified (after duplicates removed) and 10 citations qualified for the inclusion criteria. Only two studies received an overall rating of strong quality and low-risk bias. The selected articles varied in primary outcomes; however, main focuses were experiences, knowledge, and perspective after practicing ABME. Data varied on timing of ABME, but most studies started between 34 and 36 weeks. The average amount of expressed milk was reported in four studies but was variable. Conclusions: This systematic review found that the literature is limited regarding ABME, and most studies were focused on women with diabetes. The current limited evidence suggests that ABME may be a helpful tool in improving maternal breastfeeding confidence and breastfeeding outcomes. Negative side effects reported related to ABME included difficulty learning the technique, discomfort, and feeling of awkwardness while expressing. Future research should focus on higher quality studies regarding use of ABME, proper teaching of ABME technique, and the use of ABME to improve breastfeeding outcomes in diverse populations of maternal-infant dyads.

Assessing pediatric perioperative affect: A concise review of research and clinically relevant scales.

Perioperative anxiety and distress are common in pediatric patients undergoing general anesthesia and increase the risk for immediate and long-term postoperative complications. This concise review outlines key research and clinically-relevant scales that measure pediatric perioperative affect. Strengths and weaknesses of each scale are highlighted. A literature review identified 11 articles with the following inclusion criteria: patients less than or equal to 18 years, perioperative anxiety or distress, and original studies with reliability or validity data. Although robust research-based assessment tools to measure anxiety have been developed, such as the Modified Yale Preoperative Anxiety Scale, they are too complex and time-consuming to complete by clinicians also providing anesthesia. Clinically-based anxiety measurement scales tend to be easier to use, however they require further testing before widespread standard utilization. The HRAD ± scale (Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperation) may be a promising observational anxiety scale that is efficient and includes an assessment of compliance. Further studies are needed to refine a clinically-relevant anxiety assessment tool and appraise interventions that reduce perioperative distress.

Use of Patient-Reported Outcomes in Acne Vulgaris and Rosacea Clinical Trials From 2011 to 2021: A Systematic Review.

Importance: Acne and rosacea have substantial implications for quality of life, and it is therefore important to ensure the patient's voice is being captured in pivotal randomized clinical trials (RCTs). Although patient-reported outcome measures (PROMs) are a valuable tool to capture the patient perspective, little is known about use of PROMs in RCTs on acne and rosacea. Objective: To characterize the use of PROMs in RCTs on acne and rosacea. Evidence Review: A systematic literature search was conducted using the search terms acne vulgaris and rosacea in the following databases: MEDLINE through PubMed, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. A modified search hedge for RCTs from the McGill Library was applied. All phase 2, 3, and 4 RCTs published between December 31, 2011, through December 31, 2021, that evaluated the efficacy and safety of therapies for acne and rosacea vs any comparator were eligible for inclusion. Findings: A total of 2461 publications describing RCTs were identified, of which 206 RCTs met the inclusion criteria (163 trials [79%] on acne and 43 [21%] on rosacea). At least 1 PROM was used in 53% of trials (110) included; PROM use was more common in rosacea RCTs (67% [n = 29]) compared with acne RCTs (50% [n = 81]). At least 1 dermatology-specific (13% [n = 27]) or disease-specific (14% [n = 28]) PROM was included in the RCTs analyzed. Only 7% of trials (14) included a PROM as a primary outcome measure. There was no statistically significant increase in PROM inclusion over the study period (11 of 21 trials in 2011 vs 5 of 12 trials in 2021). Conclusions and Relevance: In this systematic review, PROMs were included in approximately one-half of acne and rosacea RCTs performed over the study period. In addition, PROMs were rarely used as a primary outcome measure, and inclusion of PROMs has not increased substantially over the past 10 years. Increasing use of PROMs in RCTs can ensure that the patient's perspective is captured during the development of new treatments for acne and rosacea.

Incidence, prevalence, and timing of postpartum complications and mortality in Canada and the United States: a systematic review and meta-analysis protocol.

OBJECTIVE: The goal of this systematic review is to assess the incidence, prevalence, and timing of common postpartum (up to 1 year after delivery) medical, surgical/procedural, and psychosocial complications and mortality. INTRODUCTION: Childbirth is the most common cause for hospitalization, and cesarean delivery is the most commonly performed inpatient surgery. After delivery, mothers are at risk of short- and long-term complications that can impact their well-being. The results of this review will inform evidence-based recommendations for patient education, monitoring, and follow-up. INCLUSION CRITERIA: We will include studies performed in Canada and/or the United States that report the incidence or prevalence of medical, procedural/surgical, and psychosocial complications within 1 year postpartum. Observational studies (analytical cross-sectional studies, retrospective and prospective cohorts), randomized or non-randomized controlled trials with a control or standard of care group, systematic reviews, and meta-analyses will be included. Studies with fewer than 100 patients, participants younger than 18 years, no reporting of duration, or focus on patients with a specific condition rather than a general postpartum population will be excluded. METHODS: The search strategy was codeveloped with a medical librarian and included full-text English-language articles published within the past 10 years (2011-2021) in PubMed, CINHAL, Web of Science, and Cochrane Database of Systematic Reviews. Screening, critical appraisal, and data extraction will be performed by two independent reviewers using Covidence, standardized JBI tools, and a standardized form, respectively. For each complication, the incidence or prevalence, timing of the frequency measurement, and duration of follow-up from individual studies will be determined. Meta-analysis will be performed if feasible. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42022303047.

Assessment of Patient-Reported Outcome Measures for Maternal Postpartum Depression Using the Consensus-Based Standards for the Selection of Health Measurement Instruments Guideline: A Systematic Review.

Importance: Maternal depression is frequently reported in the postpartum period, with an estimated prevalence of approximately 15% during the first postpartum year. Despite the high prevalence of postpartum depression, there is no consensus regarding which patient-reported outcome measure (PROM) should be used to screen for this complex, multidimensional construct. Objective: To evaluate psychometric measurement properties of existing PROMs of maternal postpartum depression using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guideline and identify the best available patient-reported screening measure. Evidence Review: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. PubMed, CINAHL, Embase, and Web of Science were searched on July 1, 2019, for validated PROMs of postpartum depression, and an additional search including a hand search of references from eligible studies was conducted in June 2021. Included studies evaluated 1 or more psychometric measurement properties of the identified PROMs. A risk-of-bias assessment was performed to evaluate methods of each included study. Psychometric measurement properties of each PROM were rated according to COSMIN criteria. A modified Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the level of evidence supporting each rating, and a recommendation class (A, recommended for use; B, further research required; or C, not recommended) was given based on the overall quality of each included PROM. Findings: Among 10 264 postpartum recovery studies, 27 PROMs were identified. Ten PROMs (37.0%) met the inclusion criteria and were used in 43 studies (0.4%) involving 22 095 postpartum women. At least 1 psychometric measurement property was assessed for each of the 10 validated PROMs identified. Content validity was sufficient in all PROMs. The Edinburgh Postnatal Depression Scale (EPDS) demonstrated adequate content validity and a moderate level of evidence for sufficient internal consistency (with sufficient structural validity), resulting in a recommendation of class A. The other 9 PROMs evaluated received a recommendation of class B. Conclusions and Relevance: The findings of this systematic review suggest that the EPDS is the best available patient-reported screening measure of maternal postpartum depression. Future studies should focus on evaluating the cross-cultural validity, reliability, and measurement error of the EPDS to improve understanding of its psychometric properties and utility.

Outcomes of women treated with progestin and metformin for atypical endometrial hyperplasia and early endometrial cancer: a systematic review and meta-analysis.

OBJECTIVE: Progestin therapy is the recommended fertility-sparing management of atypical endometrial hyperplasia or early-stage endometrial cancer in reproductive-aged women. Our objective was to evaluate disease relapse after progestin and metformin versus progestin therapy alone in patients with endometrial hyperplasia or cancer. Our secondary outcomes were disease remission, clinical pregnancy and live birth rate. METHODS: A systematic review of the literature was conducted (MEDLINE, Web of Science, Cochrane Library, CINAHL, LILACS, clinicaltrials.gov) from inception to April 2021. Studies of reproductive-aged women with atypical endometrial hyperplasia or early endometrial cancer who received progestin and metformin or progestin alone for fertility-sparing management, were included in the review. Early endometrial cancer was defined as grade 1, stage 1 disease. Exclusion criteria included women with higher grade endometrial cancer and when conservative management was not for fertility-sparing purposes. Data are presented as odds ratios (ORs) and 95% confidence intervals (CIs) with fixed or random effects meta-analysis. Quality scoring was based on the Newcastle-Ottawa and Jadad scales. RESULTS: In total, 271 reports were identified and six studies met the inclusion criteria. These studies included 621 women; 241 (38.8%) patients received combined therapy and 380 (61.2%) received progestin therapy alone. Relapse rates were lower for progestin and metformin than for progestin therapy alone (pooled OR 0.46, 95% CI 0.24 to 0.91, p=0.03). The remission rates were not different (pooled OR 1.35, 95% CI 0.91 to 2.00, p=0.14). Women who received progestin and metformin achieved pregnancy and live birth rates similar to those who received progestin therapy only (pooled OR 1.01, 95% CI 0.44 to 2.35, p=0.98; pooled OR 0.46, 95% CI 0.21 to 1.03, p=0.06). CONCLUSION: For reproductive-aged women with atypical endometrial hyperplasia or early endometrial cancer, progestin and metformin therapy compared with progestin therapy alone is associated with lower relapse rates, and similar remission, clinical pregnancy and live birth rates. PROSPERO REGISTRATION NUMBER: CRD42020179069.disease remission.

Adherence to guideline creation recommendations for suicide prevention in the emergency department: A systematic review.

OBJECTIVES: Suicide rates in the United States rose 35.2% from 1999-2018. As emergency department (ED) providers often have limited training in management of suicidal patients and minimal access to mental health experts, clinical practice guidelines (CPGs) may improve care for these patients. However, clinical practice guidelines that do not adhere to quality standards for development may be harmful both to patients, if they promote practices based on flawed evidence, and to ED providers, if used in malpractice claims. In 2011, the Institute of Medicine created standards to determine the trustworthiness of CPGs. This review assessed the adherence of suicide prevention CPGs, intended for the ED, to these standards. Secondary objectives were to assess the association of adherence both with first author/organization specialty (ED vs non-ED) and with inclusion of recommendations on substance use, a potent risk factor for suicide. METHODS: This is a systematic review of available suicide-prevention CPGs for the ED in both peer-reviewed and gray literature. This review followed the PRISMA standards for reporting systematic reviews. RESULTS: Of 22 included CPGs, the 7 ED-sponsored CPGs had higher adherence to quality standards (3.1 vs 2.4) and included the highest-rated CPG (ICAR2E) identified by this review. Regardless of specialty, nearly all CPGs included some mention of identifying or managing substance use. CONCLUSIONS: Most suicide prevention CPGs intended for the ED are written by non-ED first authors or organizations and have low adherence to quality standards. Future CPGs should be developed with more scientific rigor, include a multidisciplinary writing group, and be created by authors working in the practice environment to which the CPG applies.

Impact of enhanced recovery after cesarean delivery on maternal outcomes: A systematic review and meta-analysis.

BACKGROUND: This meta-analysis explores the impact of enhanced recovery after cesarean delivery (ERAC) on maternal outcomes. METHODS: We searched 4 databases (Web of Science, Embase, PubMed and CINAHL) in October 2020 without date limiters, for studies quantitatively comparing ERAC implementation to a control group. The primary outcome was length of hospital stay and secondary outcomes included time to mobilization and time to urinary catheter removal, opioid consumption, readmission rates and cost savings. Mean differences and odds ratios (MD and OR with 95% confidence intervals) were calculated. Levels of evidence were assessed using GRADE. RESULTS: Twelve studies involving 17,607 patients (9693 without ERAC and 7914 with ERAC) were included. ERAC was associated with reduced: length of hospital stay (MD -0.51 days [-0.94, -0.09]; p = 0.018; I2 = 99%), time to first mobilization (MD -11.05 h [-18.64, -3.46]; p = 0.004; I2 = 98%), time to urinary catheter removal (MD -13.19 h [-17.59, -8.79]; p < 0.001; I2 = 97%) and opioid consumption (MD -21.85 mg morphine equivalents [-33.19, -10.50]; p = < 0.001; I2 = 91%), with no difference in maternal readmission rate (OR 1.23 [0.96, 1.57]; p = 0.10; I2 = 0%). Three studies reported cost savings associated with ERAC. The GRADE levels of evidence were rated as low or very low quality for all study outcomes. CONCLUSION: ERAC is associated with reduction in length of stay, times to first mobilization and urinary catheter removal and opioid consumption. ERAC does not significantly affect maternal hospital readmission rates following discharge. Further studies are required to determine which ERAC interventions to implement and which outcomes best determine ERAC efficacy.

A systematic review of patient-reported outcome measures to assess postpartum pain using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines.

BACKGROUND: We performed a systematic review using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to identify the best available patient-reported outcome measure (PROM) of postpartum pain. METHODS: This review follows COSMIN guidelines. We searched four databases with no date limiters, for previously identified validated PROMs used to assess postpartum pain. PROMs evaluating more than one author-defined domain of postpartum pain were assessed. We sought studies evaluating psychometric properties. An overall rating was then assigned based upon COSMIN analysis, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the level of evidence for psychometric properties of included PROMs. These assessments were used to make recommendations and identify the best PROM to assess postpartum pain. RESULTS: We identified 19 studies using seven PROMs (involving 3511 women), which evaluated postpartum pain. All included studies evaluated ≥1 psychometric property of the included PROMs. An adequate number of pain domains was assessed by the Brief Pain Inventory (BPI), Short Form-BPI (SF-BPI), and McGill Pain Questionnaire (MPQ). The SF-BPI was the only PROM to demonstrate adequate content validity and at least a low-level of evidence for sufficient internal consistency, resulting in a Class A recommendation (the best performing instrument, recommended for use). CONCLUSION: SF-BPI is the best currently available PROM to assess postpartum pain. However, it fails to assess several important domains and only just met the criteria for a Class A recommendation. Future studies are warranted to develop, evaluate, and implement a new PROM designed to specifically assess postpartum pain.

Use of Patient-Reported Outcome Measures to Assess Outpatient Postpartum Recovery: A Systematic Review.

Importance: Outpatient postpartum recovery is an underexplored area of obstetrics. There is currently no consensus regarding which patient-reported outcome measure (PROM) clinicians and researchers should use to evaluate postpartum recovery. Objective: To evaluate PROMs of outpatient postpartum recovery using Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. Evidence Review: An initial literature search performed in July 2019 identified postpartum recovery PROMs and validation studies. A secondary search in July 2020 identified additional validation studies. Both searches were performed using 4 databases (Web of Science, Embase, PubMed, and CINAHL), with no date limiters. Studies with PROMs evaluating more than 3 proposed outpatient postpartum recovery domains were considered. Studies were included if they assessed any psychometric measurement property of the included PROMs in the outpatient postpartum setting. The PROMs were assessed for the following 8 psychometric measurement properties, as defined by COSMIN: content validity, structural validity, internal consistency, cross-cultural validity and measurement invariance, reliability, measurement error, hypothesis testing, and responsiveness. Psychometric measurement properties were evaluated in each included study using the COSMIN criteria by assessing (1) the quality of the methods (very good, adequate, doubtful, inadequate, or not assessed); (2) overall rating of results (sufficient, insufficient, inconsistent, or indeterminate); (3) level of evidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations assessment tool; and (4) level of recommendation, which included class A (recommended for use; showed adequate content validity with at least low-quality evidence for sufficient internal consistency), class B (not class A or class C), or class C (not recommended). Findings: In total, 15 PROMs (7 obstetric specific and 8 non-obstetric specific) were identified, evaluating outpatient postpartum recovery in 46 studies involving 19 165 women. The majority of psychometric measurement properties of the included PROMs were graded as having very-low-level or low-level evidence. The best-performing PROMs that received class A recommendations were the Maternal Concerns Questionnaire, the Postpartum Quality of Life tool, and the World Health Organization Quality of Life-BREF. The remainder of the evaluated PROMs had insufficient evidence to make recommendations regarding their use (and received class B recommendations). Conclusions and Relevance: This review found that the best-performing PROMs currently available to evaluate outpatient postpartum recovery were the Maternal Concerns Questionnaire, the Postpartum Quality of Life tool, and the World Health Organization Quality of Life-BREF; however, these tools all had significant limitations. This study highlights the need to focus future efforts on robustly developing and validating a new PROM that may comprehensively evaluate outpatient postpartum recovery.