Medical and psychiatric comorbidities, somatic and cognitive symptoms, injuries and medical procedure history in patients with functional seizures from a public and a private hospital.

PURPOSE: Patients with functional seizures (FS), otherwise known as psychogenic non-epileptic seizures (PNES), from different socioeconomic backgrounds may differ, however, this remains a gap in current literature. Comorbidities can play both a precipitating and a perpetuating role in FS and are important in the planning of individual treatment for this condition. With this study, we aimed to describe and compare the reported medical and psychiatric comorbidities, injuries, somatic and cognitive symptoms, and medical procedures among patients with FS from a private and a public epilepsy monitoring unit (EMU) in Cape Town, South Africa. METHODS: This is a retrospective case-control study. We collected data on the comorbidity and medical procedure histories, as well as symptoms and clinical signs reported by patients with video-electroencephalographically (video-EEG) confirmed FS without comorbid epilepsy. We used digital patient records starting with the earliest available digital record for each hospital until the year 2022. RESULTS: A total of 305 patients from a private hospital and 67 patients from a public hospital were included in the study (N = 372). Public hospital patients had higher odds of reporting intellectual disability (aOR=15.58, 95% CI [1.80, 134.95]), circulatory system disease (aOR=2.63, 95% CI [1.02, 6.78]) and gait disturbance (aOR=8.52, 95% CI [1.96, 37.08]) compared to patients with FS attending the private hospital. They did, however, have fewer odds of reporting a history of an infectious or parasitic disease (aOR=0.31, 95% CI [0.11, 0.87]), respiratory system disease (aOR=0.23, 95% CI [0.06, 0.82]), or medical procedures in the past (aOR=0.32, 95% CI [0.16, 0.63]). CONCLUSION: The study presents prevalence and comparative data on the medical profiles of patients with FS from different socioeconomic backgrounds which may inform future considerations in FS diagnosis and treatment.

Water, a powerful tool in surgery.

Inflammation of the gallbladder, also known as acute cholecystitis, may be caused by infection and inflammation of the gallbladder wall due to bile stasis, with or without gallstones. It is one of the most common surgical procedures that are performed laparoscopically. Gangrenous gallbladders are one of the most difficult conditions to treat clinically and surgically, being the cause of many medical malpractice litigations. Gangrenous gallbladders constitute 15% of all laparoscopic surgeries, with the cost of these surgeries being approximately $48,000, compared to other laparoscopic gallbladder surgeries being around $7,000. Dr. Dinesh Vyas and his team have worked together to develop the novel HydroLap, which is a tool that utilizes hydrodissection technology during laparoscopic cholecystectomies to remove the delicate, dead tissue while preserving the healthy tissue of surrounding structures. This decade-long journey began in the operating room and resulted in an innovation that is awaiting Food and Drug Administration (FDA) approval for use in 2023.

A New Option for Pain Prevention Using a Therapeutic Virtual Reality Solution for Bone Marrow Biopsy (REVEH Trial): Open-Label, Randomized, Multicenter, Phase 3 Study.

BACKGROUND: Evidence regarding the analgesic effect of distraction through immersion in virtual reality (VR) for care-induced pain has been documented in several phase 2 trials, but comparison with standard treatments in large, randomized studies is needed. OBJECTIVE: In this open-label, multicenter, randomized, phase 3 trial, we evaluated the safety and efficacy of a novel VR therapy solution for distraction in the context of bone marrow biopsy. METHODS: Bliss is a VR software with 4 imaginary interactive environments in 3 dimensions with binaural sound (head-mounted display). Efficacy regarding pain intensity was evaluated using a visual analog scale (VAS; score from 0 to 10) immediately after the biopsy. Secondary end points were anxiety and tolerance. Modified intention-to-treat analysis was performed. RESULTS: Overall, 126 patients with previously documented untreated or suspected malignant hemopathy between September 6, 2018, and May 18, 2020, were randomly assigned in a 1:1 ratio to receive pain prevention with a mixture of nitrous oxide/oxygen (MEOPA; n=63) or VR (n=63) before and during the bone marrow biopsy. We excluded 8 patients from the final analysis (3 in the MEOPA group and 5 in the VR group). All patients received local anesthesia (lidocaine) before biopsy. Follow-up was limited to 1 month after the biopsy. Participants' median age was 65.5 (range 18-87) years, and 54.2% (64/118) of patients were male. The average pain intensity was 3.5 (SD 2.6, 95% CI -1.6 to 8.6) for the MEOPA group and 3.0 (SD 2.4, 95% CI -1.7 to 7.7) for the VR group, without any significant differences in age, sex, center, and hemopathy (P=.26). Concerning anxiety, 67.5% (79/117; fear of pain questionnaire) of the patients were afraid before the biopsy, and anxiety scores were moderate to very high in 26.3% (30/114; revised Spielberger State-Trait Anxiety Inventory questionnaire) of the patients before the biopsy and 9.0% (10/114) after the biopsy for all patients, without a significant difference between the 2 groups (P=.83). Immersion in VR was well tolerated by the majority (54/57, 95%) of patients in the VR group. CONCLUSIONS: The intensity of pain did not significantly differ between both arms. VR was well tolerated, and the satisfaction of patients, nurses, and physicians was very high. VR could be an alternative treatment in case of contraindication or intolerance to MEOPA. TRIAL REGISTRATION: ClinicalTrials.gov NCT03483194; https://clinicaltrials.gov/ct2/show/NCT03483194.

Stacking-BERT model for Chinese medical procedure entity normalization.

Medical procedure entity normalization is an important task to realize medical information sharing at the semantic level; it faces main challenges such as variety and similarity in real-world practice. Although deep learning-based methods have been successfully applied to biomedical entity normalization, they often depend on traditional context-independent word embeddings, and there is minimal research on medical entity recognition in Chinese Regarding the entity normalization task as a sentence pair classification task, we applied a three-step framework to normalize Chinese medical procedure terms, and it consists of dataset construction, candidate concept generation and candidate concept ranking. For dataset construction, external knowledge base and easy data augmentation skills were used to increase the diversity of training samples. For candidate concept generation, we implemented the BM25 retrieval method based on integrating synonym knowledge of SNOMED CT and train data. For candidate concept ranking, we designed a stacking-BERT model, including the original BERT-based and Siamese-BERT ranking models, to capture the semantic information and choose the optimal mapping pairs by the stacking mechanism. In the training process, we also added the tricks of adversarial training to improve the learning ability of the model on small-scale training data. Based on the clinical entity normalization task dataset of the 5th China Health Information Processing Conference, our stacking-BERT model achieved an accuracy of 93.1%, which outperformed the single BERT models and other traditional deep learning models. In conclusion, this paper presents an effective method for Chinese medical procedure entity normalization and validation of different BERT-based models. In addition, we found that the tricks of adversarial training and data augmentation can effectively improve the effect of the deep learning model for small samples, which might provide some useful ideas for future research.

Accidental guide wire migration and late percutaneous externalization after central venous catheterization.

A 70-year-old man was admitted to the emergency department with recent spontaneous externalization of a metallic device from his right inner thigh. He had been experiencing mild local pain for 2 weeks and had a recent hospitalization due to cardiogenic hemodynamic instability, requiring a central venous catheter placement in his right internal jugular vein 3 months earlier. Doppler ultrasound confirmed the intravascular foreign body hypothesis as a guidewire was identified inside the right femoral vein, associated with femoropopliteal venous thrombosis. The guidewire was successfully removed percutaneously through simple manual traction guided by radioscopy. The patient was discharged the following day on oral anticoagulation with rivaroxaban. On outpatient follow-up 4 weeks post discharge, he had no complaints in the right lower limb except for slight swelling. Central venous catheterization is a common invasive procedure that, although unquestionably safe and well stablished in medical practice, can lead to serious complications when performed without proper technique.

The Trajectory of Nutritional Status and Physical Activity before and after Transcatheter Aortic Valve Implantation.

It is suggested that older patients waiting for an elective surgical procedure have a poor nutritional status and low physical activity level. It is unknown if this hypothesis is true and if these conditions improve after a medical procedure. We aimed to determine the trajectory of both conditions before and after transcatheter aortic valve implantation (TAVI). Included patients (n = 112, age 81 ± 5 years, 58% male) received three home visits (preprocedural, one and six months postprocedural). Nutritional status was determined with the mini nutritional assessment­short form (MNA-SF) and physical activity using an ankle-worn monitor (Stepwatch). The median MNA-SF score was 13 (11−14), and 27% of the patients were at risk of malnutrition before the procedure. Physical activity was 6273 ± 3007 steps/day, and 69% of the patients did not meet the physical activity guidelines (>7100 steps/day). We observed that nutritional status and physical activity did not significantly change after the procedure (ß 0.02 [95% CI −0.03, 0.07] points/months on the MNA-SF and ß 16 [95% CI −47, 79] steps/month, respectively). To conclude, many preprocedural TAVI patients should improve their nutritional status or activity level. Both conditions do not improve naturally after a cardiac procedure.

Classification of user queries according to a hierarchical medical procedure encoding system using an ensemble classifier.

The Swiss classification of surgical interventions (CHOP) has to be used in daily practice by physicians to classify clinical procedures. Its purpose is to encode the delivered healthcare services for the sake of quality assurance and billing. For encoding a procedure, a code of a maximal of 6-digits has to be selected from the classification system, which is currently realized by a rule-based system composed of encoding experts and a manual search in the CHOP catalog. In this paper, we will investigate the possibility of automatic CHOP code generation based on a short query to enable automatic support of manual classification. The wide and deep hierarchy of CHOP and the differences between text used in queries and catalog descriptions are two apparent obstacles for training and deploying a learning-based algorithm. Because of these challenges, there is a need for an appropriate classification approach. We evaluate different strategies (multi-class non-terminal and per-node classifications) with different configurations so that a flexible modular solution with high accuracy and efficiency can be provided. The results clearly show that the per-node binary classification outperforms the non-terminal multi-class classification with an F1-micro measure between 92.6 and 94%. The hierarchical prediction based on per-node binary classifiers achieved a high exact match by the single code assignment on the 5-fold cross-validation. In conclusion, the hierarchical context from the CHOP encoding can be employed by both classifier training and representation learning. The hierarchical features have all shown improvement in the classification performances under different configurations, respectively: the stacked autoencoder and training examples aggregation using true path rules as well as the unified vocabulary space have largely increased the utility of hierarchical features. Additionally, the threshold adaption through Bayesian aggregation has largely increased the vertical reachability of the per node classification. All the trainable nodes can be triggered after the threshold adaption, while the F1 measures at code levels 3-6 have been increased from 6 to 89% after the threshold adaption.

Pain Assessment Using Virtual Reality Facemask During Bone Marrow Aspiration: Prospective Study Including Propensity-Matched Analysis.

BACKGROUND: Bone marrow aspiration (BMA) is a medical procedure necessary to the diagnosis and monitoring of patients with hematological or nonhematological disorders. This procedure is considered painful, and patients are generally anxious before and during BMA. OBJECTIVE: This study assesses the effect of immersive virtual reality on pain during BMA. METHODS: This observational prospective and monocentric study enrolled 105 consecutive patients who underwent sternal BMA with lidocaine anesthesia. The study was carried on during 2 periods. First, virtual reality facemask (VRF) was proposed to all patients in the absence of exclusion criteria. During the second period, BMA was performed without the VRF. For all patients, pain intensity after the procedure was assessed using a 10-point numerical pain rating scale (NPRS). All analyses were performed on propensity score-matched cohort (with or without VRF) to evaluate efficacy on NRPS levels. RESULTS: The final matched cohort included 12 patients in the VRF group and 24 in the control group. No difference in anxiety level before BMA evaluated by the patient and by the operator was observed between groups (P=.71 and .42 respectively). No difference of NPRS was observed using VRF when compared to control group (median NPRS 3.8, IQR 2.0-6.3 vs 3.0, IQR 1.9-3.0, respectively; P=.09). CONCLUSIONS: Our study did not prove the efficacy of VRF to reduce pain during BMA.

Patient Safety in Hysteroscopic Procedure.

This article aims to explain about outpatient hysteroscopy, where this procedure is currently being carried out. However, this procedure is also widely chosen by patients, because of its convenience, fast procedure, minimal complications, and of course more economical than day-case hysteroscopy. Before taking the procedure, it is important to explain to the patient about the disease, therapy, and the procedure to be carried out. Consent needs to be obtained voluntarily. We searched related publications using "patient safety" and "office hysteroscopy" and "informed consent" and "medical procedure" and "patient safety" and "injury" and "operative hysteroscopy" as keywords. This search had considered articles that had been published between 2002 and 2021. The conclusion from this library is that patient's convenient and safety is the top priority of outpatient hysteroscopy. Outpatient hysteroscopy showed higher satisfaction results than day-case hysteroscopy. Because it is more comfortable, faster, patients can immediately return to their activities and of course more efficient.

Acceptability of a novel device to improve child patient experience during venepuncture for blood sampling: Intervention with 'MyShield'.

This study aimed to explore the acceptability of a novel device ('MyShield'): a device used for distraction during clinical procedures. It is a cardboard cuff, designed to fit around the arm, either above the elbow or around the wrist and used to hide the procedure from view. This device was tested in practice, to establish acceptability to children, parents and clinical staff. Fifty-eight children tried 'MyShield' during a venepuncture procedure. Feedback from 54 children, 58 parents/carers and 16 clinical staff was collected using surveys and interviews. In 24 cases, observational data were also collected. A large majority of children (94%, n = 51) and parents (96%, n = 56) reported a positive experience when using 'MyShield'; saying they would likely use it again. Potential of 'MyShield' in promoting parent/clinician interaction with the child was highlighted. Data suggests that 'MyShield' may be a useful device for children undergoing venepuncture, when used in conjunction with standard care, and subject to individual preferences and choice. Further work is required to establish mechanism of action and whether use of 'MyShield' has any impact across a range of short- and long-term outcome measures relating to patient experience and effectiveness.

The economics of medical procedure innovation.

This paper explores the economic incentives for medical procedure innovation. Using a proprietary dataset on billing code applications for emerging medical procedures, we highlight two mechanisms that could hinder innovation. First, the administrative hurdle of securing permanent, reimbursable billing codes substantially delays innovation diffusion. We find that Medicare utilization of innovative procedures increases nearly nine-fold after the billing codes are promoted to permanent (reimbursable) from provisional (non-reimbursable). However, only 29 percent of the provisional codes are promoted within the five-year probation period. Second, medical procedures lack intellectual property rights, especially those without patented devices. When appropriability is limited, specialty medical societies lead the applications for billing codes. We indicate that the ad hoc process for securing billing codes for procedure innovations creates uncertainty about both the development process and the allocation and enforceability of property rights. This stands in stark contrast to the more deliberate regulatory oversight for pharmaceutical innovations.

Optimal Relocation of Medical Procedures Under the Covid-19 Regime: an Urology Case Study.

We present a prototype system, OptiLoc, that aims at analysing consequences of medical capacity restrictions under the Covid-19 regime as well as at providing medical analysts and decision makers with medical procedure relocation plans for a given area in a given time period. This is achieved by first forecasting the demand of medical procedures of different types at the selected geographical granularity level and then finding relocations which are optimal according to a well defined objective function that takes into account procedure and relocation costs, under constraints imposed by Covid-19 restrictions and hospital capacities. Allocation plans are visualized in a user friendly web-based application. We demonstrate the effectiveness of the developed system on the data on urological procedures from Poland.

Revised recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic - what a difference a year makes.

BACKGROUND: During the early part of the COVID-19 pandemic, the Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force published recommendations on performance of tracheotomy. Since then, our understanding of the virus has evolved with ongoing intensive research efforts. New literature has helped us better understand various aspects including patient outcomes and health care worker (HCW) risks associated with tracheotomy during the COVID-19 pandemic. Accordingly, the task force has re-evaluated and revised some of the previous recommendations. MAIN BODY: Based on recent evidence, a negative reverse transcription polymerase chain reaction (RT-PCR) COVID-19 swab status is no longer the main deciding factor in the timing of tracheotomy. Instead, tracheotomy may be considered as soon as COVID-19 swab positive patients are greater than 20 days beyond initial symptoms and 2 weeks of mechanical ventilation. Furthermore, both open and percutaneous surgical techniques may be considered with both techniques showing similar safety and outcome profiles. Additional recommendations with discussion of current evidence are presented. CONCLUSION: These revised recommendations apply new evidence in optimizing patient and health care system outcomes as well as minimizing risks of COVID-19 transmission during aerosol-generating tracheotomy procedures. As previously noted, additional evidence may lead to further evolution of these and other similar recommendations.

Re Imogen: the role of the Family Court of Australia in disputes over gender dysphoria treatment.

This article examines Re Imogen (No 6) (2020) 61 Fam LR 344, a decision of the Family Court of Australia, which held that an application to the Family Court is mandatory if a parent or a medical practitioner of a child or adolescent diagnosed with gender dysphoria disputes the diagnosis, the capacity to consent, or the proposed treatment. First, we explain the regulatory framework for the medical treatment of gender dysphoria in children and adolescents, including the development of the welfare jurisdiction under Section 67ZC of the Family Law Act 1975 (Cth). We then provide an overview of the Re Imogen decision, and discuss the balancing exercise involved in determining a child's best interests in the medical treatment context. We challenge the Family Court's conclusion that, in relation to a dispute about diagnosis or treatment, a finding that the child or adolescent is Gillick competent to consent to treatment is not determinative, and the Family Court must determine the dispute. We argue that this conclusion represents an unjustified incursion into the right of Gillick competent transgender children and adolescents to make decisions about their own bodies and identities, and that the protective role of parents and the Family Court cannot justify interfering with their bodily autonomy in this context. Finally, we propose an alternative regulatory framework that removes the Family Court from the medical treatment process for gender dysphoria in circumstances of dispute between a parent and their Gillick competent child.

Difficult tracheal extubation due to endotracheal tube malfunction: A challenge during the COVID-19 pandemic.

Tracheal extubation is an aerosol-generating medical procedure. Difficult tracheal extubation is a serious complication that increases the risk of respiratory aerosol and pathogen spread, especially during the COVID-19 pandemic. The management of difficult extubation is potentially even more challenging during the pandemic. We report two cases of difficult extubation due to endotracheal tube cuff malfunction during the COVID-19 pandemic. Special airway maneuvers and infection control measures were employed to successfully manage the unexpected dilemma. This case series highlights the risk of COVID-19 virus transmission during difficult extubation. This report describes the preventive and reactive management of difficult extubation.

Medical Procedure Services in Internal Medicine Residencies in the US: a Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: The number of procedures performed by internal medicine residents in the United States (US) is declining. An increasing proportion of residents do not feel confident performing essential invasive bedside procedures and, upon graduation, desire additional training. Several residency programs have utilized the medical procedure service (MPS) to address this issue. We aim to summarize the current state of evidence by systematically evaluating the effect of the MPS on resident education, comfort, and training, as well as patient safety and procedural outcomes in the US. METHODS: We conducted a systematic review of all studies reporting the use of an MPS with supervision from a board-certified physician in internal medicine residencies in the US. Database search was performed on PubMed, Embase, ERIC, and Cochrane Library from January 2000 to November 2020 for relevant studies. Quality of evidence assessment and random-effects proportion meta-analyses were performed. RESULTS: A total of nine studies reporting on 3879 procedures performed by MPS were identified. Procedures were safely performed, with a pooled complication rate of 2.1% (95% CI: 1.0-3.5) and generally successful, with a pooled success rate of 94.7% (95% CI: 90.8-97.7). The range of procedures performed by residents under MPS was 6.7-72.8 procedures per month (n = 9) compared to 4.3-64.4 procedures (n = 4) without MPS. MPS significantly increased confidence, comfort, and use of appropriate safety measures among residents. CONCLUSION: There are a limited number of published studies on MPS supervised by a board-certified physician in US internal medicine residencies. Procedures performed by MPS are generally successfully completed and safe. MPS benefits internal medicine residents training by improving competency, comfort, and confidence.

Aerosol-generating otolaryngology procedures and the need for enhanced PPE during the COVID-19 pandemic: a literature review.

BACKGROUND: Adequate personal protective equipment is needed to reduce the rate of transmission of COVID-19 to health care workers. Otolaryngology groups are recommending a higher level of personal protective equipment for aerosol-generating procedures than public health agencies. The objective of the review was to provide evidence that a.) demonstrates which otolaryngology procedures are aerosol-generating, and that b.) clarifies whether the higher level of PPE advocated by otolaryngology groups is justified. MAIN BODY: Health care workers in China who performed tracheotomy during the SARS-CoV-1 epidemic had 4.15 times greater odds of contracting the virus than controls who did not perform tracheotomy (95% CI 2.75-7.54). No other studies provide direct epidemiological evidence of increased aerosolized transmission of viruses during otolaryngology procedures. Experimental evidence has shown that electrocautery, advanced energy devices, open suctioning, and drilling can create aerosolized biological particles. The viral load of COVID-19 is highest in the upper aerodigestive tract, increasing the likelihood that aerosols generated during procedures of the upper aerodigestive tract of infected patients would carry viral material. Cough and normal breathing create aerosols which may increase the risk of transmission during outpatient procedures. A significant proportion of individuals infected with COVID-19 may not have symptoms, raising the likelihood of transmission of the disease to inadequately protected health care workers from patients who do not have probable or confirmed infection. Powered air purifying respirators, if used properly, provide a greater level of filtration than N95 masks and thus may reduce the risk of transmission. CONCLUSION: Direct and indirect evidence suggests that a large number of otolaryngology-head and neck surgery procedures are aerosol generating. Otolaryngologists are likely at high risk of contracting COVID-19 during aerosol generating procedures because they are likely exposed to high viral loads in patients infected with the virus. Based on the precautionary principle, even though the evidence is not definitive, adopting enhanced personal protective equipment protocols is reasonable based on the evidence. Further research is needed to clarify the risk associated with performing various procedures during the COVID-19 pandemic, and the degree to which various personal protective equipment reduces the risk.

Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic.

INTRODUCTION: The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic. MAIN BODY: The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure. CONCLUSION: The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.

Practice Makes Perfect: Simulation in Emergency Medicine Risk Management.

Simulation has been steadily changing the safety culture in the healthcare industry and allowing individual clinicians and interdisciplinary teams to be proactive in the culture of risk reduction and improved patient safety. Literature has demonstrated improved patient outcomes, improved team based skills, systems testing and mitigation of latent safety threats. Simulation may be incorporated into practice via different modalities. The simulation lab is helpful for individual procedures, in situ simulation (ISS) for system testing and teamwork, community outreach ISS for sharing of best practices and content resource experts. Serious medical gaming is developing into a useful training adjunct for the future.

Psychological interventions using virtual reality for pain associated with medical procedures: a systematic review and meta-analysis.

BACKGROUND: Virtual reality (VR) may enhance the effectiveness of psychological interventions for acute pain. We conducted a meta-analysis to assess the efficacy and safety of VR-based interventions for pain associated with medical procedures. METHODS: We searched PubMed, EMBASE, the Cochrane Library, and PsycINFO until June 17th 2018. We identified randomized controlled trials (RCTs), comparing VR-based psychological interventions to usual care, for pain intensity (primary outcome) or affective and cognitive components of pain (secondary outcomes), assessed real-time or retrospectively. Two independent reviewers performed study selection and data extraction. Risk of bias was independently evaluated by three raters using the revised Cochrane Collaboration tool. A random-effects model using the Paule and Mandel estimator was used for pooling effect sizes. RESULTS: 27 RCTs (1452 patients) provided enough data for meta-analysis. Compared to usual care, VR-based interventions reduced pain intensity both real-time (9 RCTs, Hedges' g = 0.95, 95% CI 0.32-1.57) and retrospectively (22 RCTs, g = 0.87, 95% CI 0.54-1.21). Results were similar for cognitive (8 RCTs, g = 0.82, 95% CI 0.39-1.26) and affective pain components (14 RCTs, g = 0.55, 95% CI 0.34-0.77). There was marked heterogeneity, which remained similarly high in sensitivity analyses. Across domains, few trials were rated as low risk of bias and there was evidence of publication bias. Adverse events were rare. CONCLUSIONS: Though VR-based interventions reduced pain for patients undergoing medical procedures, inferring clinical effectiveness is precluded by the predominance of small trials, with substantial risk of bias, and by incomplete reporting.