Skin Gambling Contributes to Gambling Problems and Harm After Controlling for Other Forms of Traditional Gambling.

Esports betting and skin gambling involve betting on the outcomes of video game competitions and/or using virtual currencies for betting. The present study evaluated a conceptual model linking video game involvement, video-game related gambling, traditional gambling, and gambling problems and harm. Data were collected via a cross-sectional online survey with 737 participants aged 18 + who engaged in esports cash betting (n = 576), esports skin betting (n = 184), or skin gambling on games of chance (n = 330). The findings highlighted the distinctly different relationships esports cash betting versus skin gambling had with traditional gambling involvement and harmful gambling. Gambling with skins on games of chance was predictive of gambling problems and gambling harm after controlling for participation in traditional gambling (OR = 1.32 and 1.17 respectively). Whereas betting on esports with cash was associated with betting on a variety of other forms of gambling, and there was no unique contribution to problems and harm over and above participation on these other forms (e.g., EGMs, sports betting). Skin gambling is directly implicated in gambling problems and harm, whereas cash betting on esports is only indicative of interest in many forms of potentially harmful gambling. Greater research attention to skin gambling is warranted, and particularly with respect to its role as a virtual currency more easily accessible for gambling.

Motivations for Esports Betting and Skin Gambling and Their Association with Gambling Frequency, Problems, and Harm.

This study aimed to examine gambling motivations for esports betting and skin gambling and their association with gambling frequency, problems, and harm. Data were collected via a cross-sectional online survey with 736 participants aged 18 + who engaged in esports cash betting (n = 567), esports skin betting (n = 180), or skin gambling on games of chance (n = 325). Respondents were asked to rate their motivations for the three activities across seven domains: social, financial, positive feelings or enhancement, internal regulation, skill building, competition/challenge, and skin acquisition. The results highlight both similarities and differences in gambling motivations across products. Financial gain and enhancement (i.e., excitement) were the main motivations endorsed for all activities, whereas skin acquisition was an additional motivation for esports skin betting and skin gambling. Across all three products, gambling to escape or improve mood was associated with higher levels of problem gambling and harm. Financial gain motivation was associated with problem gambling only for esports skin betting and skin gambling on games of chance. These findings underscore the importance of considering motivational influences on engagement with emerging gambling activities, especially since some motivations may be a contributing factor in harmful gambling outcomes.

Seeking Solace in Gambling: The Cycle of Gambling and Intimate Partner Violence Against Women Who Gamble.

This study explored women's gambling in response to male intimate partner violence (IPV). Twenty-four women were recruited through service providers and online advertising. All women had been victimised by IPV and all experienced problems relating to the gambling on electronic gaming machines (EGMs). Thematic analysis of their in-depth interviews identified three major themes. The main pattern of gambling and IPV (Theme 1) was where ongoing coercive control preceded the woman's gambling. Situational violence in response to gambling was also observed. Regardless of temporal sequence, a self-perpetuating cycle of gambling and IPV victimisation was typically apparent, with both issues escalating over time. Reflecting severe traumatic violence, push factors from IPV that motivated the women's gambling (Theme 2) included physical escape, psychological escape, hope of regaining control over their lives, and gambling to cope with the legacy of abuse. Pull factors attracting these women to gambling venues (Theme 3) appeared to have heightened appeal to these victims of IPV. These included venues' social, geographic and temporal accessibility, allowance for uninterrupted play on EGMs, and the addictive nature of EGMs. These push and pull factors led to these women's prolonged and harmful gambling while exacerbating their partner's violence. Concerted efforts are needed to assist women in this cycle of IPV and gambling, prevent violence against women, and reduce harmful gambling products and environments.

Major Update: Remdesivir for Adults With COVID-19 : A Living Systematic Review and Meta-analysis for the American College of Physicians Practice Points.

BACKGROUND: Remdesivir is being studied and used for treatment of coronavirus disease 2019 (COVID-19). PURPOSE: To update a previous review of remdesivir for adults with COVID-19, including new meta-analyses of patients with COVID-19 of any severity compared with control. DATA SOURCES: Several sources from 1 January 2020 through 7 December 2020. STUDY SELECTION: English-language, randomized controlled trials (RCTs) of remdesivir for COVID-19. New evidence is incorporated by using living review methods. DATA EXTRACTION: 1 reviewer abstracted data; a second reviewer verified the data. The Cochrane Risk of Bias Tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) method were used. DATA SYNTHESIS: The update includes 5 RCTs, incorporating data from a new large RCT and the final results of a previous RCT. Compared with control, a 10-day course of remdesivir probably results in little to no reduction in mortality (risk ratio [RR], 0.93 [95% CI, 0.82 to 1.06]; 4 RCTs) but may result in a small reduction in the proportion of patients receiving mechanical ventilation (RR, 0.71 [CI, 0.56 to 0.90]; 3 RCTs). Remdesivir probably results in a moderate increase in the percentage of patients who recovered and a moderate decrease in serious adverse events and may result in a large reduction in time to recovery. Effect on hospital length of stay or percentage remaining hospitalized is mixed. Compared with a 10-day course for those not requiring ventilation at baseline, a 5-day course may reduce mortality, the need for ventilation, and serious adverse events while increasing the percentage of patients who recovered or clinically improved. LIMITATION: Summarizing findings was challenging because of varying disease severity definitions and outcomes. CONCLUSION: In hospitalized adults with COVID-19, remdesivir probably results in little to no mortality difference but probably improves the percentage recovered and reduces serious harms and may result in a small reduction in the proportion receiving ventilation. For patients not receiving ventilation, a 5-day course may provide greater benefits and fewer harms with lower drug costs than a 10-day course. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.

Remdesivir for Adults With COVID-19 : A Living Systematic Review for American College of Physicians Practice Points.

BACKGROUND: Few treatments exist for coronavirus disease 2019 (COVID-19). PURPOSE: To evaluate the effectiveness and harms of remdesivir for COVID-19. DATA SOURCES: Several databases, tables of contents of journals, and U.S. Food and Drug Administration and company websites were searched from 1 January through 31 August 2020. STUDY SELECTION: English-language, randomized trials of remdesivir treatments for adults with suspected or confirmed COVID-19. New evidence will be incorporated using living review methods. DATA EXTRACTION: Single-reviewer abstraction and risk-of-bias assessment verified by a second reviewer; GRADE (Grading of Recommendations Assessment, Development and Evaluation) methods used for certainty-of-evidence assessments. DATA SYNTHESIS: Four randomized trials were included. In adults with severe COVID-19, remdesivir compared with placebo probably improves recovery by a large amount (absolute risk difference [ARD] range, 7% to 10%) and may result in a small reduction in mortality (ARD range, -4% to 1%) and a shorter time to recovery or clinical improvement. Remdesivir may have little to no effect on hospital length of stay. Remdesivir probably reduces serious adverse events by a moderate amount (ARD range, -6% to -8%). Compared with a 10-day remdesivir course, a 5-day course may reduce mortality, increase recovery or clinical improvement by small to moderate amounts, reduce time to recovery, and reduce serious adverse events among hospitalized patients not requiring mechanical ventilation. Recovery due to remdesivir may not vary by age, sex, symptom duration, or disease severity. LIMITATIONS: Low-certainty evidence with few published trials, including 1 preliminary report and 2 open-label trials. Trials excluded pregnant women and adults with severe kidney or liver disease. CONCLUSION: In hospitalized adults with COVID-19, remdesivir probably improves recovery and reduces serious adverse events and may reduce mortality and time to clinical improvement. For adults not receiving mechanical ventilation or extracorporeal membrane oxygenation, a 5-day course of remdesivir may provide similar benefits to and fewer harms than a 10-day course. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs, Veterans Health Administration Office of Research and Development, Health Services Research and Development Service, and Evidence Synthesis Program.

Effectiveness and Harms of High-Flow Nasal Oxygen for Acute Respiratory Failure: An Evidence Report for a Clinical Guideline From the American College of Physicians.

BACKGROUND: Use of high-flow nasal oxygen (HFNO) for treatment of adults with acute respiratory failure (ARF) has increased. PURPOSE: To assess HFNO versus noninvasive ventilation (NIV) or conventional oxygen therapy (COT) for ARF in hospitalized adults. DATA SOURCES: English-language searches of MEDLINE, Embase, CINAHL, and Cochrane Library from January 2000 to July 2020; systematic review reference lists. STUDY SELECTION: 29 randomized controlled trials evaluated HFNO versus NIV (k = 11) or COT (k = 21). DATA EXTRACTION: Data extraction by a single investigator was verified by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. DATA SYNTHESIS: Results are reported separately for HFNO versus NIV, for HFNO versus COT, and by initial or postextubation management. Compared with NIV, HFNO may reduce all-cause mortality, intubation, and hospital-acquired pneumonia and improve patient comfort in initial ARF management (low-certainty evidence) but not in postextubation management. Compared with COT, HFNO may reduce reintubation and improve patient comfort in postextubation ARF management (low-certainty evidence). LIMITATIONS: Trials varied in populations enrolled, ARF causes, and treatment protocols. Trial design, sample size, duration of treatment and follow-up, and results reporting were often insufficient to adequately assess many outcomes. Protocols, clinician and health system training, cost, and resource use were poorly characterized. CONCLUSION: Compared with NIV, HFNO as initial ARF management may improve several clinical outcomes. Compared with COT, HFNO as postextubation management may reduce reintubations and improve patient comfort; HFNO resulted in fewer harms than NIV or COT. Broad applicability, including required clinician and health system experience and resource use, is not well known. PRIMARY FUNDING SOURCE: American College of Physicians. (PROSPERO: CRD42019146691).

Accuracy of Biomarker Testing for Neuropathologically Defined Alzheimer Disease in Older Adults With Dementia.

BACKGROUND: Biomarker accuracy for Alzheimer disease (AD) is uncertain. PURPOSE: To summarize evidence on biomarker accuracy for classifying AD in older adults with dementia. DATA SOURCES: Electronic bibliographic databases (searched from January 2012 to November 2019 for brain imaging and cerebrospinal fluid [CSF] tests and from inception to November 2019 for blood tests), ClinicalTrials.gov (to November 2019), and systematic review bibliographies. STUDY SELECTION: English-language studies evaluating the accuracy of brain imaging, CSF testing, or blood tests for distinguishing neuropathologically defined AD from non-AD among older adults with dementia. Studies with low or medium risk of bias were analyzed. DATA EXTRACTION: Two reviewers rated risk of bias. One extracted data; the other verified accuracy. DATA SYNTHESIS: Fifteen brain imaging studies and 9 CSF studies met analysis criteria. Median sensitivity and specificity, respectively, were 0.91 and 0.92 for amyloid positron emission tomography (PET), 0.89 and 0.74 for 18F-labeled fluorodeoxyglucose (18F-FDG) PET, 0.64 and 0.83 for single-photon emission computed tomography, and 0.91 and 0.89 for medial temporal lobe atrophy on magnetic resonance imaging (MRI). Individual CSF biomarkers and ratios had moderate sensitivity (range, 0.62 to 0.83) and specificity (range, 0.53 to 0.69); in the few direct comparisons, ß-amyloid 42 (Aß42)/phosphorylated tau (p-tau) ratio, total tau (t-tau)/Aß42 ratio, and p-tau appeared more accurate than Aß42 and t-tau alone. Single studies suggested that amyloid PET, 18F-FDG PET, and CSF test combinations may add accuracy to clinical evaluation. LIMITATIONS: Studies were small, biomarker cut points and neuropathologic AD were inconsistently defined, and methods with uncertain applicability to typical clinical settings were used. Few studies directly compared biomarkers, assessed test combinations, evaluated whether biomarkers improved classification accuracy when added to clinical evaluation, or reported harms. CONCLUSION: In methodologically heterogeneous studies of uncertain applicability to typical clinical settings, amyloid PET, 18F-FDG PET, and MRI were highly sensitive for neuropathologic AD. Amyloid PET, 18F-FDG PET, and CSF test combinations may add accuracy to clinical evaluation. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42018117897).

Efficacy and Safety of Testosterone Treatment in Men: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians.

Background: Testosterone treatment rates in adult men have increased in the United States over the past 2 decades. Purpose: To assess the benefits and harms of testosterone treatment for men without underlying organic causes of hypogonadism. Data Sources: English-language searches of multiple electronic databases (January 1980 to May 2019) and reference lists from systematic reviews. Study Selection: 38 randomized controlled trials (RCTs) of at least 6 months' duration that evaluated transdermal or intramuscular testosterone therapies versus placebo or no treatment and reported prespecified patient-centered outcomes, as well as 20 long-term observational studies, U.S. Food and Drug Administration review data, and product labels that reported harms information. Data Extraction: Data extraction by a single investigator was confirmed by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. Data Synthesis: Studies enrolled mostly older men who varied in age, symptoms, and testosterone eligibility criteria. Testosterone therapy improved sexual functioning and quality of life in men with low testosterone levels, although effect sizes were small (low- to moderate-certainty evidence). Testosterone therapy had little to no effect on physical functioning, depressive symptoms, energy and vitality, or cognition. Harms evidence reported in trials was judged to be insufficient or of low certainty for most harm outcomes. No trials were powered to assess cardiovascular events or prostate cancer, and trials often excluded men at increased risk for these conditions. Observational studies were limited by confounding by indication and contraindication. Limitation: Few trials exceeded a 1-year duration, minimum important outcome differences were often not established or reported, RCTs were not powered to assess important harms, few data were available in men aged 18 to 50 years, definitions of low testosterone varied, and study entry criteria varied. Conclusion: In older men with low testosterone levels without well-established medical conditions known to cause hypogonadism, testosterone therapy may provide small improvements in sexual functioning and quality of life but little to no benefit for other common symptoms of aging. Long-term efficacy and safety are unknown. Primary Funding Source: American College of Physicians. (PROSPERO: CRD42018096585).

Brief Cognitive Tests for Distinguishing Clinical Alzheimer-Type Dementia From Mild Cognitive Impairment or Normal Cognition in Older Adults With Suspected Cognitive Impairment.

BACKGROUND: The accuracy and harms of brief cognitive tests for identifying clinical Alzheimer-type dementia (CATD) are uncertain. PURPOSE: To summarize evidence on accuracy and harms of brief cognitive tests for CATD in older adults with suspected cognitive impairment. DATA SOURCES: Electronic bibliographic databases (from inception to November 2019) and systematic review bibliographies. STUDY SELECTION: English-language, controlled observational studies in older adults that evaluated the accuracy of brief cognitive tests (standalone tests; memory, executive function, and language tests; and brief multidomain batteries) for distinguishing CATD from mild cognitive impairment (MCI) or normal cognition as defined by established diagnostic criteria. Studies with low or medium risk of bias (ROB) were analyzed. DATA EXTRACTION: Two reviewers rated ROB. One reviewer extracted data; the other verified extraction accuracy. DATA SYNTHESIS: Fifty-seven studies met analysis criteria. Many brief, single cognitive tests were highly sensitive and specific for distinguishing CATD from normal cognition. These included standalone tests (clock-drawing test, median sensitivity 0.79 and specificity 0.88 [8 studies]; Mini-Mental State Examination, 0.88 and 0.94 [7 studies]; Montreal Cognitive Assessment, 0.94 and 0.94 [2 studies]; and Brief Alzheimer Screen, 0.92 and 0.97 [1 study]), memory tests (list delayed recall, 0.89 and 0.94 [5 studies]), and language tests (category fluency, 0.92 and 0.89 [9 studies]). Accuracy was lower in distinguishing mild CATD from normal cognition and distinguishing CATD from MCI. No studies reported on testing harms. LIMITATIONS: Studies were small. Few test metrics were evaluated by multiple studies. Few studies directly compared different tests, scores, cut points, or test combinations. CONCLUSION: Many brief, single cognitive tests accurately distinguish CATD from normal cognition in older adults but are less accurate in distinguishing mild CATD from normal cognition or CATD from MCI. No studies reported on testing harms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42018117897).

Orthobiologics in Foot and Ankle Arthrodesis: A Systematic Review.

Orthobiologics are biologically-derived materials intended to promote bone formation and union. We review evidence on effectiveness and harms of orthobiologics compared to no orthobiologics for foot and ankle arthrodesis. We searched multiple databases (1995-2019) and included clinical trials and other studies with concurrent controls, English language, and reporting patient-centered outcomes, union/time to union, costs/resource utilization, or harms. Studies were organized by orthobiologic used. We describe quality and limitations of available evidence but did not formally rate risk of bias or certainty of evidence. Most of the 21 studies included were retrospective chart reviews with orthobiologics used at surgeon's discretion for patients considered at higher risk for nonunion. Ten studies compared autologous bone graft versus no graft and 2 compared remote versus local graft with few studies of other orthobiologics. All studies reported a measure of fusion and about half reported on function/quality of life. Few studies reported harms. Due to limited reporting, we were unable to assess whether effectiveness varies by risk factors for nonunion (eg, age, gender, smoking status, obesity, diabetes) or whether orthobiologics were cost-effective. Available evidence is of poor quality with small sample sizes, inadequate reporting of risk factors for nonunion, variations in orthobiologics, surgical techniques used, and outcome assessment, and potential selection bias. Research is needed to adequately inform surgeons about benefits and harms and guide patient selection for use, or type, of orthobiologics. Careful assessment of individual patient risk for nonunion is critical prior to orthobiologic use.

Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis.

BACKGROUND: Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults. METHODS: We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes. RESULTS: Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes. DISCUSSION: In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. REGISTRY INFORMATION: PROSPERO - CRD42019132420.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews.

BACKGROUND: With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP). METHODS: We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors). RESULTS: Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP. DISCUSSION: Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

Prevalence and Severity of Psychiatric Disorders and Suicidal Behavior in Service Members and Veterans With and Without Traumatic Brain Injury: Systematic Review.

OBJECTIVES: Assess prevalence and severity of posttraumatic stress disorder, suicidal behavior, and depressive, substance use, and anxiety disorders in US service members or Veterans with and without a deployment-related mild traumatic brain injury (TBI) (mTBI). DESIGN: Systematic review using multiple databases (January 2000 to October 2017). We included national or geographically diverse samples. MAIN MEASURE: Prevalence and severity of psychiatric conditions based on diagnostic codes, clinician assessments, and self-report measures with results stratified by sample type. RESULTS: We identified 11 studies on the basis of national samples and 22 studies on the basis of geographically diverse samples. Traumatic brain injury severity was not always ascertained or reported. In national studies, posttraumatic stress disorder, depressive disorder, substance use disorder, and anxiety disorder prevalence were higher in those with TBI than in those without. One national sample reported prevalence of suicide attempts. Across psychiatric conditions, strength of evidence ranged from insufficient to moderate. In geographically diverse samples, the pattern of findings was similar. National studies provided insufficient evidence on psychiatric condition severity; geographically diverse studies found greater severity of posttraumatic stress disorder symptoms with mixed results for symptoms of depressive or substance use disorders. CONCLUSIONS: Service members and Veterans with TBI history have higher prevalence and possibly severity of selected psychiatric conditions.

Mobile EGM Games: Evidence That Simulated Games Encourage Real-Money Gambling.

Electronic gaming machines (EGMs) and other gambling-themed simulators are a popular sub-genre of video-games or "apps" played on mobile devices (King et al. in Comput Hum Behav 31(Supplement C):305-313, 2014). Qualitative evidence suggests that some people use gambling-themed simulators in an attempt to limit their real-money expenditure (Thorne et al. in J Gambl Issues 34:221-243, 2016), although playing such games might also encourage gambling due to anticipated enjoyment or profit. To test the potential relationship between use of simulated mobile gambling products and real-money gambling, a study was devised to explore current and retrospective accounts, as well as a prospective trial of how weekly play on EGM simulators might influence subsequent gambling. A total of 736 EGM gamblers (421 male) completed an initial scoping survey on their current and retrospective use of simulated and real-money gambling products. By invitation, 556 people (314 male) from the initial survey also volunteered in a 24 weeks follow-up study where approximately half (48.2%) were randomly assigned to play a simulated game, "Lucky Lolly Slots", for at least 5 min each week. Simulated gambling sessions were recorded for both Lucky Lolly Slots and any other gambling apps played by the participants. Results showed that people who had played gambling-themed EGM apps at some point in their lifetime had a higher frequency of play on real-money EGMs and were more likely to admit to current gambling problems. In addition, those people who played a simulated EGM app prior to age 13 nominated an earlier age at which they "gambled the most" in adolescence. In the 24 weeks trial, people's app play (number of sessions) in 1 week reliably predicted increases in real-money gambling the following week. We found no evidence that people who were trying to reduce their expenditure were contrarily influenced to gamble less as a result of their app play, with their app-sessions similarly being related to increases in expenditure. The present results suggest that gamblers who play simulated games are likely to be influenced to gamble more on real-money forms of gambling as a result of their use. The study raises particular concerns about the widespread availability and popularity of such gambling-themed simulators amongst children and adolescents.

Assessing the Effectiveness of Complex Interventions to Meet the Needs of VA Stakeholders: Experience of the Department of Veterans Affairs Evidence Synthesis Program.

BACKGROUND: Complex health care interventions involve multiple distinct elements that contribute to their functioning. Conducting systematic reviews of complex interventions has substantial challenges. Although methodological guidance exists, less is known about the practical strategies and approaches undertaken by systematic review groups to navigate common challenges and enhance impacts of systematic review findings. OBJECTIVES: Describe pragmatic approaches taken by Department of Veterans Affairs Evidence Synthesis Programs (VA ESP) in conducting systematic reviews of effectiveness and implementation barriers and facilitators for complex interventions to provide VA stakeholders with evidence to guide national health care practice and policy. RESULTS: We describe 3 systematic reviews conducted by VA ESP teams to evaluate the evidence for complex health care interventions. We summarize key findings, implications for future research needs and policy, dissemination of findings, and approaches taken to address common challenges. The VA ESP experience adds to existing systematic review methods and provides a perspective on generating rigorous and relevant reviews of complex interventions. CONCLUSIONS: Reviews of complex interventions often encounter challenges related to sources of variability in many dimensions, and lack of clarity and information in reporting of intervention elements, local context, and implementation factors. Evidence synthesis teams should work closely with stakeholders to understand their needs, synthesize and interpret results in meaningful ways, and explore implications that are most relevant for day-to-day clinical practice and operational decisions of learning health care systems. More evaluation of the impact of systematic reviews may improve uptake of findings from future reviews and enhance translation of evidence into practice and policy.

Provider Types and Outcomes in Obstructive Sleep Apnea Case Finding and Treatment: A Systematic Review.

Background: Obstructive sleep apnea (OSA) diagnosis and care models rely on sleep specialist physicians (SSPs) and can be expensive and inefficient. Purpose: To assess OSA case-finding accuracy and comparative effectiveness of care by non-sleep specialists (NSSs) and SSPs. Data Sources: MEDLINE and CINAHL from January 2000 through July 2017. Study Selection: English-language trials or observational studies comparing case finding or care by SSPs versus providers not specifically trained as SSPs (NSSs) for adults with suspected or diagnosed OSA. Data Extraction: One investigator extracted data and assessed risk of bias and strength of evidence, with confirmation by a second investigator. Primary outcomes were patient-centered (mortality, access to care, quality of life, patient satisfaction, adherence, symptom scores, and adverse events). Intermediate outcomes included resource use, costs, time to initiation of treatment, and case finding. Data Synthesis: Four observational studies (n = 580; mean age, 52 years; 77% male) reported good agreement between NSSs and SSPs on appropriate diagnostic testing and classification of OSA severity (low-strength evidence). Five randomized trials and 3 observational studies (n = 1515; mean age, 52 years; 68% male) found that care provided by NSSs and SSPs resulted in similar quality of life, adherence, and symptom scores (low-strength evidence). Evidence was insufficient for access to care and adverse events. Limitations: Many outcomes were reported infrequently or not at all. Many NSSs had extensive training or experience in sleep medicine, which limits generalizability of findings to providers with less experience. Conclusion: Care by NSSs and SSPs resulted in similar outcomes in adults with known or suspected OSA. Studies are needed to determine care model implementation and reproducibility of results in nonacademic settings and among less experienced NSSs. Primary Funding Source: Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO: CRD42016036810 [full Veterans Affairs Evidence-based Synthesis Program report]).

Where's the Bonus in Bonus Bets? Assessing Sports Bettors' Comprehension of their True Cost.

Wagering inducements with bonus bets are prominently marketed and often have play-through conditions requiring further expenditure. However, these conditions are not usually presented in the inducement advertisement and may be difficult to locate. The play-through conditions themselves are complex and may lead bettors to miscalculate the inducement's true cost. Therefore, in relation to inducements with bonus bets, this study aimed to assess: (1) whether their perceived attractiveness varies with the amount and type of information provided about their play-through conditions; (2) bettors' comprehension of their true cost; and (3) whether bettors' comprehension of their true cost varies with problem gambling severity. A sample of 299 Australian sports bettors completed an online survey and rated the attractiveness of three variations of an inducement. Promo1 simply noted that "terms and conditions apply"; promo2 included the terms and conditions immediately below the offer; and promo3 revealed the true cost of the offer. Respondents were asked to calculate the true cost before this was revealed. The study found that detailing key terms and conditions for an offer directly below the advertisement impacts negatively on its perceived attractiveness. Moreover, nearly three in five bettors underestimated the additional amount they would need to bet to access any winnings from the bonus bet. No significant differences were found amongst gambler risk groups. The results imply that current approaches to marketing these inducements are likely to lead consumers to overestimate their attractiveness and underestimate their cost. To enhance responsible gambling practice, these promotional offers should be presented in ways that enable informed decision-making.

Focused Evidence Review: Psychometric Properties of Patient-Reported Outcome Measures for Chronic Musculoskeletal Pain.

BACKGROUND: Developing successful interventions for chronic musculoskeletal pain requires valid, responsive, and reliable outcome measures. The Minneapolis VA Evidence-based Synthesis Program completed a focused evidence review on key psychometric properties of 17 self-report measures of pain severity and pain-related functional impairment suitable for clinical research on chronic musculoskeletal pain. METHODS: Pain experts of the VA Pain Measurement Outcomes Workgroup identified 17 pain measures to undergo systematic review. In addition to a MEDLINE search on these 17 measures (1/2000-1/2017), we hand-searched (without publication date limits) the reference lists of all included studies, prior systematic reviews, and-when available-Web sites dedicated to each measure (PROSPERO registration CRD42017056610). Our primary outcome was the measure's minimal important difference (MID). Secondary outcomes included responsiveness, validity, and test-retest reliability. Outcomes were synthesized through evidence mapping and qualitative comparison. RESULTS: Of 1635 abstracts identified, 331 articles underwent full-text review, and 43 met inclusion criteria. Five measures (Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), SF-36 Bodily Pain Scale (SF-36 BPS), Numeric Rating Scale (NRS), and Visual Analog Scale (VAS)) had data reported on MID, responsiveness, validity, and test-retest reliability. Seven measures had data reported on three of the four psychometric outcomes. Eight measures had reported MIDs, though estimation methods differed substantially and often were not clinically anchored. CONCLUSIONS: In this focused evidence review, the most evidence on key psychometric properties in chronic musculoskeletal pain populations was found for the ODI, RMDQ, SF-36 BPS, NRS, and VAS. Key limitations in the field include substantial variation in methods of estimating psychometric properties, defining chronic musculoskeletal pain, and reporting patient demographics. TRIAL REGISTRATION: Registered in the PROSPERO database: CRD42017056610.

Evidence Review-Social Determinants of Health for Veterans.

BACKGROUND: Veterans Health Administration (VHA) is committed to providing high-quality care and addressing health disparities for vulnerable Veterans. To meet these goals, VA policymakers need guidance on how to address social determinants in operations planning and day-to-day clinical care for Veterans. METHOD: MEDLINE (OVID), CINAHL, PsycINFO, and Sociological Abstracts were searched from inception to January 2017. Additional articles were suggested by peer reviewers and/or found through search of work associated with US and VA cohorts. Eligible articles compared Veterans vs non-Veterans, and/or Veterans engaged with those not engaged in VA healthcare. Our evidence maps summarized study characteristics, social determinant(s) addressed, and whether health behaviors, health services utilization, and/or health outcomes were examined. Qualitative syntheses and quality assessment were performed for articles on rurality, trauma exposure, and sexual orientation. RESULTS: We screened 7242 citations and found 131 eligible articles-99 compared Veterans vs non-Veterans, and 40 included engaged vs non-engaged Veterans. Most articles were cross-sectional and addressed socioeconomic factors (e.g., education and income). Fewer articles addressed rurality (N = 20), trauma exposure (N = 17), or sexual orientation (N = 2); none examined gender identity. We found no differences in rural residence between Veterans and non-Veterans, nor between engaged and non-engaged Veterans (moderate strength evidence). There was insufficient evidence for role of rurality in health behaviors, health services utilization, or health outcomes. Trauma exposures, including from events preceding military service, were more prevalent for Veterans vs non-Veterans and for engaged vs non-engaged Veterans (low-strength evidence); exposures were associated with smoking (low-strength evidence). DISCUSSION: Little published literature exists on some emerging social determinants. We found no differences in rural residence between our groups of interest, but trauma exposure was higher in Veterans (vs non-Veterans) and engaged (vs non-engaged). We recommend consistent measures for social determinants, clear conceptual frameworks, and analytic strategies that account for the complex relationships between social determinants and health.

Enhanced Recovery Protocols for Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Enhanced surgical recovery protocols are designed to reduce hospital length of stay and health care costs. OBJECTIVE: This study aims to systematically review and summarize evidence from randomized and controlled clinical trials comparing enhanced recovery protocols versus usual care in adults undergoing elective colorectal surgery with emphasis on recent trials, protocol components, and subgroups for surgical approach and colorectal condition. DATA SOURCES: MEDLINE from 2011 to July 2017; reference lists of existing systematic reviews and included studies were reviewed to identify all eligible trials published before 2011. STUDY SELECTION: English language trials comparing a protocol of preadmission, preoperative, intraoperative, and postoperative components with usual care in adults undergoing elective colorectal surgery were selected. INTERVENTION: The enhanced recovery protocol for colorectal surgery was investigated. MAIN OUTCOME MEASURES: Length of stay, perioperative morbidity, mortality, readmission within 30 days, and surgical site infection were the primary outcomes measured. RESULTS: Twenty-five trials of open or laparoscopic surgery for cancer or noncancer conditions were included. Enhanced recovery protocols consisted of 4 to 18 components. Few studies fully described the various components. Length of stay (mean reduction, 2.6 days; 95% CI, -3.2 to -2.0) and risk of overall perioperative morbidity (risk ratio, 0.66; 95% CI, 0.54-0.80) were lower in enhanced recovery protocol groups than in usual care groups (moderate-quality evidence). All-cause mortality (rare), readmissions, and surgical site infection rates were similar between protocol groups (low-quality evidence). In predefined subgroup analyses, findings did not vary by surgical approach (open vs laparoscopic) or colorectal condition. LIMITATIONS: Protocols varied across studies and little information was provided regarding compliance with, or implementation of, specific protocol components. CONCLUSIONS: Enhanced recovery protocols for adults undergoing colorectal surgery improve patient outcomes with no increase in adverse events. Evidence was insufficient regarding which components, or component combinations, are key to improving patient outcomes. PROSPERO registration number: CRD42017067991.