Reported Outcome Measures in Mohs Micrographic Surgery in Studies With Defined Techniques for Embedding and Processing of Tissue: A Systematic Review.

BACKGROUND: Mohs micrographic surgery (MMS) is a technique that combines surgical excision and histologic evaluation to achieve higher cure rates for skin cancer than traditional surgical excision. Competing performance measures have fostered numerous histologic techniques for MMS. OBJECTIVE: To analyze differences in primary outcomes in the published literature regarding the technique of tissue processing and embedding during the MMS process. METHODS: A systematic review was performed of the published literature in MEDLINE, PubMed, Embase, and Cochrane library that included a description of the manipulation of tissue during the grossing and embedding steps of MMS. RESULTS: Inclusion criteria were met by 61 articles. Of these studies, the cure/recurrence rate was assessed in 1 article (1.6%), tissue conservation was assessed in 47 (77%), time-saving was assessed in 35 (57%), cost-saving was assessed in 6 (10%), and decreased artifact were assessed in 20 (33%). CONCLUSION: There is a lack of standardization for assessing clinical outcomes in the published literature regarding MMS process techniques. Cure is a critical outcome in studies comparing MMS processing methodologies.

Factors Associated with Long-Term Retention in Buprenorphine-Based Addiction Treatment Programs: a Systematic Review.

BACKGROUND: The average length of buprenorphine treatment for opioid use disorder is less than 6 months. OBJECTIVE: We conducted a systematic review to determine what factors were associated with longer retention in buprenorphine treatment. DESIGN: We searched Medline, Embase, and Cochrane Database of Systematic Reviews in February 2018. Articles were restricted to randomized controlled trials on human subjects, written in English, which contained ≥ 24 weeks of objective data on retention in buprenorphine treatment. MAIN MEASURES: We assessed whether dose of buprenorphine, treatment setting, or co-administration of behavioral therapy was associated with retention rates. KEY RESULTS: Over 14,000 articles were identified. Thirteen articles (describing 9 studies) met inclusion criteria. Measures of retention varied widely. Three studies compared doses of buprenorphine between 1 and 8 mg and showed significantly higher rates of retention with higher doses (p values < 0.01). All other studies utilized buprenorphine doses between 8 and 24 mg daily, without comparison. No study found a significant difference in retention between buprenorphine alone and buprenorphine plus behavioral therapy (p values > 0.05). Initiating buprenorphine while hospitalized or within criminal justice settings prior to outpatient treatment programs was significantly associated with retention in buprenorphine treatment (p values < 0.01 respectively). CONCLUSIONS: Setting of treatment initiation and a higher buprenorphine dose are associated with improved long-term treatment retention. More objective data on buprenorphine treatment programs are needed, including a standardized approach to defining retention in buprenorphine treatment programs. REGISTRATION: This review was registered with PROSPERO (#CRD42019120336) in March 2019.

Prevalence of Asymptomatic Bacteriuria in Children: A Meta-Analysis.

OBJECTIVE: To determine the point prevalence of bacteriuria and bacteriuria without pyuria in asymptomatic children by a systematic review of the literature. STUDY DESIGN: We searched MEDLINE and EMBASE for English-, French-, German-, Italian-, and Spanish-language articles. We included articles reporting data on bacteriuria in asymptomatic children up to 19 years of age who had urine collected by suprapubic bladder aspiration, bladder catheterization, or by 3 consecutive clean catch samples. Two independent reviewers assessed studies for inclusion and abstracted data. RESULTS: Fourteen studies (49 806 children) were included. The prevalence of asymptomatic bacteriuria was 0.37% (95% CI, 0.09-0.82) in boys and 0.47% (95% CI, 0.36-0.59) in girls. The corresponding values for asymptomatic bacteriuria without pyuria were 0.18% (95% CI, 0.02-0.51) and 0.38% (95% CI, 0.22-0.58), respectively. The subgroups with the highest prevalence of asymptomatic bacteriuria were uncircumcised males <1 year of age and females >2 years of age. In males, the prevalence of asymptomatic bacteriuria after infancy was 0.08% (95% CI, 0.01-0.37). The median duration of asymptomatic bacteriuria in untreated boys and girls, from the one study reporting this outcome, was 1.5 and 2 months, respectively. CONCLUSIONS: Some clinicians are concerned that when a preverbal child with asymptomatic bacteriuria develops a nonlocalizing febrile illness and presents for evaluation, they may be mistakenly diagnosed as having a urinary tract infection (UTI). Given that the prevalence of asymptomatic bacteriuria is considerably lower than the prevalence of UTI in most subgroups examined, this will occur extremely rarely. These data suggest that the current definition of UTI should be revisited.

Continuing education for systematic reviews: a prospective longitudinal assessment of a workshop for librarians.

OBJECTIVE: This prospective, longitudinal study explored the impact of a continuing education class on librarians' knowledge levels about and professional involvement with systematic reviews. Barriers to systematic review participation and the presence of formal systematic review services in libraries were also measured. METHODS: Participants completed web-based surveys at three points in time: pre-class, post-class, and six-months' follow-up. Descriptive statistics were calculated for demographics and survey questions. Linear mixed effects models assessed knowledge score changes over time. RESULTS: Of 160 class attendees, 140 (88%) completed the pre-class survey. Of those 140, 123 (88%) completed the post-class survey, and 103 (74%) completed the follow-up survey. There was a significant increase (p<0.00001) from pre-class to post-class in knowledge test scores, and this increase was maintained at follow-up. At post-class, 69% or more of participants intended to promote peer review of searches, seek peer review of their searches, search for grey literature, read or follow published guidelines on conduct and documentation of systematic reviews, and ask for authorship on a systematic review. Among librarians who completed a systematic review between post-class and follow-up, 73% consulted published guidelines, 52% searched grey literature, 48% sought peer review, 57% asked for authorship, and 70% received authorship. CONCLUSIONS: Attendance at this continuing education class was associated with positive changes in knowledge about systematic reviews and in librarians' systematic review-related professional practices. This suggests that in-depth professional development classes can help librarians develop skills that are needed to meet library patrons' changing service needs.

A Systematic Review of Gender-Based Differences in Hirsch Index Among Academic Surgeons.

BACKGROUND: The h-index is a commonly used bibliometric in academic medicine which enumerates the number of publications (h) that have been cited h times. Recent investigations have suggested that gender-based differences in h-index may exist among academic physicians. We systematically reviewed studies of academic surgeons' h-index, hypothesizing that a significant difference would exist between the h-index of men and women at all academic ranks. METHODS: Peer-reviewed journal articles authored by academic surgeons of any subspecialization in the United States between January 1, 2006, and November 20, 2017, were reviewed. We excluded studies of trainees or gender-based differences in funding without mention of h-index. Two reviewers assessed article quality using the Newcastle-Ottawa criteria. Pooled estimates of standard mean differences (SMD) in h-index between genders were calculated using random-effects meta-analyses. A subgroup analysis based on the academic rank was performed. Heterogeneity was assessed using the I2 statistic. Sensitivity analyses determined the effect of study on h-index. Meta-regression identified whether surgical specialty contributed to heterogeneity. RESULTS: Twelve articles comparing h-index between genders were selected from 7950. Men possessed higher h-indices than women (SMD, 0.547; P < 0.001; I2 = 89.5%). Men exhibited higher h-indices at the assistant rank (SMD, 0.12; 95% confidence interval [CI], 0.01-0.24; P = 0.039) but not at the associate (SMD, 0.14; 95% CI, -0.06 to 0.33; P = 0.165) or full professor (SMD, 0.12; 95% CI, -0.08 to -0.31; P = 0.25) ranks. CONCLUSIONS: The h-index is higher for men than that for women in academic surgery overall but not at individual ranks. Further investigations are necessary to address limitations in h-index and to further characterize the relationship between h-index, gender, and promotion.

Use of fictional medical television in health sciences education: a systematic review.

While medical television programs are popular among health profession trainees, it is not clear to what extent these programs affect their knowledge, perceptions, and/or behaviors. Therefore, we conducted a systematic review of research evaluating associations between program exposure and outcomes. We conducted systematic literature searches in Pubmed, CINAHL, and PsycINFO. Selected studies were required to be scholarly research, involve exposure to fictionalized medical television programming by health professional students, and assess associations between exposure and outcomes. Studies were classified according to quality and factors related to population, exposure, and outcomes. Of 3541 studies identified, 13 met selection criteria. Six studies involved undergraduate medical students, one involved nursing students, two involved both medical and nursing students, two involved medical residents, one involved medical students, residents and attending physicians, and one involved graduate epidemiology students. Mean study quality according to the MERSQI was 8.27. The most commonly assessed television programs were ER and Grey's Anatomy (six each). Five studies assessed regular viewing habits, and found that fictional medical programs are popular among students and that students recall health topics from episodes. The eight studies that assessed the association with outcomes when using clips as educational tools reported high satisfaction and increased knowledge of the presented health topics. While relatively few published studies have explored influences of fictional medical television on health professional students, those conducted suggest that students often view these television programs independently and that integration of this programming into medical education is feasible and acceptable.

Comparative effectiveness in urology: a state of the art review utilizing a systematic approach.

PURPOSE OF REVIEW: Comparative effectiveness research plays a vital role in healthcare delivery by guiding evidence-based practices. We performed a state-of-the-art review of comparative effectiveness research in the urology literature for 2016, utilizing a systematic approach. Seven high-impact papers are reviewed in detail. RECENT FINDINGS: Across the breadth of urology, there were several important studies in comparative effectiveness research, of which we will highlight two randomized controlled trials and five observational trials: radiotherapy, prostatectomy, and active monitoring have equivalent mortality outcomes in patients with localized prostate cancer; the ideal modality of patient education is yet to be determined, and written education has minimal effect on patient perception of prostate specific antigen screening; robotic prostatectomy is associated with higher perioperative complication rates on a population basis; racial disparities exist in incontinence rates after treatment for localized prostate cancer, but not in irritative, bowel, or sexual function; androgen deprivation therapy is associated with higher fracture, peripheral artery disease, and cardiac-related complications than bilateral orchiectomy; robotic and open cystectomy offer comparable cancer-specific mortality and perioperative outcomes; and bonuses for low-cost hospitals can inadvertently reward low-quality hospitals. SUMMARY: There have been major advancements in comparative effectiveness research in urology in 2016.

Leaving the Lecture Behind: Putting PubMed Instruction into the Hands of the Students.

This column describes the development of a one-shot PubMed instruction class for medical students at a health sciences library. Background information on the objective is presented and discussed in the context of educational practice literature. The new course design centers on a guided group method of instruction in order to integrate more active learning. Surveyed students reported that the method was an effective way to learn how to search PubMed and that they preferred it to a traditional lecture. Pros and cons of the method are offered for other health sciences libraries interested in presenting PubMed instruction in a similar manner.

Staphylococcus aureus screening and decolonization in orthopaedic surgery and reduction of surgical site infections.

BACKGROUND: Staphylococcus aureus is the most common organism responsible for orthopaedic surgical site infections (SSIs). Patients who are carriers for methicillin-sensitive S. aureus or methicillin-resistant S. aureus (MRSA) have a higher likelihood of having invasive S. aureus infections. Although some have advocated screening for S. aureus and decolonizing it is unclear whether these efforts reduce SSIs. QUESTIONS/PURPOSES: The purposes of this study were to determine (1) whether S. aureus screening and decolonization reduce SSIs in orthopaedic patients and (2) if implementing this protocol is cost-effective. METHODS: Studies for this systematic review were identified by searching PubMed, which includes MEDLINE (1946-present), EMBASE.com (1974-present), and the Cochrane Library's (John Wiley & Sons) Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTAD), and the NHS Economic Evaluation Database (NHSEED). Comprehensive literature searches were developed using EMTREE, MeSH, and keywords for each of the search concepts of decolonization, MRSA, and orthopedics/orthopedic surgery. Studies published before 1968 were excluded. We analyzed 19 studies examining the ability of the decolonization protocol to reduce SSIs and 10 studies detailing the cost-effectiveness of S. aureus screening and decolonization. RESULTS: All 19 studies showed a reduction in SSIs or wound complications by instituting a S. aureus screening and decolonization protocol in elective orthopaedic (total joints, spine, and sports) and trauma patients. The S. aureus screening and decolonization protocol also saved costs in orthopaedic patients when comparing the costs of screening and decolonization with the reduction of SSIs. CONCLUSIONS: Preoperative screening and decolonization of S. aureus in orthopaedic patients is a cost-effective means to reduce SSIs. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies. See the Guidelines for Authors for a complete description of levels of evidence.

Clinical and academic use of electronic and print books: the Health Sciences Library System e-book study at the University of Pittsburgh.

OBJECTIVES: The purpose of the Health Sciences Library System (HSLS) electronic book (e-book) study was to assess use, and factors affecting use, of e-books by all patron groups of an academic health sciences library serving both university and health system-affiliated patrons. METHODS: A web-based survey was distributed to a random sample (n=5,292) of holders of library remote access passwords. A total of 871 completed and 108 partially completed surveys were received, for an approximate response rate of 16.5%-18.5%, with all user groups represented. Descriptive and chi-square analysis was done using SPSS 17. RESULTS: Library e-books were used by 55.4% of respondents. Use by role varied: 21.3% of faculty reported having assigned all or part of an e-book for class readings, while 86% of interns, residents, and fellows reported using an e-book to support clinical care. Respondents preferred print for textbooks and manuals and electronic format for research protocols, pharmaceutical, and reference books, but indicated high flexibility about format choice. They rated printing and saving e-book content as more important than annotation, highlighting, and bookmarking features. CONCLUSIONS: Respondents' willingness to use alternate formats, if convenient, suggests that libraries can selectively reduce title duplication between print and e-books and still support library user information needs, especially if publishers provide features that users want. Marketing and user education may increase use of e-book collections.

Defining emergency telehealth.

The American College of Emergency Physicians Emergency Telehealth Section was charged with development of a working definition of emergency telehealth that aligns with the College's definition of emergency medicine. A modified Delphi method was used by the section membership who represented telehealth providers in both private and public health-care delivery systems, academia and industry, rural and urban settings. Presented in this manuscript is the final definition of emergency telehealth developed with an additional six clarifying statements to address the context of the definition. Emergency telehealth is a core domain of emergency medicine and is inclusive of remotely providing all types of care for acute conditions of any kind requiring expeditious care irrespective of any prior relationship. The development of this definition is important to the global community of emergency physicians and all patients seeking acute care to ensure that appropriately trained clinicians are providing the highest quality of emergency services via the telehealth modality. We recommend implementing emergency telehealth in a manner that ensures appropriate qualifications of providers, appropriate/parity reimbursement for telehealth services and, most importantly, the delivery of quality care to patients in a safe, efficient, timely and cost-effective manner.

Development of a clinical information tool for the electronic medical record: a case study.

QUESTION: What is the process of developing a clinical information tool to be embedded in the electronic health record of a very large and diverse academic medical center? SETTING: The development took place at the University of Pittsburgh Health Sciences Library System. METHOD: The clinical information tool developed is a search box with subject tabs to provide quick access to designated full-text information resources. Each subject tab offers a federated search of a different pool of resources. Search results are organized "on the fly" into meaningful categories using clustering technology and are directly accessible from the results page. RESULTS: After more than a year of discussion and planning, a clinical information tool was embedded in the academic medical center's electronic health record. CONCLUSION: The library successfully developed a clinical information tool, called Clinical-e, for use at the point of care. Future development will refine the tool and evaluate its impact and effectiveness.

Cutaneous squamous cell carcinoma in the organ transplant recipient.

One in twenty solid organ transplant recipients (SOTRs) will develop a highly morbid or fatal cutaneous carcinoma after transplantation. The majority of these cases develop on the head and neck and may require intervention on the part of dermatology, dermatologic surgery, otolaryngology, transplant medicine, radiation oncology, and medical oncology. In this review, we discuss the problem of cutaneous squamous cell carcinoma (cSCC) in SOTRs as well as the prognostic factors and management strategies to care for this population.

A systematic review and meta-analysis of traumatic intracranial hemorrhage in patients taking prehospital antiplatelet therapy: Is there a role for platelet transfusions?

BACKGROUND: Platelet transfusion has been utilized to reverse platelet dysfunction in patients on preinjury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication. METHODS: Controlled, observational and randomized, prospective and retrospective studies describing tICH, preinjury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression. RESULTS: Twelve of 18,609 screened references were applicable to our questions and were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.76-2.18; p = 0.346; I = 32.5%). There was no significant reduction in hemorrhage progression (OR, 0.88; 95% CI, 0.34-2.28; p = 0.788; I = 78.1%). There was no significant reduction in the need for neurosurgical intervention (OR, 1.00; 95% CI, 0.53-1.90, p = 0.996; I = 59.1%; p = 0.032). CONCLUSION: Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets, highlighting the need for a prospective evaluation of this practice. LEVEL OF EVIDENCE: Systematic Reviews and Meta-Analyses, Level III.

A review of peripheral nerve blocks for cesarean delivery analgesia.

Peripheral nerve blocks have a unique role in postcesarean delivery multimodal analgesia regimens. In this review article, options for peripheral nerve blocks for cesarean delivery analgesia will be reviewed, specifically paravertebral, transversus abdominis plane, quadratus lumborum, iliohypogastric and ilioinguinal, erector spinae, and continuous wound infiltration blocks. Anatomy, existing literature evidence, and specific areas in need of future research will be assessed. Considerations for local anesthetic toxicity, and for informed consent for these modalities in the context of emergency cesarean deliveries, will be presented.

The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents.

OBJECTIVE: To establish consensus recommendations for empirical treatment of uncomplicated cystitis with anti-infectives in noncatheterized older nursing home residents to be implemented in the Improving Outcomes of UTI Management in Long-Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality. DESIGN: Two-round modified Delphi survey. PARTICIPANTS: Expert panel of 19 clinical pharmacists. MEASUREMENTS: Comprehensive literature search and development/review/edit of draft survey by the investigative group (one geriatric clinical pharmacist, two geriatric medicine physicians, and one infectious disease physician). The expert panel members rated their agreement with each of 31 recommendations for drugs of choice, dosing medications at various levels of renal function, drug-drug interactions to avoid, and duration of therapy by sex on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Consensus agreement was defined as a lower 95% confidence limit of 4.0 or higher for the recommendation-specific mean score. RESULTS: The response rate was 95% for the first round, and three recommendations achieved consensus (dosing for nitrofurantoin and trimethoprim/sulfamethoxazole in those without chronic kidney disease, and drug-drug interaction between trimethoprim/sulfamethoxazole and warfarin). In the second round, 90% responded and reached consensus on an additional eight recommendations (two for nitrofurantoin or trimethoprim/sulfamethoxazole as initial drugs of choice, three for dosing ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole at various levels of chronic kidney disease, and three drug-drug interactions to avoid: trimethoprim/sulfamethoxazole with phenytoin and ciprofloxacin with theophylline or with tizanidine). CONCLUSION: An expert panel of clinical pharmacists was able to reach consensus on a set of recommendations for the empirical treatment of cystitis with oral anti-infective medications in older nursing home residents. The recommendations were incorporated into a treatment algorithm for uncomplicated cystitis in noncatheterized nursing home residents and used in educational materials for health professionals in an ongoing controlled intervention study. J Am Geriatr Soc 67:539-545, 2019.

Parenteral calcium for intensive care unit patients.

BACKGROUND: Hypocalcemia is prevalent among critically ill patients requiring intensive care. Several epidemiological studies highlight a direct association between hypocalcemia and mortality. These data provide the impetus for current guidelines recommending parenteral calcium administration to normalize serum calcium. However, in light of the considerable variation in the threshold for calcium replacement, the lack of evidence to support a causal role of hypocalcemia in mortality, and animal studies illustrating that calcium supplementation may worsen outcomes, a systematic review is essential to evaluate whether or not the practice of calcium supplementation for intensive care unit (ICU) patients provides any benefit. OBJECTIVES: To assess the effects of parenteral calcium administration in ICU patients on the following outcomes: mortality, multiple organ dysfunction, ICU and hospital length of stay, costs, serum ionized calcium concentration, and complications of parenteral calcium administration. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, Current Controlled Trials, and the National Research Register. We hand-searched conference abstracts from the Society of Critical Care Medicine, the European Society of Intensive Care Medicine, the American Thoracic Surgery, the American College of Surgeons, the American College of Chest Physicians, the American College of Physicians, and the International Consensus Conference in Intensive Care Medicine. We checked references of publications and attempted to contact authors to identify additional published or unpublished data. SELECTION CRITERIA: Randomised controlled and controlled clinical trials of ICU patients comparing parenteral calcium chloride or calcium gluconate administration with no treatment or placebo. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied eligibility criteria to trial reports for inclusion and extracted data. MAIN RESULTS: There are no identifiable studies that have evaluated the association between parenteral calcium supplementation in critically ill ICU patients and the following outcomes: mortality, multiple organ dysfunction, ICU and hospital length of stay, costs, and complications of calcium administration. Serum ionized calcium concentration was reported in 5 studies (12 trial arms, 159 participants). These trials showed a small but significant increase in serum ionized calcium concentration after calcium administration. These trials showed considerable statistical heterogeneity and differed extensively in the population studied (adult versus neonate), the indication (hypocalcemia versus prophylaxis) and threshold of hypocalcemia for which parenteral calcium was administered, and the timing of subsequent measurement of serum ionized calcium concentration to the extent that we consider a pooled estimate almost inappropriate. AUTHORS' CONCLUSIONS: There is no clear evidence that parenteral calcium supplementation impacts the outcome of critically ill patients.

Effect of Lactation on Maternal Hypertension: A Systematic Review.

INTRODUCTION: Hypertension is relatively common in pregnancy, and pregnancy may unmask hypertension among women who are predisposed to it. Lactation may be a means through which to mitigate pregnancy-related vascular risk. The impact of lactation on maternal blood pressure, and the duration of any effect, remains unclear. This study aimed at systematically reviewing the literature evaluating the impact of lactation on the development of hypertension. MATERIALS AND METHODS: We searched PubMed, including EMBASE and MEDLINE, for studies that reported on the association between breastfeeding and maternal risk of hypertension that were published in a peer-reviewed source. The quality of the studies included was assessed by using the Newcastle-Ottawa Scale. RESULTS: Nineteen studies met all inclusion criteria for this review. Of the four studies with short-term follow-up, 50% showed a protective association. The fifteen studies with longer-term follow-up were stratified by outcome assessed. Sixty-seven percent of the studies that evaluated for elevated blood pressure and 100% of the studies evaluating for an outcome of hypertension showed a protective association. The minimum duration of lactation associated with a benefit was 1 month. This association was demonstrated in follow-up periods as long as two to three decades. Studies that showed a protective association had overall higher quality ratings. DISCUSSION: Lactation is associated with a beneficial effect on maternal blood pressure that persists for decades. These results add to the growing body of literature demonstrating the protective association of lactation on maternal cardiovascular risk. Providers may incorporate the decreased risk of hypertension into their counseling on the maternal benefits of lactation.

The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents.

OBJECTIVES: To identify a set of signs and symptoms most likely to indicate uncomplicated cystitis in noncatheterized nursing home residents ≥65 years of age using consensus-based methods informed by a literature review. DESIGN: Literature review and modified Delphi survey with strict inclusion criteria. SETTING AND PARTICIPANTS: Expert panel of 20 physicians certified in geriatric medicine and/or medical direction, actively practicing in post-acute and long-term care settings. METHODS: The authors performed a literature review to produce a comprehensive list of potential signs and symptoms of presumptive uncomplicated cystitis, including nonspecific "quality control" items deemed unlikely to indicate uncomplicated cystitis. The expert panel rated their agreement for each sign/symptom using a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree). Agreed upon signs and symptoms were summarized using a diagnostic algorithm for easy clinical use. RESULTS: The literature review identified 16 signs and symptoms that were evaluated in 3 Delphi survey rounds. The response rate was 100% for round 1 and 95% for the second 2 rounds. Consensus agreement for inclusion was achieved for dysuria on round 1 with exclusion of the 3 quality controls, and "offensive smelling urine." Consensus in the second round was reached for including 4 additional items (gross hematuria, suprapubic pain, urinary frequency, and urinary urgency). Round 3 evaluated dysuria alone and combinations of symptoms. Consensus that dysuria alone is sufficient for diagnosis of cystitis was not reached. CONCLUSIONS/IMPLICATIONS: The panel identified 5 signs and symptoms likely indicative of uncomplicated cystitis in nursing home residents and developed a diagnostic algorithm that can be used to promote antibiotic stewardship in nursing homes. Given similarities in populations, the algorithm may also be applicable to the older adult and the broader post-acute/long-term care populations.