Prehabilitation for Total Knee or Total Hip Arthroplasty: A Systematic Review.

ABSTRACT: We sought to systematically review the evidence on the benefits and harms of prehabilitation interventions for patients who are scheduled to undergo elective, unilateral total knee arthroplasty or total hip arthroplasty surgery for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We selected for inclusion randomized controlled trials and adequately adjusted nonrandomized comparative studies of prehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. Experts in rehabilitation content and complex interventions independently coded rehabilitation interventions. The team assessed strength of evidence. While large heterogeneity across evaluated prehabilitation programs limited strong conclusions, evidence from 13 total knee arthroplasty randomized controlled trials suggest that prehabilitation may result in increased strength and reduced length of stay and may not lead to increased harms but may be comparable in terms of pain, range of motion, and activities of daily living (all low strength of evidence). There was no evidence or insufficient evidence for all other outcomes after total knee arthroplasty. Although there were six total hip arthroplasty randomized controlled trials, there was no evidence or insufficient evidence for all total hip arthroplasty outcomes.

Rehabilitation for Total Hip Arthroplasty: A Systematic Review.

ABSTRACT: We sought to determine the comparative benefits and harms of rehabilitation interventions for patients who have undergone elective, unilateral THA surgery for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Register of Clinical Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We included randomized controlled trials and adequately adjusted nonrandomized comparative studies of rehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. Experts in rehabilitation content and complex interventions independently coded rehabilitation interventions. The team assessed strength of evidence. Large heterogeneity across evaluated rehabilitation programs limited conclusions. Evidence from 15 studies suggests that diverse rehabilitation programs may not differ in terms of risk of harm or outcomes of pain, strength, activities of daily living, or quality of life (all low strength of evidence). Evidence is insufficient for other outcomes. In conclusion, no differences in outcomes were found between different rehabilitation programs after THA. Further evidence is needed to inform decisions on what attributes of rehabilitation programs are most effective for various outcomes.

Implant-based Breast Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis.

Women undergoing implant-based reconstruction (IBR) after mastectomy for breast cancer have numerous options, including timing of IBR relative to radiation and chemotherapy, implant materials, anatomic planes, and use of human acellular dermal matrices. We conducted a systematic review to evaluate these options. Methods: We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies, from inception to March 23, 2021, without language restriction. We assessed risk of bias and strength of evidence (SoE) using standard methods. Results: We screened 15,936 citations. Thirty-six mostly high or moderate risk of bias studies (48,419 patients) met criteria. Timing of IBR before or after radiation may result in comparable physical, psychosocial, and sexual well-being, and satisfaction with breasts (all low SoE), and probably comparable risks of implant failure/loss or explantation (moderate SoE). No studies addressed timing relative to chemotherapy. Silicone and saline implants may result in clinically comparable satisfaction with breasts (low SoE). Whether the implant is in the prepectoral or total submuscular plane may not impact risk of infections (low SoE). Acellular dermal matrix use probably increases the risk of implant failure/loss or need for explant surgery (moderate SoE) and may increase the risk of infections (low SoE). Risks of seroma and unplanned repeat surgeries for revision are probably comparable (moderate SoE), and risk of necrosis may be comparable with or without human acellular dermal matrices (low SoE). Conclusions: Evidence regarding IBR options is mostly of low SoE. New high-quality research is needed, especially for timing, implant materials, and anatomic planes of implant placement.

Autologous Reconstruction after Mastectomy for Breast Cancer.

Background: Women undergoing autologous reconstruction (AR) after mastectomy for breast cancer and their surgeons must make decisions regarding timing of the AR and choose among various flap types. We conducted a systematic review to evaluate the comparative benefits and harms of (1) timing of AR relative to chemotherapy and radiation therapy, and (2) various flap types for AR. Methods: We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies, from inception to March 23, 2021, without language restriction. We assessed risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods. Results: We screened 15,936 citations. Twelve mostly high risk of bias studies, including three randomized controlled trials and nine nonrandomized comparative studies met criteria (total N = 31,833 patients). No studies addressed timing of AR relative to chemotherapy or radiation therapy. Six flap types were compared, but conclusions were feasible for only the comparison between transverse rectus abdominus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. The choice of either flap may result in comparable patient satisfaction with breasts and comparable risk of necrosis (low SoE for both outcomes), but TRAM flaps probably pose a greater risk of harm to the area of flap harvest (abdominal bulge/hernia and need for surgical repair) (moderate SoE). Conclusions: Evidence regarding details for AR is mostly of low SoE. New high-quality research among diverse populations of women is needed for the issue of timing of AR and for comparisons among flap types.

Implant-based versus Autologous Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis.

For women undergoing breast reconstruction after mastectomy, the comparative benefits and harms of implant-based reconstruction (IBR) and autologous reconstruction (AR) are not well known. We performed a systematic review with meta-analysis of IBR versus AR after mastectomy for breast cancer. Methods: We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies from inception to March 23, 2021. We assessed the risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods. Results: We screened 15,936 citations and included 40 studies (two randomized controlled trials and 38 adjusted nonrandomized comparative studies). Compared with patients who undergo IBR, those who undergo AR experience clinically significant better sexual well-being [summary adjusted mean difference (adjMD) 5.8, 95% CI 3.4-8.2; three studies] and satisfaction with breasts (summary adjMD 8.1, 95% CI 6.1-10.1; three studies) (moderate SoE for both outcomes). AR was associated with a greater risk of venous thromboembolism (moderate SoE), but IBR was associated with a greater risk of reconstructive failure (moderate SoE) and seroma (low SoE) in long-term follow-up (1.5-4 years). Other outcomes were comparable between groups, or the evidence was insufficient to merit conclusions. Conclusions: Most evidence regarding IBR versus AR is of low or moderate SoE. AR is probably associated with better sexual well-being and satisfaction with breasts and lower risks of seroma and long-term reconstructive failure but a higher risk of thromboembolic events. New high-quality research is needed to address the important research gaps.

Evaluation and Management After Acute Left-Sided Colonic Diverticulitis : A Systematic Review.

BACKGROUND: The value of interventions used after acute colonic diverticulitis is unclear. PURPOSE: To evaluate postdiverticulitis colonoscopy and interventions to prevent recurrent diverticulitis. DATA SOURCES: MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020. STUDY SELECTION: Comparative studies of interventions of interest reporting critical or important outcomes, and larger single-group studies to evaluate prevalence of colonoscopy findings and harms. DATA EXTRACTION: 6 researchers extracted study data and risk of bias. The team assessed strength of evidence. DATA SYNTHESIS: 19 studies evaluated colonoscopy. Risk for prevalent colorectal cancer (CRC) compared with the general population is unclear. Based on low-strength evidence, long-term CRC diagnosis is similar with or without colonoscopy. High-strength evidence indicates that risk for prevalent CRC is higher among patients with complicated diverticulitis and colonoscopy complications are rare. Based on high-strength evidence, mesalamine does not reduce recurrence risk (6 randomized controlled trials [RCTs]). Evidence on other nonsurgical interventions is insufficient. For patients with prior complicated or smoldering or frequently recurrent diverticulitis, elective surgery is associated with reduced recurrence (3 studies; high strength). In 19 studies, serious surgical complications were uncommon. LIMITATIONS: Few RCTs provided evidence. Heterogeneity of treatment effect was not adequately assessed. CONCLUSION: It is unclear whether patients with recent acute diverticulitis are at increased risk for prevalent CRC, but those with complicated diverticulitis are at increased risk. Mesalamine is ineffective in preventing recurrence; other nonsurgical treatments have inadequate evidence. Elective surgery reduces recurrence in patients with prior complicated or smoldering or frequently recurrent diverticulitis, but it is unclear which of these patients may benefit most. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).

Diagnostic Imaging and Medical Management of Acute Left-Sided Colonic Diverticulitis : A Systematic Review.

BACKGROUND: Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis. PURPOSE: To evaluate CT imaging, outpatient treatment of uncomplicated diverticulitis, antibiotic treatment, and interventional radiology for patients with complicated diverticulitis. DATA SOURCES: MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020. STUDY SELECTION: Existing systematic reviews of CT imaging accuracy, as well as randomized trials and adjusted nonrandomized comparative studies reporting clinical or patient-centered outcomes. DATA EXTRACTION: 6 researchers extracted study data and risk of bias, which were verified by an independent researcher. The team assessed strength of evidence across studies. DATA SYNTHESIS: Based on moderate-strength evidence, CT imaging is highly accurate for diagnosing acute diverticulitis. For patients with uncomplicated acute diverticulitis, 6 studies provide low-strength evidence that initial outpatient and inpatient management have similar risks for recurrence or elective surgery, but they provide insufficient evidence regarding other outcomes. Also, for patients with uncomplicated acute diverticulitis, 5 studies comparing antibiotics versus no antibiotics provide low-strength evidence that does not support differences in risks for treatment failure, elective surgery, recurrence, posttreatment complications, and other outcomes. Evidence is insufficient to determine choice of antibiotic regimen (7 studies) or effect of percutaneous drainage (2 studies). LIMITATIONS: The evidence base is mostly of low strength. Studies did not adequately assess heterogeneity of treatment effect. CONCLUSION: Computed tomography imaging is accurate for diagnosing acute diverticulitis. For patients with uncomplicated diverticulitis, no differences in outcomes were found between outpatient and inpatient care. Avoidance of antibiotics for uncomplicated acute diverticulitis may be safe for most patients. The evidence is too sparse for other evaluated questions. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).

Semi-automated Tools for Systematic Searches.

Traditionally, literature identification for systematic reviews has relied on a two-step process: first, searching databases to identify potentially relevant citations, and then manually screening those citations. A number of tools have been developed to streamline and semi-automate this process, including tools to generate terms; to visualize and evaluate search queries; to trace citation linkages; to deduplicate, limit, or translate searches across databases; and to prioritize relevant abstracts for screening. Research is ongoing into tools that can unify searching and screening into a single step, and several protype tools have been developed. As this field grows, it is becoming increasingly important to develop and codify methods for evaluating the extent to which these tools fulfill their purpose.

Safety of Systemic Medications Among Older Adults With Psoriasis and Atopic Dermatitis: A Systematic Review of Observational Studies.

BACKGROUND: Psoriasis and atopic dermatitis are common among older adults (≥65 years old), but clinical trials often exclude that population. OBJECTIVE: To synthesize evidence from observational studies on the safety of systemic therapies (conventional or biologic) for psoriasis and atopic dermatitis among older adults in a systematic review. METHODS: We searched MEDLINE and EMBASE (inception to October 31, 2019) and included observational studies reporting adverse events among older people treated with systemic therapy for psoriasis or atopic dermatitis. Outcomes were death, hospitalization, emergency department visits, infections, major cardiovascular events, renal toxicity, hepatotoxicity, and cytopenias. We assessed study quality using the Newcastle-Ottawa Scale. RESULTS: We included 22 studies on treatment for psoriasis and 2 for atopic dermatitis. Most studies were small and non-comparative and 20 of 24 were low quality. Studies comparing safety between medications or medication classes or between older and younger adults did not show apparent differences but had wide confidence intervals around relative effect estimates. Heterogeneity of study design and reporting precluded quantitative synthesis. CONCLUSIONS: There is scant evidence on the safety of conventional systemic and biologic medications for older adults with psoriasis or atopic dermatitis; older adults and their clinicians should be aware of this evidence gap.

Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes.

Background: Urinary incontinence (UI), a common malady in women, most often is classified as stress, urgency, or mixed. Purpose: To compare the effectiveness of pharmacologic and nonpharmacologic interventions to improve or cure stress, urgency, or mixed UI in nonpregnant women. Data Sources: MEDLINE, Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), EMBASE (Elsevier), CINAHL (EBSCO), and PsycINFO (American Psychological Association) from inception through 10 August 2018. Study Selection: 84 randomized trials that evaluated 14 categories of interventions and reported categorical cure or improvement outcomes. Data Extraction: 1 researcher extracted study characteristics, results, and study-level risk of bias, with verification by another independent researcher. The research team collaborated to assess strength of evidence (SoE) across studies. Data Synthesis: 84 studies reported cure or improvement outcomes (32 in stress UI, 16 in urgency UI, 4 in mixed UI, and 32 in any or unspecified UI type). The most commonly evaluated active intervention types included behavioral therapies, anticholinergics, and neuromodulation. Network meta-analysis showed that all interventions, except hormones and periurethral bulking agents (variable SoE), were more effective than no treatment in achieving at least 1 favorable UI outcome. Among treatments used specifically for stress UI, behavioral therapy was more effective than either α-agonists or hormones in achieving cure or improvement (moderate SoE); α-agonists were more effective than hormones in achieving improvement (moderate SoE); and neuromodulation was more effective than no treatment for cure, improvement, and satisfaction (high SoE). Among treatments used specifically for urgency UI, behavioral therapy was statistically significantly more effective than anticholinergics in achieving cure or improvement (high SoE), both neuromodulation and onabotulinum toxin A (BTX) were more effective than no treatment (high SoE), and BTX may have been more effective than neuromodulation in achieving cure (low SoE). Limitation: Scarce direct (head-to-head trial) evidence and population heterogeneity based on UI type, UI severity, and history of prior treatment. Conclusion: Most nonpharmacologic and pharmacologic interventions are more likely than no treatment to improve UI outcomes. Behavioral therapy, alone or in combination with other interventions, is generally more effective than pharmacologic therapies alone in treating both stress and urgency UI. Primary Funding Source: Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42017069903).

Treatments of Primary Basal Cell Carcinoma of the Skin: A Systematic Review and Network Meta-analysis.

Background: Most interventions for basal cell carcinoma (BCC) have not been compared in head-to-head randomized trials. Purpose: To evaluate the comparative effectiveness and safety of treatments of primary BCC in adults. Data Sources: English-language searches of MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase from inception to May 2018; reference lists of guidelines and systematic reviews; and a search of ClinicalTrials.gov in August 2016. Study Selection: Comparative studies of treatments currently used in adults with primary BCC. Data Extraction: One investigator extracted data on recurrence, histologic clearance, clinical clearance, cosmetic outcomes, quality of life, and mortality, and a second reviewer verified extractions. Several investigators evaluated risk of bias for each study. Data Synthesis: Forty randomized trials and 5 nonrandomized studies compared 18 interventions in 9 categories. Relative intervention effects and mean outcome frequencies were estimated using frequentist network meta-analyses. Estimated recurrence rates were similar for excision (3.8% [95% CI, 1.5% to 9.5%]), Mohs surgery (3.8% [CI, 0.7% to 18.2%]), curettage and diathermy (6.9% [CI, 0.9% to 36.6%]), and external-beam radiation (3.5% [CI, 0.7% to 16.8%]). Recurrence rates were higher for cryotherapy (22.3% [CI, 10.2% to 42.0%]), curettage and cryotherapy (19.9% [CI, 4.6% to 56.1%]), 5-fluorouracil (18.8% [CI, 10.1% to 32.5%]), imiquimod (14.1% [CI, 5.4% to 32.4%]), and photodynamic therapy using methyl-aminolevulinic acid (18.8% [CI, 10.1% to 32.5%]) or aminolevulinic acid (16.6% [CI, 7.5% to 32.8%]). The proportion of patients reporting good or better cosmetic outcomes was better for photodynamic therapy using methyl-aminolevulinic acid (93.8% [CI, 79.2% to 98.3%]) or aminolevulinic acid (95.8% [CI, 84.2% to 99.0%]) than for excision (77.8% [CI, 44.8% to 93.8%]) or cryotherapy (51.1% [CI, 15.8% to 85.4%]). Data on quality of life and mortality were too sparse for quantitative synthesis. Limitation: Data are sparse, and effect estimates are imprecise and informed by indirect comparisons. Conclusion: Surgical treatments and external-beam radiation have low recurrence rates for the treatment of low-risk BCC, but substantial uncertainty exists about their comparative effectiveness versus other treatments. Gaps remain regarding high-risk BCC subtypes and important outcomes, including costs. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42016043353).

Comparative Effectiveness and Safety of Bariatric Procedures in Medicare-Eligible Patients: A Systematic Review.

Importance: The prevalence of obesity in patients older than 65 years is increasing. A substantial number of beneficiaries covered by Medicare meet eligibility criteria for bariatric procedures. Objective: To assess the comparative effectiveness and safety of bariatric procedures in the Medicare-eligible population. Evidence Review: This systematic review was conducted according to the PRISMA guidelines. Articles were identified through searches of PubMed, Embase, CINAHL, PsycINFO, Cochrane Central Trials Registry, Cochrane Database of Systematic Reviews, and scientific information packages from manufacturers, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and US Food and Drug Administration drugs and devices portals from January 1, 2000, to June 31, 2017. Randomized and nonrandomized comparative studies that evaluated bariatric procedures in the Medicare-eligible population were eligible. Six researchers extracted data on design, interventions, outcomes, and study quality. Findings were synthesized qualitatively; a planned meta-analysis was not undertaken owing to clinical heterogeneity. Findings: A total of 11 455 citations were screened for eligibility. Of those, 16 met the eligibility criteria. Compared with no surgery or conventional weight-loss treatment, bariatric surgery results in greater weight loss. Overall mortality after 30 days is lower among bariatric patients (hazard ratio, HR, 0.50; 95% CI, 0.31-0.79, in the study with the longest follow-up of 5.9 years), although, based on 1 study, mortality within 30 days of surgery was higher than in nonsurgically treated controls (1.55% vs 0.53%; P < .001). Bariatric surgery is associated with lower risk of cardiovascular disease (HR, 0.59; 95% CI, 0.44-0.79 in the largest study comparison) and with improvements in respiratory, musculoskeletal, metabolic, and renal outcomes (increase in estimated glomerular filtration rate, 9.84; 95% CI, 8.05-11.62 mL/min/1.73m2). Compared with sleeve gastrectomy (SG) and adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGB) appears to be associated with greater weight loss (percent excess weight loss, 23.8% [95% CI, 16.2%-31.4%] at the longest follow-up of 4 years) but the 3 procedures have similar associations with most non-weight loss outcomes. Overall postoperative complications are not statistically significantly different between RYGB and SG, although major and/or serious complications are more common after RYGB. However, these associations are susceptible to at least moderate risk of confounding, selection, or measurement biases. Conclusions and Relevance: In the Medicare population, there is low to moderate strength of evidence that bariatric surgery as a weight loss treatment improves non-weight loss outcomes. Well-designed comparative studies are needed to credibly determine the treatment effects for bariatric procedures in this patient population.

Effectiveness of Tympanostomy Tubes for Otitis Media: A Meta-analysis.

CONTEXT: Tympanostomy tube placement is the most common ambulatory surgery performed on children in the United States. OBJECTIVES: The goal of this study was to synthesize evidence for the effectiveness of tympanostomy tubes in children with chronic otitis media with effusion and recurrent acute otitis media. DATA SOURCES: Searches were conducted in Medline, the Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews, Embase, and the Cumulative Index to Nursing and Allied Health Literature. STUDY SELECTION: Abstracts and full-text articles were independently screened by 2 investigators. DATA EXTRACTION: A total of 147 articles were included. When feasible, random effects network meta-analyses were performed. RESULTS: Children with chronic otitis media with effusion treated with tympanostomy tubes compared with watchful waiting had a net decrease in mean hearing threshold of 9.1 dB (95% credible interval: -14.0 to -3.4) at 1 to 3 months and 0.0 (95% credible interval: -4.0 to 3.4) by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after placement of tympanostomy tubes. Associated adverse events are poorly defined and reported. LIMITATIONS: Sparse evidence is available, applicable only to otherwise healthy children. CONCLUSIONS: Tympanostomy tubes improve hearing at 1 to 3 months compared with watchful waiting, with no evidence of benefit by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after tympanostomy tube placement, but the evidence base is severely limited. The benefits of tympanostomy tubes must be weighed against a variety of associated adverse events.