American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity.

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity.

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

Use of patient-reported outcome measures after breast reconstruction in low- and middle-income countries: a scoping review.

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly administered in high-income countries to monitor health-related quality of life of breast cancer patients undergoing breast reconstruction. Although low- and middle-income countries (LMICs) face a disproportionate burden of breast cancer, little is known about the use of PROMs in LMICs. This scoping review aims to examine the use of PROMs after post-mastectomy breast reconstruction among patients with breast cancer in LMICs. METHODS: MEDLINE, Embase, Web of Science, CINAHL, and PsycINFO were searched in August 2022 for English-language studies using PROMs after breast reconstruction among patients with breast cancer in LMICs. Study screening and data extraction were completed. Data were analyzed descriptively. RESULTS: The search produced 1024 unique studies, 33 of which met inclusion criteria. Most were observational (48.5%) or retrospective (33.3%) studies. Studies were conducted in only 10 LMICs, with 60.5% in China and Brazil and none in low-income countries. Most were conducted in urban settings (84.8%) and outpatient clinics (57.6%), with 63.6% incorporating breast-specific PROMs and 33.3% including breast reconstruction-specific PROMs. Less than half (45.5%) used PROMs explicitly validated for their populations of interest. Only 21.2% reported PROM response rates, ranging from 43.1 to 96.9%. Barriers and facilitators of PROM use were infrequently noted. CONCLUSIONS: Despite the importance of PROM collection and use in providing patient-centered care, it continues to be limited in middle-income countries and is not evident in low-income countries after breast reconstruction. Further research is necessary to determine effective methods to address the challenges of PROM use in LMICs.

The Association of a Peritoneal Interposition Flap With Lymphocele Formation After Pelvic Lymph Node Dissection During Robotic-assisted Laparoscopic Radical Prostatectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis to evaluate the association of a peritoneal interposition flap (PIF) with lymphocele formation following robotic-assisted laparoscopic radical prostatectomy (RALP) with pelvic lymph node dissection. METHODS: We conducted a systematic search of MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials through August 30, 2023, to identify randomized and nonrandomized studies comparing RALP with pelvic lymph node dissection with and without PIF. A random effects meta-analysis was then performed to evaluate the associations of PIF with 90-day postoperative outcomes. RESULTS: Five randomized controlled trials (RCTs) and four observational studies, including a total of 2941 patients, were included. The use of PIF was associated with a reduced risk of 90-day symptomatic lymphocele formation after RALP when examining only RCTs (pooled odds ratios [OR] 0.44, 95% CI 0.28-0.69; I2 =3%) and both RCTs and observational studies (OR 0.35, 95% CI 0.22-0.56; I2 =17%). Similarly, use of PIF was associated with a reduced risk of 90-day any lymphocele formation (OR 0.40, 95% CI 0.28-0.56, I2 =39%). There were no statistically significant differences in postoperative complications between the two groups (OR 0.89; 95% CI 0.69-1.14; I2 =20%). CONCLUSION: Use of the PIF is associated with an approximately 50% reduced risk of symptomatic and any lymphocele formation within 90-days of surgery, and it is not associated with an increase in postoperative complications.

United States-Based Colorectal Cancer Surgical Trials Lack Representation and Adequate Reporting of Racially and Ethnically Diverse Participants: Systematic Review and Regression Analysis.

BACKGROUND: Despite the established National Institute of Health Revitalization Act, which aims to include ethnic and racial minority representation in surgical trials, racial and ethnic enrollment disparities persist. OBJECTIVE: To assess the proportion of patients from minority races and ethnicities that are included in colorectal cancer surgical trials and reporting characteristics. DATA SOURCES: Search was performed using MEDLINE (Ovid), Embase, Web of Science, and Cochrane Central. STUDY SELECTION: Inclusion criteria included 1) trials performed in the United States between January 1, 2000, and May 30, 2022; 2) patients with colorectal cancer diagnosis; and 3) surgical intervention, technique, or postoperative outcome. Trials evaluating chemotherapy, radiotherapy, or other nonsurgical interventions were excluded. INTERVENTIONS: Pooled proportion and regression analysis was performed to identify the proportion of patients by race and ethnicity included in surgical trials and the association of year of publication and funding source. MAIN OUTCOME MEASURES: Proportion of trials reporting race and ethnicity and proportion of participants by race and ethnicity included in surgical trials. RESULTS: We screened 10,673 unique publications, of which 80 were examined in full text. Fifteen studies met our inclusion criteria. Ten (66.7%) trials did not report race, 3 reported races as a proportion of White participants only, and 3 reported 3 or more races. There was no description of ethnicity in 11 (73.3%) trials, with 2 describing "non-Caucasian" as ethnicity and 2 describing only Hispanic ethnicity. Pooled proportion of White participants was 81.3%, of Black participants was 6.2%, of Asian participants was 3.6%, and of Hispanic participants was 3.5%. LIMITATIONS: A small number of studies was identified that reported racial or ethnic characteristics of their participants. CONCLUSIONS: Both race and ethnicity are severely underreported in colorectal cancer surgical trials. To improve outcomes and ensure the inclusion of vulnerable populations in innovative technologies and novel treatments, reporting must be closely monitored.

Imaging and Biomarker Surveillance for Head and Neck Squamous Cell Carcinoma: A Systematic Review and American Radium Society Appropriate Use Criteria Statement.

Surveillance for survivors of head and neck cancer (HNC) is focused on early detection of recurrent or second primary malignancies. After initial restaging confirms disease-free status, the use of surveillance imaging for asymptomatic patients with HNC is controversial. Our objective was to comprehensively review literature pertaining to imaging and biomarker surveillance of asymptomatic patients treated for head and neck squamous cell carcinoma and to convene a multidisciplinary expert panel to provide appropriate use criteria for surveillance in representative clinical scenarios. The evidence base for the appropriate use criteria was gathered through a librarian-mediated search of literature published from 1990 to 2022 focused on surveillance imaging and circulating tumor-specific DNA for nonmetastatic head and neck squamous cell carcinoma using MEDLINE (Ovid), Embase, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials. The systematic review was reported according to PRISMA guidelines. Using the modified Delphi process, the expert panel voted on appropriate use criteria, providing recommendations for appropriate use of surveillance imaging and human papillomavirus (HPV) circulating tumor DNA. Of 5178 studies identified, 80 met inclusion criteria (5 meta-analyses/systematic reviews, 1 randomized control trial, 1 post hoc analysis, 25 prospective, and 48 retrospective cohort studies [with ≥50 patients]), reporting on 27,525 patients. No large, randomized, prospective trials examined whether asymptomatic patients who receive surveillance imaging or HPV circulating tumor DNA monitoring benefit from earlier detection of recurrence or second primary tumors in terms of disease-specific or quality-of-life outcomes. In the absence of prospective data, surveillance imaging for HNC survivors should rely on individualized recurrence-risk assessment accounting for initial disease staging, HPV disease status, and tobacco use history. There is an emerging surveillance role for circulating tumor biomarkers.

Authorship Patterns in the Orthopaedic Journals of Low-Income and Lower-Middle-Income Countries.

Background: Extensive research collaborations exist between researchers from high-income countries (HICs) and those from low-income countries (LICs) and lower-middle-income countries (LMICs). Previous research has suggested that authors from LICs and LMICs are underrepresented as first and last authors in the orthopaedic literature on local populations, particularly in LICs. We present a bibliometric analysis of authorship solely in studies published in orthopaedic journals that are based in LICs and LMICs. Methods: The Global Index Medicus was queried, and all articles published from January 1, 2010, to December 31, 2021, in journals with a focus on orthopaedic surgery that were based in an LIC or an LMIC were included. Logistic regressions were calculated to assess the predictors of local authorship. Results: Over 92% of studies included in our analysis had first or last authors from LICs or LMICs. In terms of study type, the majority (89%) of studies were clinical, although largely of low-level evidence (78% of clinical studies were case reports, case series, or descriptive studies). None received funding. LIC or LMIC first authorship and last authorship were less likely for most types of nonclinical studies. LIC or LMIC first authorship was more likely when there were more study authors. LIC or LMIC first authorship and last authorship were less likely when there were more countries affiliated with the study authors. Finally, when compared with studies with only LIC or LMIC authors, those with a combination of HIC and LIC or LMIC authors had significantly lower rates of LIC or LMIC first authorship (93.3% versus 62.5%) and last authorship (97.7% versus 70.8%). Conclusions: Our study presents one of the first analyses to assess authorship patterns in the orthopaedic literature of locally published journals in LICs and LMICs. Future studies are needed to contextualize our findings within a broader bibliometric landscape in order to better address the ongoing challenges to building research capacity in LICs and LMICs. Clinical Relevance: Our study highlights important observations regarding authorship in international, collaborative research in orthopaedics.

Bias in Surgical Residency Evaluations: A Scoping Review.

OBJECTIVE: Given widespread disparities in the surgical workforce and the advent of competency-based training models that rely on objective evaluations of resident performance, this review aims to describe the landscape of bias in the evaluation methods of residents in surgical training programs in the United States. DESIGN: A scoping review was conducted within PubMed, Embase, Web of Science, and ERIC in May 2022, without a date restriction. Studies were screened and reviewed in duplicate by 3 reviewers. Data were described descriptively. SETTING/PARTICIPANTS: English-language studies conducted in the United States that assessed bias in the evaluation of surgical residents were included. RESULTS: The search yielded 1641 studies, of which 53 met inclusion criteria. Of the included studies, 26 (49.1%) were retrospective cohort studies, 25 (47.2%) were cross-sectional studies, and 2 (3.8%) were prospective cohort studies. The majority included general surgery residents (n = 30, 56.6%) and nonstandardized examination modalities (n = 38, 71.7%), such as video-based skills evaluations (n = 5, 13.2%). The most common performance metric evaluated was operative skill (n = 22, 41.5%). Overall, the majority of studies demonstrated bias (n = 38, 73.6%) and most investigated gender bias (n = 46, 86.8%). Most studies reported disadvantages for female trainees regarding standardized examinations (80.0%), self-evaluations (73.7%), and program-level evaluations (71.4%). Four studies (7.6%) assessed racial bias, of which all reported disadvantages for trainees underrepresented in surgery. CONCLUSIONS: Evaluation methods for surgery residents may be prone to bias, particularly with regard to female trainees. Research is warranted regarding other implicit and explicit biases, such as racial bias, as well as for nongeneral surgery subspecialties.

What is the Current State of Extended Reality Use in Otolaryngology Training? A Scoping Review.

OBJECTIVE: To map current literature on the educational use of extended reality (XR) in Otolaryngology-Head and Neck Surgery (OHNS) to inform teaching and research. STUDY DESIGN: Scoping Review. METHODS: A scoping review was conducted, identifying literature through MEDLINE, Ovid Embase, and Web of Science databases. Findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review checklist. Studies were included if they involved OHNS trainees or medical students who used XR for an educational purpose in OHNS. XR was defined as: fully-immersive virtual reality (VR) using head-mounted displays (HMDs), non-immersive and semi-immersive VR, augmented reality (AR), or mixed reality (MR). Data on device use were extracted, and educational outcomes were analyzed according to Kirkpatrick's evaluation framework. RESULTS: Of the 1,434 unique abstracts identified, 40 articles were included. All articles reported on VR; none discussed AR or MR. Twenty-nine articles were categorized as semi-immersive, none used occlusive HMDs therefore, none met modern definitions of immersive VR. Most studies (29 of 40) targeted temporal bone surgery. Using the Kirkpatrick four-level evaluation model, all studies were limited to level-1 (learner reaction) or level-2 (knowledge or skill performance). CONCLUSIONS: Current educational applications of XR in OHNS are limited to VR, do not fully immerse participants and do not assess higher-level learning outcomes. The educational OHNS community would benefit from a shared definition for VR technology, assessment of skills transfer (level-3 and higher), and deliberate testing of AR, MR, and procedures beyond temporal bone surgery. Laryngoscope, 133:227-234, 2023.

Is There an Optimal Repetitive Transcranial Magnetic Stimulation Target to Treat Chronic Tinnitus?

OBJECTIVE: Chronic tinnitus is a clinical symptom that affects 10% to 15% of the adult population. Repetitive transcranial magnetic stimulation (rTMS) is a promising treatment, but significant heterogeneity exists in the treatment outcomes and stimulation parameters. In this study, we perform a qualitative systematic review to determine if there is an optimal rTMS site to treat tinnitus. DATA SOURCES: A literature search was performed by searching the MEDLINE, Embase, Web of Science, and Cochrane databases. REVIEW METHODS: Sham-controlled studies in adults were included that contained >10 patients with tinnitus for >3 months and utilized 10 to 20 electroencephalography coordinates. Study outcomes were considered positive if the treatment arm reported a significant reduction in the primary tinnitus score relative to sham. RESULTS: There were 1211 studies screened. Nineteen studies met the inclusion criteria, and 8 unique stimulation sites were reported. Studies had 53.7 ± 46.0 patients (mean ± SD). The mean duration of follow-up was 10.3 ± 9.6 weeks. Positive outcomes regarding tinnitus suppression were reported in 5 of 5 (100%) studies stimulating the temporoparietal junction midway between T3 and P3 or between T4 and P4. Tinnitus suppression at all other sites was less frequent with a combined success rate of only 8 of 14 (57.1%). CONCLUSION: Significant heterogeneity exists in the literature in regard to the optimal transcranial magnetic stimulation target. These preliminary findings suggest that the temporoparietal junction midway between T3 and P3 or T4 and P4 is a promising nonauditory rTMS target in the setting of chronic tinnitus. Future research should elucidate the effectiveness of this site for tinnitus suppression.

Efficacy and safety of topical agents in the treatment of melasma: What's evidence? A systematic review and meta-analysis.

BACKGROUND: Various topical agents have been used to treat melasma; however, a large-scale evaluation among the currently available treatment is lacking. OBJECTIVES: The aim of this study was to evaluate the efficacy and safety of topical agents for melasma. METHODS: The MEDLINE, Embase, Web of Science, Cochrane, and Alt-Healthwatch databases were searched in November 2021. Original studies that reported pre- and post-treatment Melasma Area Severity Index (MASI)/modified Melasma Area Severity Index (mMASI) scores and/or adverse effects (AEs) were eligible for inclusion. The main outcome was the efficacy analyzed by the changes in the pre- and post-treatment with standardized mean difference (SMD) of MASI/mMASI scores; the AEs were calculated with incidence proportion by the reported percentage of skin irritations. RESULTS: A total of 45 studies (2359 patients) and 55 studies (4539 patients) met the inclusion criteria for efficacy and AEs, respectively. Hydroquinone (HQ) monotherapy (SMD -1.3, 95% CI [-1.6 to -1.0]), HQ-containing combination therapy (-1.4, [-1.7 to -1.1]), cysteamine (-1.6, [-2.0 to -1.2]), tranexamic acid (-1.5, [-2.0 to -1.1]), azelaic acid (-1.3, [-1.7 to -1.0]), and kojic acid (-0.9, [-1.3 to -0.5]) demonstrated comparable efficacy, while zinc sulfate did not exhibit statistically significant improvement (-1.2, [-2.7 to 0.4]). HQ-containing combination therapy (50.9%) and cysteamine (42.2%) demonstrated the highest incidence of irritation, while azelaic acid (18.7%), kojic acid (5.3%), and tranexamic acid (0.8%) revealed a lower risk. CONCLUSIONS: In this meta-analysis, non-HQ agents except zinc sulfate may be considered as an alternative to HQ-containing agents. However, treatment should be guided by patient's tolerance, availability, and physicians' experience.

Neurotization in Innervated Breast Reconstruction: A Systematic Review of Techniques and Outcomes.

BACKGROUND: Significant improvements in sensory recovery after innervated breast reconstruction have been reported. However, surgical approaches and sensory testing methods have been widely variable. This systematic review aimed to synthesize neurotization techniques and outcomes in breast reconstruction surgery. METHODS: A comprehensive literature search of the MEDLINE, Embase, Web of Science, and Cochrane databases was conducted to identify all studies reporting outcomes of neurotization in innervated breast reconstruction. Data extracted from each study included neurotization techniques, operative times, sensory methods and outcomes, and patient-reported outcomes. RESULTS: A total of 1,350 articles were identified, and 23 articles were included for analysis. Nerve coaptation was performed in 536 breasts and 419 patients, with techniques consisting of direct coaptation (65.1% of flaps), coaptation with nerve conduit (26.3%), and coaptation with nerve allograft (8.6%). The neural component of operating time ranged from 8 to 38 min, and the pooled neurotization success rate among nine studies that reported this outcome was 90.6% (95% CI: 83.6%-96.0%). Overall, innervated breasts achieved earlier and superior sensory recovery that was more uniformly distributed throughout the flap compared to non-innervated breasts. Despite high heterogeneity between studies, all included studies supported neurotized breast reconstruction to improve the rate, quality, and magnitude of sensory recovery. CONCLUSIONS: Neurotization during breast reconstruction may be worth the investment of additional operating time to increase the prospect of high-quality sensory recovery. Further investigation with standardized sensory testing methods and patient-reported outcome tools is needed to definitively support neurotization as a standard of care in breast reconstruction surgery.

Quality of Life in Patients with Benign Non-Toxic Goiter After Surgical Intervention: A Systematic Review and Meta-Analysis.

BACKGROUND: Prior studies evaluating health-related quality of life (HR-QoL) outcomes in patients undergoing surgery for benign non-toxic goiter have used different instruments and time points, leading to conflicting results. We sought to systematically review the differences in HR-QoL among patients with BNTG at baseline and 6 months after surgery, using exclusively the ThyPRO questionnaire. METHODS: A systematic search was performed using PubMed, Embase, Web of Science, Cochrane Central, CINAHL, and PsycINFO for papers reporting the assessment of HR-QoL utilizing ThyPRO. Data were meta-analyzed using a random-effects model, and pooled estimates were calculated using weighted mean differences (WMD) between baseline and 6 months after surgery. We assessed the quality and risk of bias of the studies using the Robins-I tool and previously published minimally important change (MIC) values to assess clinical significance. RESULTS: Six papers met the predefined inclusion criteria, describing a total of 496 patients. Meta-analysis demonstrated improved QoL in all thirteen domains of ThyPRO six months post-surgical intervention compared to baseline. Specifically, the largest improvement in QoL was seen in the domains of overall QoL, WMD -25.84 (95% CI -29.70, -21.98, p < 0.001, I2 = 23%), goiter symptoms, 23.96 (95% CI -30.29, -17.64, p < 0.001, I2 = 91%), and tiredness, -16.20 (95% CI -19.23, -13.16, p < 0.001, I2 = 3%). The differences in scores 9 of 13 domains were clinically significant based on MIC. CONCLUSIONS: Disease-specific HR-QoL improved in all ThyPRO domains after surgery in patients with BNTG. Future studies of QoL in thyroid surgery patients will benefit from a standard questionnaire and improved reporting of covariates including complications to ensure comparability across studies.

Prehabilitation Exercise Before Urologic Cancer Surgery: A Systematic and Interdisciplinary Review.

CONTEXT: The Consensus on Therapeutic Exercise Training (CONTENT) scale assesses the therapeutic validity of exercise programs. To date, prehabilitation exercise programs for heath optimization before urologic cancer surgeries have not been assessed for therapeutic validity or efficacy. OBJECTIVE: To systematically assess prehabilitation exercise programs before urologic cancer surgery for therapeutic validity and efficacy, informing discussion of best practices for future intervention. EVIDENCE ACQUISITION: A systematic review was performed using Ovid, Embase, Web of Science, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases through June 2020. The review included prospective (randomized controlled and uncontrolled) trials where patients were enrolled in prehabilitation exercise programs before urologic cancer surgery. The primary outcomes of interest included therapeutic validity and efficacy (measures of cardiorespiratory fitness and postsurgical outcomes). Studies were evaluated for the risk of bias. A narrative synthesis was carried out given heterogeneity in populations, interventions, and outcomes across studies. EVIDENCE SYNTHESIS: Ten unique studies and two associated post hoc analyses met the inclusion criteria. Seven studies demonstrated therapeutic validity. Eight demonstrated a high risk of bias. All demonstrated significant improvement in cardiorespiratory fitness. Four of five studies evaluating quality of life observed significant improvements. To date, zero trials have demonstrated reduction in postsurgical complications, mortality, length of stay, or readmission rates following prehabilitation exercise interventions. CONCLUSIONS: While prehabilitation exercise may result in improved cardiorespiratory fitness and quality of life, current studies have yet to demonstrate impact on surgical outcomes. When designing prehabilitation exercise programs for use before urologic cancer surgery, the therapeutic validity of the intervention should be considered. Future prehabilitation studies should employ standardized content rubrics to ensure therapeutic validity. Consensus is needed regarding the appropriate outcomes to adjudicate prehabilitation efficacy. PATIENT SUMMARY: In this report, we looked at the effectiveness and quality of prehabilitation exercise programs before urologic cancer surgery. We found that these programs effectively improve presurgical fitness, but may benefit from the use of structured methodology and outcome assessment to understand their potential to improve surgical outcomes.

A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery.

BACKGROUND: Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients. OBJECTIVES: This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes. METHODS: A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL and postoperative hematoma were performed. RESULTS: Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3 mL average blood loss reduction (95% CI, -40.0 to -12.7 mL; P < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (odds ratio, 0.280; 95% CI, 0.076-1.029; P = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, 3 studies found statistically significant reductions in postoperative drain output, and 1 study reported significantly improved surgical site quality for patients who received TXA (P = 0.001). CONCLUSIONS: TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation.

Effectiveness and Safety of Tofacitinib for Ulcerative Colitis: Systematic Review and Meta-analysis.

BACKGROUND: The objective of our systematic review and meta-analysis was to evaluate the effectiveness and safety of tofacitinib in the treatment of moderate-severe ulcerative colitis (UC). METHODS: We searched Medline, Embase, Web of Science, and Cochrane Central to identify articles and abstracts reporting efficacy or safety data on tofacitinib use in UC. Primary outcome assessed was remission. Secondary outcomes included clinical response, steroid free remission, and adverse events (AEs). RESULTS: A total of 26 studies were included. The rates of remission were 29.81% [95% confidence interval (CI): 22.37%-37.25%, I2 : 90%] at week 8, 32.27% (95% CI: 27.67%-36.88%, I2 : 42%) at 6 months and 38.03% (95% CI: 33.59%-42.48%, I2 : 0%) at 1-year. Clinical response rates were 59.41% (95% CI: 55.03%-63.94%, I2 : 61%) at week 8, 48.99% (95% CI: 36.92%-61.06%, I2 : 91%) at 6 months and 50.87% (95% CI: 42.16%-59.58%, I2 : 67%) at 1-year. Odds ratio of clinical response at week 8 in biologic naive versus biologic experienced patients was 1.59 (95% CI: 0.54-4.63). Pooled incidence rate for serious infections, major adverse cardiovascular events, and nonmelanotic squamous cell malignancies across all doses was 4.41 per 100-patient years (PYs) (95% CI: 2.32-8.38 per 100-PY, I2 : 78%), 0.91 per 100-PY (95% CI: 0.43-1.93 per 100-PY, I2 : 37%) and 0.91 per 100-PY (95% CI: 0.61-1.34 per 100-PY, I2 : 0%), respectively. Higher dose was associated with an increased frequency of AEs. CONCLUSIONS: While the overall efficacy and safety of tofacitinib in moderate-severe UC is consistent with clinical trial data, the dose dependent increase in AEs highlights the significance of early dose de-escalation. Rate of clinical response after tofacitinb induction was similar in biologic naive and biologic experienced patients.

Topical treatments for early-stage mycosis fungoides using Grading Recommendations Assessment, Development and Evaluation (GRADE) criteria: A systematic review.

BACKGROUND: Mycosis fungoides (MF) is a cutaneous lymphoma; most patients present with early, skin-limited disease and are managed by dermatologists. OBJECTIVE: The purpose of this study was to systematically review and assess the evidence on topical treatments for early-stage (IA, IB, IIA) MF. METHODS: We performed a literature search via MEDLINE, Embase, Web of Science, and Cochrane databases. Grading Recommendations Assessment, Development and Evaluation (GRADE) criteria were used to assess the certainty of the data. RESULTS: Two searches yielded 1252 references; 26 met the inclusion criteria and included literature on nitrogen mustard, retinoids, corticosteroids, carmustine, fluorouracil, methotrexate-laurocapram, hexadecylphosphocholine, peldesine, ingenol mebutate, topical methotrexate with oxygen flow-assisted LP3 carrier, and resiquimod. Most studies were single intervention, observational series. Nitrogen mustard, with the most published reports, was effective with 12%-82% early-stage MF patients (total n > 1000) achieving complete remission (CR) (low certainty evidence). Clinical CR was achieved among 10%-60% treated with topical retinoids (low certainty evidence). Two moderate-sized retrospective case series on topical steroids had 18%-63% CR (low certainty evidence). Only single studies were available for the other therapies. CONCLUSIONS: For most outcomes of interest, the GRADE certainty for topical therapies for early-stage MF was low. Further randomized controlled trials and inclusion of quality of life indicators are needed.

Preoperative Nonsurgical Weight Loss Interventions Before Total Hip and Knee Arthroplasty: A Systematic Review.

BACKGROUND: An upcoming total joint arthroplasty (TJA) may motivate patients with severe obesity (body mass index [BMI] > 40 kg/m2) to lose weight. Weight loss can optimize outcomes following TJA, and many surgeons use a 40 kg/m2 cut-off for undergoing TJA to reduce the risk of complications. However, few patients who are denied TJA for severe obesity successfully lose weight. This is the first systematic review of nonsurgical weight loss interventions before TJA. METHODS: Five electronic databases were searched for articles on January 11, 2021. Studies that utilized preoperative nonsurgical weight loss interventions for patients with obesity (BMI ≥ 30 kg/m2) scheduled for or awaiting TJA of the hip or knee were included. Two reviewers independently screened articles, assessed methodological quality, and extracted data. RESULTS: We retrieved 1943 unique records, of which 7 met inclusion criteria including 2 randomized clinical trials and 5 single-arm case series. Overall, weight loss ranged from 5.0 to 32.5 kg. Four interventions reduced BMI by 3 kg/m2 at 3-5 months, while 1 reduced BMI by 12.7 kg/m2. Other weight outcomes and those related to pain, function, complications, and adverse events were inconsistently reported. CONCLUSION: Although larger trials are needed, particularly randomized controlled trials that measure preoperative weight loss in a control group, nutritional status, and postoperative complications, the available evidence indicates that short-term, nonsurgical, preoperative weight loss interventions before TJA produce both statistically significant weight loss and reduced BMI before surgery. It remains unknown if the amount of weight loss from these interventions is clinically significant and sufficient to improve outcomes after TJA.

Value-Based Healthcare in Urology: A Collaborative Review.

CONTEXT: In response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated. OBJECTIVE: To systematically review the literature regarding the implementation and impact of value-based healthcare in urology. EVIDENCE ACQUISITION: A systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion. EVIDENCE SYNTHESIS: Reorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms. CONCLUSIONS: Few studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented. PATIENT SUMMARY: While few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.