Comment on: "Operator gender differences in major mechanical complications after central line insertions: a subgroup analysis of a prospective multicentre cohort study".

We read with great interest the recent study by Naddi et al. in BMC Anesthesiology, which explores operator gender differences in major mechanical complications following central venous catheterization. The study identifies male operator gender as an independent risk factor for complications. However, our attempt to replicate these findings using Colombian data did not support this association. We caution against oversimplifying the influence of sex and gender on health outcomes, as numerous factors, including cultural norms, healthcare practices, and resource availability, significantly impact procedural outcomes. Differences in complication rates may reflect risk-taking behaviors and systemic healthcare disparities rather than inherent biological differences. We emphasize the need for a comprehensive approach to understand the multifaceted nature of central venous related complications. Replication studies across diverse populations are crucial for validating these findings and informing effective strategies for complication prevention and management.

Efficacy of different routes of acetaminophen administration for postoperative pain in children: a systematic review and network meta-analysis.

PURPOSE: Acetaminophen is the most common drug used to treat acute pain in the pediatric population, given its wide safety margin, low cost, and multiple routes for administration. We sought to determine the most efficacious route of acetaminophen administration for postoperative acute pain relief in the pediatric surgical population. METHODS: We conducted a systematic review of randomized controlled trials (RCTs) that included children aged between 30 days and 17 yr who underwent any type of surgical procedure and that evaluated the analgesic efficacy of different routes of administration of acetaminophen for the treatment of postoperative pain. We searched MEDLINE, CENTRAL, Embase, CINAHL, LILACs, and Google Scholar databases for trials published from inception to 16 April 2023. We assessed the risk of bias in the included studies using the Cochrane Risk of Bias 1.0 tool. We performed a frequentist network meta-analysis using a random-effects model. Our primary outcome was postoperative pain using validated pain scales. RESULTS: We screened 2,344 studies and included 14 trials with 829 participants in the analysis. We conducted a network meta-analysis for the period from zero to two hours, including six trials with 496 participants. There was no evidence of differences between intravenous vs rectal routes of administration of acetaminophen (difference in means, -0.28; 95% confidence interval [CI], -0.62 to 0.06; very low certainty of the evidence) and intravenous vs oral acetaminophen (difference in means, -0.60; 95% CI, -1.20 to 0.01; low certainty of the evidence). For the comparison of oral vs rectal routes, we found evidence favouring the oral route (difference in means, -0.88; 95% CI, -1.44 to -0.31; low certainty of the evidence). Few trials reported secondary outcomes of interest; when comparing the oral and rectal routes in the incidence of nausea and vomiting, there was no evidence of differences (relative risk, 1.20; 95% CI, 0.81 to 1.78). CONCLUSION: The available evidence on the effect of the administration route of acetaminophen on postoperative pain in children is very uncertain. The outcomes of postoperative pain control and postoperative vomiting may differ very little between the oral and rectal route. Better designed and executed RCTs are required to address this important clinical question. STUDY REGISTRATION: PROSPERO (CRD42021286495); first submitted 19 November 2021.

RéSUMé: OBJECTIF: Compte tenu de sa large marge de sécurité, de son faible coût et de ses multiples voies d'administration, l'acétaminophène est le médicament le plus couramment utilisé pour traiter la douleur aiguë dans la population pédiatrique. Nous avons cherché à déterminer la voie d'administration d'acétaminophène la plus efficace pour le soulagement de la douleur aiguë postopératoire dans la population chirurgicale pédiatrique. MéTHODE: Nous avons réalisé une revue systématique d'études randomisées contrôlées (ERC) qui ont inclus des enfants âgé·es de 30 jours à 17 ans ayant bénéficié de n'importe quel type d'intervention chirurgicale et qui ont évalué l'efficacité analgésique de différentes voies d'administration d'acétaminophène pour le traitement de la douleur postopératoire. Nous avons mené des recherches dans les bases de données MEDLINE, CENTRAL, Embase, CINAHL, LILAC et Google Scholar pour en tirer les études publiées depuis leur création jusqu'au 16 avril 2023. Le risque de biais dans les études incluses a été évalué à l'aide de l'outil de Risque de biais 1.0 de Cochrane. Nous avons réalisé une méta-analyse de réseau fréquentiste à l'aide d'un modèle à effets aléatoires. Notre critère d'évaluation principal était la douleur postopératoire mesurée à l'aide d'échelles de douleur validées. RéSULTATS: Nous avons passé en revue 2344 études et inclus 14 études incluant un total de 829 enfants dans l'analyse. Nous avons mené une méta-analyse en réseau pour une période allant de zéro à deux heures, comprenant six études avec 496 participant·es. Il n'y avait aucune preuve de différences entre les voies d'administraion intraveineuse vs rectale de l'acétaminophène (différence de moyennes, −0,28; intervalle de confiance [IC] à 95 %, −0,62 à 0,06; très faible certitude des données probantes) et entre les voies intraveineuse vs orale (différence de moyennes, −0,60; IC 95 %, −1,20 à 0,01; faible certitude des données probantes). Pour la comparaison des voies orale vs rectale, nous avons trouvé des données probantes en faveur de la voie orale (différence de moyennes, −0,88; IC 95 %, −1,44 à −0,31; faible degré de certitude des données probantes). Peu d'études ont rapporté des résultats secondaires d'intérêt; en comparant les voies orale et rectale dans l'incidence des nausées et des vomissements, il n'y avait aucune preuve de différences (risque relatif, 1,20; IC 95 %, 0,81 à 1,78). CONCLUSION: Les données probantes disponibles sur l'effet de la voie d'administration de l'acétaminophène sur la douleur postopératoire chez les enfants sont très incertaines. Les résultats de contrôle de la douleur postopératoire et de vomissements postopératoires peuvent différer très peu entre la voie orale et la voie rectale. Des ERC mieux conçues et mieux exécutées sont nécessaires pour répondre à cette importante question clinique. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021286495); première soumission le 19 novembre 2021.

Developing research priorities for palliative care in Colombia: a priority setting partnership approach.

BACKGROUND: A recent Lancet commission called for more research on palliative care in low- and middle-income (LMIC) countries such as Colombia. A research priority setting approach has been recommended by The Global Forum for Health Research to address the huge gap in research output between LMIC and high-income countries, with influential health service bodies recommending the active involvement of non-research expert stakeholders in establishing research priorities to address service user needs. METHOD: Priority setting partnership (PSP) following the four stages of the James Lind Alliance methodology; establishing the partnership, identifying evidence uncertainties, refining questions and uncertainties, and prioritization. Data from MS forms were analysed using descriptive statistics. RESULTS: A total of 33 stakeholders attended an online PSP workshop and completed the Mentimeter exercise in Microsoft Teams. A total of 48 attended the subsequent in person prioritisation exercise in urban Bogota (n = 22) and rural Popayan (n = 25). The stakeholders were a diverse group of health professionals (physicians, medical students, nurses, dentists, physiotherapists, nutritionist, occupational and speech therapists), financial and administrative staff and patients with life-limiting illness and caregivers. Top research priorities included patient and caregiver needs, service provider education and training, and better integration of palliative care with cancer and non-cancer services. The key challenges included a lack of interest in palliative care research, along with funding, time and resource constraints. Key solutions included collaboration across disciplines and settings, highlighting benefits of palliative research to help secure adequate resources, and multicentre, mixed method research, with patient involvement from the research development stage. CONCLUSION: The findings of this PSP should be disseminated among palliative care associations worldwide to inform international multicentre studies, and among governmental and nongovernmental organisations that promote research in Colombia. A focus on patient and family caregiver palliative care needs in Colombia should be prioritised.

Translation and linguistic validation of the Sheffield Profile for Assessment and Referral for Care (SPARC) to Colombian Spanish.

OBJECTIVES: We aimed to translate and linguistically and cross-culturally validate Sheffield Profile for Assessment and Referral for Care (SPARC) in Spanish for Colombia (SPARC-Sp). METHODS: The linguistic validation of SPARC followed a standard methodology. We conducted focus groups to assess the comprehensibility and feasibility. The acceptability was assessed using a survey study with potential users. RESULTS: The comprehensibility assessment showed that additional adjustments to those made during the translation-back-translation process were required to apply SPARC-Sp in rural and low-schooled populations. It also identified the need for alternative administration mechanisms for illiterate people. The acceptability survey showed that potential users found SPARC-Sp as not only acceptable but also highly desirable. However, they desired to expand the number of items in all domains. SIGNIFICANCE OF RESULTS: Beyond the semantic and conceptual validity attained through the back-translation process, actual cultural validity could be acquired thanks to the comprehensibility tests. Although extending the instrument is something potential users would like to do, it would make it less feasible to utilize the SPARC-Sp in clinical settings. Nonetheless, the instrument might benefit from the inclusion of a domain that evaluates challenges encountered when accessing the health-care system. For communities lacking literacy, alternate administration methods must also be considered.

Validation of the Spanish translation Sheffield Profile for Assessment and Referral for Care (SPARC-Sp) at the Hospital Universitario San Jose of Popayan, Colombia.

OBJECTIVES: We determined the validity and reliability of the Spanish translation Sheffield Profile for Assessment and Referral for Care (SPARC-Sp) questionnaire to identify the palliative care (PC) needs of patients with chronic noncommunicable diseases (NCDs) in Colombia. METHODS: We developed a cross-sectional observational study of scale assessment in adults with the aim of determining the validity and reliability of the SPARC-Sp questionnaire to identify the PC needs of patients with NCDs receiving outpatient or inpatient care at the Hospital Universitario San Jose of Popayan - ESE, Colombia, from 2021 to 2022. RESULTS: We applied a questionnaire consisting of demographic, clinical data, and SPARC-Sp to 507 participants. The constructed model explained 75% of the variance with an adequate fit according to the root mean square residual (0.03), the comparative fit index (0.98), and acceptable reliability (McDonald's total omega 0.4-0.9). Opportunities for improvement are the reformulation and inclusion of particular words to improve the representativeness and clarity of the domains of communication and information, religious, and spiritual issues. SIGNIFICANCE OF RESULTS: This research represents the first validation of SPARC in Spanish. SPARC-Sp is an instrument that allows initiating a conversation of the patient's main needs through a systematic assessment of the patients' main needs. Its psychometric validation demonstrated good fit and acceptable reliability.

Factors associated with suffering from dying in patients with cancer: a cross-sectional analytical study among bereaved caregivers.

BACKGROUND: In Colombia, cancer incidence is increasing, as is the demand for end-of-life care. Understanding how patients who die from cancer experience this phase will allow the identification of factors associated with greater suffering and actions to improve end-of-life care. We aimed to explore associations between the level of suffering of patients who died from cancer and were cared for in three Colombian hospitals with patient, tumor, treatment, and care characteristics and provided information. METHODS: Data on the last week of life and level of suffering were collected through proxies: Bereaved caregivers of patients who died from cancer in three participating Colombian hospitals. Bereaved caregivers participated in a phone interview and answered a series of questions regarding the last week of the patient's life. An ordinal logistic regression model explored the relationship between the level of suffering reported by bereaved caregivers with the patient's demographic and clinical characteristics, the bereaved caregivers, and the care received. Multivariate analyses were adjusted for place of death, treatments to prolong of life, prolongation of life during the dying process, suffering due to prolongation of life, type of cancer, age, if patient had partner, rural/urban residence of patient, importance of religion for the caregiver, caregivers´ relationship with the patient, and co-living with the patient. RESULTS: A total of 174 interviews were included. Median age of the deceased patients was 64 years (IQR 52-72 years), and 93 patients were women (53.4%). Most caregivers had rated the level of suffering of their relative as "moderately to extremely" (n = 139, 80%). In multivariate analyses, factors associated with a higher level of suffering were: unclear information about the treatment and the process before death Odds Ratio (OR) 2.26 (90% CI 1.21-4.19), outpatient palliative care versus home care OR 3.05 (90% CI 1.05-8.88), procedures inconsistent with the patient's wishes OR 2.92 (90% CI 1.28-6.70), and a younger age (18-44 years) at death versus the oldest age group (75-93 years) OR 3.80 (90% CI 1.33-10.84, p = 0.04). CONCLUSION: End-of-life care for cancer patients should be aligned as much as possible with patients´ wishes, needs, and capacities. A better dialogue between doctors, family members, and patients is necessary to achieve this.

End of Life in Patients With Advanced Non-curable Cancer: Patient Considerations Around the Moment of Death.

There is limited knowledge regarding Colombian patients with advanced cancer preferences regarding their final moments, place of death, and post-death wishes. To better understand these preferences, we conducted 23 in-depth interviews with patients between the ages of 28 and 78 receiving treatment at two academic hospitals and the National Cancer Institute. While many participants desired a peaceful death, few were comfortable discussing the topic of death directly. Some younger participants expressed an interest in euthanasia but had not received any guidance or support. While several participants preferred a home death, some expressed a desire to die in a hospital due to better symptom control. Additionally, when discussing post-death wishes, some participants expressed frustration about being unable to have these conversations with their loved ones and their preferences for funeral arrangements. Socioeconomic and geographical factors significantly impacted the wishes and preferences expressed, with many individuals hesitant to initiate difficult conversations.

Causal and Associational Language in Observational Health Research: A Systematic Evaluation.

We estimated the degree to which language used in the high-profile medical/public health/epidemiology literature implied causality using language linking exposures to outcomes and action recommendations; examined disconnects between language and recommendations; identified the most common linking phrases; and estimated how strongly linking phrases imply causality. We searched for and screened 1,170 articles from 18 high-profile journals (65 per journal) published from 2010-2019. Based on written framing and systematic guidance, 3 reviewers rated the degree of causality implied in abstracts and full text for exposure/outcome linking language and action recommendations. Reviewers rated the causal implication of exposure/outcome linking language as none (no causal implication) in 13.8%, weak in 34.2%, moderate in 33.2%, and strong in 18.7% of abstracts. The implied causality of action recommendations was higher than the implied causality of linking sentences for 44.5% or commensurate for 40.3% of articles. The most common linking word in abstracts was "associate" (45.7%). Reviewers' ratings of linking word roots were highly heterogeneous; over half of reviewers rated "association" as having at least some causal implication. This research undercuts the assumption that avoiding "causal" words leads to clarity of interpretation in medical research.

Knowledge of end-of-life wishes by physicians and family caregivers in cancer patients.

OBJECTIVES: To describe communication regarding cancer patient's end-of-life (EoL) wishes by physicians and family caregivers. METHODS: An online questionnaire and telephone-based surveys were performed with physicians and family caregivers respectively in three teaching hospitals in Colombia which had been involved in the EoL care of cancer patients. RESULTS: For 138 deceased patients we obtained responses from physicians and family caregivers. In 32 % physicians reported they spoke to the caregiver and in 17 % with the patient regarding EoL decisions. In most cases lacking a conversation, physicians indicated the treatment option was "clearly the best for the patient" or that it was "not necessary to discuss treatment with the patient". Twenty-six percent of the caregivers indicated that someone from the medical team spoke with the patient about treatment, and in 67% who had a conversation, caregivers felt that the provided information was unclear or incomplete. Physicians and family caregivers were aware if the patient had any advance care directive in 6% and 26% of cases, respectively, with low absolute agreement (34%). CONCLUSIONS: There is a lack of open conversation regarding EoL in patients with advanced cancer with their physicians and family caregivers in Colombia. Communication strategies are urgently needed.

Medical decisions concerning the end of life for cancer patients in three Colombian hospitals - a survey study.

BACKGROUND: Cancer patients' end-of-life care may involve complex decision-making processes. Colombia has legislation regarding provision of and access to palliative care and is the only Latin American country with regulation regarding euthanasia. We describe medical end-of-life decision-making practices among cancer patients in three Colombian hospitals. METHODS: Cancer patients who were at the end-of-life and attended in participating hospitals were identified. When these patients deceased, their attending physician was invited to participate. Attending physicians of 261 cancer patients (out of 348 identified) accepted the invitation and answered a questionnaire regarding end-of-life decisions: a.) decisions regarding the withdrawal or withholding of potentially life-prolonging medical treatments, b.) intensifying measures to alleviate pain or other symptoms with hastening of death as a potential side effect, and c.) the administration, supply or prescription of drugs with an explicit intention to hasten death. For each question addressing the first two decision types, we asked if the decision was fully or partially made with the intention or consideration that it may hasten the patient's death. RESULTS: Decisions to withdraw potentially life-prolonging treatment were made for 112 (43%) patients, 16 of them (14%) with an intention to hasten death. For 198 patients (76%) there had been some decision to not initiate potentially life-prolonging treatment. Twenty-three percent of patients received palliative sedation, 97% of all patients received opioids. Six patients (2%) explicitly requested to actively hasten their death, for two of them their wish was fulfilled. In another six patients, medications were used with the explicit intention to hasten death without their explicit request. In 44% (n = 114) of all cases, physicians did not know if their patient had any advance care directives, 26% (n = 38) of physicians had spoken to the patient regarding the possibility of certain treatment decisions to hasten death where this applied. CONCLUSIONS: Decisions concerning the end of life were common for patients with cancer in three Colombian hospitals, including euthanasia and palliative sedation. Physicians and patients often fail to communicate about advance care directives and potentially life-shortening effects of treatment decisions. Specific end-of-life procedures, patients' wishes, and availability of palliative care should be further investigated.

Completeness of reporting of case reports in high-impact medical journals.

INTRODUCTION: Case reports represent a relevant, timely and important study design in advancing medical scientific knowledge. They allow integration between clinical practice and clinical epidemiology. We aimed to assess the completeness of reporting (COR) of case reports published in high-impact journals. We assessed the COR of case reports using the CARE guidelines. MATERIALS AND METHODS: We selected three high-impact journals and one journal specialized in publishing case reports, in which we included all published case reports from July to December 2017. Median COR score was calculated per study, and CORs were compared between journals with and without endorsement of CARE guidelines. RESULTS: One hundred and fourteen case reports were included. Overall median COR was 81%, IQR [63%-96%]. Sections with the highest COR (84%-100%) were patient information, clinical findings, therapeutic intervention, follow-up and outcomes, discussion and informed consent. Sections with the lowest COR were title, keywords, timeline and patient perspective (2%-34%). COR was higher in journals endorsing in comparison to those not endorsing CARE guidelines (77% vs 65%), respectively, median difference = -12% 95% CI [-16% to -7%]. DISCUSSION: Overall completeness of case reports in included journals is high especially for CARE endorsing and dedicated journals but reporting of some items could be improved. Ongoing and future evaluations of endorsement status of reporting guidelines in medical journals should be assessed to improve completeness and reduce waste of clinical research, including case reports.

Unmet device reprogramming needs at the end of life among patients with implantable cardioverter defibrillator: A systematic review and meta-analysis.

BACKGROUND: Use of implantable cardioverter defibrillators is increasingly common. As patients approach the end of life, it is appropriate to deactivate the shock function. AIM: To assess the prevalence of implantable cardioverter defibrillator reprogramming to deactivate the shock function at the end of life and the prevalence of advance directives among this population. DESIGN: Following a previously established protocol available in PROSPERO, we performed a narrative synthesis of our findings and used the logit transformation method to perform our quantitative synthesis. DATA SOURCES: We searched seven bibliographic databases (Embase, Cochrane Central register of controlled Trials, Medline-Ovid, Web-of-Science, Scopus, PsychInfo, and CINAHL) and additional sources until April 2019. RESULTS: Of the references we identified, 14 were included. We found a pooled prevalence of implantable cardioverter defibrillator reprogramming at the end of life of 28% (95% confidence interval, 22%-36%) with higher reprogramming rates after the recommendations for managing the device at the end of life were published. Among patients with advance directives, the pooled prevalence of advance directives that explicitly mentioned the device was 1% (95% confidence interval, 1%-3%). CONCLUSIONS: The prevalence of implantable cardioverter defibrillator reprogramming and advance directives that explicitly mentioned the device was very low. Study data suggested reprogramming decisions were made very late, after the patient experienced multiple shocks. Patient suffering could be ameliorated if physicians and other healthcare professionals adhere to clinical guidelines for the good management of the device at the end of life and include deactivating the shock function in the discussion that leads to the advance directive.

Methodological quality and transparency of clinical practice guidelines for difficult airway management using the appraisal of guidelines research & evaluation II instrument: A systematic review.

BACKGROUND: Complications arising from airway management represent an important cause of morbidity and mortality. Clinical practice guidelines (CPGs) are systematically created documents that summarise knowledge and assist the delivery of high-quality medical care by identifying evidence that supports best clinical care. OBJECTIVE: Using the Appraisal of Guidelines for Research & Evaluation II instrument, we aimed to evaluate the methodological rigour and transparency of unanticipated difficult airway management CPGs in adults. DESIGN: Using PUBMED without language restrictions, we identified eligible CPGs between 1 January 1996 and 30 June 2019. All versions of a CPG were included as independent guidelines to assess improvements over time or the methodological limitations of each version. CPGs-related obstetrics or paediatrics or the management extubation in cases of difficult airway were excluded. RESULTS: Fourteen CPGs were included. Of the six domains suggested by the Appraisal of Guidelines for Research & Evaluation II instrument, 'applicability' had the lowest score (23%) and 'scope and objectives' had the highest score (88%). The remaining domains (stakeholder involvement, editorial independence, rigour of development and clarity of presentation) had scores ranging between 56 and 81%. Overall, the highest scored CPG was the Difficult Airway Society 2015. CONCLUSION: Future updates of CPGs for difficult airway management in adults and severely ill patients should consider more emphasis on the applicability of their recommendations to real clinical practice.

Fluids in the treatment of diabetic ketoacidosis in children: A systematic review.

AIM: To determine the comparative effectiveness of fluid schemes for children with diabetic ketoacidosis (DKA). METHODS: We conducted a systematic review with an attempt to conduct network meta-analysis (NMA). We searched MEDLINE, EMBASE, CENTRAL, Epistemonikos, Virtual Health Library, and gray literature from inception to July 31, 2022. We included randomized controlled trials (RCTs) in children with DKA evaluating any intravenous fluid schemes. We planned to conduct NMA to compare all fluid schemes if heterogeneity was deemed acceptable. RESULTS: Twelve RCTs were included. Studies were heterogeneous in the population (patients and DKA episodes), interventions with different fluids (saline, Ringer's lactate (RL), and polyelectrolyte solution-PlasmaLyte®), tonicity, volume, and administration systems. We identified 47 outcomes that measured clinical manifestations and metabolic control, including single and composite outcomes and substantial heterogeneity preventing statistical combination. No evidence was found of differences in neurological deterioration (main outcome), but differences were found among interventions in some comparisons to normalize acid-base status (∼2 h less with low vs. high volume); time to receive subcutaneous insulin (∼1 h less with low vs. high fluid rate); length of stay (∼6 h less with RL vs. saline); and resolution of the DKA (∼3 h less with two-bag vs. one-bag scheme). However, available evidence is scarce and poor. CONCLUSIONS: There is not enough evidence to determine the best fluid therapy in terms of fluid type, tonicity, volume, or administration time for DKA treatment. There is an urgent need for more RCTs, and the development of a core outcome set on DKA in children.

Modeling the relative influence of socio-demographic variables on post-acute COVID-19 quality of life.

Importance: Post-acute sequelae of SARS-CoV-2, referred to as "long COVID", are a globally pervasive threat. While their many clinical determinants are commonly considered, their plausible social correlates are often overlooked. Objective: To compare social and clinical predictors of differences in quality of life (QoL) with long COVID. Additionally, to measure how much adjusted associations between social factors and long COVID-associated quality of life are unexplained by important clinical intermediates. Design Setting and Participants: Data from the ISARIC long COVID multi-country prospective cohort study. Subjects from Norway, the United Kingdom (UK), and Russia, aged 16 and above, with confirmed acute SARS-CoV-2 infection reporting >= 1 long COVID-associated symptoms 1+ month following infection. Exposure: The social exposures considered were educational attainment (Norway), employment status (UK and Russia), and female vs male sex (all countries). Main outcome and measures: Quality of life-adjusted days, or QALDs, with long COVID. Results: This cohort study included a total of 3891 participants. In all three countries, educational attainment, employment status, and female sex were important predictors of long COVID QALDs. Furthermore, a majority of the estimated relationships between each of these social correlates and long COVID QALDs could not be attributed to key long COVID-predicting comorbidities. In Norway, 90% (95% CI: 77%, 100%) of the adjusted association between the top two quintiles of educational attainment and long COVID QALDs was not explained by clinical intermediates. The same was true for 86% (73%, 100%) and 93% (80%,100%) of the adjusted associations between full-time employment and long COVID QALDs in the United Kingdom (UK) and Russia. Additionally, 77% (46%,100%) and 73% (52%, 94%) of the adjusted associations between female sex and long COVID QALDs in Norway and the UK were unexplained by the clinical mediators. Conclusions and Relevance: This study highlights the role of socio-economic status indicators and female sex, in line with or beyond commonly cited clinical conditions, as predictors of long COVID-associated QoL, and further reveal that other (non-clinical) mechanisms likely drive their observed relationships. Our findings point to the importance of COVID interventions which go further than an exclusive focus on comorbidity management in order to help redress inequalities in experiences with this chronic disease. Key Points: Question: How do social and medical factors compare in predicting differences in quality of life (QoL) with long COVID and to what extent do clinical mediators explain social variables' relationships with long COVID QoL?Findings: Socio-economic proxies employment status and educational attainment and female sex ranked on par with or above age and neuropsychological and rheumatological comorbidities as predictors of variation in long COVID QoL across participants. Additionally, estimated adjusted associations between each of these social factors and long COVID QoL were largely unexplained by a set of key comorbidities.Meaning: Long COVID-based interventions may be more broadly beneficial if they account for social disparities as important risk factors for differential long COVID burden and, in addition to clinical targets, address broader structural determinants of health.

How Low Back Pain is Managed-A Mixed-Methods Study in 32 Countries. Part 2 of Low Back Pain in Low- and Middle-Income Countries Series.

BACKGROUND: The Lancet Low Back Pain (LBP) Series highlighted the lack of LBP data from low- and middle-income countries (LMICs). The study aimed to describe (1) what LBP care is currently delivered in LMICs and (2) how that care is delivered. DESIGN: An online mixed-methods study. METHODS: A Consortium for LBP in LMICs (n = 65) was developed with an expert panel of leading LBP researchers (>2 publications on LBP) and multidisciplinary clinicians and patient partners with 5 years of clinical/lived LBP experience in LMICs. Quantitative data were analyzed using descriptive statistics. Two researchers independently analyzed qualitative data using inductive and deductive coding and developed a thematic framework. RESULTS: Forty-seven (85%) of 55 invited panel members representing 32 LMICs completed the survey (38% women, 62% men). The panel included clinicians (34%), researchers (28%), educators (6%), and people with lived experience (4%). Pharmacotherapies and electrophysiological agents were the most used LBP treatments. The thematic framework comprised 8 themes: (1) self-management is ubiquitous, (2) medicines are the cornerstone, (3) traditional therapies have a place, (4) society plays an important role, (5) imaging use is very common, (6) reliance on passive approaches, (7) social determinants influence LBP care pathway, and (8) health systems are ill-prepared to address LBP burden. CONCLUSION: LBP care in LMICs did not consistently align with the best available evidence. Findings will help research prioritization in LMICs and guide global LBP clinical guidelines. J Orthop Sports Phys Ther 2024;54(8):560-572. Epub 11 April 2024. doi:10.2519/jospt.2024.12406.

Methodological transparency of preoperative clinical practice guidelines for elective surgery. Systematic review.

BACKGROUND: Clinical practice guidelines (CPG) are statements that provide recommendations regarding the approach to different diseases and aim to increase quality while decreasing the risk of complications in health care. Numerous guidelines in the field of perioperative care have been published in the previous decade but their methodological quality and transparency are relatively unknown. OBJECTIVE: To critically evaluate the transparency and methodological quality of published CPG in the preoperative assessment and management of adult patients undergoing elective surgery. DESIGN: Systematic review and methodological appraisal study. DATA SOURCES: We searched for eligible CPG published in English or Spanish between January 1, 2010, and June 30, 2022, in Pubmed MEDLINE, TRIP Database, Embase, the Cochrane Library, as well as in representatives' medical societies of Anaesthesiology and developers of CPG. ELIGIBILITY CRITERIA: CPG dedicated on preoperative fasting, cardiac assessment for non-cardiac surgery, and the use of routine preoperative tests were included. Methodological quality and transparency of CPG were assessed by 3 evaluators using the 6 domains of the AGREE-II tool. RESULTS: We included 20 CPG of which 14 were classified as recommended guidelines. The domain of "applicability" scored the lowest (44%), while the domains "scope and objective" and "editorial interdependence" received the highest median scores of 93% and 97% respectively. The remaining domains received scores ranging from 44% to 84%. The top mean scored CPG in preoperative fasting was ASA 2017 (93%); among cardiac evaluation, CPG for non-cardiac surgery were CCS 2017 (91%), ESC-ESA 2014 (90%), and AHA-ACC 2014 (89%); in preoperative testing ICSI 2020 (97%). CONCLUSIONS: In the last ten years, most published CPG in the preoperative assessment or management of adult patients undergoing elective surgery focused on preoperative fasting, cardiac assessment for non-cardiac surgery, and use of routine preoperative tests, present moderate to high methodological quality and can be recommended for their use or adaptation. Applicability and stakeholder involvement domains must be improved in the development of future guidelines.

Liver injury in hospitalized patients with COVID-19: An International observational cohort study.

BACKGROUND: Using a large dataset, we evaluated prevalence and severity of alterations in liver enzymes in COVID-19 and association with patient-centred outcomes. METHODS: We included hospitalized patients with confirmed or suspected SARS-CoV-2 infection from the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) database. Key exposure was baseline liver enzymes (AST, ALT, bilirubin). Patients were assigned Liver Injury Classification score based on 3 components of enzymes at admission: Normal; Stage I) Liver injury: any component between 1-3x upper limit of normal (ULN); Stage II) Severe liver injury: any component ≥3x ULN. Outcomes were hospital mortality, utilization of selected resources, complications, and durations of hospital and ICU stay. Analyses used logistic regression with associations expressed as adjusted odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Of 17,531 included patients, 46.2% (8099) and 8.2% (1430) of patients had stage 1 and 2 liver injury respectively. Compared to normal, stages 1 and 2 were associated with higher odds of mortality (OR 1.53 [1.37-1.71]; OR 2.50 [2.10-2.96]), ICU admission (OR 1.63 [1.48-1.79]; OR 1.90 [1.62-2.23]), and invasive mechanical ventilation (OR 1.43 [1.27-1.70]; OR 1.95 (1.55-2.45). Stages 1 and 2 were also associated with higher odds of developing sepsis (OR 1.38 [1.27-1.50]; OR 1.46 [1.25-1.70]), acute kidney injury (OR 1.13 [1.00-1.27]; OR 1.59 [1.32-1.91]), and acute respiratory distress syndrome (OR 1.38 [1.22-1.55]; OR 1.80 [1.49-2.17]). CONCLUSIONS: Liver enzyme abnormalities are common among COVID-19 patients and associated with worse outcomes.

Latin American surgical outcomes study: study protocol for a multicentre international observational cohort study of patient outcomes after surgery in Latin American countries.

Background: Reported data suggest that 4.2 million deaths will occur within 30 days of surgery worldwide each year, half of which are in low- and middle-income countries. Postoperative complications are a leading cause of long-term morbidity and mortality. Patients who survive and leave the hospital after surgical complications regularly experience reductions in long-term survival and functional independence, resulting in increased costs. With a high volume of surgery performed, there is a growing perception of the substantial impact of even minor enhancements in perioperative care. The Latin American Surgical Outcomes Study (LASOS) is an international, multicentre, prospective cohort study of adults submitted to in-patient surgery in Latin America aiming to provide detailed data describing postoperative complications and surgical mortality. Methods: LASOS is a 7 day cohort study of adults undergoing surgery in Latin America. Details of preoperative risk factors, intraoperative care, and postoperative outcomes will be collected. The primary outcome will be in-hospital postoperative complications of any cause. Secondary outcomes include in-hospital all-cause mortality, duration of hospital stay after surgery, and admission to a critical care unit within 30 days after surgery during the index hospitalisation. Results: The LASOS results will be published in peer-reviewed journals, reported and presented at international meetings, and widely disseminated to patients and public in participating countries via mainstream and social media. Conclusions: The LASOS may augment our understanding of postoperative complications and surgial mortality in Latin America. Clinical trial registration: NCT05169164.

The financial impact of a terminal cancer on patient's families in Colombia - A survey study.

AIM OF THE STUDY: The socio-economic impact of caring for a cancer patient in the family is unknown in Colombia. This survey aimed to evaluate the existence of financial burden caused by cancer on the caregiving families of terminally ill patients. METHODS: We used the Covinsky Family Impact Scale in a telephone survey with families of patients who died from cancer between May 2019 and June 2020 in three Colombian hospitals. RESULTS: We obtained answers of 176 caregivers, of whom 74.4 % indicated to have experienced at least one hardship of the Covinsky items. The most commonly reported financial hardship involved the use of all or most of the family savings for the care provided to the patient (45.6 %); 27.6 % indicated that a major source of family income was lost. A quarter (25 %) postponed educational or other important plans of family members and 10-11 % indicated to have moved to another home or postponed medical treatments. CONCLUSION: In Colombia, a country with universal health coverage, substantial financial impacts of terminal cancer care exist not only for patients, but also for family members and other caregivers. The system is failing to avoid financial toxicity of cancer among this group. POLICY SUMMARY STATEMENT: Informal caregivers are of vital importance for cancer patients but also to the healthcare system, particularly in LMICs. It is very important for policy makers to consider the hardships, not only emotionally but also financially, that the care for a (terminally ill) cancer patient implies on caregivers.