Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials.

BACKGROUND: Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0-10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050). FINDINGS: 47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI -0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes. INTERPRETATION: Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field. FUNDING: The Canadian Institutes of Health Research.

A Case Series of Patients with Large Uterine Fibroids and Venous Thromboembolisms.

OBJECTIVE: The purpose of this case series is to identify the clinical characteristics of women with uterine fibroids who developed venous thromboembolisms (VTE) and possible risk factors for the development of VTE in this group. DATA SOURCES: We conducted a systematic search of the Medline, Embase, Cochrane and Scopus databases to retrieve case reports and case series that describe women with an enlarged uterus and VTE. The databases were searched up to August 2019. STUDY SELECTION: A total of 1485 articles were identified by a librarian. All case series and case reports that reported uterine weight and size of the fibroids were included. DATA EXTRACTION AND SYNTHESIS: A total of 27 articles were included, describing 35 patients who developed VTE in the presence of uterine fibroids. On average, the uterus measured 22.9 ± 5.0 weeks gestational age and occupied a volume of 2715 cm3 (interquartile range 1296.3-3878.8) on imaging. Two-thirds (60%) of VTEs occurred on the left side, and 87% showed signs of venous compression on imaging. Most patients (89%) required surgical management to relieve the compression caused by the enlarged uterus. CONCLUSION: VTE in cases of large uterine leiomyomas can be associated with mechanical compression, which requires surgical management to relieve compression. There is an obvious increased risk of VTE in patients with venous stasis secondary to uterine compression; however, there is no current evidence evaluating the use of anticoagulation in such patients. Further research is required to determine the role of prophylactic anticoagulation in reducing the risk of VTE in high-risk patients with large uterine fibroids.

A Scoping Review of Pediatric Mass-Casualty Incident Triage Algorithms.

OBJECTIVE: For the pediatric population, there is no consensus on which triage system to use for mass-casualty incidents (MCI). A scoping review was conducted to identify the most accurate triage system for pediatric patients in MCIs. METHODS: MEDLINE (NLM, Bethesda, MA, USA), Embase (Elsevier Inc., Amsterdam, Netherlands), CINAHL (EBSCO Information Services, Ipswitch, MA, USA), and The Cochrane CENTRAL Register of Controlled Trials (John Wiley & Sons, Hoboken, NJ, USA), as well as Scopus (Elsevier Inc., Amsterdam, Netherlands), Global Health (Centre for Agriculture and Bioscience International, Wallingford, UK), Global Health Archive (Centre for Agriculture and Bioscience International, Wallingford, UK), and Global Index Medicus (World Health Organization, Geneva, Switzerland) were searched for relevant studies that were divided into 3 categories: accuracy of a single system, comparison of 2 or more primary triage system and comparison of secondary triage systems. Grey literature was also searched. RESULTS: 996 studies were identified from which 18 studies were included. Systems studied were found to have poor inter-rater reliability, had a low level of agreement between providers, had missed critically ill patients or were not externally validated. 11 studies compared pediatric MCI triage algorithms using different strategies and the most accurate algorithm was not identified. A recently developed secondary triage system, specifically for pediatric patients, was found to perform better than the comparison triage system. CONCLUSION: Although some algorithms performed better than others, no primary triage algorithm was accurate enough for the pediatric population. However, only 1 secondary triage algorithm was found to be superior to the others.

Local Insulin Improves Wound Healing: A Systematic Review and Bayesian Network Meta-Analysis.

BACKGROUND: Wounds are a significant health issue, and reliable and safe strategies to promote repair are needed. Clinical trials have demonstrated that local insulin promotes healing in acute and chronic wounds (ie, reductions of 7% to 40% versus placebo). However, the trials' sample sizes have prevented drawing solid conclusions. Furthermore, no analysis has focused on safety concerns (ie, hypoglycemia). Under the hypothesis that local insulin promotes healing through proangiogenic effects and cellular recruitment, the aim of this systematic review and network meta-analysis (NMA) was to assess its safety and relative effectiveness using a Bayesian approach. METHODS: Medline, CENTRAL, Embase, Scopus, LILACS, and gray literature sources were searched for human studies assessing the local use of insulin versus any comparator since inception to October of 2020. Data on glucose changes and adverse events, wound and treatment characteristics, and healing outcomes were extracted, and an NMA was conducted. RESULTS: A total of 949 reports were found, of which 23 ( n = 1240 patients) were included in the NMA. The studies evaluated six different therapies, and most comparisons were against placebo. NMA showed -1.8 mg/dL blood glucose level change with insulin and a lack of reported adverse events. Statistically significant clinical outcomes identified include reduction in wound size (-27%), increased healing rate (23 mm/day), reduction in Pressure Ulcer Scale for Healing scores (-2.7), -10 days to attain complete closure, and an odds ratio of 20 for complete wound closure with insulin use. Likewise, significantly increased neoangiogenesis (+30 vessels/mm 2 ) and granulation tissue (+25%) were also found. CONCLUSION: Local insulin promotes wound healing without significant adverse events.

Non-invasive diagnosis of Pneumocystis jirovecii pneumonia: a systematic review and meta-analysis.

BACKGROUND: Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection commonly affecting immunocompromised people. Diagnosis usually requires invasive techniques to obtain respiratory specimens. Minimally invasive detection tests have been proposed, but their operating characteristics are poorly described. OBJECTIVES: To systematically review and meta-analyse the performance of minimally invasive PCP detection tests to inform diagnostic algorithms. DATA SOURCES: Medline, Embase, Cochrane Library (inception to 15 October 2020). STUDY ELIGIBILITY CRITERIA: Studies of minimally invasive PCP detection tests were included if they contained a minimum of ten PCP cases. PARTICIPANTS: Adults at risk of PCP. TESTS: Non-invasive PCP detection tests. REFERENCE STANDARD: Diagnosis using the combination of clinical and radiographical features with invasive sampling. ASSESSMENT OF RISK BIAS: Using the QUADAS-2 tool. METHODS: We used bivariate and, when necessary, univariate analysis models to estimate diagnostic test sensitivity and specificity. RESULTS: Fifty-two studies were included; most studies (40) comprised exclusively human immunodeficiency virus (HIV) -infected individuals; nine were mixed (HIV and non-HIV), two were non-HIV and one study did not report HIV status. Sampling sites included induced sputum, nasopharyngeal aspirate, oral wash and blood. The four testing modalities evaluated were cytological staining, fluorescent antibody, PCR and lactate dehydrogenase. Induced sputum had the most data available; this modality was both highly sensitive at 99% (95% CI 51%-100%) and specific at 96% (95% CI 88%-99%). Induced sputum cytological staining had moderate sensitivity at 50% (95% CI 39%-61%) and high specificity at 100% (95% CI 100%-100%), as did fluorescent antibody testing with sensitivity 74% (95% CI 62%-87%) and specificity 100% (95% CI 91%-100%). CONCLUSION: There are several promising minimally invasive PCP diagnostic tests available, some of which may reduce the need for invasive respiratory sampling. Understanding the operating characteristics of these tests can augment current diagnostic strategies and help establish a more confident clinical diagnosis of PCP. Further studies in non-HIV infected populations are needed.

Utility of mobile technology in medical interpretation: A literature review of current practices.

OBJECTIVES: Language barriers limit healthcare access. However, professional interpretation usage is infrequent due to high cost and poor interpreter availability. Healthcare-oriented mobile applications are becoming more accepted and may help alleviate this burden. This literature review aims to better understand the utility of mobile technology in healthcare interpretation. Specifically, the objective of this review is to synthesize the feasibility, outcome, and challenges of implementing technological medical interpretation services. PATIENT INVOLVEMENT: No patients were involved for this review. METHODS: In December 2019, MEDLINE (Ovid) was systematically searched according to PRISMA guidelines. All articles discussing the utility of technology in healthcare interpretation encounters were included. RESULTS: Two major themes emerged: 1) comparing video and phone interpretation with in-person interpretation and 2) assessing direct translation software in healthcare settings. Phone and video interpretation help reduce overall patient wait-times. Both patients and clinicians preferred in-person or video interpretation over interpretation by phone. Chief benefits of using direct translation software include immediate access, low costs, and sustainability. Several studies discussed potential translation inaccuracies and the importance of having professional interpreters in medico-legal discussions. CONCLUSION: Mobile applications may be used to facilitate access to medical interpreters with high clinician and patient satisfaction. Direct in-app translations facilitate access but risk inaccuracies with important medico-legal considerations. PRACTICAL VALUE: Mobile applications are available at low costs and can improve access to interpreters though video and phone calls. Mobile software can also provide direct translation and facilitate clinical care. Clinicians should prioritize face-to-face encounters with professional medical interpreters, whenever possible. In a time of social distancing amidst the current COVID-19 pandemic, there is crucial value in elucidating the best telehealth interpretation practices.

Barriers to Veterans Health Administration care in a nationally representative sample of women veterans.

BACKGROUND: Women veterans are generally less healthy than their nonveteran female counterparts or male veterans. Accumulating evidence suggests there may be barriers to women veterans' access to and use of Veterans Health Administration (VHA) care. OBJECTIVE: To document perceived and/or actual barriers to care in a nationally representative sample of women veterans and examine associations with VHA use. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: Women who are current and former users of VHA from VA's National Registry of Women Veterans. MEASUREMENTS: Assessments of perceptions of VHA care, background characteristics, and health service use. RESULTS: Perceptions of VHA care were most positive regarding facility/physical environment characteristics and physician skill and sensitivity and least positive regarding the availability of needed services and logistics of receiving VHA care (M=0.05 and M=-0.10; M=-0.23 and M=-0.25, respectively). The most salient barrier to the use of VHA care was problems related to ease of use. Moreover, each of the barriers constructs contributed unique variance in VHA health care use above and beyond background characteristics known to differentiate current users from former VHA users (Odds ratio [OR]=4.03 for availability of services; OR=2.63 for physician sensitivity and skill: OR=2.70 for logistics of care; OR=2.30 for facility/physical environment). Few differences in barriers to care and their association with VHA health care use emerged for women with and without service-connected disabilities. CONCLUSIONS: Findings highlight several domains in which VHA decisionmakers can intervene to enhance the care available to women veterans and point to a number of areas for further investigation.