Perioperative care of patients with recent stroke undergoing nonemergent, nonneurological, noncardiac, nonvascular surgery: a systematic review and meta-analysis.

PURPOSE OF REVIEW: To systematically review and perform a meta-analysis of published literature regarding postoperative stroke and mortality in patients with a history of stroke and to provide a framework for preoperative, intraoperative, and postoperative care in an elective setting. RECENT FINDINGS: Patients with nonneurological, noncardiac, and nonvascular surgery within three months after stroke have a 153-fold risk, those within 6 months have a 50-fold risk, and those within 12 months have a 20-fold risk of postoperative stroke. There is a 12-fold risk of in-hospital mortality within three months and a three-to-four-fold risk of mortality for more than 12 months after stroke. The risk of stroke and mortality continues to persist years after stroke. Recurrent stroke is common in patients in whom anticoagulation/antiplatelet therapy is discontinued. Stroke and time elapsed after stroke should be included in the preoperative assessment questionnaire, and a stroke-specific risk assessment should be performed before surgical planning is pursued. SUMMARY: In patients with a history of a recent stroke, anesthesiology, surgery, and neurology experts should create a shared mental model in which the patient/surrogate decision-maker is informed about the risks and benefits of the proposed surgical procedure; secondary-stroke-prevention medications are reviewed; plans are made for interruptions and resumption; and intraoperative care is individualized to reduce the likelihood of postoperative stroke or death.

Molecular characterization of plasmacytoid urothelial carcinoma and the impact on treatment implications.

Bladder cancer researchers and clinicians have increasingly viewed tumor biology through the lens of genomic and molecular alterations, drastically improving our knowledge of the underlying disease biology. This understanding has led to significant advances in treatment options that allow implementation of a personalized approach to cancer treatment. Large-scale genomic studies initially focused on the most common forms of bladder cancer. However, as genomic and molecular technologies become more widespread and are applied to less common variant histologies, we are gaining additional insight into the unique molecular and genomic characteristics driving the biology of variant histologies of bladder cancer. In this review, we summarize the current state of knowledge of molecular alterations underlying the distinct tumor biology of plasmacytoid urothelial carcinoma and how these alterations may impact treatment options.

Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis.

STUDY OBJECTIVE: An incidental finding is defined as a newly discovered mass or lesion detected on imaging performed for an unrelated reason. The identification of an incidental finding may be an opportunity for the early detection of a serious medical condition, including a malignancy. However, little is known about the prevalence of incidental findings in the emergency department (ED) setting and the strategies that can be used to mitigate the risk associated with them in the ED. This study aimed to estimate the overall prevalence of incidental findings and to summarize the currently described measures to mitigate the risks associated with incidental findings. METHODS: On November 22, 2020, a systematic literature search of PubMed, EMBASE, and Scopus was performed for studies that were published in peer-reviewed journals and reported the prevalence of incidental findings in computed tomography (CT) scans in patients in the ED. Patients who received CT scans that included the head, neck, chest, or abdomen/pelvis were included. The study characteristics, overall prevalence of incidental findings, prevalence of incidental findings by body region, and prespecified subgroups were extracted. The criteria used for risk stratification within individual studies were also extracted. Pooled estimates were calculated using a random-effects meta-analysis. RESULTS: A total of 1,385 studies were identified, and 69 studies met the inclusion criteria. The included studies represented 147,763 ED encounters or radiology reports across 16 countries, and 83% of studies were observational, cross-sectional studies. A total of 35 studies (50.7%) were in trauma patients. A large degree of heterogeneity was observed across the included studies. The overall pooled prevalence estimate for any incidental finding was 31.3% (95% confidence interval 24.4% to 39.1%). We found great variation in the methods described to mitigate the risk associated with incidental findings, including a lack of standardized risk stratification, inconsistent documentation practices, and only a small subset of studies describing prospective interventions aimed at improving the recognition and management of incidental findings from the ED. CONCLUSION: In patients in the ED receiving CT scans, incidental findings are commonly encountered across a broad range of ED chief complaints. This review highlights the existence of great heterogeneity in the definitions used to classify incidental findings. Future studies are needed to determine a clinically feasible categorization standard or terminology for commonly encountered incidental findings in the ED setting to standardize classification and documentation.

Developing a toolkit to improve resident and family engagement in the safety of assisted living: Engage-A stakeholder-engaged research protocol.

Assisted living (AL) communities are experiencing rising levels of resident acuity, challenging efforts to balance person-centered care-which prioritizes personhood, autonomy, and relationship-based care practices-with efforts to keep residents safe. Safety is a broad-scale problem in AL that encompasses care concerns (e.g., abuse/neglect, medication errors, inadequate staffing, and infection management) as well as resident issues (e.g., falls, elopement, and medical emergencies). Person and family engagement (PFE) is one approach to achieving a balance between person-centered care and safety. In other settings, PFE interventions have improved patient care processes, outcomes, and experiences. In this paper, we describe the protocol for a multiple methods AHRQ-funded study (Engage) to develop a toolkit for increasing resident and family engagement in AL safety. The study aims are to engage AL residents and family caregivers, AL staff, and other AL stakeholders to (1) identify common AL safety problems; (2) prioritize safety problems and identify and evaluate existing PFE interventions with the potential to address safety problems in the AL setting; and (3) develop a testable toolkit to improve PFE in AL safety. We discuss our methods, including qualitative interviews, a scoping review of existing PFE interventions, and stakeholder panel meetings that involved a Delphi priority-setting exercise. In addition to describing the protocol, we detail how we modified the protocol to address the unique challenges of the COVID-19 pandemic. Study findings will result in a toolkit to improve resident and family engagement in the safety of AL that will be tested in future research.

Carcinogenic biomarkers of exposure in the urine of heated tobacco product users associated with bladder cancer: A systematic review.

To identify biomarkers of exposure present in Heated Tobacco Products (HTPs) users' urine which are associated with bladder cancer and to compare quantitative biomarker levels to those seen in combustible cigarette users. A systematic literature review was conducted in December 2020 with no date limits. Relevant studies that reported quantitative urinary biomarker of exposure in HTP users were included. Biomarkers and their parent compounds were classified by carcinogenicity according to the International Agency for Research on Cancer Monographs and were cross-referenced with the Collaborative on Health and the Environment Toxicant and Disease Database to determine associations with bladder cancer. Our literature search identified 561 articles and 30 clinical trial reports. 11 studies met inclusion criteria. These studies identified 29 biomarkers of exposure present in HTP users' urine, which reflect exposure to 21 unique parent compounds. Of these parent compounds, 14 are carcinogens and 10 have a known link to bladder cancer. HTP users' biomarkers of exposure were present at lower levels than combustible cigarette users but higher than never-smokers. Biomarkers of exposure to bladder carcinogens are present in the urine of HTP users. While levels of these biomarkers appear to be lower than combustible cigarette users, chronic urothelial exposure to bladder carcinogens is concerning and degree of bladder cancer risk remains unknown. Further long-term study is needed to elucidate the bladder cancer risk of HTP use.

Quality improvement studies in nursing homes: a scoping review.

BACKGROUND: Quality improvement (QI) is used in nursing homes (NH) to implement and sustain improvements in patient outcomes. Little is known about how QI strategies are used in NHs. This lack of information is a barrier to replicating successful strategies. Guided by the Framework for Implementation Research, the purpose of this study was to map-out the use, evaluation, and reporting of QI strategies in NHs. METHODS: This scoping review was completed to identify reports published between July 2003 through February 2019. Two reviewers screened articles and included those with (1) the term "quality improvement" to describe their methods, or reported use of a QI model (e.g., Six Sigma) or strategy (e.g., process mapping) (2), findings related to impact on service and/or resident outcomes, and (3) two or more NHs included. Reviewers extracted data on study design, setting, population, problem, solution to address problem, QI strategies, and outcomes (implementation, service, and resident). Vote counting and narrative synthesis were used to describe the use of QI strategies, implementation outcomes, and service and/or resident outcomes. RESULTS: Of 2302 articles identified, the full text of 77 articles reporting on 59 studies were included. Studies focused on 23 clinical problems, most commonly pressure ulcers, falls, and pain. Studies used an average of 6 to 7 QI strategies. The rate that strategies were used varied substantially, e.g., the rate of in-person training (55%) was more than twice the rate of plan-do-study-act cycles (20%). On average, studies assessed two implementation outcomes; the rate these outcomes were used varied widely, with 37% reporting on staff perceptions (e.g., feasibility) of solutions or QI strategies vs. 8% reporting on fidelity and sustainment. Most studies (n = 49) reported service outcomes and over half (n = 34) reported resident outcomes. In studies with statistical tests of improvement, service outcomes improved more often than resident outcomes. CONCLUSIONS: This study maps-out the scope of published, peer-reviewed studies of QI in NHs. The findings suggest preliminary guidance for future studies designed to promote the replication and synthesis of promising solutions. The findings also suggest strategies to refine procedures for more effective improvement work in NHs.

A Systematic Review of the Effect of Telepharmacy Services in the Community Pharmacy Setting on Care Quality and Patient Safety.

While community pharmacy-based telepharmacy services can expand medication access for underserved communities, the safety and quality of these services is uncertain. A systematic review was conducted in August 2020 exploring the effect of community pharmacy-based telepharmacy services on patient safety and care quality. Database searches identified 866 studies, of which six met the inclusion and the risk of bias measurement criteria. Medication dispensing errors, adherence, and patient satisfaction were the most frequently evaluated outcomes. Literature suggests no overall difference in medication safety and adherence, conflicting evidence on patient satisfaction, and insufficient evidence on inappropriate medication use in community pharmacy-based telepharmacies compared with traditional pharmacies. Due to the potential for high risk of bias, no definitive conclusions could be made about telepharmacy outcomes. Research with stronger study designs and more rigorous evaluation methodologies is needed to create conclusive evidence on the effectiveness of community pharmacy-based telepharmacy services.

Parenting Interventions and Secondary Outcomes Related to Maternal Mental Health: A Systematic Review.

PURPOSE: Perinatal mood and anxiety disorders can have far reaching negative impact on both maternal mental health and child growth and development. Multimodal group parenting programs have been shown to improve maternal mental health symptoms however, they are often costly to provide and not accessible to many mothers, especially those mothers suffering from mental health symptoms. Therefore, the authors sought to answer the following question by undertaking a systematic review of the literature: are parenting interventions aimed at improving maternal-child interaction also a way to address mental health symptoms (i.e. depression, anxiety, stress) in mothers? METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. An online platform that supports the systematic review process and quality assessment according to Cochrane guidelines, Covidence, was used in conjunction with an adapted extraction tool to identify relevant studies and extract data for analysis. RESULTS: 11 articles were included in the qualitative synthesis. There was great heterogeneity between study interventions and measurement of outcomes for maternal mental health symptoms which precluded meta-analysis. CONCLUSION: Studies reviewed did not demonstrate consistent evidence to recommend that parenting interventions leads to improvement in maternal mental health symptoms for depression, anxiety or stress. However, there was evidence that participating in parenting programs does not worsen these symptoms and some encouraging evidence that alternative delivery methods, beyond face to face, could, with more research, lead to more financially feasible and sustainable models of delivery of these types of interventions in the future.

PROTOCOL: Searching and reporting in Campbell Collaboration systematic reviews: An assessment of current methods.

This is the protocol for a Campbell review. The aim of this study is to comprehensively assess the quality and nature of the search methods and reporting across Campbell systematic reviews. The search methods used in systematic reviews provide the foundation for establishing the body of literature from which conclusions are drawn and recommendations made. Searches should be comprehensive and reporting of search methods should be transparent and reproducible. Campbell Collaboration systematic reviews strive to adhere to the best methodological guidance available for this type of searching. The current work aims to provide a comprehensive assessment of the quality of the search methods and reporting in Campbell Collaboration systematic reviews. Our specific objectives include the following: To examine how searches are currently conducted in Campbell systematic reviews. To identify any machine learning or automation methods used, or emerging and less commonly used approaches to web searching. To examine how search strategies, search methods and search reporting adhere to the Methodological Expectations of Campbell Collaboration Intervention Reviews (MECCIR) and PRISMA guidelines. The findings will be used to identify opportunities for advancing current practices in Campbell reviews through updated guidance, peer review processes and author training and support.

Transitional care of older adults in skilled nursing facilities: A systematic review.

Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients.

Closing the loop on nursing library instruction: using student performance to improve outcomes.

Two librarians analyzed nursing students' performance on an information literacy assignment to determine how they could change their instruction to better assist the students in comprehending the material. After identifying major areas of difficulty, including the use of search techniques, they revised both the instruction and the assignment, closing the loop by utilizing their assessment data. Next, they analyzed those results to evaluate the effectiveness of their changes and to make further improvements, thus demonstrating the iterative nature of instruction and assessment. The evidence-based instruction cycle of teaching, assessing, and revising should be repeated frequently to keep the assignment fresh and relevant.