Order of first-play in simulated versus monetary gambling.

Background and aims: Simulated gambling products, like loot boxes and social casino games, contain gambling elements, but are not classified as gambling. They are available to minors, raising concerns about a "gateway effect" into gambling. This study examined the time course of young people's engagement in simulated and monetary gambling, and associations between simulated gambling and gambling problems and harm. A necessary, although not sufficient, condition for simulated games leading to real money gambling is that simulated play must come first. Method: Participants were 1,026 young adults (aged 18-25 years) who played video games in the last year. They reported the age at which they first took part in seven simulated and twelve monetary gambling products, and current gambling problems and harm. Results: First use of loot boxes and video games with gambling content tended to precede monetary gambling. Forms where gambling is a core gameplay element, such as social casino and demonstration games, tended to follow some monetary gambling forms. Engagement in most simulated gambling products was associated with greater harm from monetary gambling. Discussion: The findings leave open the possibility of a catalyst pathway from youth engagement in loot boxes and games with gambling content to later monetary gambling, but causal psychosocial mechanisms remain unclear. However, a pathway from social casino and demonstration games to monetary gambling appears less likely, which may instead reflect containment or substitution effects. Simulated gambling disproportionately attracts youth who are vulnerable to gambling problems and harm, indicating the need for consumer protection measures.

Electronic gaming machine accessibility and gambling problems: A natural policy experiment.

Background: Electronic gaming machines (EGMs) are one of the most harmful forms of gambling at an individual level. It is unclear whether restriction of EGM functions and accessibility results in meaningful reductions in population-level gambling harm. Methods: A natural policy experiment using a large (N = 15,000) national dataset weighted to standard population variables was employed to compare estimates of gambling problems between Australian residents in Western Australia (WA), where EGMs are restricted to one venue and have different structural features, to residents in other Australian jurisdictions where EGMs are widely accessible in casinos, hotels and clubs. Accessibility of other gambling forms is similar across jurisdictions. Results: Gambling participation was higher in WA, but EGM participation was approximately half that of the rest of Australia. Aggregate gambling problems and harm were about one-third lower in WA, and self-reported attribution of harm from EGMs by gamblers and affected others was 2.7× and 4× lower, respectively. Mediation analyses found that less frequent EGM use in WA accounted for the vast majority of the discrepancy in gambling problems (indirect path = -0.055, 95% CI -0.071; -0.038). Moderation analyses found that EGMs are the form most strongly associated with problems, and the strength of this relationship did not differ significantly across jurisdictions. Discussion: Lower harm from gambling in WA is attributable to restricted accessibility of EGMs, rather than different structural features. There appears to be little transfer of problems to other gambling forms. These results suggest that restricting the accessibility of EGMs substantially reduces gambling harm.

Motivations for Esports Betting and Skin Gambling and Their Association with Gambling Frequency, Problems, and Harm.

This study aimed to examine gambling motivations for esports betting and skin gambling and their association with gambling frequency, problems, and harm. Data were collected via a cross-sectional online survey with 736 participants aged 18 + who engaged in esports cash betting (n = 567), esports skin betting (n = 180), or skin gambling on games of chance (n = 325). Respondents were asked to rate their motivations for the three activities across seven domains: social, financial, positive feelings or enhancement, internal regulation, skill building, competition/challenge, and skin acquisition. The results highlight both similarities and differences in gambling motivations across products. Financial gain and enhancement (i.e., excitement) were the main motivations endorsed for all activities, whereas skin acquisition was an additional motivation for esports skin betting and skin gambling. Across all three products, gambling to escape or improve mood was associated with higher levels of problem gambling and harm. Financial gain motivation was associated with problem gambling only for esports skin betting and skin gambling on games of chance. These findings underscore the importance of considering motivational influences on engagement with emerging gambling activities, especially since some motivations may be a contributing factor in harmful gambling outcomes.

Seeking Solace in Gambling: The Cycle of Gambling and Intimate Partner Violence Against Women Who Gamble.

This study explored women's gambling in response to male intimate partner violence (IPV). Twenty-four women were recruited through service providers and online advertising. All women had been victimised by IPV and all experienced problems relating to the gambling on electronic gaming machines (EGMs). Thematic analysis of their in-depth interviews identified three major themes. The main pattern of gambling and IPV (Theme 1) was where ongoing coercive control preceded the woman's gambling. Situational violence in response to gambling was also observed. Regardless of temporal sequence, a self-perpetuating cycle of gambling and IPV victimisation was typically apparent, with both issues escalating over time. Reflecting severe traumatic violence, push factors from IPV that motivated the women's gambling (Theme 2) included physical escape, psychological escape, hope of regaining control over their lives, and gambling to cope with the legacy of abuse. Pull factors attracting these women to gambling venues (Theme 3) appeared to have heightened appeal to these victims of IPV. These included venues' social, geographic and temporal accessibility, allowance for uninterrupted play on EGMs, and the addictive nature of EGMs. These push and pull factors led to these women's prolonged and harmful gambling while exacerbating their partner's violence. Concerted efforts are needed to assist women in this cycle of IPV and gambling, prevent violence against women, and reduce harmful gambling products and environments.

Not all games are created equal: Adolescents who play and spend money on simulated gambling games show greater risk for gaming disorder.

Research reports positive associations between gaming disorder (GD) in adolescents and loot box purchasing but has not examined this relationship for other types of simulated gambling. This study examined whether greater engagement and expenditure in three types of simulated gambling were associated with meeting the criteria for GD in adolescents. A sample of Australians aged 12-17 years (N = 826) was recruited through an online panel aggregator. It included 646 gamers (57.7% male) with 89 being classified as having past-year GD, as defined and measured by the Internet Gaming Disorder Scale. Independent variables comprised past-month engagement in three simulated gambling activities (games with 'mini' gambling components, social casino games, and loot boxes), loot box purchasing, other microtransactions, impulsiveness, and demographics. Logistic regressions first examined whether engagement in each of the three simulated gambling activities was individually associated with GD, then with all three in the same model, and then controlling for demographic variables and impulsivity. Logistic regressions also examined whether microtransactions and purchasing loot boxes were individually associated with GD, then with both in the same model, and then controlling for demographic variables and impulsivity. Adolescents who had engaged in each simulated gambling activity in the past month were more likely to report meeting the criteria for GD. These relationships remained significant when controlling for common demographics and impulsiveness. Past-month engagement in social casino games increased the odds of GD 2.5 times (95% CI: 1.54; 4.02), 2.4 times for games with 'mini' gambling components (95% CI: 1.42; 3.90) and 2.0 times for engaging in loot boxes (95% CI: 1.22; 3.21), but only social casino games remained significant when controlling for engagement in all three activities. The likelihood of meeting the criteria for GD increased 3.8 times with expenditure on microtransactions (95% CI: 2.32; 6.27) and 4.6 times for buying loot boxes, and each remained significant when both were included in the model. Compared to digital games without simulated gambling elements, simulated gambling appears to attract adolescents who report GD. Implications of the results are discussed in detail.

Skin Gambling Contributes to Gambling Problems and Harm After Controlling for Other Forms of Traditional Gambling.

Esports betting and skin gambling involve betting on the outcomes of video game competitions and/or using virtual currencies for betting. The present study evaluated a conceptual model linking video game involvement, video-game related gambling, traditional gambling, and gambling problems and harm. Data were collected via a cross-sectional online survey with 737 participants aged 18 + who engaged in esports cash betting (n = 576), esports skin betting (n = 184), or skin gambling on games of chance (n = 330). The findings highlighted the distinctly different relationships esports cash betting versus skin gambling had with traditional gambling involvement and harmful gambling. Gambling with skins on games of chance was predictive of gambling problems and gambling harm after controlling for participation in traditional gambling (OR = 1.32 and 1.17 respectively). Whereas betting on esports with cash was associated with betting on a variety of other forms of gambling, and there was no unique contribution to problems and harm over and above participation on these other forms (e.g., EGMs, sports betting). Skin gambling is directly implicated in gambling problems and harm, whereas cash betting on esports is only indicative of interest in many forms of potentially harmful gambling. Greater research attention to skin gambling is warranted, and particularly with respect to its role as a virtual currency more easily accessible for gambling.

An integrative review of research on gambling and domestic and family violence: Fresh perspectives to guide future research.

This paper presents an integrative review of research on domestic and family violence (DFV), including intimate partner violence (IPV), experienced by victims and perpetrators with a gambling problem. It aims to review, critique, and synthesize research on this topic to generate fresh and alternative perspectives to guide future research. Based on a systematic search of the academic literature and a targeted search of gray literature, the paper summarizes findings from empirical studies pertaining to the prevalence of perpetration and victimization, characteristics of perpetrators and victims, and explanations for this violence. Based on this review, the paper suggests several potential improvements that can be considered in future studies. These include a shift from focusing on situational violence to also include coercive control; greater sensitivity in research design and interpretation to gender differences in experiences of violence; and the need to include economic abuse as a form of DFV/IPV. Adopting a public health lens is also recommended to broaden the research focus from victims and perpetrators to also consider contextual factors. In particular, gambling research should examine the contribution of gambling products, practices, environments, and marketing to DFV/IPV and how this might be ameliorated. While research to date has drawn much needed attention to the risks that gambling presents for DFV/IPV, this review provides some suggestions for future research so that it can provide more nuanced findings to inform policy and practice.

Legacy gambling harms: What are they and how long do they last?

Background and aims: Legacy gambling harms are negative consequences of gambling that extend past periods of low risk, moderate risk and problem gambling. Gambling harm is typically measured within a 12-month timeframe and is often restricted to examining harm amongst active gamblers. The present research aimed to explore whether people experienced gambling harms 12 months or more after the resolution of at-risk or problem gambling, and how long these legacy harms lasted. Methods: An online survey was conducted in New Zealand with past and current gamblers and concerned significant others (CSOs) of gamblers, N = 1,240 (50.8% female), that asked them about both past and current gambling harms. Results: A majority of both gamblers and CSOs of gamblers indicated that they still suffered from gambling harm even after most of their behavioural issues with gambling had been resolved, 12+ months ago. Legacy gambling harms reduced over time, with harms diminishing most quickly in the early years, and having an average half-life of 4 years. Harms involving community-relationships, church involvement, and domestic and other violence resolved more quickly than others. Discussion and conclusions: Legacy harms are common among ex-problem gamblers and should be considered in any full accounting of the impacts of gambling. Conclusion: Understanding the time course and persistence of legacy harms from gambling can provide gamblers, treatment professionals and public health experts with insights into how to address gambling's long-term consequences.

Adolescents Who Play and Spend Money in Simulated Gambling Games Are at Heightened Risk of Gambling Problems.

Simulated gambling, such as playing a virtual slot machine for points rather than money, is increasingly part of the online gaming experience for youth. This study aimed to examine (1) if youth participation in simulated gambling games is associated with participation in monetary gambling; (2) if youth participation in simulated gambling games is associated with increased risk of problematic gambling when controlling for breadth of monetary gambling (i.e., number of gambling forms); and (3) if monetary expenditure and time spent playing simulated gambling games increase the risk of problematic gambling. Two samples of Australians aged 12-17 years were recruited-826 respondents through an online panel aggregator (mean age 14.1 years) and 843 respondents through advertising (mean age 14.6 years). Aim 1 was addressed using chi-square and correlation analyses. Linear multiple regression analyses were conducted to address Aims 2 and 3. The findings in both samples supported the study's hypotheses-that (1) youth who play simulated gambling games are more likely to participate in monetary gambling, and that (2) participation and (3) time and money expenditure on simulated gambling are positively and independently associated with risk of problematic gambling when controlling for the number of monetary gambling forms, impulsivity, age and gender. To better protect young people, simulated gambling should, at minimum, emulate the consumer protection measures required for online gambling.

COVID-19 postacute care major organ damage: a systematic review.

BACKGROUND: Major organ complications have been reported in patients hospitalised for COVID-19; most studies lacked controls. OBJECTIVE: Examine major organ damage postdischarge among adults hospitalised for COVID-19 versus non-COVID-19 controls. DATA SOURCES: MEDLINE, Embase and Cochrane Library from 1 January 2020 to 19 May 2021. STUDY ELIGIBILITY CRITERIA: English language studies of adults discharged from hospital for COVID-19; reporting major organ damage. Single review of abstracts; independent dual review of full text. STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was assessed using the Joanna Briggs Institute Appraisal Checklist for Cohort Studies. Outcome data were not pooled due to heterogeneity in populations, study designs and outcome assessment methods; findings are narratively synthesised. RESULTS: Of 124 studies in a full evidence report, 9 included non-COVID controls and are described here. Four of the nine (three USA, one UK) used large administrative databases. Four of the remaining five studies enrolled <600 COVID-19 patients. Mean or median age ranged from 49 to 70 years with 46%-94% male and 48%-78% White race; 10%-40% had been in intensive care units. Follow-up ranged from 4 weeks to 22 weeks postdischarge. Four used hospitalised controls, three non-hospitalised controls and two were unclear. Studies used various definitions of, and methods to assess, major organ damage outcomes. While the magnitude of effect differed across studies, incident cardiac, pulmonary, liver, acute and chronic kidney, stroke, diabetes, and coagulation disorders were consistently greater in adults hospitalised for COVID-19 compared with non-COVID-19 controls. LIMITATIONS: Applicability to subgroups (age, gender, COVID-19 severity, treatment, vaccination status) and non-hospitalised patients is unknown. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Postacute COVID-19 major organ damage is common and likely higher than controls. However, there is substantial uncertainty. More consistent reporting of clinical outcomes and pre-COVID health status along with careful selection of control groups are needed to address evidence gaps. PROSPERO REGISTRATION NUMBER: CRD42020204788.

Gambling-related harms to concerned significant others: A national Australian prevalence study.

Background and aims: Gambling-related harm to concerned significant others (CSOs) is an important public health issue since it reduces CSOs' health and wellbeing in numerous life domains. This study aimed to 1) estimate the first national prevalence of CSOs harmed by gambling in Australia; 2) identify the characteristics of CSOs most at risk of harm from another person's gambling; 3) compare the types and number of harms experienced by CSOs based on their relationship to the person who gambles; and 4) compare the number of harms experienced by CSOs by self-identified gender. Methods: Based on a national CATI survey weighted to population norms, 11,560 respondents reported whether they had been personally and negatively affected by another person's gambling in the past 12 months; and if so, answered detailed questions about the harms experienced from the person's gambling who had harmed them the most. Results: Past-year prevalence of gambling-related harm to adult Australian CSOs was (6.0%; 95% CI 5.6%-6.5%). CSOs most commonly reported emotional harms, followed by relationship, financial, health and vocational harms, respectively. Former partners reported the most harm, followed by current partners, other family members and non-family members, respectively. Female CSOs were more likely to report more harm and being harmed by a partner or other family member, and male CSOs from a non-family member. Discussion and conclusions: The findings provide new insights into the wider societal burden of gambling and inform measures aimed at reducing harm to CSOs from gambling and supporting them to seek help.

Adolescent betting on esports using cash and skins: Links with gaming, monetary gambling, and problematic gambling.

Adolescents can easily access esports betting sites and place bets using cash or skins. This descriptive cross-sectional study examined the characteristics of adolescent esports bettors and relationships between their esports betting, video gaming activities, monetary gambling participation, and at-risk/problem gambling. Two survey samples of Australians aged 12-17 years were recruited through advertisements (n = 841) and online panel providers (n = 826). In both samples, gender and parents' living situation did not differ by past-month esports cash and skin betting, but recent esports betting was associated with engaging in esports gaming activities such as playing and watching esports, and in monetary gambling activities. Past-month esports betting using cash and skins was significantly associated with at-risk/problem gambling. After controlling for recent monetary gambling, recent esports skin bettors were over 3 times more likely to meet criteria for at-risk/problem gambling. Esports betting using skins appears to pose risks for young people and is easily accessible through unlicensed operators.

Loot box purchasing is linked to problem gambling in adolescents when controlling for monetary gambling participation.

Background and aims: Purchasing loot boxes in digital games is akin to gambling as it involves risking money for a chance-based reward of uncertain value. Research has linked buying loot boxes to problem gambling amongst adolescents, but has not examined co-occurring gambling participation. This study examined links between loot box purchasing and problem gambling amongst adolescents while controlling for monetary gambling participation. Methods: Two survey samples of Australians aged 12-17 years were recruited through advertisements (n = 843) and online panels (n = 826). They included n = 421 and n = 128 adolescents, respectively, who met criteria for problem gambling. Results: Past-month loot box purchasing was significantly related to gambling problems in bivariate analyses. When including age, gender and past-month monetary gambling, loot box purchases were still associated with at-risk and problem gambling in both samples. As expected, these other predictors attenuated the predictive value of recent loot box purchases in relation to gambling problems. The odds-ratios, nevertheless, were still in the predicted direction and remained significant. When controlling for monetary gambling, age and gender, recent loot box purchasing increased the odds of problem gambling 3.7 to 6.0 times, and at-risk gambling 2.8 to 4.3 times. Discussion and conclusions: While causal relationships between loot box purchasing and problem gambling remain unclear, the results indicate that loot boxes disproportionately attract adolescents experiencing gambling problems, adding to the financial stress already caused by gambling. Consumer protection measures, youth and parental education, and age restrictions on loot box games are needed to protect young people.

Gambling-Related Intimate Partner Violence Against Women: A Grounded Theory Model of Individual and Relationship Determinants.

This study aimed to examine how problem gambling interacts with gendered drivers of intimate partner violence (IPV) against women to exacerbate this violence. Interviews were conducted with 48 female victims of IPV linked to a male partner's gambling; 24 female victims of IPV linked to their own gambling; and 39 service practitioners from 25 services. Given limited research into gambling-related IPV, but a stronger theoretical base relating to IPV against women, this study used an adaptive grounded theory approach. It engaged with existing theories on gendered drivers of violence against women, while also developing a grounded theory model of individual and relationship determinants based on emergent findings from the data. Gambling-related IPV against women was found to occur in the context of expressions of gender inequality, including men's attitudes and behaviors that support violence and rigid gender expectations, controlling behaviors, and relationships condoning disrespect of women. Within this context, the characteristics of problem gambling and the financial, emotional and relationship stressors gambling causes intensified the IPV. Alcohol and other drug use, and co-morbid mental health issues, also interacted with gambling to intensify the IPV. Major implications. Reducing gambling-related IPV against women requires integrated, multi-level interventions that reduce both problem gambling and gendered drivers of violence. Gambling operators can act to reduce problem gambling and train staff in responding to IPV. Financial institutions can assist people to limit their gambling expenditure and families to protect their assets. Service providers can be alert to the co-occurrence of gambling problems and IPV and screen, treat, and refer clients appropriately. Public education can raise awareness that problem gambling increases the risk of IPV. Reducing gender inequality is also critical.

Skin gambling predicts problematic gambling amongst adolescents when controlling for monetary gambling.

BACKGROUND AND AIMS: Skin gambling uses in-game items (skins) acquired in video games, to gamble on esports, games of chance, other competitive events and privately with friends. This study examined characteristics of adolescent skin gamblers, their engagement in monetary gambling, and relationships between skin gambling and at risk/problem gambling. METHODS: Two samples of Australian adolescents aged 12-17 years were recruited to an online survey through advertisements (n = 843) and an online panel provider (n = 826). RESULTS: In both samples, past-month skin gamblers (n = 466 advertisements sample; n = 185 online panel sample) were more likely to have lower wellbeing, score as having an internet gaming disorder on the IGD, engage in more types of monetary gambling, and meet criteria for problem gambling on the DSM-IV-MR-J. Past-month skin gambling uniquely predicted problem gambling when controlling for past-month gambling on 11 monetary forms and the total number of monetary gambling forms. DISCUSSION AND CONCLUSIONS: Underage participation in skin gambling is a growing concern. The strong convergence between engagement in skin gambling and monetary gambling suggests common risk factors may increase the propensity of some adolescents to gamble on these multiple forms. Nonetheless, past-month skin gambling predicted problem gambling even when controlling for past-month monetary gambling, indicating its unique contribution to gambling problems and harm. While the study was based on non-probability samples, its results strengthen the case for regulatory reforms, age restrictions and public health education to prevent underage skin gambling and its potentially harmful consequences for children and young people.

Newer Minimally Invasive Treatment Modalities to Treat Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia.

CONTEXT: Several newer device-based procedures have recently become available for treating men with lower urinary tract symptoms attributed to benign prostatic hyperplasia, but their effectiveness remains uncertain. OBJECTIVE: To assess the longer-term comparative effectiveness (defined as >12 mo of follow-up) of the newer treatment modalities prostatic urethral lift (PUL), transurethral prostate convective radiofrequency water vapor (Rezum), Aquablation, and prostatic arterial embolization (PAE). EVIDENCE ACQUISITION: Ovid Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Agency for Healthcare Research and Quality databases were searched through September 30, 2019; hand searches of references of relevant studies were also performed. Eligible studies were randomized controlled trials (RCTs) published in English language. We excluded observational studies. EVIDENCE SYNTHESIS: One RCT (n = 91) found that patients undergoing PUL may be less likely to respond (risk ratio [RR] 0.8; 95% confidence interval [CI] 0.7-1.0; low certainty of evidence [CoE]) and have a higher mean International Prostate Symptom Score (IPSS; mean difference 6.1; 95% CI 2.2-10.0; low CoE) than those undergoing transurethral resection of the prostate (TURP). Among patients undergoing PAE, one small RCT (n = 30) reported similar IPSS response rates (RR 0.9; 95% CI 0.7-1.1; low CoE) and one trial (n = 107) found similar mean IPSS (-0.7; 95% CI -1.3 to 2.7; moderate CoE) scores to those among patients undergoing TURP. A single study on Aquablation reported 12 mo of follow-up only, and a single 3-mo trial compared Rezum with sham treatment. CONCLUSIONS: The current best evidence underlying these newer therapies is limited to few trials (PUL and PAE), short-term follow-up of 12 mo (Aquablation and Rezum), or sham comparison only (Rezum). PATIENT SUMMARY: Evidence for four of the newer surgical treatments for men with an enlarged prostate is limited to few small trials with short-term follow-up; only one trial compared a new treatment modality with sham surgery.

Are esports bettors a new generation of harmed gamblers? A comparison with sports bettors on gambling involvement, problems, and harm.

BACKGROUND AND AIMS: Esports betting is expanding in popularity, yet little is known about who participates in this niche gambling activity. This study aimed to determine whether esports bettors are more vulnerable to harms and problems than gamblers engaged in traditional sports betting. METHODS: Data were collected from 298 regular esports bettors and 300 sports bettors (who regularly bet on traditional sports, but not esports). These groups were compared on demographics, gambling involvement, problem gambling, and gambling-related harms. RESULTS: Compared to sports bettors, esports bettors were more likely to be younger, university-educated, employed (lower income earners), and speak a non-English language at home. Esports bettors gambled on fewer traditional gambling activities in the last 12 months, but compared to sports bettors, gambled more frequently on some activities, were more likely to meet problem gambler criteria (64.8.% vs 17.3%), and experience at least one gambling-related harm (81.9% vs 45.3%). Being an esports bettor significantly predicted greater problem gambling severity and gambling-related harms. More frequent esports skin betting and skin gambling (on games of chance) were significant predictors of gambling problems amongst esports bettors. DISCUSSION AND CONCLUSION: The results provide preliminary evidence that esports bettors are more likely to experience gambling problems compared to their sports betting counterparts, potentially stemming from their involvement in emerging video-game related gambling products.

Orthobiologics in Foot and Ankle Arthrodesis: A Systematic Review.

Orthobiologics are biologically-derived materials intended to promote bone formation and union. We review evidence on effectiveness and harms of orthobiologics compared to no orthobiologics for foot and ankle arthrodesis. We searched multiple databases (1995-2019) and included clinical trials and other studies with concurrent controls, English language, and reporting patient-centered outcomes, union/time to union, costs/resource utilization, or harms. Studies were organized by orthobiologic used. We describe quality and limitations of available evidence but did not formally rate risk of bias or certainty of evidence. Most of the 21 studies included were retrospective chart reviews with orthobiologics used at surgeon's discretion for patients considered at higher risk for nonunion. Ten studies compared autologous bone graft versus no graft and 2 compared remote versus local graft with few studies of other orthobiologics. All studies reported a measure of fusion and about half reported on function/quality of life. Few studies reported harms. Due to limited reporting, we were unable to assess whether effectiveness varies by risk factors for nonunion (eg, age, gender, smoking status, obesity, diabetes) or whether orthobiologics were cost-effective. Available evidence is of poor quality with small sample sizes, inadequate reporting of risk factors for nonunion, variations in orthobiologics, surgical techniques used, and outcome assessment, and potential selection bias. Research is needed to adequately inform surgeons about benefits and harms and guide patient selection for use, or type, of orthobiologics. Careful assessment of individual patient risk for nonunion is critical prior to orthobiologic use.

Effectiveness and Harms of High-Flow Nasal Oxygen for Acute Respiratory Failure: An Evidence Report for a Clinical Guideline From the American College of Physicians.

BACKGROUND: Use of high-flow nasal oxygen (HFNO) for treatment of adults with acute respiratory failure (ARF) has increased. PURPOSE: To assess HFNO versus noninvasive ventilation (NIV) or conventional oxygen therapy (COT) for ARF in hospitalized adults. DATA SOURCES: English-language searches of MEDLINE, Embase, CINAHL, and Cochrane Library from January 2000 to July 2020; systematic review reference lists. STUDY SELECTION: 29 randomized controlled trials evaluated HFNO versus NIV (k = 11) or COT (k = 21). DATA EXTRACTION: Data extraction by a single investigator was verified by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. DATA SYNTHESIS: Results are reported separately for HFNO versus NIV, for HFNO versus COT, and by initial or postextubation management. Compared with NIV, HFNO may reduce all-cause mortality, intubation, and hospital-acquired pneumonia and improve patient comfort in initial ARF management (low-certainty evidence) but not in postextubation management. Compared with COT, HFNO may reduce reintubation and improve patient comfort in postextubation ARF management (low-certainty evidence). LIMITATIONS: Trials varied in populations enrolled, ARF causes, and treatment protocols. Trial design, sample size, duration of treatment and follow-up, and results reporting were often insufficient to adequately assess many outcomes. Protocols, clinician and health system training, cost, and resource use were poorly characterized. CONCLUSION: Compared with NIV, HFNO as initial ARF management may improve several clinical outcomes. Compared with COT, HFNO as postextubation management may reduce reintubations and improve patient comfort; HFNO resulted in fewer harms than NIV or COT. Broad applicability, including required clinician and health system experience and resource use, is not well known. PRIMARY FUNDING SOURCE: American College of Physicians. (PROSPERO: CRD42019146691).

Major Update: Remdesivir for Adults With COVID-19 : A Living Systematic Review and Meta-analysis for the American College of Physicians Practice Points.

BACKGROUND: Remdesivir is being studied and used for treatment of coronavirus disease 2019 (COVID-19). PURPOSE: To update a previous review of remdesivir for adults with COVID-19, including new meta-analyses of patients with COVID-19 of any severity compared with control. DATA SOURCES: Several sources from 1 January 2020 through 7 December 2020. STUDY SELECTION: English-language, randomized controlled trials (RCTs) of remdesivir for COVID-19. New evidence is incorporated by using living review methods. DATA EXTRACTION: 1 reviewer abstracted data; a second reviewer verified the data. The Cochrane Risk of Bias Tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) method were used. DATA SYNTHESIS: The update includes 5 RCTs, incorporating data from a new large RCT and the final results of a previous RCT. Compared with control, a 10-day course of remdesivir probably results in little to no reduction in mortality (risk ratio [RR], 0.93 [95% CI, 0.82 to 1.06]; 4 RCTs) but may result in a small reduction in the proportion of patients receiving mechanical ventilation (RR, 0.71 [CI, 0.56 to 0.90]; 3 RCTs). Remdesivir probably results in a moderate increase in the percentage of patients who recovered and a moderate decrease in serious adverse events and may result in a large reduction in time to recovery. Effect on hospital length of stay or percentage remaining hospitalized is mixed. Compared with a 10-day course for those not requiring ventilation at baseline, a 5-day course may reduce mortality, the need for ventilation, and serious adverse events while increasing the percentage of patients who recovered or clinically improved. LIMITATION: Summarizing findings was challenging because of varying disease severity definitions and outcomes. CONCLUSION: In hospitalized adults with COVID-19, remdesivir probably results in little to no mortality difference but probably improves the percentage recovered and reduces serious harms and may result in a small reduction in the proportion receiving ventilation. For patients not receiving ventilation, a 5-day course may provide greater benefits and fewer harms with lower drug costs than a 10-day course. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.