The Effect of Hormonal Treatment on Ovarian Endometriomas: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the effect of hormonal suppression of endometriosis on the size of endometriotic ovarian cysts. DATA SOURCES: The authors searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov from January 2012 to December 2022. METHODS OF STUDY SELECTION: We included studies of premenopausal women undergoing hormonal treatment of endometriosis for ≥3 months. The authors excluded studies involving surgical intervention in the follow-up period and those using hormones to prevent endometrioma recurrence after endometriosis surgery. Risk of bias was assessed with the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. The protocol was registered in PROSPERO (CRD42022385612). TABULATION, INTEGRATION, AND RESULTS: The primary outcome was the mean change in endometrioma volume, expressed as a percentage, from baseline to at least 6 months. Secondary outcomes were the change in volume at 3 months and analyses by class of hormonal therapy. The authors included 16 studies (15 cohort studies, 1 randomized controlled trial) of 888 patients treated with dienogest (7 studies), other progestins (4), combined hormonal contraceptives (2), and other suppressive therapy (3). Globally, the decrease in endometrioma volume became statistically significant at 6 months with a mean reduction of 55% (95% confidence interval, -40 to -71; 18 treatment groups; 730 patients; p <.001; I2 = 96%). The reduction was the greatest with dienogest and norethindrone acetate plus letrozole, followed by relugolix and leuprolide acetate. The volume reduction was not statistically significant with combined hormonal contraceptives or other progestins. There was high heterogeneity, and studies were at risk of selection bias. CONCLUSION: Hormonal suppression can substantially reduce endometrioma size, but there is uncertainty in the exact reduction patients may experience.

The Evolving Roles and Expectations of Inpatient Palliative Care Through COVID-19: a Systematic Review and Meta-synthesis.

BACKGROUND: Palliative care performed a central role in responding to the systemic suffering incurred by the COVID-19 pandemic. Yet, few studies have elucidated the inpatient palliative care specialists' experiences and perceptions. OBJECTIVE: Systematically review and synthesize the evolving roles and expectations of inpatient palliative care specialists in response to COVID-19. DESIGN: A systematic review and meta-synthesis informed by Thomas and Harden's framework and Pozzar et al.'s approach was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. DATA SOURCES: MEDLINE, EMBASE, CINAHL, and PubMed were systematically searched for articles published between December 2019 and March 2023. We included all peer-reviewed qualitative and mixed-method literature studying the roles and expectations of inpatient palliative care specialists. A mixed-method appraisal tool was used for quality assessment. RESULTS: Of 3869 unique articles, 52 were included. Studies represented North American (n = 23), European (n = 16), South American (n = 4), Oceanic (n = 2), Asian (n = 2), West African (n = 1), Middle Eastern (n = 1), and inter-continental settings (n = 3). Most were reported in English (n = 50), conducted in 2020 (n = 28), and focused on the perspectives of inpatient palliative care clinicians (n = 28). Three descriptive themes captured the roles and expectations of inpatient palliative care specialists: shifting foundations, reorienting to relationships, and evolving identity. Two analytical themes were synthesized: palliative care propagates compassion through a healing presence, and palliative care enhances the systemic response to suffering through nimble leadership. CONCLUSION: Inpatient palliative care specialists responded to the COVID-19 pandemic by establishing their healing presence and leading with their adaptability. To develop institutionally tailored and collaborative responses to future pandemics, future studies are needed to understand how inpatient palliative care clinicians are recognized and valued within their institutions.

Indications and Outcomes for Planned Cesarean Hysterectomy in Non-Placenta Accreta Spectrum Disorder Patients: A Systematic Review.

OBJECTIVE: Planned hysterectomy at the time of cesarean delivery may be reasonable in cases other than placenta accreta spectrum disorders. Our objective was to synthesize the published literature on the indications and outcomes for planned cesarean hysterectomy. DATA SOURCES: We performed a systematic review of published literature from the following databases from inception (1946) to June 2021: MEDLINE, PubMed, EMBASE, Cochrane CENTRAL, DARE, and clinicaltrials.gov. STUDY SELECTION: We included all study designs where subjects underwent planned cesarean delivery with simultaneous hysterectomy. Emergency procedures and those performed for placenta accreta spectrum disorders were excluded. DATA EXTRACTION AND SYNTHESIS: The primary outcome was surgical indication, though other surgical outcomes were evaluated when data permitted. Quantitative analysis was limited to studies published in 1990 or later. Risk of bias was assessed using an adaptation of the ROBINS-I tool. CONCLUSION: The most common indication for planned cesarean hysterectomy was malignancy, with cervical cancer being the most frequent. Other indications included permanent contraception, uterine fibroids, menstrual disorders, and chronic pelvic pain. Common complications included bleeding, infection, and ileus. The surgical skill for cesarean hysterectomy continues to be relevant in contemporary obstetrical practice for reproductive malignancy and several benign indications. Although the data indicate relatively safe outcomes, these studies show significant publication bias and, therefore, further systematic study of this procedure is justified. PROSPERO REGISTRATION NUMBER: CRD42021260545, registered June 16, 2021.

Moderators uncertainty tolerance (UT) in healthcare: a systematic review.

Uncertainty tolerance (UT) is integral to healthcare. Providers' responses to medical uncertainty has ramifications on the healthcare system, the healthcare provider and the patient. Understanding healthcare providers' UT, is important for improving patient-care outcomes. Understanding whether and to what extent it is possible to modulate individuals' perceptions and responses to medical uncertainty, can provide insights into mechanisms for support for training and education. The objectives of this review were to further characterize moderators of healthcare UT and explore moderator influences on the perceptions and responses to uncertainty experienced by healthcare professionals. Framework analysis of qualitative primary literature was conducted on 17 articles, focusing on the impacts of UT on healthcare providers. Three domains of moderators were identified and characterized relating to the healthcare provider's personal attributes, patient-derived uncertainty and the healthcare system. These domains were further categorized into themes and subthemes. Results suggest these moderators influence perceptions and responses to healthcare uncertainty across a spectrum ranging from positive to negative to uncertain. In this way, UT could be a state-based construct within healthcare settings and is contextually determined. Our findings further characterize the integrative model of uncertainty tolerance (IMUT) (Hillen Social Science and Medicine 180, 62-75, 2017) and provide evidence for the relationship between moderators and their influences on cognitive, emotional and behavioral responses to uncertainty. These findings provide a foundation for understanding the complex nature of the UT construct, add to theory development, and provide groundwork for future research exploring appropriate support for training and education in healthcare fields.

Patient outcomes associated with cancer diagnosis through the emergency department: A systematic review.

OBJECTIVE: Many patients are initially diagnosed with a new suspected cancer through the emergency department (ED). The objective of this systematic review was to compare stage of cancer and survival of patients diagnosed with cancer through the ED to patients diagnosed elsewhere. METHODS: Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Studies comparing adult patients diagnosed with any type of cancer through the ED (ED diagnosis) to patients diagnosed elsewhere (non-ED diagnosis) were included. Two reviewers independently screened titles and abstracts, assessed quality of the studies, and extracted data. The risk of bias of included studies was assessed using the Newcastle-Ottawa Scale. Data pertaining to patient outcomes were summarized and pooled using random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs), where applicable. RESULTS: Fourteen studies were included. There was an increased risk of more advanced/later stage cancer (Stage III/IV or late-stage vs. earlier stage) among patients with an ED diagnosis of cancer compared to a non-ED diagnosis of cancer (RR 1.30, 95% CI 1.39-1.58). Survival was lower for patients with an ED diagnosis of cancer compared to those diagnosed elsewhere (RR 0.61, 95% CI 0.49-0.75). CONCLUSIONS: Patients with an ED diagnosis of cancer had more advanced/late stage of cancer at diagnosis and worse survival compared to patients diagnosed elsewhere. Future research examining patients diagnosed with cancer through the ED is required.

Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis.

OBJECTIVE: Anterior shoulder dislocations are commonly treated in the emergency department (ED). Analgesia for reduction is provided by intra-articular lidocaine (IAL) injection or intravenous sedation (IV sedation). The objective of this systematic review and meta-analysis was to compare IAL versus IV sedation for closed reduction of acute anterior shoulder dislocation in the ED. METHODS: Electronic searches of MEDLINE and EMBASE (1946-September 2021) were completed and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing IAL and IV sedation for reduction of acute anterior shoulder dislocations among patients ≥ 15 years old in the ED were included. Outcomes of interest included a successful reduction, adverse events, ED length of stay, pain scores, procedure time, ease of reduction, patient satisfaction, and cost. Two reviewers independently screened abstracts, assessed study quality and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RR) with 95% confidence intervals (CIs). RESULTS: 12 RCTs were included with a total of 630 patients (IAL = 327; IV sedation = 303). There was no difference in reduction success between IAL and IV sedation (RR 0.93; 95% CI 0.86-1.01, I2 = 69%), significantly lower adverse events with IAL (RR 0.16; 95% CI 0.07-0.33, I2 = 0%), shorter ED length of stay with IAL (mean difference - 1.48; 95% CI - 2.48 to - 0.47, I2 = 93%), no difference in pain scores post-analgesia and no difference in ease of reduction. CONCLUSIONS: Intra-articular lidocaine may have similar effectiveness as IV sedation in the successful reduction of anterior shoulder dislocations in the ED with fewer adverse events, shorter ED length of stay, and no difference in pain scores or ease of reduction. Intra-articular lidocaine may be an effective alternative to IV sedation for reducing anterior shoulder dislocations, particularly when IV sedation is contraindicated or not feasible.

RéSUMé: OBJECTIF: Les luxations antérieures de l'épaule sont couramment traitées au service des urgences (SU). L'analgésie pour la réduction est fournie par une injection intra-articulaire de lidocaïne (IAL) ou par une sédation intraveineuse (sédation IV). L'objectif de cette revue systématique et méta-analyse était de comparer la sédation IAL par rapport à la sédation IV pour la réduction fermée de la luxation antérieure aiguë de l'épaule aux urgences. MéTHODES: Des recherches électroniques ont été effectuées sur MEDLINE et EMBASE (1946-septembre 2021) et les listes de références ont été consultées manuellement. Les essais contrôlés randomisés (ECR) comparant la sédation IAL et IV pour la réduction des luxations antérieures aiguës de l'épaule chez les patients ≥ 15 ans aux urgences ont été inclus. Les résultats d'intérêt comprenaient une réduction réussie, les effets indésirables, la durée de séjour aux urgences, les scores de douleur, la durée de la procédure, la facilité de réduction, la satisfaction du patient et le coût. Deux examinateurs ont indépendamment passé en revue les résumés, évalué la qualité des études et extrait les données. Les données ont été regroupées à l'aide de modèles à effets aléatoires et présentées sous forme de différences moyennes et de rapports de risque (RR) avec des intervalles de confiance (IC) à 95 %. RéSULTATS: 12 ECR ont été inclus avec un total de 630 patients (IAL = 327 ; sédation IV = 303). Il n'y avait pas de différence dans le succès de réduction entre la sédation IAL et la sédation IV (RR = 0,93; IC à 95 % : 0,86 à 1,01, I2 = 69 %), événements indésirables significativement plus faibles avec IAL (RR = 0,16; IC à 95 % : 0,07 à 0,33, I2 = 0 %), durée de séjour plus courte avec IAL (différence moyenne = -1,48; IC à 95 % : -2,48 à -0,47, I2 = 93 %), aucune différence dans les scores de douleur après l'analgésie et aucune différence dans la facilité de réduction. CONCLUSIONS: La lidocaïne intra-articulaire peut avoir une efficacité similaire à celle de la sédation IV dans la réduction réussie des luxations antérieures de l'épaule aux urgences avec moins d'effets indésirables, une durée de séjour aux urgences plus courte et aucune différence dans les scores de douleur ou la facilité de réduction. La lidocaïne intra-articulaire peut être une alternative efficace à la sédation IV pour réduire les luxations antérieures de l'épaule, en particulier lorsque la sédation IV est contre-indiquée ou impossible.

Cesarean scar defects and abnormal uterine bleeding: a systematic review and meta-analysis.

OBJECTIVE: To synthesize the published literature to better understand the association between cesarean scar defects (CSDs) and abnormal uterine bleeding (AUB). In particular, we aimed to evaluate the risk and pattern(s) of CSD-associated AUB in addition to exploring the relationship between defect morphology with bleeding symptoms. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENTS: Patients with CSD and reports of uterine bleeding as an outcome were identified in 60 studies from database searches. INTERVENTIONS: Studies that investigated CSD (as defined by investigators) and reported uterine bleeding, menstrual bleeding, or AUB as an outcome were included. MAIN OUTCOME MEASURES: The prevalence and risk of AUB (intermenstrual, postmenstrual, and unscheduled bleeding) in patients with confirmed CSD. RESULTS: Nine studies reported on the prevalence of AUB in patients with a confirmed CSD. Patients with CSD were more likely to experience AUB, compared with those without CSD (relative risk, 3.47; 95% confidence interval [CI], 2.02-5.97; 6 studies, 1,385 patients; I2 = 67%). In a population of patients with at least 1 cesarean delivery, the prevalence of AUB in those with CSD was 25.5% (95% CI, 14.7-40.5; 6 studies, 667 patients, I2 = 93%). However, symptom prevalence was much higher in patients presenting for imaging for a gynecologic indication where the prevalence of AUB in the presence of a CSD was 76.4% (95% CI, 67.8-83.3; 5 studies, 505 patients; I2 = 71%). The mean menstrual duration in symptomatic patients with CSD was 13.4 days (95% CI, 12.6-14.2; 19 studies, 2,095 patients; I2 = 96%), and the mean duration of early-cycle intermenstrual bleeding was 6.8 days (95% CI, 5.7-7.8 days; 9 studies, 759 patients; I2 = 93%). The most common descriptor of CSD-associated AUB was "brown discharge". Patients with larger CSD experienced more bleeding symptoms. CONCLUSION: There is a strong and consistent association between patients with CSD and AUB. These patients experience a unique bleeding pattern, namely prolonged menstruation and early-cycle intermenstrual bleeding. These data should provide impetus for including CSD as a distinct entity in AUB classification systems. High heterogeneity in our results calls for standardization of nomenclature and outcome reporting for this condition.

Retrograde Bladder Filling After Outpatient Gynecologic Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review and meta-analyze randomized controlled trials (RCTs) comparing postoperative bladder retrofilling to passive filling after outpatient gynecologic surgery to evaluate effects on postoperative outcomes. DATA SOURCES: We searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and ClinicalTrials.gov from 1947 to August 2020. METHODS OF STUDY SELECTION: Two reviewers screened 1,465 articles. We included RCTs that compared postoperative bladder retrofilling to passive filling in patients who underwent outpatient gynecologic surgery by any approach. The primary outcome was the time to first void. Secondary outcomes included time to discharge, postoperative urinary retention, urinary tract infection, and patient satisfaction. Mean differences and relative risks (RRs) were calculated for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias Tool. TABULATION, INTEGRATION, AND RESULTS: We included eight studies with 1,173 patients. Bladder retrofilling in the operating room resulted in a significant decrease in the time to first void (mean difference -33.5 minutes; 95% CI -49.1 to -17.9, 4 studies, 403 patients) and time to discharge (mean difference -32.0 minutes; 95% CI -51.5 to -12.6, eight studies, 1,164 patients). Bladder retrofilling did not shorten time to discharge when performed in the postanesthetic care unit (mean difference -14.8 min; 95% CI -62.6 to 32.9, three studies, 258 patients) or after laparoscopic hysterectomy (mean difference -26.0 min; 95% CI -56.5 to 4.5, five studies, 657 patients). There were no differences in postoperative urinary retention (RR 0.77; 95% CI 0.45-1.30, five studies, 910 patients) or risk of urinary tract infection between the retrofill and passive fill groups (RR 0.50; 95% CI 0.14-1.77, four studies, 387 patients). Patient satisfaction was comparable between groups. CONCLUSION: Retrofilling the bladder in the operating room after outpatient gynecologic surgery modestly reduces the time to first void and discharge with no increase in adverse events. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42020203692.

Medical treatment of uterine arteriovenous malformation: a systematic review and meta-analysis.

OBJECTIVE: To quantify the efficacy of medical management of uterine arteriovenous malformation (AVM) and compare efficacy between different classes of medication. In addition, we evaluated for factors associated with treatment success and pregnancy outcomes after medical management. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Thirty-two studies representing 121 premenopausal women with medically-treated uterine AVM were identified via database searches of MEDLINE, Embase, Web of Science, and cited references. INTERVENTION(S): Medical treatment with progestins, gonadotropin-releasing hormone agonists (GnRH-a), methotrexate, combined hormonal contraception , uterotonics, danazol, or combination of the above. MAIN OUTCOME MEASURE(S): Primary outcome of treatment success was defined as AVM resolution without subsequent procedural interventions. Secondary outcome was treatment complication (readmission or transfusion). RESULT(S): The overall success rate of medical management was 88% (106/121). After adjusting for clustering effects, success rates for progestin (82.5%; 95% confidence interval [CI], 70.1%-90.4%), GnRH-a (89.3%; 99% CI, 71.4%-96.5%) and methotrexate (90.0%; 99% CI, 55.8%-98.8%) were significantly different from the null hypothesis of 50% success. The agents with the lowest adjusted proportion of complications were progestins (10.0%; 99% CI, 3.3%-26.8%) and GnRH-a (10.7%; 99% CI, 3.5%-28.4%). No clinical factors were found to predict treatment success. Twenty-six subsequent pregnancies are described, with no reported recurrences of AVM. CONCLUSION(S): Medical management for uterine AVM is a reasonable approach in a well selected patient. These data should be interpreted in the context of significant publication bias.

Antibiotic prophylaxis for urodynamic testing in women: a systematic review.

INTRODUCTION AND HYPOTHESIS: Urinary tract infection is the most common complication after urodynamic studies (UDS). Practice guidelines recommend against antibiotic prophylaxis based on an outdated review of the literature, which advised on the premise of "a lack of good quality studies" and based on an assumed low incidence not consistently supported by the literature. OBJECTIVES: This systematic review aims to update the assessment of the efficacy of antibiotic prophylaxis compared with placebo or no treatment for prevention of urinary tract infection in females over the age of 18 years undergoing UDS. METHODS: MEDLINE, EMBASE, COCHRANE, DISSERTATIONS, conference proceedings and clinical trial registries were searched for relevant randomized controlled trials. Two authors independently screened and selected articles, assessed these for quality according to Cochrane guidelines and extracted their data. RESULTS: A total of 2633 records were screened, identifying three relevant randomized controlled trials. The one study that was critically appraised as being the least likely biased showed a statistically significant effect of antibiotic prophylaxis in reducing bacteriuria post UDS in female patients. The other two studies included in the review did not. None of the studies included were powered to show a significant change in the incidence of urinary tract infection following UDS in female patients receiving antibiotic prophylaxis versus no prophylaxis. CONCLUSIONS: Similar to the 2012 Cochrane review on this subject, this systematic review demonstrated that antibiotic prophylaxis may decrease bacteriuria in women post UDS; however, further research is required to assess its effect on urinary tract infections in this context.

Mesenchymal Stem/Stromal Cells Increase Cardiac miR-187-3p Expression in a Polymicrobial Animal Model of Sepsis.

ABSTRACT: Sepsis-induced myocardial dysfunction (MD) is an important pathophysiological feature of multiorgan failure caused by a dysregulated host response to infection. Patients with MD continue to be managed in intensive care units with limited understanding of the molecular mechanisms controlling disease pathogenesis. Emerging evidences support the use of mesenchymal stem/stromal cell (MSC) therapy for treating critically ill septic patients. Combining this with the known role that microRNAs (miRNAs) play in reversing sepsis-induced myocardial-dysfunction, this study sought to investigate how MSC administration alters miRNA expression in the heart. Mice were randomized to experimental polymicrobial sepsis induced by cecal ligation and puncture (CLP) or sham surgery, treated with either MSCs (2.5 × 105) or placebo (saline). Twenty-eight hours post-intervention, RNA was collected from whole hearts for transcriptomic and microRNA profiling. The top microRNAs differentially regulated in hearts by CLP and MSC administration were used to generate a putative mRNA-miRNA interaction network. Key genes, termed hub genes, within the network were then identified and further validated in vivo. Network analysis and RT-qPCR revealed that septic hearts treated with MSCs resulted in upregulation of five miRNAs, including miR-187, and decrease in three top hit putative hub genes (Itpkc, Lrrc59, and Tbl1xr1). Functionally, MSC administration decreased inflammatory and apoptotic pathways, while increasing cardiac-specific structural and functional, gene expression. Taken together, our data suggest that MSC administration regulates host-derived miRNAs production to protect cardiomyocytes from sepsis-induced MD.

Low-dose Ketamine For Acute Pain Control in the Emergency Department: A Systematic Review and Meta-analysis.

OBJECTIVE: There has been increased interest in the use of low-dose ketamine (LDK) as an alternative analgesic for the management of acute pain in the emergency department (ED). The objective of this systematic review was to compare the analgesic effectiveness and safety profile of LDK and morphine for acute pain management in the ED. METHODS: Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing LDK to morphine for acute pain control in the ED were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence. RESULTS: Eight RCTs were included with a total of 1,191 patients (LDK = 598, morphine = 593). There was no significant difference in reported mean pain scores between LDK and morphine within the first 60 minutes after analgesia administration and a slight difference in pain scores favoring morphine at 60 to 120 minutes. The need for rescue medication was also similar between groups (RR = 1.26, 95% CI = 0.50 to 3.16), as was the proportion of patients who experienced nausea (RR = 0.97, 95% CI = 0.63 to 1.49) and hypoxia (RR = 0.38, 95% CI = 0.10 to 1.41). All outcomes were judged to have low certainty in the evidence. CONCLUSION: Low-dose ketamine and morphine had similar analgesic effectiveness within 60 minutes of administration with comparable safety profiles, suggesting that LDK is an effective alternative analgesic for acute pain control in the ED.

A machine learning-based clinical tool for diagnosing myopathy using multi-cohort microarray expression profiles.

BACKGROUND: Myopathies are a heterogenous collection of disorders characterized by dysfunction of skeletal muscle. In practice, myopathies are frequently encountered by physicians and precise diagnosis remains a challenge in primary care. Molecular expression profiles show promise for disease diagnosis in various pathologies. We propose a novel machine learning-based clinical tool for predicting muscle disease subtypes using multi-cohort microarray expression data. MATERIALS AND METHODS: Muscle tissue samples originating from 1260 patients with muscle weakness. Data was curated from 42 independent cohorts with expression profiles in public microarray gene expression repositories, which represent a broad range of patient ages and peripheral muscles. Cohorts were categorized into five muscle disease subtypes: immobility, inflammatory myopathies, intensive care unit acquired weakness (ICUAW), congenital, and chronic systemic disease. The data contains expression data on 34,099 genes. Data augmentation techniques were used to address class imbalances in the muscle disease subtypes. Support vector machine (SVM) models were trained on two-thirds of the 1260 samples based on the top selected gene signature using analysis of variance (ANOVA). The model was validated in the remaining samples using area under the receiver operator curve (AUC). Gene enrichment analysis was used to identify enriched biological functions in the gene signature. RESULTS: The AUC ranges from 0.611 to 0.649 in the observed imbalanced data. Overall, using the augmented data, chronic systemic disease was the best predicted class with AUC 0.872 (95% confidence interval (CI): 0.824-0.920). The least discriminated classes were ICUAW with AUC 0.777 (95% CI: 0.668-0.887) and immobility with AUC 0.789 (95% CI: 0.716-0.861). Disease-specific gene set enrichment results showed that the gene signature was enriched in biological processes including neural precursor cell proliferation for ICUAW and aerobic respiration for congenital (false discovery rate q-value < 0.001). CONCLUSION: Our results present a well-performing molecular classification tool with the selected gene markers for muscle disease classification. In practice, this tool addresses an important gap in the literature on myopathies and presents a potentially useful clinical tool for muscle disease subtype diagnosis.

Outpatient versus Inpatient Parotidectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: Parotidectomies are commonly performed procedures by head and neck surgeons. Although parotidectomies are historically inpatient procedures, recent observational evidence has highlighted the potential for parotidectomies to be performed on an outpatient basis. This systematic review and meta-analysis sought to compare complications and unplanned health care utilization between patients undergoing outpatient versus inpatient parotidectomy. DATA SOURCES: A systematic review was performed using MEDLINE, EMBASE, and the Cochrane Library. REVIEW METHODS: Studies comparing the outcomes of outpatient parotidectomy with those of inpatient parotidectomy were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. Postoperative complications (hematoma, facial nerve dysfunction, seroma, fistulisation, Frey syndrome, and wound infection) and rates of 30-day readmission, reintervention, and emergency department presentation were compared. RESULTS: We screened 1018 nonduplicate articles to include 5 studies, all of which were retrospective cohort studies. There were fewer complications found in the outpatient group (relative risk = 0.61, 95% confidence interval: 0.40-0.93). Outpatient procedures were more commonly performed on patients who lived close to the hospital, had fewer comorbidities, and had less extensive planned surgery. CONCLUSION: Outpatient parotidectomy appears safe in select patients with outcomes comparable with inpatient surgery. However, evidence overall is of low quality, and further work is needed to delineate a satisfactory set of criteria for appropriate patient identification.

Palliative Care Transitions From Acute Care to Community-Based Care-A Systematic Review.

CONTEXT: Although the literature on transitions from hospital to the community is extensive, little is known about this experience within the context of palliative care (PC). OBJECTIVE: We conducted a systematic review to investigate the impact of receiving palliative care in hospital on the transition from hospital to the community. METHODS: We systematically searched MEDLINE, Embase, ProQuest, and CINAHL from 1995 until April 10, 2018, and extracted relevant references. Eligible articles were published in English, included adult patients receiving PC as inpatients, and explored transitions from hospital to the community. RESULTS: A total of 1514 studies were identified and eight met inclusion criteria. Studies were published recently (>2012; n = 7, 88%). Specialist PC interventions were delivered by multidisciplinary care teams as part of inpatient PC triggers, discharge planning programs, and transitional care programs. Common outcomes reported with significant findings consisted of length of stay (n = 5), discharge support (n = 5), and hospital readmissions (n = 6) for those who received inpatient PC. Most studies were at high risk of bias. CONCLUSION: Heterogeneity of study designs, outcomes, findings, and poor methodological quality renders it challenging to draw conclusions regarding PC's impact on the transition from hospital to home. Further research should use standardized outcomes with randomized controlled trial and/or propensity matched cohort designs.

The Cancer Stories Project: narratives of encounters with cancer in Aotearoa, New Zealand.

OBJECTIVE: The Cancer Stories Study aimed to identify the factors that empower people who have experienced cancer. More specifically the project sought to explore the coping and support mechanisms people adopted to help understand and manage their cancer experience. METHODS: A participatory research approach involved researchers and consumers working in partnership on the project. This research team agreed on a qualitative method that focused on cancer survivors' personal stories. Semi-structured interviews were conducted with 38 cancer survivors in the lower half of the North Island, New Zealand (NZ). Generic qualitative analysis methods were employed including the recording, transcribing and thematic coding of interview narratives. RESULTS: Seven distinct themes were classified under the overarching theme of empowerment: attitude, change, family/whanau and friends, healthcare professionals and services, sources of support, employment and tangata whenua (NZ's indigenous peoples). The unique needs of each individual were strongly emphasised throughout all the themes indicating a 'one-size-fits-all' approach has its limitations. The need for improvements in communication, cultural and spiritual care was highlighted by many participants. CONCLUSIONS: It is anticipated that this project will contribute to a greater understanding of the factors that might empower people in their cancer journey. An empowerment lens, that asks how those affected by cancer may be further enabled at an individual, family/whanau, employer and healthcare professional level may be useful in assisting people navigate and manage their cancer.

Testing the predictive value of peripheral gene expression for nonremission following citalopram treatment for major depression.

Major depressive disorder (MDD) in general, and anxious-depression in particular, are characterized by poor rates of remission with first-line treatments, contributing to the chronic illness burden suffered by many patients. Prospective research is needed to identify the biomarkers predicting nonremission prior to treatment initiation. We collected blood samples from a discovery cohort of 34 adult MDD patients with co-occurring anxiety and 33 matched, nondepressed controls at baseline and after 12 weeks (of citalopram plus psychotherapy treatment for the depressed cohort). Samples were processed on gene arrays and group differences in gene expression were investigated. Exploratory analyses suggest that at pretreatment baseline, nonremitting patients differ from controls with gene function and transcription factor analyses potentially related to elevated inflammation and immune activation. In a second phase, we applied an unbiased machine learning prediction model and corrected for model-selection bias. Results show that baseline gene expression predicted nonremission with 79.4% corrected accuracy with a 13-gene model. The same gene-only model predicted nonremission after 8 weeks of citalopram treatment with 76% corrected accuracy in an independent validation cohort of 63 MDD patients treated with citalopram at another institution. Together, these results demonstrate the potential, but also the limitations, of baseline peripheral blood-based gene expression to predict nonremission after citalopram treatment. These results not only support their use in future prediction tools but also suggest that increased accuracy may be obtained with the inclusion of additional predictors (eg, genetics and clinical scales).

Shock, stress or signal? Implications of freshwater flows for a top-level estuarine predator.

Physicochemical variability in estuarine systems plays an important role in estuarine processes and in the lifecycles of estuarine organisms. In particular, seasonality of freshwater inflow to estuaries may be important in various aspects of fish lifecycles. This study aimed to further understand these relationships by studying the movements of a top-level estuarine predator in response to physicochemical variability in a large, temperate south-east Australian estuary (Shoalhaven River). Mulloway (Argyrosomus japonicus, 47-89 cm total length) were surgically implanted with acoustic transmitters, and their movements and migrations monitored over two years via fixed-position VR2W acoustic receivers configured in a linear array along the length of the estuary. The study period included a high degree of abiotic variability, with multiple pulses (exponentially high flows over a short period of time) in fresh water to the estuary, as well as broader seasonal variation in flow, temperature and conductivity. The relative deviation of fish from their modal location in the estuary was affected primarily by changes in conductivity, and smaller fish (n = 4) tended to deviate much further downstream from their modal position in the estuary than larger fish (n = 8). High-flow events which coincided with warmer temperatures tended to drive mature fish down the estuary and potentially provided a spawning signal to stimulate aggregation of adults near the estuary mouth; however, this relationship requires further investigation. These findings indicate that pulse and press effects of freshwater inflow and associated physicochemical variability play a role in the movements of mulloway, and that seasonality of large freshwater flows may be important in spawning. The possible implications of river regulation and the extraction of freshwater for consumptive uses on estuarine fishes are discussed.

Environmental change drives long-term recruitment and growth variation in an estuarine fish.

How individuals respond to environmental change determines the strength and direction of biological processes like recruitment and growth that underpin population productivity. Ascertaining the relative importance of environmental factors can, however, be difficult given the numerous mechanisms through which they affect individuals. This is especially true in dynamic and complex estuarine environments. Here, we develop long-term otolith-based indices of recruitment and growth for estuary perch Percalates colonorum (Bemm River, Australia), to explore the importance of intrinsic (individual, demographic) and extrinsic (hydrologic, climatic, density-dependent) factors in driving estuarine fish productivity. Analyses involved a novel zero-inflated specification of catch curve regression and mixed effects modelling. The 39 years of recruitment and 46 years of growth data, spanning a period of environmental change including severe drought, displayed considerable inter-annual variation. Recruitment success was strongly related to high freshwater inflows during the spawning season, suggesting that these conditions act as spawning cues for adults and potentially provide favourable conditions for larvae. Individuals displayed age-dependent growth, with highest rates observed at younger ages in years characterized by warm temperatures, and to a lesser degree, greater magnitude base inflow conditions. We detected systematic among-year-class growth differences, but these were not attributable to year class strength, suggesting that environmental conditions experienced by individuals as juveniles can have long-lasting effects of greater importance to population productivity than density-dependent growth responses. The primacy of temperature in driving growth variation highlights that under-appreciated climatic variation can affect estuarine fish productivity through direct physiological and indirect food web mechanisms. We predict that climatic warming will promote individual growth in southerly populations of P. colonorum but concurrently limit recruitment due to forecast reductions in spawning season river discharge. Disparate trait responses are likely in other fishes as they respond to multiple and changing environmental drivers, making predictions of future population productivity challenging.