Methods of measurement for pneumothorax in pediatric patients: a systematic review.

Accurate measurement of pneumothorax (PTX) size is necessary to guide clinical decision making; however, there is no consensus as to which method should be used in pediatric patients. This systematic review seeks to identify and evaluate the methods used to measure PTX size with CXR in pediatric patients. A systematic review of the literature through 2021 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was conducted using the following databases: Ovid/MEDLINE, Scopus, Cochrane Database of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Original research articles that included pediatric patients (< 18 years old) and outlined the PTX measurement method were included. 45 studies were identified and grouped by method (Kircher and Swartzel, Rhea, Light, Collins, Other) and societal guideline used. The most used method was Collins (n = 16; 35.6%). Only four (8.9%) studies compared validated methods. All found the Collins method to be accurate. Seven (15.6%) studies used a standard classification guideline and 3 (6.7%) compared guidelines and found significant disagreement between them. Pediatric-specific measurement guidelines for PTX are needed to establish consistency and uniformity in both research and clinical practice. Until there is a better method, the Collins method is preferred.

Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis.

PURPOSE: To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months. METHODS: A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function. RESULTS: Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively. CONCLUSIONS: At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS. LEVEL OF EVIDENCE: Level II, meta-analysis of Level I to II studies.

Physical Activity Behavior and Measurement in Arab American Women: An Integrative Review.

Physical activity (PA) is associated with cardiovascular health; however, in the U.S., only 20% of women are physically active, compared to 28% of men. Arab American women (AAW) experience unique barriers to engaging in the recommended PA. This review examines quantitative PA studies conducted with AAW with a specific focus on how PA outcomes were assessed. Studies were analyzed to explore: (a) types of PA behavior, (b) components of PA interventions/interest (if conducted), (c) PA measurement, and (d) translation of PA tools. After screening titles, abstracts, and a full-text review of articles from five different databases, 12 studies met the inclusion criteria. Leisure-time PA was the most readily used PA measure. Only two out of the 12 studies included women-only participants. There was a total of 10 cross-sectional studies and two quasi-experimental studies. All the studies used a self-report PA questionnaire; one study used a pedometer to measure PA. Six PA questionnaires were translated into Arabic. Future studies must explore the use of reliable and valid translated instruments, objective PA measures, and randomized controlled trial designs.

Environmental Impact and Cost Savings of Operating Room Quality Improvement Initiatives: A Scoping Review.

BACKGROUND: Operating rooms are major contributors to a hospital's carbon footprint due to the large volumes of resources consumed and waste produced. The objective of this study was to identify quality improvement initiatives that aimed to reduce the environmental impact of the operating room while decreasing costs. STUDY DESIGN: A literature search was performed using PubMed, Scopus, CINAHL, and Google Scholar and included broad terms for "operating room," "costs," and "environment" or "sustainability." The "triple bottom line" framework, which considers the environmental, financial, and social impacts of interventions to guide decision making, was used to inform data extraction. The studies were then categorized using the 5 "Rs" of sustainability-refuse, reduce, reuse, repurpose, and recycle-and the impacts were discussed using the triple bottom line framework. RESULTS: A total of 23 unique quality improvement initiatives describing 28 interventions were included. Interventions were categorized as "refuse" (n = 11; 39.3%), "reduce" (n = 8; 28.6%), "reuse" (n = 3; 10.7%), and "recycle" (n = 6; 21.4%). While methods of measuring environmental impact and cost savings varied greatly among studies, potential annual cost savings ranged from $873 (intervention: education on diverting recyclable materials from sharps containers; environmental impact: 11.4 kg sharps waste diverted per month) to $694,141 (intervention: education to reduce regulated medical waste; environmental impact: 30% reduction in regulated medical waste). CONCLUSIONS: Quality improvement initiatives that reduce both cost and environmental impact have been successfully implemented across a variety of centers both nationally and globally. Surgeons, healthcare practitioners, and administrators interested in environmental stewardship and working toward a culture of sustainability may consider similar interventions in their institutions.

Education Value Units in Medical Education: A Scoping Review.

PURPOSE: On the basis of the tripartite mission of patient care, research, and education, a need has arisen to better support faculty in non-revenue-generating activities, such as education. As a result, some programs have developed education value unit (EVU) systems to incentivize these activities. The purpose of this scoping review is to analyze the existing literature on EVUs to identify current structures and future directions for research. METHOD: The authors conducted a literature search of 5 databases without restrictions, searching for any articles on EVU systems published from database inception to January 12, 2022. Two authors independently screened articles for inclusion. Two authors independently extracted data and all authors performed quantitative and qualitative synthesis, consistent with best practice recommendations for scoping reviews. RESULTS: Fifty-eight articles were included. The most common rationale was to incentivize activities prioritized by the department or institution. Of those reporting funding, departmental revenue was most common. The majority of EVU systems were created using a dedicated committee, although composition of the committees varied. Stakeholder engagement was a key component for EVU system development. Most EVU systems also included noneducational activities, such as clinical activities, scholarship activities, administrative or leadership activities, and citizenship. Incentive models varied widely but typically involved numeric- or time-based quantification. EVUs were generally seen as positive, having increased equity and transparency as well as a positive impact on departmental metrics. CONCLUSIONS: This scoping review summarizes the existing literature on EVU systems, providing valuable insights for application to practice and areas for future research.

A Scoping Review of Associations Between Cannabis Use and Anxiety in Adolescents and Young Adults.

Cannabis and anxiety are both rising issues that impact young people. This review seeks to explore the association between anxiety and cannabis in adolescents and young adults (AYA). A database search was run retrospectively from July 2020 through calendar year 2013. Articles had to present outcomes examining cannabis use and symptoms of anxiety, be written in English, contain samples with ≥ 50% who are age 25 or younger, and be published in a peer-reviewed journal. Forty-seven studies were identified that examined the relationship between anxiety and cannabis use. Twenty-three studies found a positive association that greater anxiety among AYA was associated with greater cannabis use. In contrast, seven studies found a negative association that greater anxiety was related to less cannabis use. And finally, 17 studies found no clear association between anxiety and cannabis use. Further research is needed to better understand the relationship between anxiety and cannabis use.

Apophyseal ilium avulsion fractures in young athletes: a systematic review and return to sport analysis.

The purpose of the current investigation was to synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes <18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.

Virtual interviewing for graduate medical education recruitment and selection: A BEME systematic review: BEME Guide No. 80.

BACKGROUND: The COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses. METHODS: PubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance. RESULTS: One hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel. CONCLUSIONS: The use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

Avulsion fractures of the ischial tuberosity in the pediatric athlete: a systematic review and return to sport analysis.

Apophyseal avulsion fractures of the ischial tuberosity (AFIT) in pediatric athletes are relatively uncommon injuries with treatment and return to sport (RTS) outcomes being largely unknown. The purpose of this review is to perform a systematic review analyzing RTS and predictors of successful RTS for pediatric athletes sustaining AFIT. Studies reporting on athletes strictly under the age of 18 years sustaining an AFIT with reported RTS status were included. RTS was analyzed based on injury acuity, mechanism, and management, whereas the incidence of any complications was recorded. A total of 33 studies comprising 90 cases of AFIT were identified. The mean age of athletes sustaining injuries was 14.7 + 1.4 years (range, 9-17 years), most commonly participating in soccer ( n = 25), sprinting ( n = 21), and gymnastics ( n = 7). Acute trauma during sporting activities was responsible for 74.4% ( n = 77/90) of injuries. A total of 82% ( n = 74/90) of athletes reported successful RTS at an average of 7.0 + 5.0 months. Athletes undergoing surgery had a significantly higher RTS rate ( n = 36/38, 94.7%) compared with athletes treated nonoperatively (n = 38/52, 73.08%; P = 0.008). When reported, a high rate of misdiagnosis was reported (39.4%, n = 28/71). Complications were reported in 15.8% ( n = 7/38) and 32.7% ( n = 17/52) of athletes managed surgically and conservatively, respectively. As such, the high rate of misdiagnosis and subsequent high rate of complications and poor rate of RTS highlight the importance of accurate diagnosis and treatment. Future prospective studies evaluating patient outcomes based on fracture displacement, sporting activity, and management strategies are warranted to better treat pediatric athletes. Study design: Level IV, systematic review.

Rural Otolaryngology Care Disparities: A Scoping Review.

OBJECTIVE: To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work. STUDY DESIGN: Scoping review. DATA SOURCES: A comprehensive literature search was performed in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL. REVIEW METHODS: The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded. RESULTS: The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010. The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design. CONCLUSION: Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.

Practice Quit Attempts: Scoping Review of a Novel Intervention Strategy.

OBJECTIVE: Fostering practice quit attempts (PQAs)--that is, attempts to not smoke for a few hours or days, without pressure to permanently quit--represents a potential means to engage more individuals who smoke in efforts to change their smoking. However, little is known about interventions designed to foster PQAs. We aimed to identify the available evidence on PQA-focused intervention strategies and their impact on quit attempt and cessation outcomes. METHOD: We conducted a scoping review of behavioral and pharmacological treatment studies targeting PQAs among adult cigarette smokers. RESULTS: The systematic literature search yielded 3,879 articles, and the full-text review was narrowed to 86. Twenty-three studies were deemed relevant, and 5 were added through other sources, yielding 28 studies total. Fifteen studies included behavioral intervention techniques focused on the development and rehearsal of individualized coping skills, whereas eight studies provided brief advice/instruction. More than half of the PQA-focused interventions incorporated sampling of nicotine replacement products, through either guided or ad lib use. Five studies reported on PQA-focused digital health interventions that prompted brief abstinence challenges. Of eight large-scale controlled trials, six demonstrated an increase in quit attempt and cessation outcomes among the PQA-focused intervention group. CONCLUSIONS: Fostering PQAs through behavioral and pharmacological interventions offers a promising technique for cessation induction that warrants future research.

Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis: A Systematic Review and Network Meta-analysis.

BACKGROUND: In younger patients and those without severe degenerative changes, the efficacy of intra-articular (IA) injections as a nonoperative modality for treating symptomatic knee osteoarthritis (OA)-related pain while maintaining function has become a subject of increasing interest. PURPOSE: To assess and compare the efficacy of different IA injections used for the treatment of knee OA, including hyaluronic acid (HA), corticosteroids (CS), platelet-rich plasma (PRP), and plasma rich in growth factors (PRGF), with a minimum 6-month patient follow-up. STUDY DESIGN: Meta-analysis of randomized controlled trials; Level of evidence, 1. METHODS: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Mean or mean change from baseline and standard deviation for outcome scores regarding pain and function were recorded at the 6-month follow-up and converted to either a 0 to 100 visual analog scale score for pain or a 0 to 100 Western Ontario and McMaster Universities Osteoarthritis Index score for function. A frequentist network meta-analysis model was developed to compare the effects of HA, CS, PRP, PRGF, and placebo on patient-reported outcomes. RESULTS: All IA treatments except CS were found to result in a statistically significant improvement in outcomes when compared with placebo. PRP demonstrated a clinically meaningful difference in function-related improvement when compared with CS and placebo due to large effect sizes. Studies evaluating outcomes of PRGF reported significant improvement when compared with placebo due to large effect sizes, whereas a potential clinically significant difference was detected in the same comparison parameters in pain evaluation. With regard to improvements in pain, function, and both combined, PRP was found to possess the highest probability of efficacy, followed by PRGF, HA, CS, and placebo. CONCLUSION: PRP yielded improved outcomes when compared with PRGF, HA, CS, and placebo for the treatment of symptomatic knee OA at a minimum 6-month follow-up. Further investigations evaluating different IA and other nonoperative treatment options for patients with knee OA are warranted to better understand the true clinical efficacy and long-term outcomes of nonsurgical OA management.

Effects of Home-Based Exercise on Frailty in Patients With End-Stage Renal Disease: Systematic Review.

BACKGROUND: New or worsening frailty is a common problem in patients with end-stage renal disease (ESRD) during the prolonged time awaiting kidney transplantation. Structured physical activity in the dialysis setting has been shown to mitigate frailty, but little is known about the benefits of home-based exercise. The purpose of this systematic review was to summarize the effects of home-based exercise interventions on indicators of frailty (weakness, slowness, low physical activity, perceived exhaustion, and shrinking) among patients diagnosed with ESRD. METHODS: We searched PubMed, MEDLINE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar using Medical Subject Heading terms and free text keywords including kidney failure, exercise, and frailty. We identified 13 relevant articles (eight randomized controlled trials, five quasi-experimental studies). RESULTS: Our review found potential effectiveness of home-based exercise interventions on mitigating or preventing selected indicators of frailty (e.g., weakness, slowness, low physical activity, perceived exhaustion), particularly when the interventions combined aerobic walking, resistance exercise, and behavioral components and were delivered for at least 6 months. However, no published studies measured the effect of home-based exercise interventions on frailty as a whole. CONCLUSIONS: While existing studies suggest likely benefits of home-based exercise interventions among patients with ESRD, future research is warranted to develop and test home-based physical activity interventions that address all indicators of frailty.

Medical librarians' knowledge and practices in locating clinical trials for systematic reviews.

OBJECTIVE: In regard to locating clinical trials for a systematic review, limited information is available about how librarians locate clinical trials in biomedical databases, including (1) how much information researchers provide librarians to assist with the development of a comprehensive search strategy, (2) which tools librarians turn to for information about study design methodology, and (3) librarians' confidence levels in their knowledge of study design methodology. A survey was developed to explore these aspects of how a medical librarian locates clinical trials when facilitating systematic reviews for researchers. METHODS: In this cross-sectional study, a 21-question survey was sent to medical librarians via several email listservs during April 2020. Respondents were limited to librarians who make the decisions on search terms for systematic reviews. RESULTS: Responses (n=120) indicated that librarians were often asked to search for various types of clinical trials. However, there was not a consistent method for creating search strategies that locate diverse types of clinical trials. Multiple methods were used for search strategy development, with hedges being the most popular method. In general, these librarians considered themselves to be confident in locating trials. Different resources were used to inform study types, including textbooks, articles, library guides and websites. DISCUSSION: Medical librarians indicated that while they felt confident in their searching skills, they did not have a definitive source of information about the various types of clinical trials, and their responses demonstrated a clear need and desire for more information on study design methodology.

Behavioural interventions for CVD risk reduction for blue-collar workers: a systematic review.

OBJECTIVES: Individuals working in blue-collar occupations experience high rates of cardiovascular disease (CVD). The purpose of this systematic review is to describe the characteristics and efficacy of behavioural interventions that have targeted CVD risk factors in this high-risk group. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched seven databases to find interventions focused on changing the following: blood pressure, cholesterol, diet, physical activity, smoking or weight. Eligible studies tested a behavioural intervention (not exclusively policy, environmental, or pharmaceutical), in individuals working in blue-collar occupations using a randomised study design. Study quality was evaluated using the National Heart, Lung, and Blood Institute's study quality assessment tool. RESULTS: 22 studies evaluating 31 interventions were included: 11 were rated as 'good' or 'fair' quality. Intervention intensity ranged from a single contact via a mailed letter to studies that included individual-level contacts at multiple time points between staff and participants. Studies that included at least some individual contact generally yielded the greatest effects. Interventions had the greatest observed effects on self-report changes in diet, regardless of intervention intensity. Four of the five higher quality studies that explicitly tailored the intervention to the occupational group were successful at reducing at least one risk factor. CONCLUSIONS: Interventions that used individual contact and tailored the intervention to the occupational setting yielded the greatest effects on CVD risk-factor reduction in individuals working in blue-collar occupations. Generally, studies were low quality but showed promising effects for reaching this high-risk population. Future work should incorporate these promising findings in higher quality studies. PROSPERO REGISTRATION NUMBER: CRD42019136183.

The influence of cognitive behavioral therapy on lumbar spine surgery outcomes: a systematic review and meta-analysis.

PURPOSE: As more patients undergo lumbar spine surgery, novel interventions may improve physical and mental health outcomes. Few studies summarize the benefit of cognitive behavioral therapy (CBT) among lumbar spine surgery patients. This study collects randomized control trial data to investigate the influence of CBT on patient reported outcomes among lumbar spine surgery patients. METHODS: Our study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and a medical library expert assisted in searching PubMed/MEDLINE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, and Google Scholar. We calculated standardized mean differences (SMD) to evaluate the effect size of CBT versus control groups with a sensitivity analysis. RESULTS: Our meta-analysis included seven studies with a total of 531 patients. The majority of included studies evaluated lumbar fusion, with preoperative CBT performed by physiotherapists. The largest effects were observed for overall quality of life (SMD = 0.55 [95% CI 0.05, 1.05], p < 0.001, I2 = 86.7%) and psychological outcomes (SMD = 0.61 [95% CI 0.28, 0.94], p < 0.001, I2 = 89.7%) though disability and pain outcomes also favored CBT intervention. Included studies demonstrated low overall bias but large heterogeneity. Sensitivity analysis demonstrated negligible study design differences and revealed moderators including CBT session frequency and final follow-up duration (p < 0.001). CONCLUSION: Compared to usual care or alternative therapy control arms, CBT delivered the most improvement with overall quality of life and psychological outcomes. Among appropriately selected patients, CBT could improve perioperative disability, pain, quality of life, and psychological health following lumbar spine surgery.

Effect of Medical Scribes on Throughput, Revenue, and Patient and Provider Satisfaction: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: Documentation in the medical record increases clerical burden to clinicians and reduces time available to spend with patients, thereby leading to less efficient care and increased clinician stress. Scribes have been proposed as one approach to reduce this burden on clinicians and improve efficiency. The primary objective of this study is to assess the effect of scribes on throughput, revenue, provider satisfaction, and patient satisfaction in both the emergency department (ED) and non-ED setting. METHODS: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature database, Google Scholar, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched for studies assessing the effect of scribes versus no scribes on the following outcomes: patients per hour, relative value units (RVUs) per hour, RVUs per encounter, clinic length of stay, time to disposition, ED length of stay, ED length of stay for admitted patients, ED length of stay for discharged patients, provider satisfaction, and patient satisfaction. Data were dual extracted into a predefined work sheet, and quality analysis was performed with the Newcastle-Ottawa Scale or Cochrane Risk of Bias Tool. Subgroup analyses were planned between ED versus non-ED studies. RESULTS: We identified 39 studies comprising greater than 562,682 patient encounters. Scribes increased patients treated per hour by 0.30 (95% confidence interval [CI] 0.10 to 0.51). Scribes increased RVUs per encounter by 0.14 (95% CI 0.03 to 0.24) and RVUs per hour by 0.55 (0.30 to 0.80). There was no difference in time to disposition (5.74 minutes; 95% CI -2.63 to 14.10 minutes) or ED length of stay (-3.44 minutes; 95% CI -7.68 to 0.81 minutes), although a difference was found in clinic length of stay (5.74 minutes; 95% CI 0.42 to 11.05 minutes). Fourteen of 16 studies reported favorable provider satisfaction with a scribe. Seven of 18 studies reported favorable patient satisfaction with a scribe. No studies reported negative provider or patient satisfaction with scribes. CONCLUSION: Overall, we found that scribes improved RVUs per hour, RVUs per encounter, patients per hour, provider satisfaction, and patient satisfaction. However, we did not identify an improvement in ED length of stay. Future studies are needed to determine the cost-benefit effect of scribes and ED volume necessary to support their use.

Optimising sleep and performance during night float: A systematic review of evidence and implications for graduate medical education trainees.

Graduate medical education (GME) training commonly requires residents and fellows to engage in night float shift work. This review aims to assess the effectiveness of interventions for trainees when preparing for, completing, and recovering from working night float shifts. We reviewed all available studies published prior to September 2019 using PubMed, Scopus, CINAHL, the Cochrane library, PsycINFO, and Google Scholar databases. We included all original, primary research articles assessing either non-pharmacological or pharmacological interventions on the chronobiological and physiological effects of night float shift work among GME trainees. Five studies (n = 179 patients) met inclusion criteria. Interventions included melatonin in the morning before sleep after night float shifts, napping during night float shifts, modafinil after a night of sleep deprivation, and caffeinated energy drinks after 6 consecutive night float shifts. Melatonin improved one measure of attention. A 2-hr nap was associated with improved speed related to task switching. Modafinil improved performance in tests of cognition. Caffeinated energy drinks led to improvement in select driving performance variables and reaction time. Effect sizes for outcome variables were calculated. Heterogeneity among the studies precluded combining the data in a meta-analysis. According to GRADE criteria, the quality of the evidence in these studies was low or very low. Our findings suggest GME trainees may benefit from utilising a limited number of interventions when preparing for or recovering from night float shift work. More investigation is needed to identify interventions that could help GME trainees adapt to and recover from working night float shifts.

Harnessing Phones to Target Pediatric Populations with Socially Complex Needs: Systematic Review.

BACKGROUND: Mobile and smartphones are owned and accessed by many, making them a potentially optimal delivery mechanism to reach pediatric patients with socially complex needs (ie, pediatric populations who face overlapping adversities). OBJECTIVE: To address the specialized needs of youth from such groups, this review synthesized the literature exploring the use of phone-based delivery to access pediatric populations with socially complex needs, targeting mental and behavioral health outcomes. The purpose of this synthesis was to provide recommendations for future research developing phone-based interventions for youth with socially complex needs. METHODS: A trained medical librarian conducted the search strategy in the following databases: PubMed, Scopus, CINAHL, PsycINFO, Cochrane CENTRAL Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Studies targeting youth with socially complex needs were defined by recruiting samples that were primarily from traditionally underserved populations (ie, sex/gender minorities, racial/ethnic background, low socioeconomic status, rural/remote location, and sexual orientation). A systematic narrative framework was utilized and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed (registration number CRD42020141212). RESULTS: A total of 14 studies met the inclusion criteria, with 3 depicting the use of phones to complete assessment and tracking goals and 11 to intervene on mental and behavioral health targets. CONCLUSIONS: The literature indicates important directions for future research, including (1) involving diverse and representative teens (ie, the likely users of the interventions), stakeholders, and clinical/research staff; (2) integrating evidence-based therapies with minority-focused theories; (3) harnessing mobile device capabilities; and (4) considering and assessing for potential costs in phones as delivery mechanisms. TRIAL REGISTRATION: PROSPERO CRD42020141212; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=141212.

Level of Evidence in Facial Plastic Surgery Research: A Procedure-Level Analysis.

BACKGROUND: As evidence-based medicine has taken hold across medical specialties, the level of evidence within the facial plastic surgery literature has risen, but remains weak in comparison. There has not yet been a systematic, critical appraisal of the relative strength of evidence among subsets of the practice of facial plastic surgery. METHODS: The current study is a systematic review, designed to evaluate the level of evidence observed in the facial plastic surgery literature. Five journals were queried using facial plastic surgery terms for four selected years over a 10-year period. Following screening, articles were assigned to a category regarding subject matter, assessed for the presence of various methodological traits, and evaluated for overall level of evidence. Comparisons were made in regard to level of evidence across the breadth of facial plastic surgery subject matter. RESULTS: A total of 826 articles were included for final review. Studies on operative facial rejuvenation and rhinoplasty had significantly fewer authors on average than studies on cancer reconstruction or craniofacial topics. Craniofacial studies demonstrated higher levels of evidence relative to all other categories, with the exception of facial paralysis and facial trauma studies, from which there was no significant difference. In general, reconstructive studies had significantly more authors and higher levels of evidence than did articles with an aesthetic focus. CONCLUSION: Level of evidence in facial plastic surgery remains relatively weak overall. Reconstructive and particularly craniofacial studies demonstrate higher mean level of evidence, relative to other subsets of facial plastic surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.