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We sought to determine the comparative benefits and harms of rehabilitation interventions for patients who have undergone elective, unilateral THA surgery for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Register of Clinical Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We included randomized controlled trials and adequately adjusted nonrandomized comparative studies of rehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. Experts in rehabilitation content and complex interventions independently coded rehabilitation interventions. The team assessed strength of evidence. Large heterogeneity across evaluated rehabilitation programs limited conclusions. Evidence from 15 studies suggests that diverse rehabilitation programs may not differ in terms of risk of harm or outcomes of pain, strength, activities of daily living, or quality of life (all low strength of evidence). Evidence is insufficient for other outcomes. In conclusion, no differences in outcomes were found between different rehabilitation programs after THA. Further evidence is needed to inform decisions on what attributes of rehabilitation programs are most effective for various outcomes.

We sought to systematically review the evidence on the benefits and harms of prehabilitation interventions for patients who are scheduled to undergo elective, unilateral total knee arthroplasty or total hip arthroplasty surgery for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We selected for inclusion randomized controlled trials and adequately adjusted nonrandomized comparative studies of prehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. Experts in rehabilitation content and complex interventions independently coded rehabilitation interventions. The team assessed strength of evidence. While large heterogeneity across evaluated prehabilitation programs limited strong conclusions, evidence from 13 total knee arthroplasty randomized controlled trials suggest that prehabilitation may result in increased strength and reduced length of stay and may not lead to increased harms but may be comparable in terms of pain, range of motion, and activities of daily living (all low strength of evidence). There was no evidence or insufficient evidence for all other outcomes after total knee arthroplasty. Although there were six total hip arthroplasty randomized controlled trials, there was no evidence or insufficient evidence for all total hip arthroplasty outcomes.

Background. Hypertensive disorders of pregnancy (HDP) are increasingly common and have important implications for maternal health, healthcare utilization, and health disparities. There is limited evidence to support best management of postpartum individuals with HDP, including home blood pressure (BP) monitoring (HBPM) and choice of antihypertensive agents. For patients experiencing preeclampsia with severe features, there is robust evidence supporting delivery of the infant and treatment with magnesium sulfate (MgSO4). However, MgSO4 may cause unpleasant side effects and, less commonly, toxicity. Patients receiving MgSO4 require additional monitoring (e.g., urinary catheterization) and often have activity restrictions, which impact their postpartum experience. Evidence regarding the optimal (lowest effective) dose and (shortest effective) duration of MgSO4 treatment is needed. Methods. We searched Medline®, Cochrane, Embase®, CINAHL®, and ClinicalTrials.gov from inception to December 1, 2022. After double screening, we extracted study data and risk of bias assessments into the Systematic Review Data Repository Plus (SRDR+; https://srdrplus.ahrq.gov). We evaluated the strength of evidence (SoE) using standard methods. The protocol was registered in PROSPERO (registration number CRD42022313075). Results. We found 13 eligible studies (3 randomized controlled trials [RCTs], 2 nonrandomized comparative studies [NRCSs], 8 single-arm studies) evaluating postpartum HBPM, 17 RCTs evaluating pharmacological treatment of postpartum HDP, and 43 studies (41 RCTs and 2 NRCSs) that compared alternative MgSO4 regimens. HBPM programs probably increase submission of any BP measurements during recommended time intervals (moderate SoE) and may increase the number of BP measurements obtained overall (low SoE). Studies have not found that HBPM affects the rate of BP treatment initiation (low SoE), but HBPM may reduce unplanned hypertension-related hospital admissions (low SoE). Most patients were satisfied with management related to HBPM (low SoE), and HBPM probably compensates for racial disparities in office-based follow-up (moderate SoE). In patients with preeclampsia or gestational hypertension (HTN), oral furosemide may shorten the duration of postpartum hypertension (low SoE). There was insufficient evidence regarding the comparative benefits and harms of other antihypertensive medications. Compared with 24-hour treatments, shorter duration MgSO4 regimens shorten the urinary catheterization time (high SoE), time to ambulation (high SoE), and time to breastfeeding (moderate SoE); and may shorten time from delivery to contact with the infant and decrease toxicity as manifested by lost deep tendon reflexes (both low SoE). Loading dose only regimens increase the risk of a recurrent seizure in patients with eclampsia (moderate SoE). Lower dose MgSO4 regimens, compared to standard dose regimens, reduce early signs of magnesium toxicity (high SoE), may approximately double the risk of recurrent seizure in patients with eclampsia (low SoE), but may not affect 5-minute Apgar scores in infants of patients with preeclampsia with severe features (low SoE). There is insufficient evidence regarding potential harms of concomitant use of nifedipine or other antihypertensive medications. Conclusion. HBPM probably improves ascertainment of BP, allowing early recognition of hypertension in postpartum patients, and probably compensates for racial disparities in office based follow-up. The evidence suggests furosemide may shorten the duration of postpartum HTN. However, further evidence is needed regarding the comparative benefits and harms of the antihypertensive medications used to treat postpartum HTN. Large pragmatic trials, augmented by analysis of real-world data, are needed to evaluate the effect of postpartum HBPM on clinical event outcomes (not only process outcomes) and on the comparative effectiveness of alternative antihypertensive treatments. Given that lower dose MgSO4 regimens reduce Mg toxicity, and shorter regimens decrease urinary catheterization time, time to ambulation, time to breastfeeding, and time from delivery to contact with the infant, evidence is needed to identify MgSO4 regimens with the lowest effective dose and shortest effective duration that minimize side effects and toxicity but still prevent seizures among patients with preeclampsia with severe features.

We sought to determine the comparative benefit and harm of rehabilitation interventions for patients who have undergone elective, unilateral TKA for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Register of Clinical Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005 through May 3, 2021. We included randomized controlled trials and adequately-adjusted nonrandomized comparative studies of rehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. The team assessed strength of evidence (SoE). Evidence from 53 studies RCTs suggests, various rehabilitation programs after TKA may lead to comparable improvements in pain, ranged of motion and activities of daily living. Rehabilitation in the acute phase may lead to increased strength but result in similar strength when delivered in the post-acute phase. No studies reported evidence of risk of harms due to rehabilitation delivered in the acute period following TKA; risk of harms among various post-acute rehabilitation programs appears comparable. All findings were of low SOE. Evaluation of rehabilitation after TKA needs a systematic overhaul to sufficiently guide future practice or research including the use of standardized intervention components and core outcomes.

The value of interventions used after acute colonic diverticulitis is unclear.To evaluate postdiverticulitis colonoscopy and interventions to prevent recurrent diverticulitis.MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020.Comparative studies of interventions of interest reporting critical or important outcomes, and larger single-group studies to evaluate prevalence of colonoscopy findings and harms.6 researchers extracted study data and risk of bias. The team assessed strength of evidence.19 studies evaluated colonoscopy. Risk for prevalent colorectal cancer (CRC) compared with the general population is unclear. Based on low-strength evidence, long-term CRC diagnosis is similar with or without colonoscopy. High-strength evidence indicates that risk for prevalent CRC is higher among patients with complicated diverticulitis and colonoscopy complications are rare. Based on high-strength evidence, mesalamine does not reduce recurrence risk (6 randomized controlled trials [RCTs]). Evidence on other nonsurgical interventions is insufficient. For patients with prior complicated or smoldering or frequently recurrent diverticulitis, elective surgery is associated with reduced recurrence (3 studies; high strength). In 19 studies, serious surgical complications were uncommon.Few RCTs provided evidence. Heterogeneity of treatment effect was not adequately assessed.It is unclear whether patients with recent acute diverticulitis are at increased risk for prevalent CRC, but those with complicated diverticulitis are at increased risk. Mesalamine is ineffective in preventing recurrence; other nonsurgical treatments have inadequate evidence. Elective surgery reduces recurrence in patients with prior complicated or smoldering or frequently recurrent diverticulitis, but it is unclear which of these patients may benefit most.Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).

To assess whether some, or all, of the mesh needs to be removed when a midurethral sling is removed for complications.A systematic review and meta-analysis was conducted. MEDLINE, Cochrane, and ClinicalTrials.gov databases from January 1, 1996, through May 1, 2021, were searched for articles that met the eligibility criteria with total, partial, or a combination of anti-incontinence mesh removal.All study designs were included (N≥10), and a priori criteria were used for acceptance standards. Studies were extracted for demographics, operative outcomes, and adverse events. Meta-analysis was performed when possible.We double-screened 11,887 abstracts; 45 eligible and unique studies were identified. Thirty-five were single-group studies that evaluated partial mesh removal, five were single-group studies that evaluated total mesh removal, and five were studies that compared partial mesh removal with total mesh removal. All of the studies were retrospective in nature; there were no randomized controlled studies. Comparative studies demonstrated that partial mesh removal had lower rates of postoperative stress urinary incontinence (SUI) than total mesh removal (odds ratio 0.46, 95% CI 0.22-0.96). Single-group studies supported lower rates of postoperative SUI with partial mesh removal compared with total mesh removal (19.2% [95% CI 13.5-25.7] vs 48.7% [95% CI 31.2-66.4]). Both methods were similar with respect to associated pain, bladder outlet obstruction, mesh erosion or exposure, and lower urinary tract symptoms. Adverse events were infrequent.Postoperative SUI may be lower with partial mesh removal compared with total mesh removal. Other outcomes were similar regardless of the amount of mesh removed.PROSPERO, CRD 42018093099.

Infection with the hepatitis C virus (HCV) has adverse liver, kidney, and cardiovascular consequences in patients with chronic kidney disease (CKD), including those on dialysis therapy and in those with a kidney transplant. Since the publication of the original Kidney Disease: Improving Global Outcomes (KDIGO) HCV Guideline in 2008, major advances in HCV management, particularly with the advent of direct-acting antiviral therapies, have now made the cure of HCV possible in CKD patients. In addition, diagnostic techniques have evolved to enable the noninvasive diagnosis of liver fibrosis. Therefore, the Work Group undertook a comprehensive review and update of the KDIGO HCV in CKD Guideline. This Executive Summary highlights key aspects of the guideline recommendations.

Co-occurring mental health and substance use (SU) disorders among adolescents are common, with two-thirds of adolescents who seek SU treatment also requiring support for mental health. Primary care physicians play a key role in the pharmacological treatment of mental health disorders among adolescents, however, little is known about the impact of these treatments on SU outcomes.This systematic review summarizes the evidence regarding commonly used pharmacotherapy interventions for mental health and their impact on adolescent SU.Literature searches were conducted across five databases as part of a larger systematic review of adolescent SU interventions. Studies were screened for eligibility by two researchers, and study data were extracted regarding study design, patient and treatment characteristics and results. Risk of bias analyses and qualitative syntheses were completed to evaluate the strength of the evidence and the impact of pharmacotherapy on SU outcomes.Ten randomized controlled trials exploring seven pharmacotherapies met criteria for inclusion. All studies had low to moderate risk of bias. Four studies evaluated pharmacotherapy for co-occurring depression and SU, three evaluated attention deficit hyperactivity disorder and SU, and three evaluated bipolar disorder and SU. Five of the 10 studies also included a behavioural intervention. We found no evidence that pharmacotherapy for co-occurring mental health diagnoses impacted SU.Family medicine clinicians prescribing pharmacotherapy for mental health should be aware that additional interventions will likely be needed to address co-occurring SU.Many adolescents have both mental health and substance use problems. Adolescents have difficulty getting effective treatment for both substance use and mental health concerns, in part because these treatments are often offered separately. Primary care physicians, who often care for adolescents with mental health concerns, may prescribe medications for diagnoses such as attention deficit hyperactivity disorder, depression or early symptoms of bipolar disorder. However, there is little research indicating whether these medications are helpful for co-occurring substance use disorder symptoms. This paper presents a review of existing research on medications used to treat common mental health disorders to evaluate their effect on substance use. Ten studies address this question and suggest that medications for mental health are insufficient for helping adolescents with substance use disorders or substance use problems.

Objective : To identify and suggest strategies to make insufficient evidence ratings in systematic reviews more actionable. Study Design and Setting : A workgroup comprising members from the Evidence-Based Practice (EPC) Program of the Agency for Healthcare Research and Quality convened throughout 2020. We conducted iterative discussions considering information from three data sources: a literature review for relevant publications and frameworks, a review of a convenience sample of past systematic reviews conducted by the EPCs, and an audit of methods used in past EPC technical briefs. Results : We identified five strategies for supplementing systematic review findings when evidence on benefits or harms is expected to be, or found to be, insufficient: 1) reconsider eligible study designs, 2) summarize indirect evidence, 3) summarize contextual and implementation evidence, 4) consider modelling, and 5) incorporate unpublished health system data in the evidence synthesis. While these strategies may not increase the strength of evidence, they may improve the utility of reports for decisionmakers. Adopting these strategies depends on feasibility, timeline, funding, and expertise of the systematic reviewers. Conclusion : Throughout the process of evidence synthesis of early scoping, protocol development, review conduct, and review presentation, authors can consider these five strategies to supplement evidence with insufficient rating to make it more actionable for end-users.

This was a planned secondary analysis of a systematic review that described sexual function outcomes following pelvic organ prolapse (POP) surgery. We aimed to describe the relationship of pre- and postoperative vaginal anatomic measures with sexual function outcomes. Data Sources included the Medline, Embase, and clinicaltrials.gov databases from inception to April 2018. The original systematic review included prospective, comparative studies that reported sexual function outcomes before and following POP surgery. Studies were extracted for population characteristics, sexual function outcomes, and vaginal anatomy, including total vaginal length (TVL) and genital hiatus. By meta-regression, we analyzed associations across studies between vaginal anatomic measurements and sexual function using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 (PISQ-12) and dyspareunia outcomes. We screened 3124 abstracts and identified 74 papers representing 67 original studies. Among these, 14 studies reported TVL and PISQ-12 outcomes. Nine studies reported TVL and dyspareunia outcomes, eight studies reported GH and PISQ-12 outcomes, and seven studies reported GH and dyspareunia outcomes. We found no associations between anatomic measures and PISQ-12 or dyspareunia, although, we found a statistically significant association found between preoperative TVL and change in PISQ-12. Across studies, the evidence does not support an association between vaginal anatomy and either validated, condition-specific sexual function questionnaires or dyspareunia. However, no study has directly analyzed these associations in the setting of pelvic floor reconstructive surgery.

Background Primary headaches (migraine, tension headache, cluster headache, and other trigeminal autonomic cephalgias) are common in pregnancy and postpartum. It is unclear how to best and most safely manage them. Objective We conducted a systematic review (SR) of interventions to prevent or treat primary headaches in women who are pregnant, attempting to become pregnant, postpartum, or breastfeeding. Methods We searched Medline, Embase, Cochrane CENTRAL, CINAHL, ClinicalTrials.gov, Cochrane Database of SRs, and Epistemonikos for primary studies of pregnant women with primary headache and existing SRs of harms in pregnant women regardless of indication. No date or language restrictions were applied. We assessed strength of evidence (SoE) using standard methods. Results We screened 8549 citations for studies and 2788 citations for SRs. Sixteen studies (mostly high risk of bias) comprising 14,185 patients (total) and 26 SRs met the criteria. For prevention, we found no evidence addressing effectiveness. Antiepileptics, venlafaxine, tricyclic antidepressants, benzodiazepines, β-blockers, prednisolone, and oral magnesium may be associated with fetal/child adverse effects, but calcium channel blockers and antihistamines may not be (1 single-group study and 11 SRs; low-to-moderate SoE). For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache (1 randomized controlled trial; low SoE). Triptans may not be associated with fetal/child adverse effects (8 nonrandomized comparative studies; low SoE). Acetaminophen, prednisolone, indomethacin, ondansetron, antipsychotics, and intravenous magnesium may be associated with fetal/child adverse effects, but low-dose aspirin may not be (indirect evidence; low-to-moderate SoE). We found insufficient evidence regarding non-pharmacologic treatments. Conclusions For prevention of primary headache, calcium channel blockers and antihistamines may not be associated with fetal/child adverse effects. For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine. Triptans and low-dose aspirin may not be associated with fetal/child adverse effects. Future research should identify effective and safe interventions in pregnancy and postpartum.

Infection with the hepatitis C virus (HCV) has adverse liver, kidney, and cardiovascular consequences in patients with chronic kidney disease (CKD), including those on dialysis therapy or with a kidney transplant. Since the publication of the Kidney Disease: Improving Global Outcomes (KDIGO) HCV Guideline in 2018, advances in HCV management, particularly in the field of antiviral therapy and treatment of HCV-associated glomerular diseases, coupled with increased usage of HCV-positive kidney grafts, have prompted a reexamination of the 2018 guideline. As a result, the Work Group performed a comprehensive review and revised the 2018 guidance. This Executive Summary highlights key aspects of the updated guideline recommendations for 3 chapters: Chapter 2: Treatment of HCV infection in patients with CKD; Chapter 4: Management of HCV-infected patients before and after kidney transplantation; and Chapter 5: Diagnosis and management of kidney diseases associated with HCV infection.

Background. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine plan a new evidence-based joint consensus statement to address the preferred visit schedule and the use of televisits for routine antenatal care. This systematic review will support the consensus statement. Methods. We searched PubMed®, Cochrane databases, Embase®, CINAHL®, ClinicalTrials.gov, PsycINFO®, and SocINDEX from inception through February 12, 2022. We included comparative studies from high-income countries that evaluated the frequency of scheduled routine antenatal visits or the inclusion of routine televisits, and qualitative studies addressing these two topics. We evaluated strength of evidence for 15 outcomes prioritized by stakeholders. Results. Ten studies evaluated scheduled number of routine visits and seven studies evaluated televisits. Nine qualitative studies also addressed these topics. Studies evaluated a wide range of reduced and traditional visit schedules and approaches to incorporating televisits. In comparisons of fewer to standard number of scheduled antenatal visits, moderate strength evidence did not find differences for gestational age at birth (4 studies), being small for gestational age (3 studies), Apgar score (5 studies), or neonatal intensive care unit (NICU) admissions (5 studies). Low strength evidence did not find differences in maternal anxiety (3 studies), preterm births (3 studies), and low birth weight (4 studies). Qualitative studies suggest that providers believe fewer routine visits may be more convenient for patients and may free up clinic time to provide additional care for patients with high-risk pregnancies, but both patients and providers had concerns about potential lesser care with fewer visits. In comparisons of hybrid (televisits and in-person) versus in-person only visits, low strength evidence did not find differences in preterm births (4 studies) or NICU admissions (3 studies), but did suggest greater satisfaction with hybrid visits (2 studies). Qualitative studies suggested patients and providers were open to reduced schedules and televisits for routine antenatal care, but importantly, patients and providers had concerns about quality of care, and providers and clinic leadership had suggestions on how to best implement practice changes. Conclusion. The evidence base is relatively sparse, with insufficient evidence for numerous prioritized outcomes. Studies were heterogeneous in the care models employed. Where there was sufficient evidence to make conclusions, studies did not find significant differences in harms to mother or baby between alternative models, but evidence suggested greater satisfaction with care with hybrid visits. Qualitative evidence suggests diverse barriers and facilitators to uptake of reduced visit schedules or televisits for routine antenatal care. Given the shortcomings of the evidence base, considerations other than proof of differences in outcomes may need to be considered regarding implications for clinical practice. New studies are needed to evaluate prioritized outcomes and potential differential effects among different populations or settings.

Accurately describing treatment effects using plain language and narrative statements is a critical step in communicating research findings to end users. However, the process of developing these narratives has not been historically guided by a specific framework. The Agency for Healthcare Research and Quality Evidence-based Practice Center Program developed guidance for narrative summaries of treatment effects that identifies five constructs. We explicitly identify these constructs to facilitate developing narrative statements: (1) direction of effect, (2) size of effect, (3) clinical importance, (4) statistical significance, and (5) strength or certainty of evidence. These constructs clearly overlap. It may not always be feasible to address all five constructs. Based on context and intended audience, investigators can determine which constructs will be most important to address in narrative statements.

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence. The strengths of recommendations are provided in the full report. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica-accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.

Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis.To evaluate CT imaging, outpatient treatment of uncomplicated diverticulitis, antibiotic treatment, and interventional radiology for patients with complicated diverticulitis.MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020.Existing systematic reviews of CT imaging accuracy, as well as randomized trials and adjusted nonrandomized comparative studies reporting clinical or patient-centered outcomes.6 researchers extracted study data and risk of bias, which were verified by an independent researcher. The team assessed strength of evidence across studies.Based on moderate-strength evidence, CT imaging is highly accurate for diagnosing acute diverticulitis. For patients with uncomplicated acute diverticulitis, 6 studies provide low-strength evidence that initial outpatient and inpatient management have similar risks for recurrence or elective surgery, but they provide insufficient evidence regarding other outcomes. Also, for patients with uncomplicated acute diverticulitis, 5 studies comparing antibiotics versus no antibiotics provide low-strength evidence that does not support differences in risks for treatment failure, elective surgery, recurrence, posttreatment complications, and other outcomes. Evidence is insufficient to determine choice of antibiotic regimen (7 studies) or effect of percutaneous drainage (2 studies).The evidence base is mostly of low strength. Studies did not adequately assess heterogeneity of treatment effect.Computed tomography imaging is accurate for diagnosing acute diverticulitis. For patients with uncomplicated diverticulitis, no differences in outcomes were found between outpatient and inpatient care. Avoidance of antibiotics for uncomplicated acute diverticulitis may be safe for most patients. The evidence is too sparse for other evaluated questions.Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).

Women undergoing autologous reconstruction (AR) after mastectomy for breast cancer and their surgeons must make decisions regarding timing of the AR and choose among various flap types. We conducted a systematic review to evaluate the comparative benefits and harms of (1) timing of AR relative to chemotherapy and radiation therapy, and (2) various flap types for AR.We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies, from inception to March 23, 2021, without language restriction. We assessed risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods.We screened 15,936 citations. Twelve mostly high risk of bias studies, including three randomized controlled trials and nine nonrandomized comparative studies met criteria (total N = 31,833 patients). No studies addressed timing of AR relative to chemotherapy or radiation therapy. Six flap types were compared, but conclusions were feasible for only the comparison between transverse rectus abdominus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. The choice of either flap may result in comparable patient satisfaction with breasts and comparable risk of necrosis (low SoE for both outcomes), but TRAM flaps probably pose a greater risk of harm to the area of flap harvest (abdominal bulge/hernia and need for surgical repair) (moderate SoE).Evidence regarding details for AR is mostly of low SoE. New high-quality research among diverse populations of women is needed for the issue of timing of AR and for comparisons among flap types.

Objectives. This systematic review evaluates the rehabilitation interventions for patients who have undergone (or will undergo) total knee arthroplasty (TKA) or total hip arthroplasty (THA) for the treatment of osteoarthritis. We addressed four Key Questions (KQs): comparisons of (1) rehabilitation prior (“prehabilitation”) to TKA versus no prehabilitation, (2) comparative effectiveness of different rehabilitation programs after TKA, (3) prehabilitation prior to THA versus no prehabilitation, (4) comparative effectiveness of different rehabilitation programs after THA. Data sources and review methods. We searched Medline®, PsycINFO®, Embase®, the Cochrane Register of Clinical Trials, CINAHL®, Scopus®, and ClinicalTrials.gov from Jan 1, 2005, to May 3, 2021, to identify randomized controlled trials (RCTs) and adequately adjusted nonrandomized comparative studies (NRCSs). We evaluated clinical outcomes selected with input from a range of stakeholders. We assessed the risk of bias and evaluated the strength of evidence (SoE) using standard methods. Meta-analysis was not feasible, and evidence was synthesized and reported descriptively. The PROSPERO protocol registration number is CRD42020199102. Results. We found 78 RCTs and 5 adjusted NRCSs. Risk of bias was moderate to high for most studies. • KQ 1: Compared with no prehabilitation, prehabilitation prior to TKA may increase strength and reduce length of hospital stay (low SoE) but may lead to comparable results in pain, range of motion (ROM), and activities of daily living (ADL) (low SoE). There was no evidence of an increased risk of harms due to prehabilitation (low SoE). • KQ 2: Various rehabilitation interventions after TKA may lead to comparable improvements in pain, ROM, and ADL (low SoE). Rehabilitation in the acute phase (initiated within 2 weeks of surgery) may lead to increased strength (low SoE) but result in similar strength when delivered in the post-acute phase (low SoE). No studies reported evidence of risk of harms due to rehabilitation delivered in the acute period following TKA. Compared with various controls, post-acute rehabilitation may not increase the risk of harms (low SoE). • KQ 3: For all assessed outcomes, there is insufficient (or no) evidence addressing the comparison between prehabilitation and no prehabilitation prior to THA. • KQ 4: Various rehabilitation interventions after THA may lead to comparable improvements in pain, strength, ADL, and quality of life. There is some evidence of no increased risk of harms due to the intervention (low SoE). • There is insufficient evidence regarding which patients may benefit from (p)rehabilitation for all KQs and insufficient evidence regarding comparisons of different providers and different settings of (p)rehabilitation for all KQs. There is insufficient evidence on costs of (p)rehabilitation and no evidence on cost effectiveness for all KQs. Conclusion. Despite the large number of studies found, the evidence regarding various prehabilitation programs and comparisons of rehabilitation programs for TKA and THA is ultimately sparse. This is a result of the diversity of interventions studied and outcomes reported across studies. As a result, the evidence is largely insufficient or of low SoE. New high-quality research is needed, using standardized intervention terminology and core outcome sets, especially to allow network meta-analyses to explore the impact of intervention attributes on patient-reported, performance-based, and healthcare-utilization outcomes.

BACKGROUND: Selective or non-reporting of study outcomes results in outcome reporting bias. OBJECTIVE: We sought to develop and assess tools for detecting and adjusting for outcome reporting bias. DESIGN: Using data from a previously published systematic review, we abstracted whether outcomes were reported as collected, whether outcomes were statistically significant, and whether statistically significant outcomes were more likely to be reported. We proposed and tested a model to adjust for unreported outcomes and compared our model to three other methods (Copas, Frosi, trim and fill). Our approach assumes that unreported outcomes had a null intervention effect with variance imputed based on the published outcomes. We further compared our approach to these models using simulation, and by varying levels of missing data and study sizes. RESULTS: There were 286 outcomes reported as collected from 47 included trials: 142 (48%) had the data provided and 144 (52%) did not. Reported outcomes were more likely to be statistically significant than those collected but for which data were unreported and for which non-significance was reported (RR, 2.4; 95% CI, 1.9 to 3.0). Our model and the Copas model provided similar decreases in the pooled effect sizes in both the meta-analytic data and simulation studies. The Frosi and trim and fill methods performed poorly. LIMITATIONS: Single intervention of a single disease with only randomized controlled trials; approach may overestimate outcome reporting bias impact. CONCLUSION: There was evidence of selective outcome reporting. Statistically significant outcomes were more likely to be published than non-significant ones. Our simple approach provided a quick estimate of the impact of unreported outcomes on the estimated effect. This approach could be used as a quick assessment of the potential impact of unreported outcomes. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-07135-3.

To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries.PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021.Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included.Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals.Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures.Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.

Objectives. This systematic review evaluates breast reconstruction options for women after mastectomy for breast cancer (or breast cancer prophylaxis). We addressed six Key Questions (KQs): (1) implant-based reconstruction (IBR) versus autologous reconstruction (AR), (2) timing of IBR and AR in relation to chemotherapy and radiation therapy, (3) comparisons of implant materials, (4) comparisons of anatomic planes for IBR, (5) use versus nonuse of human acellular dermal matrices (ADMs) during IBR, and (6) comparisons of AR flap types. Data sources and review methods. We searched Medline®, Embase®, Cochrane CENTRAL, CINAHL®, and ClinicalTrials.gov from inception to March 23, 2021, to identify comparative and single group studies. We extracted study data into the Systematic Review Data Repository Plus (SRDR+). We assessed the risk of bias and evaluated the strength of evidence (SoE) using standard methods. The protocol was registered in PROSPERO (registration number CRD42020193183). Results. We found 8 randomized controlled trials, 83 nonrandomized comparative studies, and 69 single group studies. Risk of bias was moderate to high for most studies. KQ1: Compared with IBR, AR is probably associated with clinically better patient satisfaction with breasts and sexual well-being but comparable general quality of life and psychosocial well-being (moderate SoE, all outcomes). AR probably poses a greater risk of deep vein thrombosis or pulmonary embolism (moderate SoE), but IBR probably poses a greater risk of reconstructive failure in the long term (1.5 to 4 years) (moderate SoE) and may pose a greater risk of breast seroma (low SoE). KQ 2: Conducting IBR either before or after radiation therapy may result in comparable physical well-being, psychosocial well-being, sexual well-being, and patient satisfaction with breasts (all low SoE), and probably results in comparable risks of implant failure/loss or need for explant surgery (moderate SoE). We found no evidence addressing timing of IBR or AR in relation to chemotherapy or timing of AR in relation to radiation therapy. KQ 3: Silicone and saline implants may result in clinically comparable patient satisfaction with breasts (low SoE). There is insufficient evidence regarding double lumen implants. KQ 4: Whether the implant is placed in the prepectoral or total submuscular plane may not be associated with risk of infections that are not explicitly implant related (low SoE). There is insufficient evidence addressing the comparisons between prepectoral and partial submuscular and between partial and total submuscular planes. KQ 5: The evidence is inconsistent regarding whether human ADM use during IBR impacts physical well-being, psychosocial well-being, or satisfaction with breasts. However, ADM use probably increases the risk of implant failure/loss or need for explant surgery (moderate SoE) and may increase the risk of infections not explicitly implant related (low SoE). Whether or not ADM is used probably is associated with comparable risks of seroma and unplanned repeat surgeries for revision (moderate SoE for both), and possibly necrosis (low SoE). KQ 6: AR with either transverse rectus abdominis (TRAM) or deep inferior epigastric perforator (DIEP) flaps may result in comparable patient satisfaction with breasts (low SoE), but TRAM flaps probably increase the risk of harms to the area of flap harvest (moderate SoE). AR with either DIEP or latissimus dorsi flaps may result in comparable patient satisfaction with breasts (low SoE), but there is insufficient evidence regarding thromboembolic events and no evidence regarding other surgical complications. Conclusion. Evidence regarding surgical breast reconstruction options is largely insufficient or of only low or moderate SoE. New high-quality research is needed, especially for timing of IBR and AR in relation to chemotherapy and radiation therapy, for comparisons of implant materials, and for comparisons of anatomic planes of implant placement.

Approximately one-third of the adult U.S. population has prediabetes, ∼5–10% of whom will progress to diabetes per year (1,2). Intensive lifestyle changes delay progression to diabetes; however, sustaining lifestyle changes long term is challenging and often insufficient to prevent development of diabetes (3). Simple, inexpensive, and sustainable approaches to complement lifestyle changes are therefore needed to lower diabetes risk in people with prediabetes. Over the last decade, vitamin D has emerged as a potential modifier of the pathophysiology of type 2 diabetes and vitamin D supplementation has been hypothesized as a promising intervention to lower diabetes risk (4). Observational studies report consistent associations between higher blood 25-hydroxy vitamin D [25(OH)D] concentration and lower risk of developing type 2 diabetes in diverse cohorts (5). Mechanistic studies provide a strong biological basis for an important role of vitamin D in improving pancreatic β-cell function, but there is less evidence on its effects on insulin resistance (6). Until recently, evidence from trials examining the effect of vitamin D supplementation for diabetes prevention was lacking. In 2019, the U.S.-based Vitamin D and Type 2 Diabetes (D2d) study reported that participants with prediabetes assigned to vitamin D supplementation had a 12% decrease in risk of developing diabetes compared with placebo, but the change was not statistically significant (hazard ratio [HR] 0.88 [95% CI 0.75–1.04) (7). The effect size in D2d was nearly identical to those reported by two similar but smaller trials (Tromso \[Norway], HR 0.90 [95% CI 0.69–1.18], and Diabetes Prevention with active Vitamin D [DPVD\] \[Japan\], HR 0.87 [95% CI 0.68–1.09]) (8,9). Prior meta-analyses did not include these recent trials; thus, the field is ripe for updated meta-analyses. In the current issue of Diabetes Care , two meta-analyses on this topic are published (10,11) . Pramono …

Background Conducting systematic reviews (“reviews”) requires a great deal of effort and resources. Making data extracted during reviews available publicly could offer many benefits, including reducing unnecessary duplication of effort, standardizing data, supporting analyses to address secondary research questions, and facilitating methodologic research. Funded by the US Agency for Healthcare Research and Quality (AHRQ), the Systematic Review Data Repository (SRDR) is a free, web-based, open-source, data management and archival platform for reviews. Our specific objectives in this paper are to describe (1) the current extent of usage of SRDR and (2) the characteristics of all projects with publicly available data on the SRDR website. Methods We examined all projects with data made publicly available through SRDR as of November 12, 2019. We extracted information about the characteristics of these projects. Two investigators extracted and verified the data. Results SRDR has had 2552 individual user accounts belonging to users from 80 countries. Since SRDR’s launch in 2012, data have been made available publicly for 152 of the 735 projects in SRDR (21%), at a rate of 24.5 projects per year, on average. Most projects are in clinical fields (144/152 projects; 95%); most have evaluated interventions (therapeutic or preventive) (109/152; 72%). The most frequent health areas addressed are mental and behavioral disorders (31/152; 20%) and diseases of the eye and ocular adnexa (23/152; 15%). Two-thirds of the projects (104/152; 67%) were funded by AHRQ, and one-sixth (23/152; 15%) are Cochrane reviews. The 152 projects each address a median of 3 research questions (IQR 1–5) and include a median of 70 studies (IQR 20–130). Conclusions Until we arrive at a future in which the systematic review and broader research communities are comfortable with the accuracy of automated data extraction, re-use of data extracted by humans has the potential to help reduce redundancy and costs. The 152 projects with publicly available data through SRDR, and the more than 15,000 studies therein, are freely available to researchers and the general public who might be working on similar reviews or updates of reviews or who want access to the data for decision-making, meta-research, or other purposes.

Objective Summarize the psychometric properties of functional, ambulatory, and quality of life instruments among adult lower limb amputees, highlighting evidence deemed generalizable to the United States Medicare population. Data Sources Six databases and existing systematic reviews through October 30, 2017. Searches included terms for lower limb amputation or prostheses and outcome measures in humans, without language restriction. Study Selection We included peer-reviewed studies of at least 20 adults (≥18 years) with lower limb amputation. Eligible studies reported on psychometric properties of functional, ambulatory, or quality of life instruments. Fifty-three of 425 retrieved articles (12%) met criteria. Data Extraction Study characteristics and psychometric property data (validity, reliability, responsiveness, minimum detectable change, minimal important difference, or floor or ceiling effect) were extracted into a customized form based on standardized criteria. All extracted data were confirmed by 2 experts in systematic review and rehabilitation outcome measurement. Instruments were categorized regarding having been validated and found reliable. Other reported psychometric properties were recorded. Studies were also assessed for applicability to the Medicare population based on age and amputation etiology (dysvascular). Data Synthesis Fifty-six studies (in 53 articles) reported psychometric properties of 50 instruments. There is evidence for both validity and reliability for 30 instruments, 17 of which have evidence that was deemed generalizable to the Medicare population. Most of the remaining instruments have evidence of either validity or reliability, but not both. Twelve instruments have been assessed specifically among lower limb amputees prior to prosthesis prescription. Thirteen instruments have been assessed regarding their predictive properties for future outcomes. Conclusions Numerous instruments assessing ambulation, function, quality of life, and other patient-centered outcomes have evidence of validity and reliability for adults with lower limb amputations. Researchers and clinicians should use validated, reliable instruments when feasible. Many existing and new instruments require validation for use with lower limb amputees.

BACKGROUND: Urinary incontinence (UI) is a common malady in women. Numerous nonsurgical treatments are available, each associated with risk of adverse events (AEs). METHODS: We systematically reviewed nonsurgical interventions for urgency, stress, or mixed UI in women, focusing on AEs. We searched MEDLINE®, Cochrane Central Trials Registry, Cochrane Database of Systematic Reviews, and Embase® through December 4, 2017. We included comparative studies and single-group studies with at least 50 women. Abstracts were screened independently in duplicate. One researcher extracted study characteristics and results with verification by another independent researcher. When at least four studies of a given intervention reported the same AE, we conducted random effects model meta-analyses of proportions. We also assessed the strength of evidence. RESULTS: There is low strength of evidence that AEs are rare with behavioral therapies and neuromodulation, and that periurethral bulking agents may result in erosion and increase the risk of voiding dysfunction. High strength of evidence finds that anticholinergics and alpha agonists are associated with high rates of dry mouth and constitutional effects such as fatigue and gastrointestinal complaints. Onabotulinum toxin A (BTX) is also associated with increased risk of urinary tract infections (UTIs) and voiding dysfunction (moderate strength of evidence). DISCUSSION: Behavioral therapies and neuromodulation have low risk of AEs. Anticholinergics and alpha agonists have high rates of dry mouth and constitutional effects. BTX is associated with UTIs and voiding dysfunction. Periurethral bulking agents are associated with erosion and voiding dysfunction. These AEs should be considered when selecting appropriate UI treatment options. AE reporting is inconsistent and AE rates across studies tended to vary widely. Trials should report AEs more consistently. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05028-0) contains supplementary material, which is available to authorized users.

We aimed to systematically review the literature on pelvic organ prolapse (POP) surgery with uterine preservation (hysteropexy). We hypothesized that different hysteropexy surgeries would have similar POP outcomes but varying adverse event (AE) rates. MEDLINE, Cochrane, and clinicaltrials.gov databases were reviewed from inception to January 2018 for comparative (any size) and single-arm studies (n ≥ 50) involving hysteropexy. Studies were extracted for participant characteristics, interventions, comparators, outcomes, and AEs and assessed for methodological quality. We identified 99 eligible studies: 53 comparing hysteropexy to POP surgery with hysterectomy, 42 single-arm studies on hysteropexy, and four studies comparing stage ≥2 hysteropexy types. Data on POP outcomes were heterogeneous and usually from

Background: Individual randomized clinical trials have not shown conclusively that taking vitamin D can prevent type 2 diabetes. Methods: We conducted a systematic review and meta-analysis of individual participant-level data to determine whether vitamin D supplementation lowers the risk of diabetes in people with prediabetes. Trials published through February 12, 2021, that compared oral vitamin D supplementation (alone) with placebo over a minimum 2-year follow up, and had new-onset diabetes as a primary outcome were included. Proportional hazards models were used to analyze individual participant data, with pre-specified intention-to-treat (ITT) and per-protocol analyses, without and after adjustment for baseline age, gender, BMI, race and hemoglobin A1c. Safety was also assessed. Results: Three trials were eligible (testing D3 20,000 IU/week [Tromsø], D3 4,000 IU/day [D2d], and eldecalcitol 0.75 μg/day [DPVD] vs. matching placebos) and contributed data from 4190 randomized participants (mean age 60.4 years, 44.2% women). After a median 3.0 years of follow-up, new-onset diabetes occurred in 475/2097 participants assigned to vitamin D and 524/2093 assigned to placebo (8.42 and 9.50 events per 100 person-years, respectively). The unadjusted hazard ratio (95% CI) for vitamin D was 0.88 (0.77 to 0.99) in the ITT and 0.85 (0.75 to 0.97) in the per-protocol analyses. Adjusted hazard ratios were 0.85 (0.75 to 0.96) in the ITT and 0.83 (0.73 to 0.94) in the per-protocol analyses. There was no evidence of heterogeneity of treatment effect among the three trials. The incidence of hypercalcemia, hypercalciuria, or kidney stones did not differ between the vitamin D and placebo groups. Conclusion: In adult patients with prediabetes, vitamin D supplementation is safe and effective for lowering the risk of diabetes by about 15%. Disclosure A. G. Pittas: None. T. Kawahara: None. R. Jorde: None. J. P. Nelson: None. E. Angellotti: None. E. Vickery: None. B. Dawson-hughes: None. T. Trikalinos: None. E. M. Balk: None. Funding American Diabetes Association (1-14-D2D-01 to A.G.P.); National Institutes of Health (U01DK098245)

Objective Women consider preservation of sexual activity and improvement of sexual function as important goals after pelvic organ prolapse surgery. This systematic review aimed to compare sexual activity and function before and after prolapse surgery among specific approaches to pelvic organ prolapse surgery including native tissue repairs, transvaginal synthetic mesh, biologic grafts, and sacrocolpopexy. Data Sources MEDLINE, Embase, and ClinicalTrials.gov databases were searched from inception to March 2021. Study Eligibility Criteria Prospective comparative cohort and randomized studies of pelvic organ prolapse surgeries were included that reported the following specific sexual function outcomes: baseline and postoperative sexual activity, dyspareunia, and validated sexual function questionnaire scores. Notably, the following 4 comparisons were made: transvaginal synthetic mesh vs native tissue repairs, sacrocolpopexy vs native tissue repairs, transvaginal synthetic mesh vs sacrocolpopexy, and biologic graft vs native tissue repairs. Methods Studies were double screened for inclusion and extracted for population characteristics, sexual function outcomes, and methodological quality. Evidence profiles were generated for each surgery comparison by grading quality of evidence for each outcome across studies using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results Screening of 3651 abstracts was performed and identified 77 original studies. The overall quality of evidence was moderate to high. There were 26 studies comparing transvaginal synthetic mesh with native tissue repairs, 5 comparing sacrocolpopexy with native tissue repairs, 5 comparing transvaginal synthetic mesh with sacrocolpopexy, and 7 comparing biologic graft with native tissue repairs. For transvaginal synthetic mesh vs native tissue repairs, no statistical differences were found in baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, persistent dyspareunia, and de novo dyspareunia. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form change scores were not different between transvaginal synthetic mesh and native tissue repairs (net difference, −0.3; 95% confidence interval, −1.4 to 0.8). For sacrocolpopexy vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, de novo dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form score differences were not different. For biologic graft vs native tissue repairs, baseline or postoperative sexual activity, baseline or postoperative total dyspareunia, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form changes were also not different. For transvaginal synthetic mesh vs sacrocolpopexy, there was no difference in sexual activity and sexual function score change. Based on 2 studies, postoperative total dyspareunia was more common in transvaginal synthetic mesh than sacrocolpopexy (27.5% vs 12.2%; odds ratio, 2.72; 95% confidence interval, 1.33–5.58). The prevalence of postoperative dyspareunia was lower than preoperative dyspareunia after all surgery types. Conclusion Sexual function comparisons are most robust between transvaginal synthetic mesh and native tissue repairs and show similar prevalence of sexual activity, de novo dyspareunia, and sexual function scores. Total dyspareunia is higher after transvaginal synthetic mesh than sacrocolpopexy. Although sexual function data are sparse in the other comparisons, no other differences in sexual activity, dyspareunia, and sexual function score change were found.

Background Opioid-related harms are increasing among older adults. Until we better understand the factors contributing to this trend, we will be unable to design and implement effective interventions to optimally manage opioid use and its potential harms among older adults. Although considerable research has been done in younger or mixed-age populations, the degree to which it is directly applicable to older adults is uncertain. Objectives To provide a framework for understanding how to reduce adverse outcomes of opioid use among older adults, and to describe the evidence available for different factors associated with and interventions to reduce adverse outcomes related to opioid use in this population. Approach With input from a diverse panel of content experts and other stakeholders, we developed a conceptual framework and evidence map to characterize empirical studies of factors associated with opioid-related outcomes and interventions to reduce opioid-related harms in older adults. We identified relevant literature among older adults (age ≥60 years) for an evidence map by systematically searching PubMed, PsycINFO, and CINAHL for studies published in English between 2000 and May 6, 2020. Findings We identified 5,933 citations, from which we identified 41 studies with multivariable models of factors associated with opioid-related outcomes and 16 studies of interventions in older adults. More than half (22/41) of the multivariable analysis studies evaluated factors associated with long-term opioid use (which, though not a harm per se, may increase the risk of harms if not appropriately managed). Prior or early postoperative opioid use, or greater amounts of prescribed opioids (high number of opioid prescriptions or higher opioid dose), were consistently (100% agreement) and strongly (measure of association ≥2.0) associated with long-term opioid use. Back pain, depression, concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs), and fibromyalgia also had consistent, but weaker, associations with long-term opioid use. Several factors were mostly associated (>75% agreement) with long-term opioid use, including benzodiazepine use, comorbidity scores, (generally undefined) substance misuse, tobacco use, and low income. However, studies were mostly consistent that alcohol abuse and healthcare utilization were not associated with long-term opioid use. Gender, age among older adults, Black race, dementia, rural/nonurban residence, prescription of long-acting opioids, unmarried status, and use of muscle relaxants were variably associated ( Six studies examined factors associated with opioid-related disorders, although only one study evaluated factors associated with opioid use disorder. Alcohol misuse and gender were variably associated with opioid misuse (examined by three studies each). All other evaluations of specific pairs of associated factors and outcomes of interest were evaluated by only one or two studies each. These included analyses of factors associated with multiple opioid prescribers, mental health outcomes, physical health outcomes, all-cause hospitalization, opioid-related hospitalization, nonopioid-specific hospitalization, emergency department visits, opioid overdose, all-cause death, opioid-related death, and nonopioid-related death. The evidence on interventions directed at older adults is sparse. Of the 16 studies of opioid-related interventions in older adults, six examined screening tools to predict opioid-related harms, but none of these tools was tested in clinical practice to assess real-world results. Two studies found that prescription drug monitoring programs are associated with less opioid use in communities. Other studied interventions include multidisciplinary pain education for patients, an educational pamphlet for patients, implementation of an opioid safety initiative, provision of patient information and pain management training for clinicians, a bundle of educational modalities for clinicians, free prescription acetaminophen, a nationally mandated tamper-resistant opioid formulation, and motivational interview training for nursing students. Few intervention studies evaluated pain or other patient-centered outcomes such as disability and functioning. Conclusions The evidence base that is directly applicable to older adults who are prescribed opioids or have opioid-related disorders is limited. Fundamental research is necessary to determine which factors may predict clinically important, patient-centered, opioid-related outcomes. Studies to date have identified numerous possible factors associated with long-term opioid use (whether appropriate or not), but analyses of other opioid-related outcomes in older adults are relatively sparse. Research is also needed to identify interventions to reduce opioid prescribing where harms outweigh benefits (including screening tools), reduce opioid-related harms and disorders, and treat existing misuse or opioid use disorder among older adults.

Background Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise. Objective Here, we aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to “Terminologia Anatomica,” the internationally standardized terminology; and (3) compile standardized anatomic terms for improved communication and understanding. Study Design From inception of the study to April 6, 2018, MEDLINE database was used to search for 40 terms relevant to the posterior female pelvis and vulvar anatomy. Furthermore, 11 investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. In addition, 11 textbook chapters were included in the study. Definitions of all pertinent anatomic terms were extracted for review. Results Overall, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. “Terminologia Anatomica” has previously accepted 186 of these terms. Based on this literature review, we proposed the adoption of 11 new standardized anatomic terms, including 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the currently accepted term rectovaginal fascia or septum was identified as controversial and requires further research and definition before continued acceptance or rejection in medical communication. Conclusion This study highlighted the variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. Therefore, we recommended the use of standardized terminology to improve communication and education across medical and anatomic disciplines.

OBJECTIVE We aimed to systematically review the literature to describe sexual activity and function before and after prolapse surgery. DATA SOURCES We searched MEDLINE, EMBASE, and ClinicalTrials.gov databases from inception to April 2018. METHODS OF STUDY SELECTION Prospective, comparative studies of reconstructive pelvic organ prolapse (POP) surgeries that reported sexual function outcomes were included. Studies were extracted for population characteristics, sexual function outcomes, and methodologic quality. Data collected included baseline and postoperative sexual activity, dyspareunia, and validated sexual function questionnaire scores. Change in validated scores were used to categorize overall sexual function as improved, unchanged, or worsened after surgery. TABULATION, INTEGRATION, AND RESULTS The search revealed 3,124 abstracts and identified 74 articles representing 67 original studies. The overall quality of evidence was moderate to high. Studies reporting postoperative results found higher rates of sexual activity than studies reporting preoperative sexual activity in all POP surgeries except sacrospinous suspension, transvaginal mesh, and sacrocolpopexy. The prevalence of dyspareunia decreased after all prolapse surgery types. The risk of de novo dyspareunia ranged from 0% to 9% for all POP surgeries except posterior repair, which lacked sufficient data. Overall sexual function based on PISQ-12 (Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12) scores improved for mixed native tissue repairs, anterior repairs, uterosacral suspensions, sacrospinous suspensions, and sacrocolpopexy; scores were similar for posterior repairs, transvaginal mesh, and biologic grafts. Sexual function did not worsen after any POP surgeries. CONCLUSION Sexual function improves or remains unchanged after all types of reconstructive POP surgeries and does not worsen for any surgery type. Prevalence of total dyspareunia was lower after all POP surgery types, and de novo dyspareunia was low ranging 0-9%. This information can help surgeons counsel patients preoperatively. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019124308.

Objective Review the analgesic effect of the transversus abdominis plane (TAP) block and its impact on postoperative pain scores and opioid usage for patients undergoing laparoscopic and robotic hysterectomies. Methods Systematic review with meta-analysis of randomized controlled trials that compared the effect of TAP block to either placebo or no block on narcotic use (in morphine equivalent units [MEq]) and pain (per visual analog scale) within 24] h after a laparoscopic or robotic hysterectomy for benign or malignant indications. Searches were conducted in PubMed and Embase through May 31, 2019. Results Nine randomized controlled trials met eligibility criteria; 7 evaluated laparoscopic hysterectomy and 2 robotic hysterectomy. A total of 688 subjects were included (559 laparoscopic hysterectomy, 129 robotic hysterectomy). Opioid consumption was similar in the first 24] h postoperative with or without TAP block (-0.8 MEq; 95% CI, -2.9, 1.3; 8 TAP arms; N] = 395). Pain scores (visual analog scale) were also similar with or without TAP block (-0.01 U; 95% CI, -0.34, 0.32; 10 TAP arms; N] = 636). Neither meta-analysis showed statistical heterogeneity across studies. Conclusions The evidence does not support a benefit of TAP block to reduce pain or opioid use for patients receiving laparoscopic or robotic hysterectomies.

CONTEXT: Adolescents with problematic substance use (SU) are at risk for far-reaching adverse outcomes. OBJECTIVE: Synthesize the evidence regarding the effects of brief behavioral interventions for adolescents (12–20 years) with problematic SU. DATA SOURCES: We conducted literature searches in Medline, the Cochrane Central Register of Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo through October 31, 2019. STUDY SELECTION: We screened 33 272 records and citations for interventions in adolescents with at least problematic SU, retrieved 1831 articles, and selected 22 randomized controlled trials of brief interventions meeting eligibility criteria for meta-analysis. DATA EXTRACTION: We followed Agency for Healthcare Research and Quality guidelines. We categorized brief interventions into components, including motivational interviewing (MI), psychoeducation, and treatment as usual. Outcomes included SU (abstinence, days used per month) for alcohol and cannabis, and substance-related problem scales. Strength of evidence (SoE) was assessed. RESULTS: Both pairwise and network meta-analyses were conducted by using random effects models. Compared to treatment as usual, the use of MI reduces heavy alcohol use days by 0.7 days per month (95% credible interval [CrI]: −1.6 to 0.02; low SoE), alcohol use days by 1.1 days per month (95% CrI −2.2 to −0.3; moderate SoE), and overall substance-related problems by a standardized net mean difference of 0.5 (95% CrI –1.0 to 0; low SoE). The use of MI did not reduce cannabis use days, with a net mean difference of −0.05 days per month (95% CrI: −0.26 to 0.14; moderate SoE). LIMITATIONS: There was lack of consistently reported outcomes and limited available comparisons. CONCLUSIONS: The use of MI reduces heavy alcohol use, alcohol use days, and SU-related problems in adolescents but does not reduce cannabis use days.

Background Sequalae of opioid misuse constitute a public health emergency in the United States. A robust evidence base informs the use of medication for opioid use disorders (MOUD) in adults, with far less research in transition-age youth. This systematic review evaluates the effectiveness of MOUD for transition-age youth (age 16 to 25). Methods This synthesis was part of a larger systematic review focused on adolescent substance use interventions. The study team conducted literature searches in MEDLINE, the Cochrane CENTRAL Registry of Controlled Trials, EMBASE, PsycINFO, and CINAHL through October 31, 2019. We screened studies, extracted data, and assessed risk of bias using standard methods. The primary and secondary outcomes were the effect of MOUD on opioid abstinence and treatment retention, respectively. Results The study team screened a total of 33,272 records and examined 1831 full-text articles. Four randomized trials met criteria for inclusion in the current analysis. All four trials assessed a combination of buprenorphine plus cognitive behavioral therapy versus a comparison condition. Some trials included additional behavioral interventions, and the specific duration/dosage of buprenorphine varied. Risk of bias was moderate for all studies. Studies found that buprenorphine was more effective than clonidine, effectively augmented by memantine, and that longer medication taper durations were more effective than shorter tapers in promoting both abstinence and retention. Notably, we did not identify any studies of methadone or naltrexone, adjunctive behavioral interventions were sparingly described, and treatment durations were far shorter than recommended guidelines in adults. Discussion The literature guiding youth MOUD is limited, and more research should evaluate the effectiveness of options other than buprenorphine, optimal treatment duration, and the benefit of adjunctive behavioral interventions. Subgroup analyses of extant randomized clinical trials could help to extend knowledge of MOUD effectiveness in this age cohort.