Low Strength Of Evidence Research Articles

Diagnosis and Treatment of Tethered Spinal Cord: A Systematic Review.

Tethered cord syndrome is associated with motor and sensory deficits. Our objective was to summarize evidence regarding the diagnosis, prophylactic surgery, symptomatic treatment, and repeat surgery of tethered spinal cord in a systematic review (CRD42023461296). We searched 13 databases, reference-mined reviews, and contacted authors to identify diagnostic accuracy studies and treatment studies published until March 2024. One reviewer abstracted data, and a content expert checked the data for accuracy. We assessed the risk of bias, strength of evidence (SoE), and applicability. The evidence base includes 103 controlled studies, many with risk of bias and applicability concerns, and 355 case series providing additional clinical information. We found moderate SoE for MRI diagnosing tethered spinal cord, with medium to high diagnostic sensitivity and specificity. A small number of prophylactic surgery studies suggested motor function benefits and stability of neurologic status over time, but also complications such as surgical site infection (low SoE). A larger body of evidence documents treatments for symptomatic patients; studies revealed improvement in neurologic status after surgical detethering (low SoE), but also postoperative complications such as cerebrospinal fluid leakage (moderate SoE). A small body of evidence exists for retethering treatment (low or insufficient SoE for all outcomes). There was insufficient evidence for key outcomes (eg, over- or undertreatment, clinical impact of diagnostic modalities, ambulation, quality of life). This comprehensive overview informs difficult clinical decisions that parents and their children with tethered spinal cords, as well as their health care providers, face.

Does pain influence control of muscle force? A systematic review and meta-analysis.

In the presence of pain, whether clinical or experimentally induced, individuals commonly show impairments in the control of muscle force (commonly known as force steadiness). In this systematic review and meta-analysis, we synthesized the available evidence on the influence of clinical and experimental pain on force steadiness. MEDLINE, EMBASE, PubMed, CINAHL Plus and Web of Science databases were searched from their inception to 19 December 2023, using MeSH terms and pre-selected keywords related to pain and force steadiness. Two independent reviewers screened studies for inclusion and assessed their methodological quality using a modified Newcastle-Ottawa risk of bias tool. In total, 32 studies (19 clinical pain and 13 experimental pain) were included. Meta-analyses revealed reduced force steadiness in the presence of clinical pain as measured by the coefficient of variation (CoV) and standard deviation (SD) of force (standardized mean difference; SMD = 0.80, 95% CI = 0.31-1.28 and SMD = 0.61, 95% CI = 0.11-1.11). These findings were supported by moderate and low strength of evidence respectively. In the presence of experimental pain, meta-analyses revealed reductions in force steadiness when measured by the CoV of force but not by the SD of force (SMD = 0.50, 95% CI = 0.01-0.99; and SMD = 0.44, 95% CI = -0.04 to 0.92), each supported by very low strength of evidence. This work demonstrates that pain, particularly clinical pain, impairs force steadiness. Such impairments likely have clinical relevance and could become targets for treatment when managing people experiencing musculoskeletal pain. This systematic review and meta-analyses enhances our understanding of motor impairments observed in people experiencing musculoskeletal pain. It underscores the significance of incorporating force steadiness assessment when managing individuals experiencing musculoskeletal pain. Additionally, it suggests that future research should explore the potential benefits of force steadiness training in alleviating patients' symptoms and enhancing their functional performance. This could potentially lead to the development of innovative therapeutic approaches for individuals suffering from musculoskeletal pain.

Treatment of Stages I-III Squamous Cell Anal Cancer: A Comparative Effectiveness Systematic Review.

To assess the effectiveness and harms of initial treatment strategies for stages I-III anal squamous cell cancer (SCC). We searched Medline®, Embase®, and CENTRAL®, between January 1, 2000- March 2024, for randomized controlled trials and nonrandomized studies of interventions comparing initial treatment strategies. Individual study risk of bias (RoB) and overall strength of evidence (SOE) were evaluated for a prespecified outcome list using standardized methods. We identified 33 eligible studies and extracted data. Six were deemed low/moderate RoB. Compared with radiotherapy (RT) alone, chemoradiotherapy (CRT) with 5-fluorouracil (FU) and mitomycin C (MMC) probably shows a benefit in locoregional failure (LRF), disease-specific (DSS), and colostomy-free survival (CFS) (moderate SOE) yet may result in greater overall and acute hematologic toxicity, with no difference in late harms (low SOE). CRT with 5FU+MMC may show a benefit in LRF, DSS, and CFS rates compared with 5FU alone (low SOE). CRT with 5FU+cisplatin vs 5FU+MMC probably results in no differences in several effectiveness outcomes or overall acute or late harms, and probably increases hematologic toxicity with MMC (moderate SOE). Compared with CRT using capecitabine+MMC, CRT with capecitabine+MMC+paclitaxel may improve OS, DSS, and CFS, yet cause more acute harms (low SOE). Evidence was insufficient for remaining comparisons. CRT with 5FU+MMC or 5FU+cisplatin is likely more effective yet incurs greater acute hematologic toxicity than RT alone or single-agent CRT. Adding paclitaxel to capecitabine+MMC may increase treatment efficacy and toxicity. Evidence is insufficient comparing post-treatment surveillance strategies and patient-reported outcomes, highlighting research opportunities.

Delivery Strategies for Postpartum Care: A Systematic Review and Meta-analysis.

To systematically review the effects of postpartum health care-delivery strategies on health care utilization and maternal outcomes. We searched Medline, EMBASE, CENTRAL, CINAHL, and ClinicalTrials.gov for studies in the United States or Canada from inception to November 16, 2022. We used duplicate screening for studies comparing health care-delivery strategies for routine postpartum care on health care utilization and maternal outcomes. We selected health care utilization, clinical, and harm outcomes prioritized by stakeholder panels. We found 64 eligible studies (50 randomized controlled trials, 14 nonrandomized comparative studies; N=543,480). For general postpartum care, care location (clinic, at home, by telephone) did not affect depression or anxiety symptoms (low strength of evidence), and care integration (by multiple types of health care professionals) did not affect depression symptoms or substance use (low strength of evidence). Providing contraceptive care earlier (compared with later) was associated with greater implant use at 6 months (summary effect size 1.36, 95% CI 1.13-1.64) (moderate strength of evidence). Location of breastfeeding care did not affect hospitalization, other unplanned care utilization, or mental health symptoms (all low strength of evidence). Peer support was associated with higher rates of any or exclusive breastfeeding at 1 month and any breastfeeding at 3-6 months (summary effect size 1.10-1.22) but not other breastfeeding measures (all moderate strength of evidence). Care by a lactation consultant was associated with higher breastfeeding rates at 6 months (summary effect size 1.43, 95% CI 1.07-1.91) but not exclusive breastfeeding (all moderate strength of evidence). Use and nonuse of information technology for breastfeeding care were associated with comparable rates of breastfeeding (moderate strength of evidence). Testing reminders for screening or preventive care were associated with greater adherence to oral glucose tolerance testing but not random glucose or hemoglobin A 1c testing (moderate strength of evidence). Various strategies have been shown to improve some aspects of postpartum care, but future research is needed on the most effective care delivery strategies to improve postpartum health. PROSPERO, CRD42022309756 .

A Systematic Review of the Impact of Remote Working Referenced to the Concept of Work-Life Flow on Physical and Psychological Health.

COVID-19 accelerated the adoption of remote working in which employers' obligations for employees' health and well-being extended into the home. This paper reports on a systematic review of the health impacts of remote working within the context of COVID-19 and discusses the implications of these impacts for the future role of the occupational health nurse. The review protocol was registered with PROSPERO (CRD42021258517) and followed the PRISMA guidelines. The review covered 2020-2021 to capture empirical studies of remote working during the COVID-19 pandemic, their physical and psychological impacts and mediating factors. Eight hundred and thirty articles were identified. After applying the inclusion criteria, a total of 34 studies were reviewed. Most studies showed low to very low strength of evidence using the GRADE approach. A minority of studies had high strength of evidence. These focused on the reduced risk of infection and negative effects in terms of reduced physical activity, increased sedentary activity, and increased screen time. The synergy of work and personal well-being with the accelerated expansion of remote working suggests a more active role in the lives of workers within the home setting on the part of occupational health nurses. That role relates to how employees organize their relationship to work and home life, promoting positive lifestyles while mitigating adverse impacts of remote working on personal well-being.

Health Insurance Coverage and Postpartum Outcomes in the US

Approximately half of postpartum individuals in the US do not receive any routine postpartum health care. Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care. To assess whether health insurance coverage extension or improvements in access to health care are associated with postpartum health care utilization and maternal outcomes within 1 year post partum. Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov were searched for US-based studies from inception to November 16, 2022. The reference lists of relevant systematic reviews were scanned for potentially eligible studies. Risk of bias was assessed using questions from the Cochrane Risk of Bias tool and the Risk of Bias in Nonrandomized Studies of Interventions tool. Strength of evidence (SoE) was assessed using the Agency for Healthcare Research and Quality Methods Guide. A total of 25 973 citations were screened and 28 mostly moderate-risk-of-bias nonrandomized studies were included (3 423 781 participants) that addressed insurance type (4 studies), policy changes that made insurance more comprehensive (13 studies), policy changes that made insurance less comprehensive (2 studies), and Medicaid expansion (9 studies). Findings with moderate SoE suggested that more comprehensive association was likely associated with greater attendance at postpartum visits. Findings with low SoE indicated a possible association between more comprehensive insurance and fewer preventable readmissions and emergency department visits. The findings of this systematic review suggest that evidence evaluating insurance coverage and postpartum visit attendance and unplanned care utilization is, at best, of moderate SoE. Future research should evaluate clinical outcomes associated with more comprehensive insurance coverage.

Major Update 2: Antibody Response and Risk for Reinfection After SARS-CoV-2 Infection-Final Update of a Living, Rapid Review.

The durability of the antibody response after SARS-CoV-2 infection and the role of antibodies in protection against reinfection are unclear. To synthesize evidence on the SARS-CoV-2 antibody response and reinfection risk with a focus on gaps identified in our prior reports. MEDLINE (Ovid), EMBASE, CINAHL, World Health Organization Research Database, and reference lists from 16 December 2021 through 8 July 2022, with surveillance through 22 August 2022. English-language, cohort studies evaluating IgG antibody duration at least 12 months after SARS-CoV-2 infection, the antibody response among immunocompromised adults, predictors of nonseroconversion, and reinfection risk. Two investigators sequentially extracted study data and rated quality. Most adults had IgG antibodies after SARS-CoV-2 infection at time points greater than 12 months (low strength of evidence [SoE]). Although most immunocompromised adults develop antibodies, the overall proportion with antibodies is lower compared with immunocompetent adults (moderate SoE for organ transplant patients and low SoE for patients with cancer or HIV). Prior infection provided substantial, sustained protection against symptomatic reinfection with the Delta variant (high SoE) and reduced the risk for severe disease due to Omicron variants (moderate SoE). Prior infection was less protective against reinfection with Omicron overall (moderate SoE), but protection from earlier variants waned rapidly (low SoE). Single review for abstract screening and sequential review for study selection, data abstraction, and quality assessment. Evidence for a sustained antibody response to SARS-CoV-2 infection is considerable for both Delta and Omicron variants. Prior infection protected against reinfection with both variants, but, for Omicron, protection was weaker and waned rapidly. This information may have limited clinical applicability as new variants emerge. Agency for Healthcare Research and Quality. (PROSPERO: CRD42020207098).

Prognostic factors for persistent pain after a distal radius fracture: a systematic review.

The aim of this systematic review was to synthesize the evidence regarding prognostic factors for persistent pain, including Complex Regional Pain Syndrome (CRPS), after a distal radius fracture (DRF), a common condition after which persistent pain can develop. Medline, Pubmed, Embase, Psychinfo, CINAHL, BNI, AMED and the Cochrane Register of Clinical Trials were searched from inception to May 2021 for prospective longitudinal prognostic factor studies investigating persistent pain in adults who had sustained a DRF. The Quality in Prognostic Studies (QUIPS) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework were used to assess the strength of evidence. A search yielded 440 studies of which 7 studies met full eligibility criteria. From five studies we found low evidence for high baseline pain or an ulnar styloid fracture as prognostic factors for persistent pain, and very low evidence for diabetes or older age. From two studies, investigating an outcome of CRPS, there was low evidence for high baseline pain, slow reaction time, dysynchiria, swelling and catastrophising as prognostic factors, and very low evidence for depression. Sex was found not to be a prognostic factor for CRPS or persistent pain. The associations between prognostic factors and persistent pain following a DRF are unclear. The small number of factors investigated in more than one study, along with poor reporting and methodological limitations contributed to an assessment of low to very low strength of evidence. Further prospective studies, investigating psychosocial factors as candidate predictors of multidimensional pain outcomes are recommended.

Maternal, Infant, and Child Health Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children : A Systematic Review.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is intended to improve maternal and child health outcomes. In 2009, the WIC food package changed to better align with national nutrition recommendations. To determine whether WIC participation was associated with improved maternal, neonatal-birth, and infant-child health outcomes or differences in outcomes by subgroups and WIC enrollment duration. Search (January 2009 to April 2022) included PubMed, Embase, CINAHL, ERIC, Scopus, PsycInfo, and the Cochrane Central Register of Controlled Trials. Included studies had a comparator of WIC-eligible nonparticipants or comparison before and after the 2009 food package change. Paired team members independently screened articles for inclusion and evaluated risk of bias. We identified 20 observational studies. We found: moderate strength of evidence (SOE) that maternal WIC participation during pregnancy is likely associated with lower risk for preterm birth, low birthweight infants, and infant mortality; low SOE that maternal WIC participation may be associated with a lower likelihood of inadequate gestational weight gain, as well as increased well-child visits and childhood immunizations; and low SOE that child WIC participation may be associated with increased childhood immunizations. We found low SOE for differences in some outcomes by race and ethnicity but insufficient evidence for differences by WIC enrollment duration. We found insufficient evidence related to maternal morbidity and mortality outcomes. Data are from observational studies with high potential for selection bias related to the choice to participate in WIC, and participation status was self-reported in most studies. Participation in WIC was likely associated with improved birth outcomes and lower infant mortality, and also may be associated with increased child preventive service receipt. Agency for Healthcare Research and Quality. (PROSPERO: CRD42020222452).

Photobiomodulation effects on Achilles tendon pain: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND: Achilles tendon pain is present in tendons’ non-rupture injuries usually exacerbated by mechanical loading (i.e., overuse injury).Photobiomodulation is a light therapy that may reduce pain in tendinopathy. AIM: This systematic review and meta-analysis of randomized clinical trials tested the acute and chronic effects of photobiomodulation on Achilles tendon pain. METHOD: Randomized clinical trials were included comparing photobiomodulation with a control group in patients with Achilles tendon pain.The search included MEDLINE (Pubmed), SCOPUS, EMBASE, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials (Cochrane CENTRAL), LILACS, and Science Direct databases, and manual search until November 2021.The bias’s risk was assessed by the Cochrane Collaboration bias risk assessment tool and PEDro scale, while the level of evidence strength by the GRADE. Quantitative analysis through meta-analyzes was performed. The protocol was registered (PROSPERO-CRD42018091509). RESULTS: The search yielded 3.239 papers in the seven databases. Five studies were included after screening, eliminating duplicates, and applying eligibility criteria, and three were included in the meta-analysis. The meta-analysis (n=79) showed no photobiomodulation acute and chronic effects compared with control group on Achilles tendon pain (p= 0.45, SMD: 0.28). In the qualitative analysis, three studies showed a high risk, and two studies a low risk of bias in all characteristics. GRADE analysis showed very low- to low-quality evidence of the studies. CONCLUSION: There is no photobiomodulation effect in Achilles tendon pain. Due to the very low and low strength of evidence, new studies with better methodological quality should be conducted to improve the level of evidence.

Simple Wound Closure for Civilian Cranial Gunshot Wounds: A Systematic Literature Review.

Civilian cranial gunshot wounds are common injuries associated with significant morbidity and mortality. Simple wound closure has been previously proposed as an alternative treatment option for a small subset of patients, but the exact outcomes of this strategy are not well-defined. The objective of this paper was to describe the scientific literature reporting simple wound closure of civilian cranial gunshot wounds, its effect on short-term and long-term neurologic outcomes, and rates of seizures and infections. A systematic literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The strength of evidence was assessed using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria. Seventeen studies were found that met inclusion criteria. There was very low strength of evidence that patients treated with simple wound closure can achieve good short and long-term neurologic outcomes. There was very low strength of evidence that simple wound closure has a higher incidence of mortality compared to operative intervention, especially in patients with initial low Glasgow Coma Scale (GCS) scores. There was very low strength of evidence that patients treated with simple wound closure have a small risk of subsequently developing infections or seizures. In conclusion, under most circumstances, neurosurgical operative intervention should be viewed as the optimal treatment for salvageable civilian cranial gunshot wound patients. However, our literature review showed that simple wound closure is safe and viable. More data are needed to determine the appropriate clinical scenario for using this alternative option.

Surgical versus medical treatment for infective endocarditis in patients on dialysis: a systematic review and meta-analysis

Infective endocarditis (IE) is a serious infection and causes significant morbidity and mortality. However, the benefit of surgery for endocarditis besides antibiotic treatment in dialysis patients remains controversial. We performed a systematic review of studies published between 1960 and February 2022. Meta-analysis was conducted with a random-effects model to explore the in-hospital, 30, 60, 90, 180-d, and 1-year mortality rates in adult dialysis patients with IE. Sensitivity analysis, subgroup analysis, and meta-regression were performed to explore potential sources of heterogeneity. Confidence of evidence was evaluated by the GRADE system. Thirteen studies were included. The pooled odds ratio of in-hospital mortality was 0.62 (95% confidence interval [CI]: 0.30–1.28, p = .17), with moderate heterogeneity (I 2 = 62%, p < .01). Three studies reported 30-d mortality, and the pooled odds ratio for surgery compared with medical treatment was even lower (0.36; 95% CI: 0.22–0.61, p < .01), with low heterogeneity (I 2 = 0%, p = .86). With studies on fewer than 30 patients excluded, the sensitivity analysis revealed a low odds ratio of in-hospital mortality for surgery versus medical treatment (0.52; 95% CI: 0.27–0.99, p = .047), with moderate heterogeneity (I 2 = 63%, p < .01). Subgroup analysis revealed no significant differences between any two comparator subgroups. Based on a very low strength of evidence, compared with medical treatment, surgical treatment for IE in patients on dialysis is not associated with lower in-hospital mortality. When studies on fewer than 30 patients were excluded, surgical treatment was associated with better survival.

Telehealth for Substance Use Disorders: A Rapid Review for the 2021 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Management of Substance Use Disorders.

Approximately 20.4 million Americans met criteria for a substance use disorder (SUD) in 2019; however, only about 12.2% of persons with an SUD receive specialty care. Telehealth offers alternatives to traditional forms of substance use treatment. To synthesize recent findings on the efficacy of telehealth for SUDs. MEDLINE, Embase, PubMed, and the Cochrane Library from January 2015 through August 2021 (English language only). Randomized controlled trials (RCTs) of adults with a diagnosis of SUD based on the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases. One investigator abstracted data and assessed study quality, and a second checked for accuracy. This rapid review synthesized evidence from 17 RCTs. Evidence is very uncertain that telehealth provided as videoconference therapy (1 RCT) or web-based cognitive behavioral therapy (CBT) (3 RCTs) has similar effects to in-person therapy for improving abstinence from alcohol or cannabis. Low-strength evidence suggests that web-based CBT has similar effects for improving abstinence in multiple SUDs (2 RCTs). Low-strength evidence suggests that adding supportive text messaging to follow-up care improves abstinence and amount of alcohol per day (2 RCTs) but does not improve emergency department visits or frequency of consumption (2 RCTs). Enhanced telephone monitoring likely reduces readmissions for SUD detoxification compared with usual follow-up alone (1 RCT) but does not reduce days of substance use (low-strength evidence). Narrative synthesis, heterogeneity of telehealth interventions, no assessment of publication bias, and study methodology. Evidence is very uncertain that telehealth is similar to in-person care for SUD outcomes. Limited evidence suggests some benefit of adding telehealth to usual SUD care. U.S. Department of Veterans Affairs Veterans Health Administration.

Implant-based Breast Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis.

Background:Women undergoing implant-based reconstruction (IBR) after mastectomy for breast cancer have numerous options, including timing of IBR relative to radiation and chemotherapy, implant materials, anatomic planes, and use of human acellular dermal matrices. We conducted a systematic review to evaluate these options.Methods: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 and strength of evidence (SoE) using standard methods.Results:We screened 15,936 citations. Thirty-six mostly high or moderate risk of bias studies (48,419 patients) met criteria. Timing of IBR before or after radiation may result in comparable physical, psychosocial, and sexual well-being, and satisfaction with breasts (all low SoE), and probably comparable risks of implant failure/loss or explantation (moderate SoE). No studies addressed timing relative to chemotherapy. Silicone and saline implants may result in clinically comparable satisfaction with breasts (low SoE). Whether the implant is in the prepectoral or total submuscular plane may not impact risk of infections (low SoE). Acellular dermal matrix use probably increases the risk of implant failure/loss or need for explant surgery (moderate SoE) and may increase the risk of infections (low SoE). Risks of seroma and unplanned repeat surgeries for revision are probably comparable (moderate SoE), and risk of necrosis may be comparable with or without human acellular dermal matrices (low SoE).Conclusions:Evidence regarding IBR options is mostly of low SoE. New high-quality research is needed, especially for timing, implant materials, and anatomic planes of implant placement.

Autologous Reconstruction after Mastectomy for Breast Cancer.

Background: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.Methods: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.Results: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).Conclusions: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.

Implant-based versus Autologous Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis.

Background:For women undergoing breast reconstruction after mastectomy, the comparative benefits and harms of implant-based reconstruction (IBR) and autologous reconstruction (AR) are not well known. We performed a systematic review with meta-analysis of IBR versus AR after mastectomy for breast cancer.Methods:We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies from inception to March 23, 2021. We assessed the risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods.Results:We screened 15,936 citations and included 40 studies (two randomized controlled trials and 38 adjusted nonrandomized comparative studies). Compared with patients who undergo IBR, those who undergo AR experience clinically significant better sexual well-being [summary adjusted mean difference (adjMD) 5.8, 95% CI 3.4–8.2; three studies] and satisfaction with breasts (summary adjMD 8.1, 95% CI 6.1–10.1; three studies) (moderate SoE for both outcomes). AR was associated with a greater risk of venous thromboembolism (moderate SoE), but IBR was associated with a greater risk of reconstructive failure (moderate SoE) and seroma (low SoE) in long-term follow-up (1.5–4 years). Other outcomes were comparable between groups, or the evidence was insufficient to merit conclusions.Conclusions:Most evidence regarding IBR versus AR is of low or moderate SoE. AR is probably associated with better sexual well-being and satisfaction with breasts and lower risks of seroma and long-term reconstructive failure but a higher risk of thromboembolic events. New high-quality research is needed to address the important research gaps.

Evaluation and Management After Acute Left-Sided Colonic Diverticulitis : A Systematic Review.

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).

Diagnostic Imaging and Medical Management of Acute Left-Sided Colonic Diverticulitis : A Systematic Review.

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).

Occupational Therapy and the IMPACT Act: Part 2. A Systematic Review of Evidence for Functional Status, Medication Reconciliation, and Skin Integrity Interventions.

Interventions that promote function, medication reconciliation, and skin integrity assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing health care costs. In this systematic review, we focus on three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: functional status, medication reconciliation, and skin integrity. We conducted a search of the literature published between 2009 and 2019 in CINAHL, Cochrane, MEDLINE, PsycINFO, OTseeker, and Scopus. We also hand searched the systematic reviews and meta-analyses in our search results for articles that met our inclusion criteria. Study Selection and Data Collection: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found 47 articles that address the three outcome areas. Regarding functional status, low strength of evidence is available for cognition and functional mobility interventions to support functional performance, moderate strength of evidence supports interventions for vision, and moderate evidence supports task-oriented and individualized interventions to promote activities of daily living (ADL) outcomes among people with neurological conditions. Strong strength of evidence supports individualized occupational therapy interventions focusing on medication adherence. Low strength of evidence was found for occupational therapy interventions to reduce pressure ulcers and promote skin integrity. Conclusion and Relevance: The evidence supports occupational therapy interventions to improve functional status in ADLs and medication management. Additional research is needed that examines the outcomes of occupational therapy interventions for other areas of function and skin integrity. What This Article Adds: We found evidence to support occupational therapy interventions that align with value-based measures in the three outcome areas of interest. The effectiveness of these interventions highlights the viability of occupational therapy as an essential profession and the worth of occupational therapy to the public, potential clients, and payers.

Occupational Therapy and the IMPACT Act: Part 1. A Systematic Review of Evidence for Fall Prevention and Reduction, Community Discharge and Reintegration, and Readmission Prevention Interventions.

Interventions that prevent falls, facilitate discharge after hospitalization, and reduce hospital readmissions assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing costs. In this systematic review, we address three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: prevention and reduction of falls, facilitation of community discharge and reintegration, and prevention of hospital readmission. We conducted a search of the literature published between 2009 and 2019. Study Selection and Data Collection: We developed operational definitions to help us identify articles that answered the search question for each outcome area. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found 53 articles that address the three outcome areas. Regarding the prevention and reduction of falls, low strength of evidence is available for interventions focusing on a single fall risk and for customized interventions addressing multiple risks. Moderate strength of evidence supports structured community fall risk prevention interventions. Low strength of evidence was found for community discharge and reintegration interventions that include physical activity and educational programming. Low to moderate strength of evidence was found for readmission prevention interventions for patients with four types of condition. Conclusion and Relevance: Several intervention themes in the three outcome areas of interest are supported by few studies or by studies with a moderate risk of bias. Additional research is needed that supports the value of occupational therapy interventions in these outcome areas. What This Article Adds: Our study provides important insights into the state of the evidence related to occupational therapy interventions to address three outcome areas of the IMPACT Act.