[Show abstract][Hide abstract] ABSTRACT: Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.
[Show abstract][Hide abstract] ABSTRACT: Background:
Acute pain frequently occurs after surgical procedures. Nicotine has been explored as an adjunctive medication for management of postoperative pain. OBJECTIVES: To assess the effect of transdermal or intranasal nicotine administration on postoperative pain, opioid analgesic use, and opioid-related adverse events. SEARCH METHODS: We searched MEDLINE (1966 to 20 March 2014), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 3), EMBASE (1980 to 20 March 2014), and also databases of ongoing trials (www.controlled-trials.com/ and http://clinicaltrials.gov/). We re-ran the search on 28 April 2015. We will assess the one study of interest when we update the review.
We included randomized, placebo-controlled clinical trials that evaluated the effects of perioperative (pre-, intra-, or postoperative) administration of nicotine on postoperative pain, opioid use, and opioid-related adverse events. We excluded all other studies.
Data collection and analysis:
Two authors independently screened all titles and abstracts for eligibility and documented reasons for exclusion. In case of disagreement, a third author decided on the inclusion or exclusion of a trial report. When additional information was needed in order to decide if a trial should be included, one of the authors contacted the corresponding author of the trial in question.
Nine trials (666 participants) evaluated nicotine for postoperative pain. Nicotine may reduce postoperative pain scores at 24 hours by a small amount compared with placebo (eight trials, mean difference -0.88 on a 0 to 10 scale, 95% confidence interval (CI) -1.58 to -0.18; low quality evidence). The effect on pain at one hour and 12 hours postoperatively was less certain (very low quality evidence). Statistical heterogeneity was substantial and not adequately explained by stratification of trials according to type of surgical procedure, smoking status, mode of nicotine administration, timing of administration, or assessed risk of bias. Excluding one trial at high risk of bias resulted in similar findings. The effect of nicotine on postoperative opioid use was uncertain due to small number of participants in the studies. Nicotine probably increases the risk of postoperative nausea (seven trials, RR 1.24, 95% CI 1.03 to 1.50; moderate quality evidence). Three trials assessed sedation but the effect is very uncertain due to the very low quality of evidence. We found no evidence that nicotine increased the risk of vomiting (seven studies, risk difference (RD) 0.03, 95% CI -0.04 to 0.09; low quality evidence). The results from one single small trial were insufficient to establish whether nicotine led to an earlier hospital discharge (very low quality evidence).
Based on evidence of generally low quality, nicotine may reduce postoperative pain at 24 hours compared with placebo, but the effects were relatively small (less than 1 point on a 10 point pain scale) and there was substantial heterogeneity in the results of our analyses. Nicotine does not appear to reduce postoperative use of opioids or opioid-related adverse events but probably increases the risk of nausea. More research is needed to determine the effectiveness of nicotine for postoperative pain and to understand the optimal timing, dose, and method of delivery of nicotine.
No preview · Article · Jan 2016 · Cochrane database of systematic reviews (Online)
[Show abstract][Hide abstract] ABSTRACT: Acute postoperative pain is a common clinical condition that when poorly controlled can result in a number of significant negative consequences. The American Pain Society (APS) commissioned an evidence-based guideline on the management of postoperative pain in in order to promote evidence-based, safe and effective perioperative pain management. An interdisciplinary panel developed 31 key questions and inclusion criteria to guide the evidence review. Investigators reviewed 6,556 abstracts from multiple electronic databases up to November 2012, an updated evidence review to October 2014 and key references suggested by expert reviewers. More than 800 primary studies not included in a systematic review and 107 systematic reviews were included. Despite a large body of evidence, a number of critical research gaps were identified where only low quality or insufficient evidence was found to help guide clinical practice recommendations. This report identifies evidence gaps including optimal methods and timing of perioperative patient education, nonpharmacological modalities, combinations of analgesic techniques, monitoring of patient response to treatment, techniques for neuraxial and regional analgesia, and organizational care delivery models. Recommendations to help guide the design of future perioperative studies are offered.
Full-text · Article · Dec 2015 · The journal of pain: official journal of the American Pain Society
[Show abstract][Hide abstract] ABSTRACT: Study Design. A systematic review. Objective. The aim of this study was to compare the effects of sequestrectomy versus conventional microdiscectomy for lumbar disc herniation (LDH). Summary of Background Data. Open surgery for LDH can be performed by sequestrectomy (removal of disc fragments) or conventional discectomy (removal of disc fragments and disc). Sequestrectomy might be associated with a higher risk of recurrence but less low back pain (LBP) after surgery. Methods. We searched MEDLINE and EMBASE from 1980 to November 2014. We selected randomized controlled trials (RCTs) and nonrandomized prospective studies of conventional discectomy versus sequestrectomy for adult patients with LDH that evaluated the following primary outcomes: radicular pain or LBP as measured by a visual analog scale, or neurological deficits of the lower extremity. We also evaluated the following secondary outcomes: complications of surgery, reherniation rate, duration of hospital stay, postoperative analgesic use, and health-related quality-of-life measures. Two authors independently reviewed citations and articles for inclusion. We assessed the risk of bias, synthesized data, and the level evidence using standard methodological procedures as recommended by the Cochrane Back Review Group. Results. We identified 5 studies (746 participants) of sequestrectomy versus microdiscectomy. One study was RCT and the other 4 were nonrandomized prospective comparisons; all studies were assessed as being at a high risk of bias. There were no significant differences for leg pain, LBP, functional outcomes, complications, and hospital stay or recurrence rate for 2 years (level of evidence: Low). Sequestrectomy was associated with less analgesic consumption versus discectomy (level of evidence: Very low). Conclusion. Sequestrectomy and standard microdiscectomy were associated with similar effects on pain after surgery, recurrence rate, functional outcome, and complications; more evidence is needed to determine whether sequestrectomy is associated with less postoperative analgesic consumption. Level of Evidence: 2
[Show abstract][Hide abstract] ABSTRACT: Background:
Urinary biomarkers may be a useful alternative or adjunct to cystoscopy for diagnosis of bladder cancer.
To systematically review the evidence on the accuracy of urinary biomarkers for diagnosis of bladder cancer in adults who have signs or symptoms of the disease or are undergoing surveillance for recurrent disease.
Ovid MEDLINE (January 1990 through June 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and reference lists.
57 studies that evaluated the diagnostic accuracy of quantitative or qualitative nuclear matrix protein 22 (NMP22), qualitative or quantitative bladder tumor antigen (BTA), fluorescent in situ hybridization (FISH), fluorescent immunohistochemistry (ImmunoCyt [Scimedx]), and Cxbladder (Pacific Edge Diagnostics USA) using cystoscopy and histopathology as the reference standard met inclusion criteria. Case-control studies were excluded.
Dual extraction and quality assessment of individual studies. Overall strength of evidence (SOE) was also assessed.
Across biomarkers, sensitivities ranged from 0.57 to 0.82 and specificities ranged from 0.74 to 0.88. Positive likelihood ratios ranged from 2.52 to 5.53, and negative likelihood ratios ranged from 0.21 to 0.48 (moderate SOE for quantitative NMP22, qualitative BTA, FISH, and ImmunoCyt; low SOE for others). For some biomarkers, sensitivity was higher for initial diagnosis of bladder cancer than for diagnosis of recurrence. Sensitivity increased with higher tumor stage or grade. Studies that directly compared the accuracy of quantitative NMP22 and qualitative BTA found no differences in diagnostic accuracy (moderate SOE); head-to-head studies of other biomarkers were limited. Urinary biomarkers plus cytologic evaluation were more sensitive than biomarkers alone but missed about 10% of bladder cancer cases.
Restricted to English-language studies; no search for studies published only as abstracts; statistical heterogeneity present in most analyses; few studies for qualitative NMP22, quantitative BTA, and Cxbladder; and methodological shortcomings in almost all studies.
Urinary biomarkers miss a substantial proportion of patients with bladder cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors.
Primary funding source:
Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014013284).
No preview · Article · Oct 2015 · Annals of internal medicine
[Show abstract][Hide abstract] ABSTRACT: Use of epidural corticosteroid injections is increasing.
To review evidence on the benefits and harms of epidural corticosteroid injections in adults with radicular low back pain or spinal stenosis of any duration.
Ovid MEDLINE (through May 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, prior systematic reviews, and reference lists.
Randomized trials of epidural corticosteroid injections versus placebo interventions, or that compared epidural injection techniques, corticosteroids, or doses.
Dual extraction and quality assessment of individual studies, which were used to determine the overall strength of evidence (SOE).
30 placebo-controlled trials evaluated epidural corticosteroid injections for radiculopathy, and 8 trials were done for spinal stenosis. For radiculopathy, epidural corticosteroids were associated with greater immediate-term reduction in pain (weighted mean difference on a scale of 0 to 100, -7.55 [95% CI, -11.4 to -3.74]; SOE, moderate), function (standardized mean difference after exclusion of an outlier trial, -0.33 [CI, -0.56 to -0.09]; SOE, low), and short-term surgery risk (relative risk, 0.62 [CI, 0.41 to 0.92]; SOE, low). Effects were below predefined minimum clinically important difference thresholds, and there were no longer-term benefits. Limited evidence showed no clear effects of technical factors, patient characteristics, or comparator interventions on estimates. There were no clear effects of epidural corticosteroid injections for spinal stenosis (SOE, low to moderate). Serious harms were rare, but harms reporting was suboptimal (SOE, low).
The review was restricted to English-language studies. Some meta-analyses were based on small numbers of trials (particularly for spinal stenosis), and most trials had methodological shortcomings.
Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.
No preview · Article · Aug 2015 · Annals of internal medicine
[Show abstract][Hide abstract] ABSTRACT: Method guideline for systematic reviews of trials of interventions for neck and back pain, and related spinal disordersObjective. To help authors design, conduct and report systematic reviews of trials in this field.
In 1997, the Cochrane Back Review Group editorial board published the Method Guideline for Systematic Reviews, which was updated in 2003 and in 2009. Since then, new methodologic evidence has emerged and standards have changed, therefore it was clear that revisions were needed to the 2009 guideline. In May 2015 the group changed its name to Cochrane Back and Neck (CBN).
The editorial board met in September 2014 to review the relevant new methodological evidence and determine how it should be incorporated. Members of the advisory board were consulted. Based on the feedback received an updated method guideline was prepared and approved by the editorial board.
We have updated recommendations in 7 categories: objectives, literature search, selection criteria, risk of bias assessment, data extraction, data analysis, and reporting of results and conclusions. Each category is classified into minimum criteria (mandatory) and further guidance (optional). This update also includes some new guidance for preparation of summary of finding tables and for conducting non-intervention reviews.
Citations of previous versions of the method guideline in published scientific articles (1193 in total) suggest that others may find this guideline useful to plan, conduct, or evaluate systematic reviews in the field of back and neck pain, and spinal disorders.
[Show abstract][Hide abstract] ABSTRACT: Study Design: This is a systematic review. Objective: This study aims to compare effects of sequestrectomy versus conventional microdiscectomy for lumbar disc herniation. Summary of Background data: Open surgery for LDH can be performed by sequestrectomy or conventional discectomy. Generally, it has been assumed that the former is associated with higher risk of recurrence and less radicular pain and low back pain after surgery. Methods: We searched MEDLINE and EMBASE from 1980 to November 2014. We selected randomized controlled trials (RCTs) and prospective studies that compared conventional discectomy versus sequestrectomy for adult patients with LDH and evaluated the following primary outcomes: radicular pain or LBP as measured by a visual analogue scale, neurological deficit of lower extremity. We also evaluated the following secondary outcomes: complications of surgery, reherniation rate, duration of hospital stay, postoperative analgesic use, and health-related quality of life measures. Two authors independently reviewed citations and articles for inclusion. We assessed the risk of bias as well as the level of evidence for each study, and we used standard methodological procedures recommended by the Cochrane Collaboration. Results: We identified five studies (746 participants) that met our inclusion criteria comparing sequestrectomy versus microdiscectomy. Comparison revealed that with low-quality evidence, there is no significant difference for radicular pain, LBP, functional outcome, complications, and hospital stay for 2 years. In addition, with moderate-quality evidence, there is no significant difference for recurrence rate. Meanwhile, there is very low-quality evidence that analgesic consumption is lower in sequestrectomy than micro/discectomy. Conclusion: Both interventions had similar effect on pain after surgery, recurrence rate, functional outcome, and complications; however, sequestrectomy may be superior in terms of postoperative analgesic consumption.
[Show abstract][Hide abstract] ABSTRACT: Several imaging modalities are available for diagnosis of hepatocellular carcinoma (HCC).
To evaluate the test performance of imaging modalities for HCC.
MEDLINE (1998 to December 2014), the Cochrane Library Database, Scopus, and reference lists.
Studies on test performance of ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI).
One investigator abstracted data, and a second investigator confirmed them; 2 investigators independently assessed study quality and strength of evidence.
Few studies have evaluated imaging for HCC in surveillance settings. In nonsurveillance settings, sensitivity for detection of HCC lesions was lower for ultrasonography without contrast than for CT or MRI (pooled difference based on direct comparisons, 0.11 to 0.22), and MRI was associated with higher sensitivity than CT (pooled difference, 0.09 [95% CI, 0.07 to 12]). For evaluation of focal liver lesions, there were no clear differences in sensitivity among ultrasonography with contrast, CT, and MRI. Specificity was generally 0.85 or higher across imaging modalities, but this item was not reported in many studies. Factors associated with lower sensitivity included use of an explanted liver reference standard, and smaller or more well-differentiated HCC lesions. For MRI, sensitivity was slightly higher for hepatic-specific than nonspecific contrast agents.
Only English-language articles were included, there was statistical heterogeneity in pooled analyses, and costs were not assessed. Most studies were conducted in Asia and had methodological limitations.
CT and MRI are associated with higher sensitivity than ultrasonography without contrast for detection of HCC; sensitivity was higher for MRI than CT. For evaluation of focal liver lesions, the sensitivities of ultrasonography with contrast, CT, and MRI for HCC are similar.
Agency for Healthcare Research and Quality. (PROSPERO: CRD42014007016).
Preview · Article · May 2015 · Annals of internal medicine
[Show abstract][Hide abstract] ABSTRACT: Screening for type 2 diabetes mellitus could lead to earlier identification and treatment of asymptomatic diabetes, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT), potentially resulting in improved outcomes.
To update the 2008 U.S. Preventive Services Task Force review on diabetes screening in adults.
Cochrane databases and MEDLINE (2007 through October 2014) and relevant studies from previous Task Force reviews.
Randomized, controlled trials; controlled, observational studies; and systematic reviews.
Data were abstracted by 1 investigator and checked by a second; 2 investigators independently assessed study quality.
In 2 trials, screening for diabetes was associated with no 10-year mortality benefit versus no screening (hazard ratio, 1.06 [95% CI, 0.90 to 1.25]). Sixteen trials consistently found that treatment of IFG or IGT was associated with delayed progression to diabetes. Most trials of treatment of IFG or IGT found no effects on all-cause or cardiovascular mortality, although lifestyle modification was associated with decreased risk for both outcomes after 23 years in 1 trial. For screen-detected diabetes, 1 trial found no effect of an intensive multifactorial intervention on risk for all-cause or cardiovascular mortality versus standard control. In diabetes that was not specifically screen-detected, 9 systematic reviews found that intensive glucose control did not reduce risk for all-cause or cardiovascular mortality and results for intensive blood pressure control were inconsistent.
The review was restricted to English-language articles, and few studies were conducted in screen-detected populations.
Screening for diabetes did not improve mortality rates after 10 years of follow-up. More evidence is needed to determine the effectiveness of treatments for screen-detected diabetes. Treatment of IFG or IGT was associated with delayed progression to diabetes.
Agency for Healthcare Research and Quality.
No preview · Article · Apr 2015 · Annals of internal medicine
[Show abstract][Hide abstract] ABSTRACT: Cardiac screening in adults with resting or stress electrocardiography, stress echocardiography, or myocardial perfusion imaging can reveal findings associated with increased risk for coronary heart disease events, but inappropriate cardiac testing of low-risk adults has been identified as an important area of overuse by several professional societies.
Narrative review based on published systematic reviews; guidelines; and articles on the yield, benefits, and harms of cardiac screening in low-risk adults.
Cardiac screening has not been shown to improve patient outcomes. It is also associated with potential harms due to false-positive results because they can lead to subsequent, potentially unnecessary tests and procedures. Cardiac screening is likely to be particularly inefficient in adults at low risk for coronary heart disease given the low prevalence and predictive values of testing in this population and the low likelihood that positive findings will affect treatment decisions. In this patient population, clinicians should focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise.
Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.
No preview · Article · Mar 2015 · Annals of internal medicine