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INTRODUCTION Barbed sutures are used in cesarean delivery with the intended benefits of better tissue approximation, hemostasis, and strength, as well as reduced operative time. A systematic review and meta-analysis was undertaken to assess the safety and efficacy of the use of barbed suture compared with conventional sutures in cesarean delivery. MATERIAL AND METHODS MEDLINE, EMBASE, PubMed, Scopus, Cochrane CENTRAL, and three clinical trial registries, were searched from inception to December 2019, without restriction by language or publication year. Randomized controlled trials comparing the use of barbed suture with conventional sutures in closure of any layer (uterine/fascial/skin) during cesarean delivery were included. The safety outcomes included estimated blood loss, pain, mortality, and other morbidity including infection, re-operation or re-admission. Effectiveness outcomes included closure time, need for additional suture and scar integrity. Study selection, data extraction, risk-of-bias, and quality assessment were independently performed by two authors. Primary analysis compared outcomes for all layers of surgical closure, whereas subgroup analysis was performed by individual layer. Pooled mean differences (MD) and risk ratios (RR) with 95% CI were calculated using a random effects model. Level of evidence was assessed using GRADE criteria. PROSPERO registration number: CRD42020168859. RESULTS The review included four trials (three comparing uterine closure and one comparing skin closure), at high risk of bias, representing 460 participants. Primary analysis showed no morbidity differences between two groups. The use of barbed suture for uterine closure was associated with shorter incision closure time (MD 110.58 seconds, 95% CI 93.79-127.36 seconds), shorter total surgical time (MD 1.92 minutes, 95% CI 0.03-3.80 minutes), and a reduced need for additional hemostatic sutures (RR 0.39, 95% CI 0.28-0.54), with no difference in estimated blood loss (MD 46.17 mL, 95% CI 13.55 to -105.89 mL) or postoperative morbidity (RR 0.96, 95% CI 0.46-2.01). The level of evidence was deemed to be low to very low, based on inconsistency and imprecision of results. CONCLUSIONS Barbed sutures may be a suitable alternative to conventional sutures for uterine closure because they reduce uterine repair time, total surgical time, and the need for additional hemostatic sutures, without an increase in blood loss or maternal morbidity.

INTRODUCTION To evaluate the effect of antibiotic regimens for chorioamnionitis on maternal and neonatal outcomes. MATERIAL AND METHODS We conducted a systematic review, wherein we searched six bibliographic databases until June 2020 and included randomized clinical trials describing antibiotic regimens for treating chorioamnionitis. Risk of bias was assessed using the Cochrane Risk of Bias tool V2.0. Random-effects meta-analysis was performed and results were presented as risk ratio (RR) and mean differences (MD) with 95% CI. RESULTS Fourteen trials at low-to-high risk of bias were included. Three trials (n = 244), comparing different intrapartum antibiotic regimens, showed no difference in outcomes except for lower composite maternal morbidity (endometritis, pneumonia, sepsis, blood transfusion, and ileus) with ampicillin/sulbactam vs ampicillin/gentamicin in one study (0/43 vs 6/49, P = .03). Three trials (n = 295) comparing different doses of intrapartum antibiotics showed no differences in maternal and neonatal outcomes, although one study showed a shorter duration of antibiotic treatment in the experimental arm (4 mg/kg gentamicin q24h + 1200 mg clindamycin q12h) vs conventional arm (1.33 mg/kg gentamicin + 800 mg clindamycin q8h) (48.0 ± 36 hours vs 55.2 ± 48 hours, P = .04). Four trials (n = 484) comparing postpartum antibiotics vs no antibiotics showed no difference in outcomes except for a shorter hospital stay (two studies, MD -7.90 hours, 95% CI -13.52 to -2.27 hours). Three trials (n = 447) comparing single vs multiple doses of postpartum antibiotics showed shorter hospital stay [MD -19.14 hours, 95% CI -29.88 to -8.41 hours), but no differences in treatment failure (RR 1.73, 95% CI 0.69-4.30) or total antibiotic dose (MD -9.24, 95% CI -19.49 to 1.01). One trial (n = 48) comparing intrapartum vs postpartum initiation of treatment found benefits to intrapartum (vs postpartum) initiation of antibiotics, in terms of postpartum maternal hospital stay (MD -24 hours, 95% CI -45.56 to -1.44 hours), neonatal hospital stay (MD -45.6 hours, -93.84 to -11.76 hours), and neonatal pneumonia or sepsis (RR 0.06, 95% CI 0.00-0.95). CONCLUSIONS Upon diagnosis of chorioamnionitis, there is limited evidence to recommend the prompt initiation of intrapartum antibiotics, and to consider a single dose of postpartum antibiotics over multiple doses or no treatment. Well-designed trials using standard definitions of chorioamnionitis, outcome measures, and newer antibiotics are required to inform clinical practice with regard to the preferred antibiotic regimen, dose, and duration to optimize maternal and neonatal outcomes.

Background Airway guidelines recommend an emergency surgical airway as a potential life-saving treatment in a “Can’t Intubate, Can’t Oxygenate” (CICO) situation. Surgical airways can be achieved either through a cricothyroidotomy or tracheostomy. The current literature has limited data regarding complications of cricothyroidotomy and tracheostomy in an emergency situation. The objective of this systematic review is to analyze complications following cricothyroidotomy and tracheostomy in airway emergencies. Methods This synthesis of literature was exempt from ethics approval. Eight databases were searched from inception to October 2018, using a comprehensive search strategy. Studies were included if they were randomized controlled trials or observational studies reporting complications following emergency surgical airway. Complications were classified as minor (evolving to spontaneous remission or not requiring intervention or not persisting chronically), major (requiring intervention or persisting chronically), early (from the start of the procedure up to 7 days) and late (beyond 7 days of the procedure). Results We retrieved 2659 references from our search criteria. Following the removal of duplicates, title and abstract review, 33 articles were selected for full-text reading. Twenty-one articles were finally included in the systematic review. We found no differences in minor, major or early complications between the two techniques. However, late complications were significantly more frequent in the tracheostomy group [OR (95% CI) 0.21 (0.20–0.22), p Conclusions Our results demonstrate that cricothyroidotomies performed in emergent situations resulted in fewer late complications than tracheostomies. This finding supports the recommendations from the latest Difficult Airway Society (DAS) guidelines regarding using cricothyroidotomy as the technique of choice for emergency surgical airway. However, emergency cricothyroidotomies should be converted to tracheostomies in a timely fashion as there is insufficient evidence to suggest that emergency cricothyrotomies are long term airways.

Importance Treatment with noninvasive oxygenation strategies such as noninvasive ventilation and high-flow nasal oxygen may be more effective than standard oxygen therapy alone in patients with acute hypoxemic respiratory failure. Objective To compare the association of noninvasive oxygenation strategies with mortality and endotracheal intubation in adults with acute hypoxemic respiratory failure. Data Sources The following bibliographic databases were searched from inception until April 2020: MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and LILACS. No limits were applied to language, publication year, sex, or race. Study Selection Randomized clinical trials enrolling adult participants with acute hypoxemic respiratory failure comparing high-flow nasal oxygen, face mask noninvasive ventilation, helmet noninvasive ventilation, or standard oxygen therapy. Data Extraction and Synthesis Two reviewers independently extracted individual study data and evaluated studies for risk of bias using the Cochrane Risk of Bias tool. Network meta-analyses using a bayesian framework to derive risk ratios (RRs) and risk differences along with 95% credible intervals (CrIs) were conducted. GRADE methodology was used to rate the certainty in findings. Main Outcomes and Measures The primary outcome was all-cause mortality up to 90 days. A secondary outcome was endotracheal intubation up to 30 days. Results Twenty-five randomized clinical trials (3804 participants) were included. Compared with standard oxygen, treatment with helmet noninvasive ventilation (RR, 0.40 [95% CrI, 0.24-0.63]; absolute risk difference, -0.19 [95% CrI, -0.37 to -0.09]; low certainty) and face mask noninvasive ventilation (RR, 0.83 [95% CrI, 0.68-0.99]; absolute risk difference, -0.06 [95% CrI, -0.15 to -0.01]; moderate certainty) were associated with a lower risk of mortality (21 studies [3370 patients]). Helmet noninvasive ventilation (RR, 0.26 [95% CrI, 0.14-0.46]; absolute risk difference, -0.32 [95% CrI, -0.60 to -0.16]; low certainty), face mask noninvasive ventilation (RR, 0.76 [95% CrI, 0.62-0.90]; absolute risk difference, -0.12 [95% CrI, -0.25 to -0.05]; moderate certainty) and high-flow nasal oxygen (RR, 0.76 [95% CrI, 0.55-0.99]; absolute risk difference, -0.11 [95% CrI, -0.27 to -0.01]; moderate certainty) were associated with lower risk of endotracheal intubation (25 studies [3804 patients]). The risk of bias due to lack of blinding for intubation was deemed high. Conclusions and Relevance In this network meta-analysis of trials of adult patients with acute hypoxemic respiratory failure, treatment with noninvasive oxygenation strategies compared with standard oxygen therapy was associated with lower risk of death. Further research is needed to better understand the relative benefits of each strategy.

The objective of this guideline from the Canadian Fertility and Andrology Society is to synthesize the evidence on preimplantation genetic testing for aneuploidies (PGT-A) using trophectoderm biopsy and 24-chromosome analysis and to provide clinical recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. To date, randomized controlled trials have been limited to good-prognosis patients who were able to generate two or more blastocysts for biopsy. In this specific population the GRADE analysis of PGT-A shows an increase in the implantation rate and ongoing pregnancy or delivery rate per transfer. Clearly, it is difficult to generalize from this subgroup of patients to the infertility population at large. As a result, the application of PGT-A should be individualized, and patient factors such as age and ability to generate embryos will influence decision-making. Comprehensive patient counselling and informed consent are imperative before undertaking PGT-A. Potential benefits must be weighed against the costs and limitations of the technology, including the risk of embryo damage, false positives, false negatives and the detection of embryonic mosaicism. Future research is required, especially with regard to the use of PGT-A in poorer prognosis patients, and with respect to reporting outcomes per cycle start and cumulatively per retrieval.

Study Objective To determine whether dienogest therapy after endometriosis surgery reduces the risk of endometriosis recurrence compared with expectant management. Data Sources Ovid MEDLINE, Ovid EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov, and International Standard Randomized Controlled Trial Number Registry were searched from inception to March 2019 for observational and randomized controlled trials. Methods of Study Selection The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Medical Subject Heading terms and keywords such as “dienogest,” “endometriosis,” and “recurrence” were used to identify relevant studies. Tabulation, Integration, and Results The search yielded 328 studies, 10 of which were eligible for inclusion, representing 1184 patients treated with dienogest and 846 expectantly managed controls. Among these studies, 9 looked exclusively at endometrioma recurrence, whereas 1 used reappearance of symptoms as evidence of disease recurrence. Data on both incidence of and time to recurrence of endometriosis were extracted. The incidence rate of endometriosis recurrence in patients treated with dienogest was 2 per 100 women over a mean follow-up of 29 months (95% confidence interval [CI], 1.43–3.11) versus 29 per 100 women managed expectantly over a mean follow-up of 36 months (95% CI, 25.66–31.74). The likelihood of recurrence was significantly reduced with postoperative dienogest (log odds −1.96, CI, −2.53 to −1.38, p Conclusion Patients receiving dienogest after conservative surgery for endometriosis had significantly lower risk of postoperative disease recurrence than those who were expectantly managed.

Background Acute hypoxemic respiratory failure is one of the leading causes of intensive care unit admission and is associated with high mortality. Noninvasive oxygenation strategies such as high-flow nasal cannula, standard oxygen therapy, and noninvasive ventilation (delivered by either face mask or helmet interface) are widely available interventions applied in these patients. It remains unclear which of these interventions are more effective in decreasing rates of invasive mechanical ventilation and mortality. The primary objective of this network meta-analysis is to summarize the evidence and compare the effect of noninvasive oxygenation strategies on mortality and need for invasive mechanical ventilation in patients with acute hypoxemic respiratory failure. Methods We will search key databases for randomized controlled trials assessing the effect of noninvasive oxygenation strategies in adult patients with acute hypoxemic respiratory failure. We will exclude studies in which the primary focus is either acute exacerbations of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. The primary outcome will be all-cause mortality (longest available up to 90 days). The secondary outcomes will be receipt of invasive mechanical ventilation (longest available up to 30 days). We will assess the risk of bias for each of the outcomes using the Cochrane Risk of Bias Tool. Bayesian network meta-analyses will be conducted to obtain pooled estimates of head-to-head comparisons. We will report pairwise and network meta-analysis treatment effect estimates as risk ratios and 95% credible intervals. Subgroup analyses will be conducted examining key populations including immunocompromised hosts. Sensitivity analyses will be conducted by excluding those studies with high risk of bias and different etiologies of acute respiratory failure. We will assess certainty in effect estimates using GRADE methodology. Discussion This study will help to guide clinical decision-making when caring for adult patients with acute hypoxemic respiratory failure and improve our understanding of the limitations of the available literature assessing noninvasive oxygenation strategies in acute hypoxemic respiratory failure. Systematic review registration PROSPERO CRD42019121755

Objectives To determine the impact of postoperative dienogest on recurrence of endometriosis following conservative surgery. Methods The following databases were searched from inception to March 2019: Ovid MEDLINE, Ovid EMBASE, PubMed (Non-Medline records only), EBM Reviews - Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov and International Standard Randomised Controlled Trial Number Registry. Observational and randomized controlled studies with pre-menopausal women undergoing conservative surgery for endometriosis followed by post-operative dienogest treatment for at least 6 months were included. Primary outcome was the rate of endometriosis/endometrioma recurrence. For studies with a comparator group, we compared post-operative suppression with dienogest to no treatment. Results After screening 328 studies, 10 met inclusion criteria (9 retrospective, 1 prospective) representing 2031 patients (1184 treated, 846 controls). Among patients treated with dienogest, there were 2.11 recurrences per 100 women (95% CI: 1.43 to 3.11, 10 studies, 1184 patients, I2 = 0% fixed effects model). Comparatively, those managed expectantly had a significantly higher incidence of disease recurrence (28.61 events/100 women; 95% CI: 25.66 to 31.74, 6 studies, 846 patients, I2 = 83% fixed effects model). The odds of recurrence were significantly lower in women treated with dienogest compared to those without postoperative medical treatment (log odds -1.96, 95% CI -2.53 to -1.38, p Conclusions Women treated with dienogest following conservative endometriosis surgery have a significantly lower rate of disease recurrence compared to those not receiving post-operative hormonal suppression.

Study Objective To determine the impact of postoperative hormonal suppression with dienogest on recurrence of endometriosis following conservative endometriosis surgery. Design We performed a meta-analysis and systematic review of observational (retrospective and prospective) studies and randomized controlled trials. Setting The following databases were search from inception to March 2019: Ovid MEDLINE, Ovid EMBASE, PubMed (Non-Medline records only), EBM Reviews - Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov and International Standard Randomised Controlled Trial Number Registry. Patients or Participants We included studies of pre-menopausal women undergoing conservative surgery for endometriosis followed by post-operative dienogest suppression for at least 6 months. Interventions Post-operative suppression with dienogest for at least 6 months duration. Measurements and Main Results Primary outcome was the rate of endometriosis/endometrioma recurrence on imaging. For studies with a comparator group, we compared post-operative suppression with dienogest to no treatment. We screened 361 studies and 11 met inclusion criteria (10 retrospective and 1 prospective cohort studies). These studies included 2243 patients (1314 treated with dienogest and 929 controls). Treatment duration ranged from 6 months to 79 months post-operatively. The mean follow-up period ranged from 6 months for 1 study to 60 months for another, with the remaining 9 studies reporting follow-up periods ranging from 12 months to 43 months. For patients treated with dienogest there were 3 recurrences per 100 women (2.92 events/100 women, 95% CI 2.08, 4.10; 11 studies, 1314 patients, I2=21%, fixed effects model). The odds of recurrence were significantly lower in women treated with dienogest compared to no post-operative hormonal suppression (Log odds -2.09, 95%CI -2.59, -1.59, p Conclusion Post-operative hormonal suppression with dienogest following endometriosis surgery is associated with a low overall recurrence rate, and is superior to no post-operative suppression.