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Background The timing at which venous thromboembolism (VTE) occurs after major surgery has major implications for the optimal duration of thromboprophylaxis. The aim of this study was to perform a systematic review and meta-analysis of the timing of postoperative VTE up to 4 weeks after surgery. Methods A systematic search of MEDLINE, Scopus, and CINAHL databases was performed between 1 January 2009 and 1 April 2022. Prospective studies that recruited patients who underwent a surgical procedure and reported at least 20 symptomatic, postoperative VTE events by time were included. Two reviewers independently selected studies according to the eligibility criteria, extracted data, and evaluated risk of bias. Data were analysed with a Poisson regression model, and the GRADE approach was used to rate the certainty of evidence. Results Some 6258 studies were evaluated, of which 22 (11 general, 5 urological, 4 mixed, and 2 orthopaedic postoperative surgical populations; total 1 864 875 patients and 24 927 VTE events) were eligible. Pooled evidence of moderate certainty showed that 47.1 per cent of the VTE events occurred during the first, 26.9 per cent during the second, 15.8 per cent during the third, and 10.1 per cent during the fourth week after surgery. The timing of VTE was consistent between individual studies. Conclusion Although nearly half of symptomatic VTE events in first 4 weeks occur during the first postoperative week, a substantial number of events occur several weeks after surgery. These data will inform clinicians and guideline developers about the duration of postoperative thromboprophylaxis.

Urinary incontinence (UI) is a common condition in elderly men causing a severe worsening of quality of life, and a significant cost for both patients and health systems.To report a practical, evidence-based, guideline on definitions, pathophysiology, diagnostic workup, and treatment options for men with different forms of UI.A comprehensive literature search, limited to studies representing high levels of evidence and published in the English language, was performed. Databases searched included Medline, EMBASE, and the Cochrane Libraries. A level of evidence and a grade of recommendation were assigned.UI can be classified into stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence. A detailed description of the pathophysiology and diagnostic workup has been reported. Simple clinical interventions, behavioural and physical modifications, and pharmacological treatments comprise the initial management for all kinds of UI. Surgery for SUI includes bulking agents, male sling, and compression devices. Surgery for UUI includes bladder wall injection of botulinum toxin A, sacral nerve stimulation, and cystoplasty/urinary diversion.This 2022 European Association of Urology guideline summary provides updated information on definition, pathophysiology, diagnosis, and treatment of male UI.Male urinary incontinence comprises a broad subject area, much of which has been covered for the first time in the literature in a single manuscript. The European Association of Urology Non-neurogenic Male Lower Urinary Tract Symptoms Guideline Panel has released this new guidance, with the aim to provide updated information for urologists to be able to follow diagnostic and therapeutic indications for optimising patient care.

Background. Overdiagnosis is an accepted harm of cancer screening, but studies of prostate cancer screening decision aids have not examined provision of information important in communicating the risk of overdiagnosis, including overdiagnosis frequency, competing mortality risk, and the high prevalence of indolent cancers in the population. Methods. We undertook a comprehensive review of all publicly available decision aids for prostate cancer screening, published in (or translated to) the English language, without date restrictions. We included all decision aids from a recent systematic review and screened excluded studies to identify further relevant decision aids. We used a Google search to identify further decision aids not published in peer reviewed medical literature. Two reviewers independently screened the decision aids and extracted information on communication of overdiagnosis. Disagreements were resolved through discussion or by consulting a third author. Results. Forty-one decision aids were included out of the 80 records identified through the search. Most decision aids ( n = 32, 79%) did not use the term overdiagnosis but included a description of it ( n = 38, 92%). Few ( n = 7, 17%) reported the frequency of overdiagnosis. Little more than half presented the benefits of prostate cancer screening before the harms ( n = 22, 54%) and only 16, (39%) presented information on competing risks of mortality. Only 2 ( n = 2, 5%) reported the prevalence of undiagnosed prostate cancer in the general population. Conclusion. Most patient decision aids for prostate cancer screening lacked important information on overdiagnosis. Specific guidance is needed on how to communicate the risks of overdiagnosis in decision aids, including appropriate content, terminology and graphical display. Highlights Most patient decision aids for prostate cancer screening lacks important information on overdiagnosis. Specific guidance is needed on how to communicate the risks of overdiagnosis.

To practice high quality healthcare, clinicians must be able to diagnose correctly, provide preventative and treatment interventions based on the best available evidence, and ensure decisions are consistent with patients’ values and preferences. The educational approaches to teaching evidence-based medicine (EBM) to ensure the clinical decisions reflect both the best evidence and patients’ values are, however, open to question. EBM experts devoted to optimising EBM education often suggest that to practice high-value, evidence-based care requires ensuring that clinicians are able to critically appraise original research studies, as well as systematic reviews. Critical appraisal includes addressing risk of bias, and that involves a careful reading of methods and results. If indeed optimal practice requires such critical appraisal, it naturally follows that in introducing EBM one should educate clinicians so that they can competently make risk of bias assessments of randomised trials and observational studies, and similarly assess the rigour of systematic reviews. Much—perhaps almost all—of the EBM educational community has adopted this position and, therefore, EBM lectures and workshops often have their primary focus on critical appraisal. These sessions usually involve detailed assessment of risk of bias by careful, critical reading of methods and results of research studies. The Centre for Evidence-Based Medicine website,1 presents critical appraisal as the systematic evaluation of clinical research papers and aims to answer the following questions: (1) does this study address a clearly focused question? (2) did the study use valid methods to address this question? (3) are the valid results of this study important? and (4) are these valid, important results applicable to my patient or population? If the answer to any of these questions is ‘no’, it is also stated on the website that ‘you can save yourself the trouble of reading the rest of it’. The second criterion represents the risk …

ObjectiveTo systematically compare the effect of direct oral anticoagulants and low molecular weight heparin for thromboprophylaxis on the benefits and harms to patients undergoing non-cardiac surgery.DesignSystematic review and network meta-analysis of randomised controlled trials.Data sourcesMedline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL), up to August 2021.Review methodsRandomised controlled trials in adults undergoing non-cardiac surgery were selected, comparing low molecular weight heparin (prophylactic (low) or higher dose) with direct oral anticoagulants or with no active treatment. Main outcomes were symptomatic venous thromboembolism, symptomatic pulmonary embolism, and major bleeding. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for network meta-analyses. Abstracts and full texts were screened independently in duplicate. Data were abstracted on study participants, interventions, and outcomes, and risk of bias was assessed independently in duplicate. Frequentist network meta-analysis with multivariate random effects models provided odds ratios with 95% confidence intervals, and GRADE (grading of recommendations, assessment, development, and evaluation) assessments indicated the certainty of the evidence.Results68 randomised controlled trials were included (51 orthopaedic, 10 general, four gynaecological, two thoracic, and one urological surgery), involving 45 445 patients. Low dose (odds ratio 0.33, 95% confidence interval 0.16 to 0.67) and high dose (0.19, 0.07 to 0.54) low molecular weight heparin, and direct oral anticoagulants (0.17, 0.07 to 0.41) reduced symptomatic venous thromboembolism compared with no active treatment, with absolute risk differences of 1-100 per 1000 patients, depending on baseline risks (certainty of evidence, moderate to high). None of the active agents reduced symptomatic pulmonary embolism (certainty of evidence, low to moderate). Direct oral anticoagulants and low molecular weight heparin were associated with a 2-3-fold increase in the odds of major bleeding compared with no active treatment (certainty of evidence, moderate to high), with absolute risk differences as high as 50 per 1000 in patients at high risk. Compared with low dose low molecular weight heparin, high dose low molecular weight heparin did not reduce symptomatic venous thromboembolism (0.57, 0.26 to 1.27) but increased major bleeding (1.87, 1.06 to 3.31); direct oral anticoagulants reduced symptomatic venous thromboembolism (0.53, 0.32 to 0.89) and did not increase major bleeding (1.23, 0.89 to 1.69).ConclusionsDirect oral anticoagulants and low molecular weight heparin reduced venous thromboembolism compared with no active treatment but probably increased major bleeding to a similar extent. Direct oral anticoagulants probably prevent symptomatic venous thromboembolism to a greater extent than prophylactic low molecular weight heparin.Systematic review registrationPROSPERO CRD42018106181.

To systematically review and meta-analyse the impact of bariatric surgery on obese patients with urinary incontinence (UI).A search of the Medical Literature Analysis and Retrieval System Online (MEDLINE), the Excerpta Medica dataBASE (EMBASE), Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed to June 2018 was performed using methods pre-published on the International Prospective Register of Systematic Reviews (PROSPERO). Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Studies comparing UI status in obese patients before and after bariatric surgery were included. Primary outcomes were the improvement or complete resolution of any UI, stress UI (SUI), and urgency UI (UUI). Secondary outcomes were validated UI questionnaire scores. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach assessed overall quality of evidence.In all, 33 cohort studies (2910 patients) were included (median follow-up 12 months). Bariatric surgery resulted in improvement or resolution of any UI in 56% (95% confidence interval [CI] 48-63%), SUI in 47% (95% CI 34-60%), and UUI in 53% (95% CI 32-73%) of patients. Moreover, bariatric surgery significantly decreased (P 0.001) questionnaire scores such as: the Urogenital Distress Inventory by 13.4 points (95% CI 7.2-19.6), International Consultation on Incontinence Questionnaire by 4.0 points (95% CI 2.3-5.7), and Incontinence Impact Questionnaire by 5.3 points (95% CI 3.9-6.6). However, worsening or new onset of UI was present in 3% of patients. The quality of evidence was very low for all outcomes.Half of obese patients report improvement or resolution of UI after bariatric surgery, but overall the quality of evidence is very low. Comparative studies examining the benefits of bariatric surgery in obese patients with UI are warranted.

To estimate the regression, persistence, and progression of untreated cervical intraepithelial neoplasia grade 2 (CIN2) lesions managed conservatively as well as compliance with follow-up protocols.Systematic review and meta-analysis.Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 1 January 1973 to 20 August 2016.Studies reporting on outcomes of histologically confirmed CIN2 in non-pregnant women, managed conservatively for three or more months.Two reviewers extracted data and assessed risk of bias. Random effects model was used to calculate pooled proportions for each outcome, and heterogeneity was assessed using IRates of regression, persistence, or progression of CIN2 and default rates at different follow-up time points (3, 6, 12, 24, 36, and 60 months).36 studies that included 3160 women were identified (seven randomised trials, 16 prospective cohorts, and 13 retrospective cohorts; 50% of the studies were at low risk of bias). At 24 months, the pooled rates were 50% (11 studies, 819/1470 women, 95% confidence interval 43% to 57%; IMost CIN2 lesions, particularly in young women (30 years), regress spontaneously. Active surveillance, rather than immediate intervention, is therefore justified, especially among young women who are likely to adhere to monitoring.PROSPERO 2014: CRD42014014406.

The Nocturia Think Tank (TT) met during the 2010 meeting of the International Consultation on Incontinence-Research Society to discuss present knowledge and future directions in care and research of this prominent component of the spectrum of lower urinary tract symptoms. Questions raised included whether nocturia should be re-defined as a function of its bother, effects on quality of life, and economic impact upon society. At issue is the need to delineate the determinants of successful nocturia management. The multifactorial nature of nocturia requires that progress in its treatment will be dependent upon the cooperative investigation on the part of urologists, urogynecologists, geriatricians, epidemiologists, medical economists and pharma. Areas for future avenues of research were outlined at the conclusion of the meeting. Wiley-Liss, Inc.

Although family studies have shown that male lower urinary tract symptoms (LUTS) are highly heritable, no systematic review exists of genetic polymorphisms tested for association with LUTS.To systematically review and meta-analyze studies assessing candidate polymorphisms/genes tested for an association with LUTS, and to assess the strength, consistency, and potential for bias among pooled associations.A systematic search of the PubMed and HuGE databases as well as abstracts of major urologic meetings was performed through to January 2013. Case-control studies reporting genetic associations in men with LUTS were included. Reviewers independently and in duplicate screened titles, abstracts, and full texts to determine eligibility, abstracted data, and assessed the credibility of pooled associations according to the interim Venice criteria. Authors were contacted for clarifications if needed. Meta-analyses were performed for variants assessed in more than two studies.We identified 74 eligible studies containing data on 70 different genes. A total of 35 meta-analyses were performed with statistical significance in five (ACE, ELAC2, GSTM1, TERT, and VDR). The heterogeneity was high in three of these meta-analyses. The rs731236 variant of the vitamin D receptor had a protective effect for LUTS (odds ratio: 0.64; 95% confidence interval, 0.49-0.83) with moderate heterogeneity (I(2)=27.2%). No evidence for publication bias was identified. Limitations include wide-ranging phenotype definitions for LUTS and limited power in most meta-analyses to detect smaller effect sizes.Few putative genetic risk variants have been reliably replicated across populations. We found consistent evidence of a reduced risk of LUTS associated with the common rs731236 variant of the vitamin D receptor gene in our meta-analyses.Combining the results from all previous studies of genetic variants that may cause urinary symptoms in men, we found significant variants in five genes. Only one, a variant of the vitamin D receptor, was consistently protective across different populations.

In late August 2011 the annual ICS meeting returned to Glasgow, for a week of Scottish themed socializing and scientific debate. In this overview of the scientific programme we have tried to highlight some of the themes of the meeting, looking at new directions for continence basic science, and focusing on abstracts with important implications for clinical practice.

The following is a report of the proceedings of the Nocturia Think Tank sessions of the annual International Consultation on Incontinence-Research Society, which took place June 13-15, 2011 in Bristol, UK. The report is organized into sections pertaining to the main topics of discussions having occurred at that meeting, centering on the relationship of nocturnal polyuria (NP) and nocturia but also synthesizing more current evidence advancing our knowledge of the diagnosis and management of nocturia. This article is not meant to be a comprehensive review on the subject of nocturia, a number of which are available in the recent literature. All authors were physically present during, or in a preliminary session just prior to, the meeting in Bristol.

Background: The risk of pregnancy-related venous thromboembolism (VTE) is increased in women with a history of thrombosis. Although antepartum low molecular weight heparin (LMWH) prophylaxis can reduce this risk; the baseline risk of recurrence and the absolute magnitude of the risk reduction with prophylaxis are uncertain. Further, LMWH prophylaxis is costly, burdensome, medicalizes pregnancy, and may increase the risk of bleeding. Therefore, uncertainty persists regarding the net benefit of thromboprophylaxis and recommendations about the use of antepartum LMWH should be sensitive to pregnant women’s values and preferences, which have not previously been studied. Methods: We undertook an international multicenter cross-sectional interview study that included women with a history of VTE who were pregnant, planning pregnancy, or might consider pregnancy in the future. Women were classified as high (5 to 10%) or low (1 to 5%) risk of recurrent antepartum VTE. We ascertained willingness to receive LMWH during pregnancy through direct choice exercises involving real-life scenarios using the participant’s estimated VTE (high or low) and bleeding risks, hypothetical scenarios (low, medium and high risk of recurrence) and a probability trade-off exercise. Study outcomes included the minimum absolute reduction in VTE risk at which women changed from declining to accepting LMWH, along with possible determinants of this threshold, and participant choice of management strategy in her real-life and the three hypothetical scenarios. Results: 123 women from seven centers in six countries participated. Using a fixed 16% VTE risk without prophylaxis, the mean threshold reduction in risk at which women were willing to use LMWH was 4.3% (95% CI, 3.5 – 5.1%). Pregnant women and those planning a pregnancy (compared to those who might consider pregnancy in the future) and those with less than 2 weeks of experience with using LMWH during pregnancy (compared to those with more experience) required a greater risk reduction to use prophylaxis. In the real life scenario, there was there a significant difference in the proportion of women choosing prophylaxis between those at high risk (87.1%) and low risk (60.0%) of recurrence (p=0.01). The proportion of women choosing to use LMWH prophylaxis was 65.1% for the low risk hypothetical scenario (4% risk of recurrence), 79.7% for the medium risk scenario (10% risk of recurrence) and 87.8% for the high risk scenario (16% risk of recurrence). Conclusions: Most women with prior VTE will choose prophylaxis during a subsequent pregnancy, regardless of whether they are categorized as high or low risk of recurrence. Nevertheless, 40% of lower risk women will decline LMWH, as will over 10% of high risk women. Thus, these results mandate individualized clinical decision-making for women considering LMWH use during pregnancy, and weak guideline recommendations for LMWH use that highlight the need for individualized decision-making. Disclosures No relevant conflicts of interest to declare.

Background Although decision aids (DA) can help to communicate evidence to patients, their production is time consuming, often not based on the best available evidence or rapidly outdated. Linking trustworthy guidelines and DA for shared-decision making could both overcome these limitations and enhance guideline dissemination. Objectives To test the feasibility of automatically translating any recommendations from GRADE guidelines into generic and interactive DA accessible on tablet computers for clinicians and their patients in the clinical encounter. Methods As part of the DECIDE project, we developed a framework for translating components of GRADE into DA, following the International Patient Decision Aid Standards. Using a recently published guideline, we implemented that framework in our MAGIC (Making Grade the Irresistible Choice) application – a prototype electronic guideline tool and publication platform that can automatically display recommendations in multilayered presentation formats. Results Our prototype was able to automatically translate a large number of GRADE recommendations and their supporting evidence into electronic and interactive DA. Preliminary results of user-testing in real patient-clinician interactions suggest that these DA can be used at the point of care to discuss estimates of treatment effects for patient relevant outcomes, confidence in estimates, burden of treatment, and cost issues. Discussion This study provides a proof-of-concept that components of GRADE recommendations can be interactively displayed in generic tools for interactive shared-decision making in a wide range of treatment alternatives. Implications for Guideline Developers/Users Our electronic DA offer promising opportunities to disseminate guidelines at the point of care.

[No abstract available]