How best to capture the impact of complementary therapies in palliative care: A systematic review to identify and assess the appropriateness and validity of multi-domain tools.

BACKGROUND: Complementary therapies are widely used in palliative care settings. Qualitative research found that people with advanced disease report a range of physical and psychological benefits from complementary therapies, however evidence of their effectiveness from clinical trials is inconclusive. This may be because trials are limited by use of inappropriate outcome measures. AIMS: To identify tools which capture the impact of massage, reflexology and aromatherapy in people with advanced disease. We (1) identified multi-domain tools used to evaluate these therapies in populations with any chronic health condition and (2) assessed whether tools were valid and psychometrically robust in populations with advanced disease. DESIGN: A two-stage systematic review was conducted using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines (PROSPERO: CRD42020161199). DATA SOURCES: Six databases were searched (August 2021). Study methodological quality, tool psychometric properties and evidence quality were assessed. A global comparison score was generated. RESULTS: Stage 1: 66 trials using 40 different multi-domain tools were identified. Stage 2: Of these tools, we identified papers for seven tools regarding development or validation in advanced disease populations. The majority of psychometric data were inconsistent or inconclusive. Data were mostly of low quality due to methodological issues. CONCLUSION: Of the tools identified, 'Functional Assessment of Cancer Therapy - General' appears to be the most suitable alternative tool against COMSIN criteria, for trials of massage, reflexology and aromatherapy in palliative care. Further tool validation is required before firm recommendations can be made. Co-development of a core outcome set could ensure relevant domains are assessed.

Prognostic decision-making about imminent death within multidisciplinary teams: a scoping review.

OBJECTIVE: To summarise evidence on how multidisciplinary team (MDTs) make decisions about identification of imminently dying patients. DESIGN: Scoping review. SETTING: Any clinical setting providing care for imminently dying patients, excluding studies conducted solely in acute care settings. DATA SOURCES: The databases AMED, CINAHL, Embase, MEDLINE, PsychINFO and Web of Science were searched from inception to May 2021.Included studies presented original study data written in English and reported on the process or content of MDT discussions about identifying imminently dying adult patients. RESULTS: 40 studies were included in the review. Studies were primarily conducted using interviews and qualitative analysis of themes.MDT members involved in decision-making were usually doctors and nurses. Some decisions focused on professionals recognising that patients were dying, other decisions focused on initiating specific end-of-life care pathways or clarifying care goals. Most decisions provided evidence for a partial collaborative approach, with information-sharing being more common than joint decision-making. Issues with decision-making included disagreement between staff members and the fact that doctors were often regarded as final or sole decision-makers. CONCLUSIONS: Prognostic decision-making was often not the main focus of included studies. Based on review findings, research explicitly focusing on MDT prognostication by analysing team discussions is needed. The role of allied and other types of healthcare professionals in prognostication needs further investigation as well. A focus on specialist palliative care settings is also necessary.

Timing of Etonogestrel Implant Insertion After Dilation and Evacuation: A Randomized Controlled Trial.

OBJECTIVE: To compare the 6-month use rate of the etonogestrel implant placed immediately after dilation and evacuation (D&E) with placement 2-4 weeks postprocedure. METHODS: This is a randomized controlled trial of women seeking abortion between 14 0/7 and 23 5/7 weeks of gestation and desiring the etonogestrel contraceptive implant at an urban family planning clinic. Participants were randomized to device insertion immediately after the D&E compared with delayed insertion in 2-4 weeks. The primary outcome was implant use rate at 6 months after insertion and was determined by follow-up phone interviews. Secondary outcomes included repeat pregnancy rates and method satisfaction. The sample size of 120 participants was calculated based on a power of 0.80 to demonstrate a 20% difference in implant use rates between groups assuming 40% of women overall are not using the device 6 months after the procedure. RESULTS: Between November 2015 and October 2016, 148 participants were enrolled. Seventy-three participants (49.3%) were randomized to and underwent immediate implant insertion after D&E. The remaining 75 (50.6%) were randomized to delayed insertion. There were no significant differences in sociodemographic characteristics between the groups. Placement rate was 100% in the immediate group compared with 42.7% in the delayed group (P<.01). At 6 months, 40 of 43 (93%) women from the immediate group who completed follow-up continued use of the implant, whereas 19 of 30 (63.3%) women from the delayed group who completed follow-up were using the device (P=.002). Follow-up rates were low at 58.9% in the immediate group compared with 40.0% in the delayed group. CONCLUSION: Women were more likely to be using the etonogestrel implant at 6 months after D&E if they underwent immediate compared with delayed insertion. The very high loss to follow-up rate makes it difficult to draw conclusions about acceptability of the device and pregnancy rates. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, 02037919.

Medication abortion failure in women with and without previous cesarean delivery.

OBJECTIVE: To investigate the association between previous cesarean delivery and medication abortion failure and the association between parity and failure. METHODS: Data were abstracted from 2035 consecutive charts of women who underwent medication abortion in 2011. All women were at 63 days gestation or less and received mifepristone 200mg orally and misoprostol 800 mcg buccally. We used multivariate logistic regression to assess the relationship between failure, defined as requiring either curettage or additional medication, and prior cesarean delivery. We also examined the relationship between failure and parity. RESULTS: Follow-up was available on 1609 (79%) patients. Overall, 4.5% of patients experienced failure. Neither cesarean delivery nor parity was associated with failure; 6.5% of women with prior cesarean delivery experienced failure, compared to 3.7% of nulliparous women [adjusted odds ratio (aOR), 1.79, 95% confidence interval (CI), 0.83-3.87]. With regard to parity, 4.7% of women with two or more previous births experienced failure, compared to 3.7% of nulliparous women (aOR, 1.07, 95% CI, 0.54-2.14). CONCLUSION: We did not find significant associations between prior cesarean delivery and failure or parity and failure. A previous study of patients who had received a less effective regimen reported significant associations between cesarean delivery and failure and parity and failure. While our results do not rule out the possibility of modest associations due to our limited statistical power, they are reassuring relative to previous findings. IMPLICATIONS: Our results suggest that if there are differences in women's odds of medication abortion failure by obstetric history, such differences are unlikely to be large. Providers and patients may factor this information into decision making about methods of pregnancy termination.

Prophylactic compared with therapeutic ibuprofen analgesia in first-trimester medical abortion: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of two oral analgesic regimens in first-trimester medical abortion. METHODS: We randomly assigned 250 participants undergoing first-trimester abortion with mifepristone and misoprostol at three clinics to two ibuprofen regimens: therapeutic (800 mg every 4-6 hours as needed for pain) or prophylactic (800 mg starting 1 hour before the misoprostol dose, then every 4-6 hours for 48 hours regardless of pain, then as needed). We asked each participant to record her maximum pain on a scale of 0-10 daily thereafter. RESULTS: Of participants assigned to the prophylactic and therapeutic regimens, 111 of 123 (90%) and 117 of 127 (92%), respectively, provided follow-up data. More than 80% of the participants in each group complied with their assigned treatment. Participants in the prophylactic group used substantially more ibuprofen than those in the therapeutic group (median of nine and four tablets, respectively). The mean maximum pain score was 7.1 in the prophylactic group and 7.3 in the therapeutic group (standard deviations 2.5 and 2.2, respectively); the difference was not statistically significant (P=.87, adjusted for site). Duration of pain, verbal pain ratings reported at follow-up, and use of other analgesics did not differ significantly by group (all P>.05). No significant benefit of the prophylactic regimen was apparent in any population subgroup. Abortion failure and ibuprofen side effects in the two groups were similar. CONCLUSION: We found no evidence that prophylactic administration of ibuprofen reduces pain severity or duration in first-trimester medical abortion. The average pain severity experienced by participants using both regimens was high. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01457521. LEVEL OF EVIDENCE: I.

Comparison of patient satisfaction with incision cosmesis after standard and minimally invasive total hip arthroplasty.

This study evaluated patient assessments and attitudes regarding incision cosmesis following standard and minimally invasive total hip arthroplasty 1 to 3 years postoperatively. A cosmesis questionnaire designed to elicit a score evaluating scar satisfaction was mailed to patients. Although the difference in total cosmesis score between the standard and minimally invasive groups was not statistically significant, patients with a standard incision had better scores at <1 year. One significant finding was worse responses in the minimal incision patients regarding sinking and curling of scar edges.