Depressive disorder subtypes, depressive symptom clusters, and risk of obesity and diabetes: A systematic review.

BACKGROUND: Overlapping but divided literatures suggest certain depression facets may pose greater obesity and diabetes risk than others. Our objectives were to integrate the major depressive disorder (MDD) subtype and depressive symptom cluster literatures and to clarify which facets are associated with the greatest cardiometabolic disease risk. METHODS: We conducted a systematic review of published studies examining associations of ≥2 MDD subtypes or symptom clusters with obesity or diabetes risk outcomes. We report which facets the literature is "in favor" of (i.e., having the strongest or most consistent results). RESULTS: Forty-five articles were included. Of the MDD subtype-obesity risk studies, 14 were in favor of atypical MDD, and 8 showed similar or null associations across subtypes. Of the symptom cluster-obesity risk studies, 5 were in favor of the somatic cluster, 1 was in favor of other clusters, and 5 were similar or null. Of the MDD subtype-diabetes risk studies, 7 were in favor of atypical MDD, 3 were in favor of other subtypes, and 5 were similar or null. Of the symptom cluster-diabetes risk studies, 7 were in favor of the somatic cluster, and 5 were similar or null. LIMITATIONS: Limitations in study design, sample selection, variable measurement, and analytic approach in these literatures apply to this review. CONCLUSIONS: Atypical MDD and the somatic cluster are most consistently associated with obesity and diabetes risk. Future research is needed to establish directionality and causality. Identifying the depression facets conferring the greatest risk could improve cardiometabolic disease risk stratification and prevention programs.

Longer-Term Mental Health Consequences of COVID-19 Infection: Moderation by Race and Socioeconomic Status.

OBJECTIVE: While evidence suggests that the mental health symptoms of COVID-19 can persist for several months following infection, little is known about the longer-term mental health effects and whether certain sociodemographic groups may be particularly impacted. This cross-sectional study aimed to characterize the longer-term mental health consequences of COVID-19 infection and examine whether such consequences are more pronounced in Black people and people with lower socioeconomic status. METHODS: 277 Black and White adults (age ≥ 30 years) with a history of COVID-19 (tested positive ≥ 6 months prior to participation) or no history of COVID-19 infection completed a 45-minute online questionnaire battery. RESULTS: People with a history of COVID-19 had greater depressive (d = 0.24), anxiety (d = 0.34), post-traumatic stress disorder (PTSD) (d = 0.32), and insomnia (d = 0.31) symptoms than those without a history of COVID-19. These differences remained for anxiety, PTSD, and insomnia symptoms after adjusting for age, sex, race, education, income, employment status, body mass index, and smoking status. No differences were detected for perceived stress and general psychopathology. People with a history of COVID-19 had more than double the odds of clinically significant symptoms of anxiety (OR = 2.22) and PTSD (OR = 2.40). Education, but not race, income, or employment status, moderated relationships of interest such that COVID-19 status was more strongly and positively associated with all the mental health outcomes for those with fewer years of education. CONCLUSION: The mental health consequences of COVID-19 may be significant, widespread, and persistent for at least 6 months post-infection and may increase as years of education decreases.

The Impact of Patient Race, Patient Socioeconomic Status, and Cognitive Load of Physician Residents and Fellows on Chronic Pain Care Decisions.

Social stereotypes are more likely to influence decision-making under conditions of high cognitive load (ie, mental workload), such as in medical settings. We examined how patient race, patient socioeconomic status (SES), physician cognitive load, and physician implicit beliefs about race and SES differences in pain tolerance impacted physicians' pain treatment decisions. Physician residents and fellows (N = 120) made treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the physicians were randomized to be interrupted during the decision task to make hypertension medication conversion calculations (high cognitive load group), while the other half completed the task without interruptions (low cognitive load group). Both groups were given equal time to make pain care decisions (2.5 minutes/patient). Results of multilevel ordinal logistic regression analyses indicated that physicians prescribed weaker analgesics to patients with high vs. low SES (odds ratio = .68, 95% confidence interval [.48, .97], P = .03). There was also a patient SES-by-cognitive load interaction (odds ratio = .56, 95% confidence interval [.31, 1.01], P = .05) that is theoretically and potentially practically meaningful but was not statistically significant at P < .05. These findings shed light on physician cognitive load as a clinically-relevant factor in the context of pain care quality and equity. PERSPECTIVE: These findings highlight the clinical relevance of physician cognitive load (eg, mental workload) when providing pain care for diverse patients. This line of work can support the development of interventions to manage physician cognitive load and its impact on pain care, which may ultimately help reduce pain disparities.

Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy.

PURPOSE: Lumbar spine surgery is associated with significant postoperative pain. The benefits of erector spinae plane blocks (ESPBs) combined with multimodal analgesia has not been adequately studied. We evaluated the analgesic effects of bilateral ESPBs as a component of multimodal analgesia after open lumbar laminectomy. METHODS: Analgesic effects of preoperative, bilateral, ultrasound-guided ESPBs combined with standardized multimodal analgesia (n = 25) was compared with multimodal analgesia alone (n = 25) in patients undergoing one or two level open lumbar laminectomy. Other aspects of perioperative care were similar. The primary outcome measure was cumulative opioid consumption at 24 h. Secondary outcomes included opioid consumption, pain scores, and nausea and vomiting requiring antiemetics on arrival to the post-anesthesia care unit (PACU), at 24 h, 48 h, and 72 h after surgery, as well as duration of the PACU and hospital stay. RESULTS: Opioid requirements at 24 h were significantly lower with ESPBs (31.9 ± 12.3 mg vs. 61.2 ± 29.9 mg, oral morphine equivalents). Pain scores were significantly lower with ESPBs in the PACU and through postoperative day two. Patients who received ESPBs required fewer postoperative antiemetic therapy (n = 3, 12%) compared to those without ESPBs (n = 12, 48%). Furthermore, PACU duration was significantly shorter with ESPBs (49.7 ± 9.5 vs. 79.9 ± 24.6 min). CONCLUSIONS: Ultrasound-guided, bilateral ESPBs, when added to an optimal multimodal analgesia technique, reduce opioid consumption and pain scores, the need for antiemetic therapy, and the duration of stay in the PACU after one or two level open lumbar laminectomy.

Cognitive-behavioral and mindfulness-based interventions for distress in patients with advanced cancer: A meta-analysis.

OBJECTIVE: Various psychosocial interventions have been developed to reduce distress and improve quality of life (QoL) in patients with advanced cancer, many of which are traditional cognitive-behavioral interventions (CBIs) or mindfulness-based interventions (MBIs). The aims of this meta-analysis were to determine and compare the overall effects of traditional CBIs and MBIs on distress and QoL in this population and to explore potential moderators of intervention efficacy. METHODS: A systematic search was conducted in CINAHL, Embase, PsycINFO, PubMed, and Web of Science. Randomized controlled trials (RCTs) comparing CBIs or MBIs to controls on distress and QoL outcomes were eligible for inclusion. Random effects meta-analyses using standardized baseline to post-intervention mean differences were calculated using Hedges's g. Meta-regressions were used to compare intervention effects and examine potential moderators. RESULTS: Across 37 RCTs (21 CBIs, 14 MBIs, 2 combination therapies), there was a small decrease in distress (Hedges's g = 0.21) and a minimal improvement in QoL (Hedges's g = 0.15). Traditional CBIs and MBIs did not differ in effect sizes. Heterogeneity was significant across distress effect sizes but not across QoL effects. Interventions delivered to individuals (vs. dyads/group) had larger effects on QoL. No moderators of intervention effects on distress were found. CONCLUSIONS: Findings suggest traditional CBIs and MBIs produce small reductions in distress compared to controls in patients with advanced cancer, although effects on QoL appear minimal. Given limitations in the number of studies and their quality, rigorous trials are needed to directly compare the impact of traditional CBIs and MBIs in this population.

Effect of modernized collaborative care for depression on brain-derived neurotrophic factor (BDNF) and depressive symptom clusters: Data from the eIMPACT trial.

Brain-derived neurotrophic factor (BDNF) levels are lower in people with depression and are normalized following pharmacological treatment. However, it is unknown if psychological treatments for depression improve BDNF and if change in BDNF is a mediator of intervention effects on depressive symptoms. Therefore, using data from the eIMPACT trial, we sought to determine the effect of modernized collaborative care for depression on 12-month changes in BDNF and cognitive/affective and somatic depressive symptom clusters and to examine whether BDNF changes mediate intervention effects on depressive symptoms. 216 primary care patients with depression from a safety net healthcare system were randomized to 12 months of the eIMPACT intervention (internet cognitive-behavioral therapy [CBT], telephonic CBT, and select antidepressant medications) or usual primary care. Plasma BDNF was measured with commercially available kits, and depressive symptom clusters were assessed by the Patient Health Questionnaire-9. The intervention did not influence BDNF but did improve both the cognitive/affective and somatic clusters over 12 months. Changes in BDNF did not mediate the intervention effect on either cluster. Our findings suggest that modernized collaborative care is an effective treatment for both the cognitive/affective and somatic symptoms of depression and that the mechanism of action is not improvements in BDNF. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02458690.

Dysmenorrhea and psychological distress: a meta-analysis.

Dysmenorrhea is characterized by pelvic pain associated with menstruation. Similar to people with other pain conditions, females who experience dysmenorrhea report increased psychological distress. However, the pooled magnitude of this association has not been quantified across studies. Accordingly, this meta-analytic review quantifies the magnitude of the associations between dysmenorrhea severity and psychological distress. We conducted a systematic search of the literature using PsycINFO, PubMed, CINHAL, Embase, and Web of Science. Analyzed studies provided observational data on dysmenorrhea severity and anxiety symptoms, depressive symptoms, and/or global psychological distress. A total of 44 studies were included, and three random-effects meta-analyses were conducted, with average pooled effect sizes calculated using Person's r. We found significant, positive associations between measures of dysmenorrhea severity and measures of depressive symptoms (r = 0.216), anxiety symptoms (r = 0.207), and global psychological distress (r = 0.311). Our review suggests that females with greater dysmenorrhea severity experience greater psychological distress. Future directions include defining a clinically meaningful dysmenorrhea severity threshold, understanding the mechanisms and directionality underlying the dysmenorrhea-psychological distress relationship, and designing and testing interventions to jointly address dysmenorrhea and psychological distress.

Effect of modernized collaborative care for depression on depressive symptoms and cardiovascular disease risk biomarkers: eIMPACT randomized controlled trial.

Although depression is a risk and prognostic factor for cardiovascular disease (CVD), clinical trials treating depression in patients with CVD have not demonstrated cardiovascular benefits. We proposed a novel explanation for the null results for CVD-related outcomes: the late timing of depression treatment in the natural history of CVD. Our objective was to determine whether successful depression treatment before, versus after, clinical CVD onset reduces CVD risk in depression. We conducted a single-center, parallel-group, assessor-blinded randomized controlled trial. Primary care patients with depression and elevated CVD risk from a safety net healthcare system (N = 216, Mage = 59 years, 78% female, 50% Black, 46% with income <$10,000/year) were randomized to 12 months of the eIMPACT intervention (modernized collaborative care involving internet cognitive-behavioral therapy [CBT], telephonic CBT, and/or select antidepressants) or usual primary care for depression (primary care providers supported by embedded behavioral health clinicians and psychiatrists). Outcomes were depressive symptoms and CVD risk biomarkers at 12 months. Intervention participants, versus usual care participants, exhibited moderate-to-large (Hedges' g = -0.65, p < 0.01) improvements in depressive symptoms. Clinical response data yielded similar results - 43% of intervention participants, versus 17% of usual care participants, had a ≥ 50% reduction in depressive symptoms (OR = 3.73, 95% CI: 1.93-7.21, p < 0.01). However, no treatment group differences were observed for the CVD risk biomarkers - i.e., brachial flow-mediated dilation, high-frequency heart rate variability, interleukin-6, high-sensitivity C-reactive protein, ß-thromboglobulin, and platelet factor 4 (Hedges' gs = -0.23 to 0.02, ps ≥ 0.09). Our modernized collaborative care intervention - which harnessed technology to maximize access and minimize resources - produced clinically meaningful improvements in depressive symptoms. However, successful depression treatment did not lower CVD risk biomarkers. Our findings indicate that depression treatment alone may not be sufficient to reduce the excess CVD risk of people with depression and that alternative approaches are needed. In addition, our effective intervention highlights the utility of eHealth interventions and centralized, remote treatment delivery in safety net clinical settings and could inform contemporary integrated care approaches. Trial Registration:ClinicalTrials.gov Identifier: NCT02458690.

Perceived Facilitators and Barriers to Treatment Fidelity in Computerized Cognitive Training Interventions.

BACKGROUND: Computerized cognitive training (CCT) interventions may have an important role in improving cognition among patients with heart failure. Ensuring treatment fidelity of CCT interventions is an essential part of testing their efficacy. OBJECTIVE: The aim of this study was to describe facilitators of and barriers to treatment fidelity perceived by CCT intervenors while delivering the interventions to patients with heart failure. METHODS AND RESULTS: A qualitative descriptive study was completed with 7 intervenors who delivered CCT interventions in 3 studies. Directed content analysis revealed 4 main themes of perceived facilitators: (1) training for intervention delivery, (2) supportive work environment, (3) prespecified implementation guide, and (4) confidence and awareness. Three main themes were identified as perceived barriers: (1) technical issues, (2) logistic barriers, and (3) sample characteristics. CONCLUSION: This study is novel because it was one of the few studies focused on the intervenors' perceptions rather than the patients' perception of using CCT interventions. Beyond the treatment fidelity recommendations, this study found new components that might help the future investigators in designing and implementing CCT interventions with high treatment fidelity.

Pain in People Experiencing Homelessness: A Scoping Review.

BACKGROUND: Prior work suggests that people experiencing homelessness (PEH) are at heightened risk for developing pain and have a uniquely burdensome pain experience. PURPOSE: The aim of this scoping review was to map the current peer-reviewed, published literature on the pain experience of PEH. METHODS: In accordance with the US Annual Homeless Assessment Report, we defined homelessness as lacking shelter or a fixed address within the last year. We conceptualized the pain experience via a modified version of the Social Communication Model of Pain, which considers patient, provider, and contextual factors. Published articles were identified with CINHAL, Embase, PubMed, PsycINFO, and Web of Science databases. RESULTS: Sixty-nine studies met inclusion criteria. Studies revealed that PEH have high rates of pain and experience high levels of pain intensity and interference. Substantially fewer studies examined other factors relevant to the pain experience, such as self-management, treatment-seeking behaviors, and pain management within healthcare settings. Nonetheless, initial evidence suggests that pain is undermanaged in PEH. CONCLUSIONS: Future research directions to understand pain and homelessness are discussed, including factors contributing to the under-management of pain. This scoping review may inform future work to develop interventions to address the specific pain care needs of PEH.

People experiencing homelessness are at increased risk for developing pain and having an especially burdensome pain experience. This scoping review described the current literature on pain in people experiencing homelessness. We searched five databases and identified 69 articles of relevance. Studies revealed that people experiencing homelessness have high rates of pain and experience high levels of pain intensity and interference. Fewer studies examined other factors relevant to pain­such as self-management, treatment-seeking behaviors, and pain care within health settings­however, initial evidence does suggest that pain is undermanaged in people experiencing homelessness. This scoping review informs future research to better understand pain and homelessness, as well as future work to develop interventions to address the specific pain care needs of people experiencing homelessness.

Independent Associations Between Trait-Anger, Depressive Symptoms and Preclinical Atherosclerotic Progression.

BACKGROUND: Previous research from our group found that recent depressive symptoms were associated with 3-year change in carotid intima-media thickness (CA-IMT), a biomarker of cardiovascular disease risk, in an initially healthy sample of older adults. Trait measures of anxiety, anger, and hostility did not predict 3-year CA-IMT progression in that report. PURPOSE: The current study sought to reexamine these associations at a 6-year follow-up point. METHODS: Two-hundred seventy-eight participants (151 males, mean age = 60.68 years) from the original sample completed an additional IMT reading 6 years following the initial baseline assessment. RESULTS: Though not significant at 3-years, trait-anger emerged as a predictor of IMT progression at the 6-year point. When examined in separate regression models, both depression and trait-anger (but not anxiety or hostility) predicted 6-year IMT change (b = .017, p = .002; b = .029, p = .01, respectively). When examined concurrently, both depression and anger were independently associated with 6-year IMT progression (b = .016, p = .010, b = .028, p = .022, respectively). Exploratory analyses suggest that the relative contributions of anger and depression may differ for males and females. CONCLUSIONS: The use of sequential follow-ups is relatively unique in this literature, and our results suggest a need for further research on the timing and duration of psychosocial risk exposures in early stages of cardiovascular disease.

Examining Depression as a Risk Factor for Cardiovascular Disease in People with HIV: A Systematic Review.

BACKGROUND: People with human immunodeficiency virus (HIV) have an increased risk of cardiovascular disease (CVD) not fully accounted for by traditional or HIV-specific risk factors. Successful management of HIV does not eliminate this excess risk. Thus, there is a need to identify novel risk factors for CVD among people with HIV (PWH). PURPOSE: Our objective was to systematically review the literature on one such candidate CVD risk factor in PWH-depression. METHODS: A systematic literature search of PubMed, PsycINFO, EMBASE, Web of Science, and CINAHL was performed to identify published English-language studies examining associations of depression with clinical CVD, subclinical CVD, and biological mechanisms (immune activation, systemic inflammation, altered coagulation) among PWH between the earliest date and June 22, 2021. RESULTS: Thirty-five articles were included. For clinical CVD (k = 8), findings suggests that depression is consistently associated with an increased risk of incident CVD. For subclinical CVD (k = 5), one longitudinal analysis reported a positive association, and four cross-sectional analyses reported null associations. For immune activation (k = 13), systemic inflammation (k = 17), and altered coagulation (k = 5), findings were mixed, and there was considerable heterogeneity in sample characteristics and methodological quality across studies. CONCLUSIONS: Depression may be an independent risk factor for CVD among PWH. Additional research is needed to confirm depression's association with clinical CVD and to determine whether depression is consistently and meaningfully associated with subclinical CVD and biological mechanisms of CVD in HIV. We propose a research agenda for this emerging area.

If not us, who? If not now, when? Paths forward in science, patient care, and training to maximize the impact of cardiovascular behavioral medicine.

One might expect that the provision of integrated cardiovascular care-an approach that treats people as more than their biology; that spans primary, secondary, and tertiary prevention; and that is consistent with our understanding of behavioral and psychosocial factors as major drivers of chronic disease burden- would be the norm. This is clearly not the case, and this fact served as our central motivation for assembling this Special Issue of Health Psychology. The response to the Special Issue announcement as represented by the papers published here reflect where cardiovascular behavioral medicine (CVBM) has been, where our field needs to go, and how we might get there. We see needs (a) to expand our research beyond the epidemiologic and mechanistic studies that have dominated the field and to refocus our science on the design, testing, and implementation of integrated interventions and health care delivery models; (b) to fully integrate CVBM patient care into holistic, team-based cardiovascular care, which will require a louder voice and a place at the table with institutions and organizations that formulate health care reimbursement policies; and (c) to create new models of clinical and research training to develop a workforce that is well prepared to achieve these visions of CVBM research and patient care. Here, we elaborate on our view of these needs, identify barriers to realizing these visions, and discuss paths forward in science, patient care, and training to maximize the impact of cardiovascular behavioral medicine. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Pain Management After Open Liver Resection: Epidural Analgesia Versus Ultrasound-Guided Erector Spinae Plane Block.

BACKGROUND: Multimodal analgesia techniques, including regional analgesia, have been shown to provide effective analgesia and minimize opioid consumption after liver resection surgery. While thoracic epidural analgesia (TEA) is considered the gold standard, its role in the current era of enhanced recovery after surgery (ERAS) has been questioned. Erector spinae plane blocks (ESPBs) have the potential to provide effective postoperative analgesia without the risks associated with epidural analgesia. The primary aim of this quality improvement project was to evaluate the analgesic efficacy of ultrasound-guided ESPB in comparison with TEA in patients undergoing open liver resection. METHODS: Fifty patients who underwent open liver resection and received TEA (n=25) or ESPB (n=25) as part of an ERAS pathway were retrospectively identified. The primary outcome measure was cumulative postoperative opioid consumption at 24 hours. Secondary outcomes included opioid consumption, pain scores, the incidence of nausea and vomiting requiring antiemetics, lower extremity muscle weakness, and occurrence of hypotension requiring treatment on arrival to the post-anesthesia care unit and at 2, 6, 12, 24 hours, and daily through postoperative day 7.  Results: Opioid requirements were significantly lower in the TEA group compared to the ESPB group. Postoperative pain scores at rest and with deep inspiration were significantly lower in the TEA group through postoperative day 5. There were no differences in other outcome measures. CONCLUSIONS: These findings suggest that compared with ESPB, TEA provides superior pain relief after open liver resection.

Associations of somatic depressive symptoms with body mass index, systemic inflammation, and insulin resistance in primary care patients with depression.

The somatic depressive symptom cluster (including appetite and sleep disturbances) is more strongly associated with insulin resistance (a diabetes risk marker) than other depressive symptom clusters. Utilizing baseline data from 129 primary care patients with depression but no diabetes in the eIMPACT trial (Mage = 59 years, 78% female, 50% Black), we examined associations of somatic depressive symptoms with insulin resistance (HOMA-IR), body mass index (BMI), and high-sensitivity C-reactive protein (hsCRP). We tested BMI and hsCRP as mediators and race as a moderator of these relationships. Hyperphagia was positively associated HOMA-IR (ß = 0.19, p = .048) and BMI (ß = 0.30, p < .001); poor appetite was negatively associated with HOMA-IR (ß = -0.24, p = .02); hypersomnia was positively associated with HOMA-IR (ß = 0.28, p = .003), BMI (ß = 0.26, p = .003), and hsCRP (ß = 0.23, p = .01); and disturbed sleep was positively associated with hsCRP (ß = 0.21, p = .04). BMI partially mediated hyperphagia and hypersomnia's associations with HOMA-IR; hsCRP partially mediated the hypersomnia-HOMA-IR association; and race moderated the hyperphagia-HOMA-IR association (positive for White participants but null for Black participants). People with depression experiencing hyperphagia and/or hypersomnia may be a subgroup with greater insulin resistance; BMI and hsCRP are likely pathways in these relationships. This study highlights the importance of considering the direction of somatic depressive symptoms in the context of cardiometabolic disease risk.

Associations between affective factors and high-frequency heart rate variability in primary care patients with depression.

OBJECTIVE: Depression is a risk factor for cardiovascular disease (CVD), and subgroups of people with depression may be at particularly elevated CVD risk. Lower high-frequency heart rate variability (HF HRV), which reflects diminished parasympathetic activation, is a candidate mechanism underlying the depression-CVD relationship and predicts cardiovascular events. Few studies have examined whether certain depression subgroups - such as those with co-occurring affective factors - exhibit lower HF HRV. The present study sought to assess associations between co-occurring affective factors and HF HRV in people with depression. METHODS: Utilizing baseline data from the 216 primary care patients with depression in the eIMPACT trial, we examined cross-sectional associations of depression's co-occurring affective factors (i.e., anxiety symptoms, hostility/anger, and trait positive affect) with HF HRV. HF HRV estimates were derived by spectral analysis from electrocardiographic data obtained during a supine rest period. RESULTS: Individual regression models adjusted for demographics and depressive symptoms revealed that anxiety symptoms (standardized regression coefficient ß = -0.24, p = .002) were negatively associated with HF HRV; however, hostility/anger (ß = 0.02, p = .78) and trait positive affect (ß = -0.05, p = .49) were not. In a model further adjusted for hypercholesterolemia, hypertension, diabetes, body mass index, current smoking, CVD prevention medication use, and antidepressant medication use, anxiety symptoms remained negatively associated with HF HRV (ß = -0.19, p = .02). CONCLUSION: Our findings suggest that, in adults with depression, those with comorbid anxiety symptoms have lower HF HRV than those without. Co-occurring anxiety may indicate a depression subgroup at elevated CVD risk on account of diminished parasympathetic activation.

Critical appraisal of randomised trials assessing regional analgesic interventions for knee arthroplasty: implications for postoperative pain guidelines development.

Guidelines are increasingly being used for clinical decision-making. Such guidelines are usually based on meta-analyses, which are generally derived from RCTs. However, their interpretations are often hindered as they do not always consider current clinical relevance. Analyses of RCTs assessing analgesic efficacy of advanced regional analgesic techniques in knee arthroplasty show that the majority of trials do not include a package of basic analgesics such as paracetamol, NSAIDs or cyclooxygenase-2 specific inhibitors, dexamethasone, and local infiltration analgesia in the comparator group. Consequently, the current approach to analyse meta-analyses of pain interventions is not optimal, and may lead to inadequate or inappropriate conclusions and clinical guidance.