A core outcome set for research and clinical practice in women with pelvic girdle pain: PGP-COS

Laparoscopic cholecystectomy versus conservative management for adults with uncomplicated symptomatic gallstones: the C-GALL RCT

Background

Gallstone disease is a common gastrointestinal disorder in industrialised societies. The prevalence of gallstones in the adult population is estimated to be approximately 10-15%, and around 80% remain asymptomatic. At present, cholecystectomy is the default option for people with symptomatic gallstone disease.

Objectives

To assess the clinical and cost-effectiveness of observation/conservative management compared with laparoscopic cholecystectomy for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones in secondary care.

Design

Parallel group, multicentre patient randomised superiority pragmatic trial with up to 24 months follow-up and embedded qualitative research. Within-trial cost-utility and 10-year Markov model analyses. Development of a core outcome set for uncomplicated symptomatic gallstone disease.

Setting

Secondary care elective settings.

Participants

Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion.

Interventions

Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management.

Main outcome measures

The primary outcome was quality of life measured by area under the curve over 18 months using the Short Form-36 bodily pain domain. Secondary outcomes included the Otago gallstones' condition-specific questionnaire, Short Form-36 domains (excluding bodily pain), area under the curve over 24 months for Short Form-36 bodily pain domain, persistent symptoms, complications and need for further treatment. No outcomes were blinded to allocation.

Results

Between August 2016 and November 2019, 434 participants were randomised (217 in each group) from 20 United Kingdom centres. By 24 months, 64 (29.5%) in the observation/conservative management group and 153 (70.5%) in the laparoscopic cholecystectomy group had received surgery, median time to surgery of 9.0 months (interquartile range, 5.6-15.0) and 4.7 months (interquartile range 2.6-7.9), respectively. At 18 months, the mean Short Form-36 norm-based bodily pain score was 49.4 (standard deviation 11.7) in the observation/conservative management group and 50.4 (standard deviation 11.6) in the laparoscopic cholecystectomy group. The mean area under the curve over 18 months was 46.8 for both groups with no difference: mean difference -0.0, 95% confidence interval (-1.7 to 1.7); p-value 0.996; n = 203 observation/conservative, n = 205 cholecystectomy. There was no evidence of differences in quality of life, complications or need for further treatment at up to 24 months follow-up. Condition-specific quality of life at 24 months favoured cholecystectomy: mean difference 9.0, 95% confidence interval (4.1 to 14.0), p < 0.001 with a similar pattern for the persistent symptoms score. Within-trial cost-utility analysis found observation/conservative management over 24 months was less costly than cholecystectomy (mean difference -£1033). A non-significant quality-adjusted life-year difference of -0.019 favouring cholecystectomy resulted in an incremental cost-effectiveness ratio of £55,235. The Markov model continued to favour observation/conservative management, but some scenarios reversed the findings due to uncertainties in longer-term quality of life. The core outcome set included 11 critically important outcomes from both patients and healthcare professionals.

Conclusions

The results suggested that in the short term (up to 24 months) observation/conservative management may be a cost-effective use of National Health Service resources in selected patients, but subsequent surgeries in the randomised groups and differences in quality of life beyond 24 months could reverse this finding. Future research should focus on longer-term follow-up data and identification of the cohort of patients that should be routinely offered surgery.

Trial registration

This trial is registered as ISRCTN55215960.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/71) and is published in full in Health Technology Assessment; Vol. 28, No. 26. See the NIHR Funding and Awards website for further award information.

Knowledge Mapping Analysis of Research on Pregnancy-Related Pelvic Girdle Pain (PPGP) from 2002 to 2022 Using Bibliometrics

Background

Pregnancy-related Pelvic Girdle Pain (PPGP) is a prevalent condition characterized by various physiological and pathological processes in the female body. The objective of this study is to offer a comprehensive understanding of the current research landscape, key areas of interest, and potential future directions in the field of PPGP.

Methods

Using Web of Science, we explored PPGP literature from 2002 to 2022. VOSviewer and CiteSpace facilitated a quantitative analysis, revealing co-authorship patterns, co-occurring themes, citations, and co-citations.

Results

We identified, peaking at 99 publications in 2021. The United States led with 138 publications and the highest citation count (3160). The Karolinska Institute boasted the highest tally of publications (n = 21). Regarding the volume of publications, the esteemed journal of BMC Pregnancy and Childbirth attained the foremost position. Notably, Gutke, Annelie emerged as the most prolific and highly cited author. The analysis of keyword co-occurrence and co-citation clustering unveiled an intricate tapestry of PPGP studies, spanning various domains including risk factors, mechanistic intricacies, diagnostic benchmark, treatment modalities, and far-reaching ramifications on one's quality of life.

Conclusion

Research endeavors exploring PPGP have unveiled an enduring trajectory of growth in contemporary times. The existing body of research primarily focuses on delving into the intricate interplay of epidemiological factors and the profound implications of interventions encompassing physical therapy, exercise protocols, and diverse modes of pain management within the domain of PPGP. Multidisciplinary integration encapsulates a prevailing trajectory of progress within this domain, while the focal point of future inquiries into PPGP may revolve around subjects pertaining to standardized outcome reporting.

Predictive Factors for Pregnancy-Related Persistent Pelvic Girdle Pain (PPGP): A Systematic Review

Background and Objectives: To identify the most frequently reported predictive factors for the persistency of pregnancy-related pelvic girdle pain (PPGP) at 3-6 months after childbirth in women with PPGP alone or PPGP in association with pregnancy-related lower back pain (PLBP). Methods: Eligibility criteria: Two authors independently selected studies excluding PPGP determined by a specific, traumatic, gynecological/urological cause or isolated PLBP and studies that did not include the presence/absence of PPGP as the the primary outcome. We, instead, included studies with an initial assessment in pregnancy (within 1 month of delivery) and with a follow-up of at least 3 months after delivery. Data sources: The research was performed using the databases of Medline, Cochrane, Pedro, Scopus, Web of Science and Cinahl from December 2018 to January 2022, following the indications of the PRISMA statement 2021 and the MOOSE checklist. It includes observational cohort studies in which data were often collected through prospective questionnaires (all in English). Study appraisal and risk of bias: Two independent authors performed evaluations of the risk of bias (ROB) using the quality in prognostic studies (QUIPS) tool. Synthesis of results: An in-depth qualitative analysis was conducted because, due to a high degree of heterogeneity in the data collection of the included studies and a lack of raw data suitable for quantitative analysis, it was not possible to carry out the originally planned meta-analyses for the subgroups. Results: The research process led to the inclusion of 10 articles which were evaluated using the QUIPS tool: 5 studies were evaluated as low ROB and 5 were evaluated as moderate ROB. High levels of pain in pregnancy, a large number of positive provocation tests, a history of lower back pain and lumbo-pelvic pain, high levels of disability in pregnancy, neurotic behavior and high levels of fear-avoidance belief were identified as strong predictors of long-term PPGP, while there was weak or contradictory evidence regarding predictions of emotional distress, catastrophizing and sleep disturbances. Discussion: The impossibility of carrying out the meta-analysis by subgroups suggests the need for further research with greater methodological rigor in the acquisition of measures based on an already existing PPGP core predictors/outcome sets.

Drivers, barriers, and response to care of Australian pregnant women seeking chiropractic care for low back and pelvic girdle pain: a qualitative case study

BACKGROUND

Pregnancy-related low back and/or pelvic girdle pain is common, with a prevalence rate of up to 86% in pregnant women. Although 19.5% of Australian pregnant women visit a chiropractor for pelvic girdle pain, little is known about the experience of pregnant women who seek this care. The aim of this study was to describe and explore the experiences of Australian pregnant women who seek chiropractic care for their current pregnancy-related low back and/or pelvic girdle pain.

METHODS

A qualitative case study approach with purposive sampling from 27 chiropractic practices was used. A grounded theory approach was informed by a constructivist and interpretivist stance, which provided understanding and meaning to the pregnant women's experiences. Online unstructured interviews were recorded, transcribed, and anonymised. A thematic analysis was subsequently conducted on the primary data. Codes and major themes were developed with the use of critical self- reflection (memos), survey finding triangulation and respondent validation.

RESULTS

Sixteen potential respondents expressed interest in participating. After eligibility screening and data saturation, nine interviews were undertaken. Four key themes were identified: "Care drivers: what drives care seeking?", "Care barriers: what barriers are encountered?", "Chiropractic treatment: what does treatment consist of?" and "Response to care: what response was there to care?".

CONCLUSION

Four key themes: care drivers, care barriers, chiropractic treatment, and response to care support an emergent substantive-level theory in women's care seeking experiences for pregnancy-related back pain and chiropractic care. This theory is that chiropractic care for pregnant women experiencing low back pain and pelvic girdle pain may improve pain and function, while reducing pregnancy-related biopsychosocial concerns. The findings may inform antenatal health providers and the chiropractic profession about pregnant women's experience seeking chiropractic care as well as directing future research.

One step at a time. Shaping consensus on research priorities and terminology in telehealth in musculoskeletal pain: an international modified e-Delphi study

BACKGROUND

Telehealth has emerged as an alternative model for treatment delivery and has become an important component of health service delivery. However, there is inconsistency in the use of terminologies and a lack of research priorities in telehealth in musculoskeletal pain. The purpose of this international, multidisciplinary expert panel assembled in a modified three-round e-Delphi survey is to achieve a consensus on research priorities and for the standard terminology for musculoskeletal pain telehealth practice.

METHODS

In this international modified e-Delphi survey, we invited an expert panel consisting of researchers, clinicians, consumer representatives, industry partners, healthcare managers, and policymakers to participate in a three-round e-Delphi. Expert panels were identified through the Expertscape website, PubMed database, social media, and a snowball approach. In Round 1, potential research priorities and terminologies were presented to panel members. Panel members rated the agreement of each research priority on a 5-point Likert scale and an 11-point numerical scale, and each terminology on a 5-point Likert scale for the "telehealth in musculoskeletal pain " field over rounds. At least 80% of the panel members were required to agree to be deemed a consensus. We analyzed the data descriptively and assessed the stability of the results using the Wilcoxon matched-pairs signed rank test.

RESULTS

We performed an international e-Delphi survey from February to August 2022. Of 694 invited people, 160 panel members participated in the first round, 133 in the second round (83% retention), and 134 in the third round (84% retention). Most of the panel members were researchers 76 (47%), clinicians 57 (36%), and consumer representatives 9 (6%) of both genders especially from Brazil 31 (19%), India 22 (14%), and Australia 19 (12%) in the first round. The panel identified fourteen telehealth research priorities spanned topics including the development of strategies using information and communication technology, telehealth implementation services, the effectiveness and cost-effectiveness of telehealth interventions, equity of telehealth interventions, qualitative research and eHealth literacy in musculoskeletal pain conditions from an initial list of 20 research priorities. The consensus was reached for "digital health" and "telehealth" as standard terminologies from an initial list of 37 terminologies.

CONCLUSION

An international, multidisciplinary expert consensus recommends that future research should consider the 14 research priorities for telehealth musculoskeletal pain reached. Additionally, the terms digital health and telehealth as the most appropriate terminologies to be used in musculoskeletal telehealth research.

REGISTER

Open Science Framework ( https://osf.io/tqmz2/ ).

Development of a Core Outcome Set for the research and assessment of inoperable malignant bowel obstruction

BACKGROUND

Malignant bowel obstruction is experienced by 15% of people with advanced cancer, preventing them from eating and drinking and causing pain, nausea and vomiting. Surgery is not always appropriate. Management options include tube or stent drainage of intestinal contents and symptom control using medication. Published literature describing palliative interventions uses a broad range of outcome measures, few of which are patient-relevant. This hinders evidence synthesis, and fails to consider the perspectives of people undergoing treatment.

AIMS

To develop a Core Outcome Set for the assessment of inoperable malignant bowel obstruction with clinician, patient and caregiver involvement, using COMET methodology (Core Outcome Measures in Effectiveness Trials).

METHODS

A systematic review of clinical trials and observational studies, a rapid review of the qualitative literature and in-depth patient and clinician interviews were conducted to identify a comprehensive list of outcomes. Outcomes were compared and consolidated by the study Steering Group and Patient and Public Involvement contributors, and presented to an international clinical Expert Panel for review. Outcomes from the finalised list were rated for importance in a three-round international Delphi process: results of two survey rounds were circulated to respondents, and two separate consensus meetings were conducted with clinicians and with patients and caregivers via virtual conferencing, using live polling to reach agreement on a Core Outcome Set.

RESULTS

130 unique outcomes were identified. Following the independent Expert Panel review, 82 outcomes were taken into round 1 of the Delphi survey; 24 outcomes reached criteria for critical importance across all stakeholder groups and none reached criteria for dropping. All outcomes rated critically important were taken forward for re-rating in round 2 and all other outcomes dropped. In round 2, all outcomes were voted critically important by at least one stakeholder group. Round 2 outcomes were presented again at online consensus meetings, categorised as high ranking (n = 9), middle ranking (n = 7) or low ranking (n = 8). Stakeholders reached agreement on 16 core outcomes across four key domains: Symptom control, Life impact, Treatment outcomes, and Communication and patient preferences.

CONCLUSION

Use of this Core Outcome Set can help to address current challenges in making sense of the evidence around treatment for inoperable malignant bowel obstruction to date, and underpin a more robust future approach. Clearer communication and an honest understanding between all stakeholders will help to provide a basis for responsible decision-making in this distressing situation in clinical practice.

Outcome Measurement Instruments and Evidence-based Recommendations for Measurement of the Pelvic Girdle Pain Core Outcome Set (PGP-COS): A Systematic Review and Consensus Process

This study provides evidence- and consensus-based recommendations for the instruments to measure the five Pelvic Girdle Pain Core Outcome Set (PGP-COS): pain frequency, pain intensity/severity, function/disability/activity limitation, health-related quality of life and fear avoidance. Studies evaluating measurement properties of instruments measuring any PGP-COS outcome in women with PGP were identified through a systematic search of MEDLINE, EMBASE and PEDro databases (inception-July 2021). The methodological quality of studies and quality of measurement properties were evaluated using the COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN) checklist. Quality criteria and the synthesized evidence were graded using the modified grading of recommendations, assessment, development, and evaluation (GRADE) approach. A consensus meeting with PGP stakeholders was then held to establish recommendations, based on the evidence, for the instruments that should be used to measure the PGP-COS. Ten instruments were identified from 17 studies. No instrument showed high quality evidence for all measurement properties and/or measured all PGP-COS outcomes. Based on current evidence and consensus, the Pelvic Girdle Questionnaire (PGQ), the Short Form-8 (SF-8) and the Fear Avoidance Beliefs Questionnaire (FABQ) are recommended for measuring the PGP-COS. Future research should establish additional measurement properties of instruments and to substantiate these recommendations.

Core outcome set for symptomatic uncomplicated gallstone disease

BACKGROUND

Heterogeneity of outcomes is a problem for assessing intervention effectiveness when considering treatments for uncomplicated symptomatic gallstone disease. The value to all stakeholders of outcomes that have been measured and reported to date is also unclear. The aim of this study was to develop a core outcome set for symptomatic uncomplicated gallstone disease.

METHODS

An in person-meeting was held with patients to prioritize potentially important outcomes from a previously developed longlist of outcomes. This was followed by an online three-round Delphi survey that was conducted with healthcare professionals. The results of each consensus process were compared and combined to produce the final core outcome set.

RESULTS

A total of 82 participants enrolled in round 1 of the Delphi survey, with a final sample of 40 participants contributing to round 3. Five patients contributed to the in-person group meeting. Following the consensus processes, 11 outcomes were considered to be core by patients and healthcare professionals, and included in the core outcome set. These were: quality of life; overall health state; overall satisfaction; overall pain; common bile duct injury; biliary leak; haemorrhage; need for endoscopic retrograde cholangiopancreatography; intra-abdominal collections; admission/readmission for problems; and reoperation.

CONCLUSION

A core outcome set for symptomatic uncomplicated gallstone disease has been developed with patients and healthcare professionals. Eleven outcomes across four key domains have been identified. These represent the minimum set of outcomes that should be reported in trials evaluating interventions for gallstone disease.

Effects of a New Mattress and Pillow and Standard Treatment for Nightly Pelvic Girdle Pain in Pregnant Women: A Randomised Controlled Study

Objective

To evaluate the efficacy of a memory-foam mattress and pillow plus standard treatment for nightly pelvic girdle pain (PGP) during pregnancy.

Method

In this randomised controlled study conducted at a tertiary-care hospital, 66 pregnant women who had nightly PGP were enrolled to receive standard treatment with the mattress and pillow (intervention group, n = 34) or solely standard treatment (control group, n = 32). The primary outcome was change in nightly posterior PGP on a visual analogue scale, VAS from baseline to 4 weeks. Secondary outcomes include nightly anterior PGP, the evening PGP score, estimated sleep duration, number of nightly wake-ups, daytime sleepiness (Epworth sleepiness scale), function (Pelvic Girdle Questionnaire), health-related quality of life, and pain catastrophizing.

Results

Forty-four women (67%) completed the treatment. The difference in nightly posterior pain intensity was significantly different in favour of the intervention group (VAS, 16.5 mm (95% CI 1.4:31.6) p = 0.028). Sleep duration increased within both groups (intervention group: 26 min, p = 0.022; control group: 14 min, p = 0.014) and the difference between groups was significant (p = 0.046). In addition, the intervention group indicated a decreased evening PGP intensity (p = 0.008) and fewer nightly wake-ups (p = 0.049). The control group showed a deterioration in function (Pelvic Girdle Questionnaire) (p = 0.018) and an increase in daytime sleepiness (Epworth sleepiness scale) (p = 0.021) from baseline to 4 weeks.

Conclusion

In conclusion, significantly lower nightly posterior PGP intensity was noted after the use of a mattress and pillow as an adjunct to standard treatment. Nightly PGP can have adverse effects on various aspects of the health and quality of life of pregnant women, and although the results of this study should be interpreted with caution considering the high drop-out rate and the inadequate statistical power, the findings indicate the potential for the use of such interventions to improve PGP in pregnant women.

Lifestyle and Chronic Pain in the Pelvis: State of the Art and Future Directions

During their lifespan, many women are exposed to pain in the pelvis in relation to menstruation and pregnancy. Such pelvic pain is often considered normal and inherently linked to being a woman, which in turn leads to insufficiently offered treatment for treatable aspects related to their pain experience. Nonetheless, severe dysmenorrhea (pain during menstruation) as seen in endometriosis and pregnancy-related pelvic girdle pain, have a high impact on daily activities, school attendance and work ability. In the context of any type of chronic pain, accumulating evidence shows that an unhealthy lifestyle is associated with pain development and pain severity. Furthermore, unhealthy lifestyle habits are a suggested perpetuating factor of chronic pain. This is of specific relevance during lifespan, since a low physical activity level, poor sleep, or periods of (di)stress are all common in challenging periods of women’s lives (e.g., during menstruation, during pregnancy, in the postpartum period). This state-of-the-art paper aims to review the role of lifestyle factors on pain in the pelvis, and the added value of a lifestyle intervention on pain in women with pelvic pain. Based on the current evidence, the benefits of physical activity and exercise for women with pain in the pelvis are supported to some extent. The available evidence on lifestyle factors such as sleep, (di)stress, diet, and tobacco/alcohol use is, however, inconclusive. Very few studies are available, and the studies which are available are of general low quality. Since the role of lifestyle on the development and maintenance of pain in the pelvis, and the value of lifestyle interventions for women with pain in the pelvis are currently poorly studied, a research agenda is presented. There are a number of rationales to study the effect of promoting a healthy lifestyle (early) in a woman’s life with regard to the prevention and management of pain in the pelvis. Indeed, lifestyle interventions might have, amongst others, anti-inflammatory, stress-reducing and/or sleep-improving effects, which might positively affect the experience of pain. Research to disentangle the relationship between lifestyle factors, such as physical activity level, sleep, diet, smoking, and psychological distress, and the experience of pain in the pelvis is, therefore, needed. Studies which address the development of management strategies for adapting lifestyles that are specifically tailored to women with pain in the pelvis, and as such take hormonal status, life events and context, into account, are required. Towards clinicians, we suggest making use of the window of opportunity to prevent a potential transition from localized or periodic pain in the pelvis (e.g., dysmenorrhea or pain during pregnancy and after delivery) towards persistent chronic pain, by promoting a healthy lifestyle and applying appropriate pain management.

Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC): a modified Delphi process to develop a core outcome set for trials in perioperative care and anaesthesia

BACKGROUND

Outcome selection underpins clinical trial interpretation. Inconsistency in outcome selection and reporting hinders comparison of different trials' results, reducing the utility of research findings.

METHODS

We conducted an iterative consensus process to develop a set of Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC), following the established Core Outcome Measures for Effectiveness Trials (COMET) methodology. First, we undertook a systematic review of RCTs in high-impact journals to describe current outcome reporting trends. We then surveyed patients, carers, researchers, and perioperative clinicians about important outcomes after surgery. Finally, a purposive stakeholder sample participated in a modified Delphi process to develop a core outcome set for perioperative and anaesthesia trials.

RESULTS

Our systematic review revealed widespread inconsistency in outcome reporting, with variable or absent definitions, levels of detail, and temporal criteria. In the survey, almost all patients, carers, and clinicians rated clinical outcome measures critically important, but clinicians rated patient-centred outcomes less highly than patients and carers. The final core outcome set was: (i) mortality/survival (postoperative mortality, long-term survival); (ii) perioperative complications (major postoperative complications/adverse events; complications/adverse events causing permanent harm); (iii) resource use (length of hospital stay, unplanned readmission within 30 days); (iv) short-term recovery (discharge destination, level of dependence, or both); and (v) longer-term recovery (overall health-related quality of life).

CONCLUSIONS

This core set, incorporating important outcomes for both clinicians and patients, should guide outcome selection in future perioperative medicine or anaesthesia trials. Mapping these alongside standardised endpoint definitions will yield a comprehensive perioperative outcome framework.