ObjectivesInadequate postoperative pain control is common and is associated with poor clinical outcomes. This study aimed to identify preoperative predictors of poor postoperative pain control in adults undergoing inpatient surgery.DesignSystematic review and meta-analysisData sourcesMEDLINE, Embase, CINAHL and PsycINFO were searched through October 2017.Eligibility criteriaStudies in any language were included if they evaluated postoperative pain using a validated instrument in adults (≥18 years) and reported a measure of association between poor postoperative pain control (defined by study authors) and at least one preoperative predictor during the hospital stay.Data extraction and synthesisTwo reviewers screened articles, extracted data and assessed study quality. Measures of association for each preoperative predictor were pooled using random effects models.ResultsThirty-three studies representing 53 362 patients were included in this review. Significant preoperative predictors of poor postoperative pain control included younger age (OR 1.18 [95% CI 1.05 to 1.32], number of studies, n=14), female sex (OR 1.29 [95% CI 1.17 to 1.43], n=20), smoking (OR 1.33 [95% CI 1.09 to 1.61], n=9), history of depressive symptoms (OR 1.71 [95% CI 1.32 to 2.22], n=8), history of anxiety symptoms (OR 1.22 [95% CI 1.09 to 1.36], n=10), sleep difficulties (OR 2.32 [95% CI 1.46 to 3.69], n=2), higher body mass index (OR 1.02 [95% CI 1.01 to 1.03], n=2), presence of preoperative pain (OR 1.21 [95% CI 1.10 to 1.32], n=13) and use of preoperative analgesia (OR 1.54 [95% CI 1.18 to 2.03], n=6). Pain catastrophising, American Society of Anesthesiologists status, chronic pain, marital status, socioeconomic status, education, surgical history, preoperative pressure pain tolerance and orthopaedic surgery (vs abdominal surgery) were not associated with increased odds of poor pain control. Study quality was generally high, although appropriate blinding of predictor during outcome ascertainment was often limited.ConclusionsNine predictors of poor postoperative pain control were identified. These should be recognised as potentially important factors when developing discipline-specific clinical care pathways to improve pain outcomes and to guide future surgical pain research.PROSPERO registration numberCRD42017080682.

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Male-to-Female (MtF) breast cancer events have been reported since 1968 however, MtF patients' risk of breast cancer remain unclear. Following PRISMA guidelines, electronic databases and grey literature were searched April 2018 to identify breast cancer events in MtF transgender persons. Screening and data extraction were independently performed in duplicate by two reviewers. Study quality was assessed using a component-based system. Qualitative analysis was performed on study characteristics, patient demographics, breast cancer characteristics, and breast cancer presentation and management. Eighteen articles met inclusion criteria representing 22 breast cancer events. Median age at breast cancer diagnosis was 51.5 years. The most common breast cancer type was adenocarcinomas (59.1%) and half of the breast cancers were hormone sensitive, with estrogen receptor positive status in 10 of 19 tested and progesterone receptor positive status in 5 of 14 tested. The most common presentation was breast lump (n = 6, 42.9%), two patients had palpable lymph nodes at presentation (14.3%), and six patients eventually developed metastases (42.9%). Seven patients had a recorded positive breast cancer family history and one was BRCA2 positive. Breast cancers were treated with mastectomies (simple, modified radical, and radical), wide local excision, lumpectomy, or were unclear. Four patients received hormone therapy (23.5%), two received radiation (11.8%), and seven received chemotherapy (41.2%). Breast cancer is present in MtF patients and commonly presents at a younger age with a palpable mass. Major gaps in the literature include lack of transgender population data and long term follow-up. This work highlights the need for screening recommendations.

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Background: Pediatric hand fractures are common and approximately 10% require surgery. Methods: This retrospective cohort study reports on hand fractures in a large pediatric population and identifies the characteristics and patterns of fractures that required surgical correction. A χ2 analysis was done to evaluate the association between individual fracture variables and surgery. The STROBE checklist was applied. Results: One thousand one-hundred seventy-three hand fractures were reviewed. Peak age was 16 years for boys and 14 years for girls. Most fractures were closed (96.0%) and nonrotated (91.3%), and had no concomitant soft tissue injury (72.7%). More than half (56.3%) were nonepiphyseal plate fractures; yet as a single diagnosis, Salter–Harris II fractures were most common (30.2%). The following variables were significantly associated with surgery: open fractures, rotational deformity, distal phalangeal fracture location, multiple fractures, oblique pattern, comminution, displacement >2 mm, intra-articular involvement, and angulation >15°. Most fractures required only immobilization and early range of motion (64.3%). Closed reduction was required in 22.7%. Minor surgery by the primary provider was performed in 3.2% of fractures. Surgery by a hand surgeon was performed in 9.8%. The most common patterns requiring surgery were proximal or middle phalanx head or neck fractures (38.2%) and metacarpal midshaft fractures (20.9%). The most common operation was open reduction internal fixation (52.2%). Conclusions: Pediatric hand fractures are common, but 90.2% do not require surgery and, as such, primary providers play a key role in management. Certain fracture variables and patterns are more likely to lead to surgery.