A protocol for developing, disseminating, and implementing a core outcome set for stress urinary incontinence

Puerarin protects fibroblasts against mechanical stretching injury through Nrf2/TGF-β1 signaling pathway

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) is the most common form of urinary incontinence in women, which affects women's quality of life worldwide. Mechanical injury of the pelvic floor may disrupt the pelvic supportive tissues and connections via the remodeling of extracellular matrix (ECM), which is supposed to be one of the main pathological mechanisms of SUI.

METHODS

The SUI mouse model was established using vaginal distension (VD). Leak point pressure (LPP), maximum cystometric capacity (MCC), collagen, Nrf2 and TGF-β1 in the anterior vaginal wall were measured in either wild-type or Nrf2-knockout (Nrf2^-/^-) female C57BL/6 mice with or without puerarin treatment. Then, the mechanical stretching (MS) loaded on L929 cells was generated by a four-point bending device. mTGF-β1 or LY2109761 (an inhibitor of TGF-β1) was used to verify the protective effect of puerarin after Nrf2 knockdown or overexpression.

RESULTS

The collagen content of the anterior vaginal tissues in VD mice and LPP and MCC was decreased significantly. Besides, the expression levels of Nrf2, TGF-β1, collagen I and collagen III of MS group were downregulated in L929 cells. Puerarin pretreatment could reverse mechanical injury-induced collagen downregulation and Nrf2/TGF-β1 signaling inhibition. Moreover, both LY2109761 pretreatment and Nrf2 knockdown could attenuate the protective effect of puerarin in the mechanical injury-induced ECM remodeling, whereas exogenous TGF-β1 could counteract the effect of Nrf2 downregulation.

CONCLUSIONS

Puerarin protected fibroblasts from mechanical injury-induced ECM remodeling through the Nrf2/TGF-β1 signaling pathway. This might be a new strategy for the treatment of SUI.

Outcome reporting in randomized controlled trials (RCTs) on the pharmacological management of idiopathic overactive bladder (OAB) in women; a systematic review for the development of core outcome sets (COS)

INTRODUCTION AND HYPOTHESIS

Evidence on OAB management remains suboptimal and methodological limitations in randomized control trials (RCTs) affect their comparability. High quality meta-analyses are lacking. This study aimed to compare selection and reporting of outcomes and outcome measures across RCTs as well as evaluate methodological quality and outcome reporting quality as a first stage in the process of developing core outcome sets (COS).

METHODS

RCTs were searched using Pubmed, EMBASE, Medline, Cochrane, ICTRP and Clinicaltrials.gov from inception to January 2020, in English language, on adult women. Pharmacological management, interventions, sample size, journal type and commercial funding were documented. Methodological and outcome reporting quality were evaluated using JADAD and MOMENT scores.

RESULTS

Thirty-eight trials (18,316 women) were included. Sixty-nine outcomes were reported, using 62 outcome measures. The most commonly reported outcome domains were efficacy (86.8%), safety (73.7%) and QoL (60.5%). The most commonly reported outcomes in each domain were urgency urinary incontinence episodes (UUI) (52.6%), antimuscarinic side effects (76.3%) and change in validated questionnaire scores (36.8%). A statistically significant correlation was found between JADAD and MOMENT (Spearman's rho = 0.548, p < 0.05) scores. This indicates that higher methodological quality is associated with higher outcome reporting quality.

CONCLUSIONS

Development of COS and core outcome measure sets will address variations and lead to higher quality evidence. We recommend the most commonly reported outcomes in each domain, as interim COS. For efficacy we recommend: UUI episodes, urgency and nocturia episodes; for safety: antimuscarinic adverse events, other adverse events and discontinuation rates; for QoL: OAB-q, PPBC and IIQ scores.

Developing Core Outcome Sets (COS) and Core Outcome Measures Sets (COMS) in Cosmetic Gynecological Interventions: Protocol for a Development and Usability Study

Background

Studies evaluating cosmetic gynecological interventions have followed variable methodology and reported a diversity of outcomes. Such variations limit the comparability of studies and the value of research-based evidence. The development of core outcome sets (COS) and core outcome measures sets (COMS) would help address these issues, ensuring a minimum of outcomes important to all stakeholders, primarily women requesting or having experienced cosmetic gynecological interventions.

Objective

This protocol describes the methods used in developing a COS and COMS for cosmetic gynecological interventions.

Methods

An international steering group within CHORUS, including health care professionals, researchers, and women with experience in cosmetic gynecological interventions from 4 continents, will guide the development of COS and COMS. Potential outcome measures and outcomes will be identified through comprehensive literature reviews. These potential COS and COMS will be entered into an international, multi-perspective web-based Delphi survey where Delphi participants judge which domains will be core. A priori thresholds for consensus will get established before each Delphi round. The Delphi survey results will be evaluated quantitatively and qualitatively in subsequent stakeholder group consensus meetings in the process of establishing “core” outcomes.

Results

Dissemination and implementation of the resulting COS and COMS within an international context will be promoted and reviewed.

Conclusions

This protocol presents the steps in developing a COS and COMS for cosmetic gynecological interventions. Embedding the COS and COMS for cosmetic gynecological interventions within future clinical trials, systematic reviews, and practice guidelines could contribute to enhancing the value of research and improving overall patient care.

Trial Registration

Core Outcome Measures in Effectiveness Trials (COMET) 1592; https://tinyurl.com/n8faysuh

International Registered Report Identifier (IRRID)

PRR1-10.2196/28032

A meta-synthesis of qualitative studies on stress urinary incontinence in women for the development of a Core Outcome Set: A systematic review

OBJECTIVE

Given the high variation of perceptions of women with stress urinary incontinence (SUI), qualitative meta-synthesis in this field appears warranted. We aimed to synthesize evidence on women's experiences of SUI by analyzing qualitative data.

METHODS

A literature search of Medline, Embase, Scopus, PsycInfo, and CINAHL databases was performed by a CHORUS Working Group, from inception to August 2020. Qualitative studies on women's perspectives on SUI were included. Thematic analysis was used as a conceptual approach to analyze the data and develop a set of overarching themes. The quality of studies was assessed based on the Critical Appraisal Skills Program tool.

RESULTS

Seven studies were included. Six themes encompassing women's perspectives on SUI emerged: experiencing SUI, awareness of SUI, treatments for SUI, sexuality, communication, and psychosocial effects. The quality appraisal of the studies showed good coherence.

CONCLUSION

This study revealed six overarching themes, of which treatment had the highest prevalence. Assessment of women's perceptions of SUI in the context of a qualitative meta-synthesis may inform policy and practice around this condition, may guide and help set research priorities, and will ideally contribute to the development of a Core Outcome Set for SUI.

Outcome reporting in trials on conservative interventions for pelvic organ prolapse: A systematic review for the development of a core outcome set

BACKGROUND

Significant risk of bias and limitations in outcome selections in trials evaluating conservative treatments for the management of Pelvic Organ Prolapse (POP) have been highlighted and preclude comparability of outcomes, synthesis of primary studies and high quality evidence.

OBJECTIVES

As systematic review of the reported outcomes is the first step in the process of development of a Core Outcome Set (COS), we aimed to systematically review reporting of outcomes and outcome measures in Randomised Control Trials (RCTs) on conservative treatments for POP and develop an inventory of them for consideration as core outcome and outcome measures sets. We evaluated methodological quality, outcome reporting quality and publication characteristics and their associations among published RCTs.

STUDY DESIGN

Systematic review of RCTs identified from the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE and MEDLINE (Pubmed). RCTs evaluating the effectiveness of conservative interventions for the management of POP were considered for inclusion. Outcomes and outcome measures were obtained from the RCTs and an inventory was created. Outcomes were grouped in domains and themes. Methodological quality, outcome reporting quality and publication characteristics were evaluated and statistically analysed.

RESULTS

Twenty-five trials (3179 women) were included and reported 31 outcomes and 50 outcome measures. Reporting rates of the outcomes investigated ranged between 4% and 56%. The most commonly reported outcome domains were patient reported symptoms, stage of POP expressed as POP-Q stage, and quality of life. Univariate analysis demonstrated no significant correlations of methodological and outcome reporting parameters.

CONCLUSIONS

There is a need to increase comparability of RCTs. Reporting standardized outcomes included in a COS for conservative interventions for POP will facilitate the comparability across RCTs. While the process of developing COS is in progress, we propose the interim use of the three most commonly reported outcomes in each domain: patient-reported outcomes (symptom distress including bowel and urinary symptoms, sexual function), stage of prolapse and quality of life parameters using validated questionnaires (Pelvic Floor Distress Inventory 20 (PFDI-20), Pelvic Floor Impact Questionnaire/Health related quality of life (PFIQ-7/HRQOL) and Pelvic Organ Prolapse Impact Questionnaire (POPIQ-7).

Systematic review and appraisal of clinical practice guidelines on pelvic organ prolapse using the AGREE II tool

AIMS

To systematically evaluate the content and quality of national and international clinical guidelines on pelvic organ prolapse (POP).

METHODS

We searched medical databases and organizations websites, to identify national and international guidelines on diagnosis and management of POP. Five authors independently assessed guidelines using the validated AGREE II tool. Its six domains include (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, and (6) editorial independence.

RESULTS

Eight guidelines met the inclusion criteria. Three hundred and thirteen different recommendations were identified. One hundred and ninety-nine recommendations were comparable across guidelines. Thirty-one recommendations were not supported by research evidence. Assessment by history and physical examination using the POP quantification system and consideration of imaging were recommendations featuring in all guidelines. Conservative treatment recommendations namely pelvic floor muscle training and vaginal pessaries were also found in all guidelines. Regarding surgical management, patient counseling, treating only symptomatic POP, consideration of apical fixation during surgical treatment, and use of biological or synthetic implants in recurrent cases were recommendations in all guidelines. Overall, the highest median scores were in the domains "scope and purpose" and "rigor of development". The lowest median score was for applicability (28.3%). Although the median score of "editorial independence" was high (85.4%), variability was also substantial (interquartile range: 12.5-100).

CONCLUSION

We identified variations in quality and deficiencies in certain areas, especially "applicability" and "editorial independence." Improvements in these key domains may enhance the quality and clinical impact of clinical practice guidelines.

Quality assessment of outcome reporting, publication characteristics and overall methodological quality in trials on synthetic mesh procedures for the treatment of pelvic organ prolapse for development of core outcome sets

Introduction and hypothesis

Variations in outcome measures and reporting of outcomes in trials on surgery for pelvic organ prolapse (POP) using synthetic mesh have been evaluated and reported. However, the quality of outcome reporting, methodology of trials and their publication parameters are important considerations in the process of development of Core Outcome Sets. We aimed to evaluate these characteristics in randomized controlled trials on surgery for POP using mesh.

Methods

Secondary analysis of randomized controlled trials on surgical treatments using synthetic mesh for POP previously included in a systematic review developing an inventory of reported outcomes and outcome measures. The methodological quality was investigated with the modified Jadad criteria. Outcome reporting quality was evaluated with the MOMENT criteria. Publication parameters included publishing journal, impact factor and year of publication.

Results

Of the 71 previously reviewed studies published from 2000 to 2017, the mean JADAD score was 3.59 and the mean MOMENT score was 4.63. Quality of outcomes (MOMENT) was related to methodological quality (JADAD) (rho = 0.662; p = 0.000) and to year of publication (rho = 0.262; p = 0.028).

Conclusions

Methodological quality and outcome reporting quality appear correlated. However, publication characteristics do not have strong associations with the methodological quality of the studies. Evaluation of the quality of outcomes, methodology and publication characteristics are all an indispensable part of a staged process for the development of Core Outcome and Outcome Measure Sets.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04749-3.

Evaluation of guidelines on the use of vaginal mesh implants for pelvic organ prolapse using the AGREE II instrument

OBJECTIVE

To systematically evaluate the content and quality of national and international guidelines on vaginal mesh procedures for pelvic organ prolapse (POP).

METHODS

We searched PubMed, Medline, Web of Science, and ScienceDirect from inception to March 2020 and organizations' websites. The quality of the guidelines was assessed independently by six appraisers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

RESULTS

Five guidelines were included. Most guidelines recommended individualized treatments, clinical observation, and conservative treatment for asymptomatic women discouraging the use of mesh. Vaginal pessary and pelvic floor muscle training are unanimously considered effective treatments. Only two guidelines recommended weight loss. Each guideline recommended patient counseling supported by data on success rates and complications. Most guidelines highlighted the importance of a specialist experienced surgeon, multidisciplinary teams, and national/international registries. All guidelines highlighted potential benefits of the use of mesh and reported possible complications. The overall quality rating ranged between 4.2 and 6.3, suggestive of moderate to high quality. The highest mean score (92.5%) pertained to "Scope and Purpose" and "Clarity of Presentation", and the lowest to "Editorial Independence" (18%). Three out of five guidelines were "strongly recommended" by the appraisers.

CONCLUSION

Although most guidelines were of moderate to high quality, methodological applicability, stakeholder involvement, and editorial independence were domains with low scores.