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Cognitive behavioural therapy (CBT) is a form of psychotherapy that focuses on the identification and modification of unhelpful thoughts and behaviour patterns and has been shown to be effective for [...], Background: Cognitive behavioural therapy (CBT) has been shown to be effective for several psychiatric and somatic conditions; however, most randomized controlled trials (RCTs) have administered treatment in person and whether remote delivery is similarly effective remains uncertain. We sought to compare the effectiveness of therapist-guided remote CBT and in-person CBT. Methods: We systematically searched MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to July 4, 2023, for RCTs that enrolled adults (aged [greater than or equal to] 18 yr) presenting with any clinical condition and that randomized participants to either therapist-guided remote CBT (e.g., teleconference, videoconference) or in-person CBT. Paired reviewers assessed risk of bias and extracted data independently and in duplicate. We performed random-effects model meta-analyses to pool patient-important primary outcomes across eligible RCTs as standardized mean differences (SMDs). We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance to assess the certainty of evidence and used the Instrument to Assess the Credibility of Effect Modification Analyses (ICEMAN) to rate the credibility of subgroup effects. Results: We included 54 RCTs that enrolled a total of 5463 patients. Seventeen studies focused on treatment of anxiety and related disorders, 14 on depressive symptoms, 7 on insomnia, 6 on chronic pain or fatigue syndromes, 5 on body image or eating disorders, 3 on tinnitus, 1 on alcohol use disorder, and 1 on mood and anxiety disorders. Moderate-certainty evidence showed little to no difference in the effectiveness of therapist-guided remote and in-person CBT on primary outcomes (SMD -0.02, 95% confidence interval -0.12 to 0.07). Interpretation: Moderate-certainty evidence showed little to no difference in the effectiveness of in-person and therapist-guided remote CBT across a range of mental health and somatic disorders, suggesting potential for the use of therapist-guided remote CBT to facilitate greater access to evidence-based care. Systematic review registration: Open Science Framework (https://osf.io/7asrc)

Chronic pain affects 20% of the population worldwide (1-5) and is commonly managed with opioids. A 2021 systematic review of 60 observational studies found that opioids are prescribed for 27% [...], Background: Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids. Methods: We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs). Results: Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78-9.04), higher opioid dose (OR 2.57, 95% CI 2.08-3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57-6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35-5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30-3.41), current substance use disorder (OR 2.62, 95% CI 2.09-3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73-2.61), depression (OR 2.22, 95% CI 1.57-3.14), bipolar disorder (OR 2.07, 95% CI 1.77-2.41) or pancreatitis (OR 2.00, 95% CI 1.52-2.64), with absolute risks among patients with the predictor ranging from 2-6 per 1000 for fatal overdose and 4-12 per 1000 for nonfatal overdose. Interpretation: We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies. Systematic review registration: Open Science Framework (https://osf.io/vznxj/)

Au 30 avril 2020, la maladie a coronavirus 2019 (COVID-19) (1) etait a l'origine de plus de 3 millions de cas d'infection et de plus de 210 000 deces dans [...], CONTEXTE : On donne de facon empirique des agents antiviraux a certains patients atteints de la maladie a coronavirus 2019 (COVID-19). Dans le but d'appuyer la redaction de lignes directrices sur la prise en charge de la COVID-19, nous avons realise une revue systematique des benefices et des prejudices associes a 7 traitements antiviraux contre cette infection. METHODES : Nous avons effectue des recherches dans MEDLINE, Embase, le Cochrane Central Register of Controlled Trials (CENTRAL), PubMed et 3 bases de donnees chinoises (CNKI, Wanfang Data et SinoMed) jusqu'au 19 avril 2020, dans medRxiv et ChinaXiv jusqu'au 27 avril 2020, ainsi que dans Chongqing VIP jusqu'au 30 avril 2020. Nous avons selectionne des etudes sur la ribavirine, la chloroquine, l'hydroxychloroquine, l'umifenovir (Arbidol), le favipiravir, l'interferon et le lopinavir/ritonavir. Lorsqu'il n'y avait pas de donnees directes d'etudes sur la COVID-19, nous avons retenu des donnees indirectes d'etudes sur le syndrome respiratoire aigu severe (SRAS) et le syndrome respiratoire du Moyen-Orient (SRMO) pour l'analyse de l'efficacite, et d'etudes sur d'autres infections respiratoires virales aigues pour l'analyse de l'innocuite. RESULTATS : Le taux de deces chez les patients atteints d'une forme sans signe clinique de gravite de COVID-19 etait extremement bas, ce qui ne permet pas de conclure a un effet important sur la mortalite. Nous n'avons obtenu que des donnees de tres faible qualite indiquant que la plupart des traitements avaient peu ou pas de benefices sur les parametres a l'etude, quelle que soit la gravite de la COVID-19. Seule exception : le traitement au lopinavir/ritonavir, pour lequel nous avons obtenu des donnees de faible qualite faisant etat d'une reduction de la duree du sejour en unite de soins intensifs (difference des risques [DR] 5 jours de moins, intervalle de confiance [IC] de 95 % 0 a 9 jours) et de la duree d'hospitalisation (DR 1 jour de moins, IC de 95 % 0 a 2 jours). En ce qui concerne l'innocuite, les donnees etaient de faible ou de tres faible qualite, sauf pour le traitement au lopinavir/ ritonavir, ou des donnees de qualite moyenne laissaient supposer une augmentation probable de la diarrhee, des nausees et des vomissements. INTERPRETATION : A l'heure actuelle, rien ne prouve de facon convaincante que les traitements antiviraux apportent des benefices importants dans la lutte contre la COVID-19, bien que les donnees propres a chaque traitement n'excluent pas cette possibilite. D'autres essais randomises et controles menes aupres de patients atteints de la COVID-19 sont necessaires avant de pouvoir recourir a ces traitements en toute confiance.

Le 11 mars 2020, l'Organisation mondiale de la Sante a qualifie de pandemie la maladie a coronavirus 2019 (COVID-19) (1). La propagation mondiale de la COVID-19 est une grande menace [...], CONTEXTE : Il existe tres peu de donnees directes sur l'administration de corticosteroides aux patients atteints de la maladie a coronavirus 2019 (COVID-19). Les donnees indirectes sur des maladies associees devront donc guider les conclusions quant aux benefices et aux prejudices associes a cette pratique. Dans le but d'appuyer la redaction d'une ligne directrice sur la prise en charge de la COVID-19, nous avons realise des revues systematiques sur les effets des corticosteroides dans le traitement de la COVID-19 et de maladies respiratoires aigues severes associees. METHODES : Dans des bases de donnees biomedicales chinoises et internationales et des sources de prepublications, nous avons cherche les essais randomises et controles (ERC) et les etudes d'observation comparant des patients atteints de la COVID-19, du syndrome respiratoire aigu severe (SRAS) ou du syndrome respiratoire du Moyen-Orient (SRMO) ayant recu des corticosteroides a des patients semblables n'ayant pas recu ce type de medicaments. Pour le syndrome de detresse respiratoire aigue (SDRA), l'influenza et la pneumonie extrahospitaliere (PEH), nous avons mis a jour les revues systematiques rigoureuses les plus recentes. Nous avons realise des meta-analyses a effets aleatoires pour cerner les risques relatifs, puis nous avons utilise le risque de reference des patients atteints de la COVID-19 pour calculer les effets absolus. RESULTATS : Pour le SDRA, selon 1 petite etude de cohorte sur des patients atteints de la COVID-19 et 7 ERC sur des patients atteints d'une autre maladie (risque relatif : 0,72, intervalle de confiance [IC] de 95 % 0,55-0,93, difference entre les moyennes [DM] 17,3 % plus faible, donnees de faible qualite), les corticosteroides pourraient reduire le risque de mortalite. Chez les patients atteints d'une forme grave de COVID-19 sans SDRA, 2 etudes d'observation ont genere des donnees directes de tres faible qualite montrant une augmentation du risque de mortalite avec l'administration de corticosteroides (rapport de risques 2,30, IC de 95 % 1,00-5,29, DM 11,9 % plus eleve). C'est aussi le cas de donnees observationnelles sur l'influenza. Des donnees observationnelles de tres faible qualite sur le SRAS et le SRMO montrent peu ou pas de reduction dans le risque de mortalite. Des essais randomises et controles sur la PEH suggerent que les corticosteroides pourraient reduire le risque de mortalite (risque relatif 0,70, IC de 95 % 0,50-0,98, DM 3,1 % plus faible, donnees de tres faible qualite), et augmenter le risque d'hyperglycemie. INTERPRETATION : Les corticosteroides pourraient reduire le risque de mortalite pour les patients atteints de la COVID-19 avec SDRA. Pour les patients atteints d'une forme grave de COVID-19 sans SDRA, les donnees sur les benefices provenant de differentes sources sont incoherentes et de tres faible qualite.

On Mar. 11, 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic. (1) The worldwide spread of COVID-19 represents a profound threat to human health. Clinicians frequently [...], BACKGROUND: Very little direct evidence exists on use of corticosteroids in patients with coronavirus disease 2019 (COVID-19). Indirect evidence from related conditions must therefore inform inferences regarding benefits and harms. To support a guideline for managing COVID-19, we conducted systematic reviews examining the impact of corticosteroids in COVID-19 and related severe acute respiratory illnesses. METHODS: We searched standard international and Chinese biomedical literature databases and prepublication sources for randomized controlled trials (RCTs) and observational studies comparing corticosteroids versus no corticosteroids in patients with COVID-19, severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS). For acute respiratory distress syndrome (ARDS), influenza and community-acquired pneumonia (CAP), we updated the most recent rigorous systematic review. We conducted random-effects meta-analyses to pool relative risks and then used baseline risk in patients with COVID-19 to generate absolute effects. RESULTS: In ARDS, according to 1 small cohort study in patients with COVID-19 and 7 RCTs in non-COVID-19 populations (risk ratio [RR] 0.72, 95% confidence interval [CI] 0.55 to 0.93, mean difference 17.3% fewer; low-quality evidence), corticosteroids may reduce mortality. In patients with severe COVID-19 but without ARDS, direct evidence from 2 observational studies provided very low-quality evidence of an increase in mortality with corticosteroids (hazard ratio [HR] 2.30, 95% CI 1.00 to 5.29, mean difference 11.9% more), as did observational data from influenza studies. Observational data from SARS and MERS studies provided very low-quality evidence of a small or no reduction in mortality. Randomized controlled trials in CAP suggest that corticosteroids may reduce mortality (RR 0.70, 95% CI 0.50 to 0.98, 3.1% lower; very low-quality evidence), and may increase hyperglycemia. INTERPRETATION: Corticosteroids may reduce mortality for patients with COVID-19 and ARDS. For patients with severe COVID-19 but without ARDS, evidence regarding benefit from different bodies of evidence is inconsistent and of very low quality.

As of Apr. 30, 2020, coronavirus disease 2019 (COVID-19) (1) has resulted in more than 3 million cases and more than 210 000 deaths worldwide. (2) The World Health Organization [...], BACKGROUND: Antiviral medications are being given empirically to some patients with coronavirus disease 2019 (COVID-19). To support the development of a COVID-19 management guideline, we conducted a systematic review that addressed the benefits and harms of 7 antiviral treatments for COVID-19. METHODS: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed and 3 Chinese databases (CNKI, WANFANG and SinoMed) through Apr. 19, medRxiv and Chinaxiv through Apr. 27, and Chongqing VIP through Apr. 30, 2020. We included studies of ribavirin, chloroquine, hydroxychloroquine, umifenovir (arbidol), favipravir, interferon and lopinavir/ritonavir. If direct evidence from COVID-19 studies was not available, we included indirect evidence from studies of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) for efficacy outcomes and other acute respiratory viral infections for safety outcomes. RESULTS: In patients with nonsevere COVID-19 illness, the death rate was extremely low, precluding an important effect on mortality. We found only very low-quality evidence with little or no suggestion of benefit for most treatments and outcomes in both nonsevere and severe COVID-19. An exception was treatment with lopinavir/ritonavir, for which we found low-quality evidence for a decrease in length of stay in the intensive care unit (risk difference 5 d shorter, 95% confidence interval [CI] 0 to 9 d) and hospital stay (risk difference 1 d shorter, 95% CI 0 to 2 d). For safety outcomes, evidence was of low or very low quality, with the exception of treatment with lopinavir/ ritonavir for which moderate-quality evidence suggested likely increases in diarrhea, nausea and vomiting. INTERPRETATION: To date, persuasive evidence of important benefit in COVID-19 does not exist for any antiviral treatments, although for each treatment evidence has not excluded important benefit. Additional randomized controlled trials involving patients with COVID-19 will be needed before such treatments can be administered with confidence.

Chronic noncancer pain includes any painful condition that persists for at least three months and is not associated with malignant disease. (1) According to seven national surveys conducted between 1994 [...]

Despite a 10-year survival rate of 83%, (1,2) between 25% and 60% of surviving patients who have undergone surgery for breast cancer experience persistent postsurgical pain, (3-9) which is associated [...], Background: Persistent pain after breast cancer surgery affects up to 60% of patients. Early identification of those at higher risk could help inform optimal management. We conducted a systematic review and meta-analysis of observational studies to explore factors associated with persistent pain among women who have undergone surgery for breast cancer. Methods: We searched the MEDLINE, Embase, CINAHL and PsycINFO databases from inception to Mar. 12, 2015, to identify cohort or case-control studies that explored the association between risk factors and persistent pain (lasting > 2 mo) after breast cancer surgery. We pooled estimates of association using random-effects models, when possible, for all independent variables reported by more than 1 study. We reported relative measures of association as pooled odds ratios (ORs) and absolute measures of association as the absolute risk increase. Results: Thirty studies, involving a total of 19 813 patients, reported the association of 77 independent variables with persistent pain. High-quality evidence showed increased odds of persistent pain with younger age (OR for every 10-yr decrement 1.36, 95% confidence interval [CI] 1.24-1.48), radiotherapy (OR 1.35, 95% CI 1.16-1.57), axillary lymph node dissection (OR 2.41, 95% CI 1.73-3.35) and greater acute postoperative pain (OR for every 1 cm on a 10-cm visual analogue scale 1.16, 95% CI 1.03-1.30). Moderate-quality evidence suggested an association with the presence of preoperative pain (OR 1.29, 95% CI 1.01-1.64). Given the 30% risk of pain in the absence of risk factors, the absolute risk increase corresponding to these ORs ranged from 3% (acute postoperative pain) to 21% (axillary lymph node dissection). High-quality evidence showed no association with body mass index, type of breast surgery, chemotherapy or endocrine therapy. Interpretation: Development of persistent pain after breast cancer surgery was associated with younger age, radiotherapy, axillary lymph node dissection, greater acute postoperative pain and preoperative pain. Axillary lymph node dissection provides the only high-yield target for a modifiable risk factor to prevent the development of persistent pain after breast cancer surgery.