Prokop, Larry J.

Importance Suicide is a leading cause of death among young people and an escalating public health crisis. Objective To assess the effectiveness and harms of available treatments for suicidal thoughts and behaviors among youths at heightened risk for suicide. Evidence Review A systematic review was conducted searching databases including MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and various gray literature sources from January 1, 2000, to September 26, 2024. We included randomized clinical trials, comparative observational studies, and before-after studies of psychosocial interventions, pharmacologic interventions, neurotherapeutics, emerging therapies, and combination therapies. Eligible patients were youths (aged 5-24 years) with heightened risk for suicide, adolescents from racial and ethnic minority groups known to be at increased risk of suicide, or those exposed to crime or violence. Pairs of independent reviewers selected and appraised studies. Findings This review included 65 studies (33 randomized clinical trials, 13 comparative observational studies, and 19 before-after studies) reporting on 14 534 patients (median age, 15.1 years; 75.1% female patients). Psychosocial interventions comprised psychotherapy interventions (33 studies; cognitive behavioral therapy, dialectical behavioral therapy, collaborative assessment and management of suicidality, dynamic deconstructive psychotherapy, attachment-based family therapy, and family-focused therapy), acute (ie, 1-4 sessions or contacts) psychosocial interventions (19 studies; safety planning, family-based crisis management, motivational interviewing crisis interventions, continuity of care after crisis, and brief adjunctive treatments), and school- or community-based psychosocial interventions (13 studies; social network interventions, school-based skills interventions, suicide awareness or gatekeeper programs, and community-based, culturally tailored adjunct programs). Dialectical behavior therapy showed moderate strength of evidence for reducing suicidal ideation. Other categories of psychosocial treatments showed insufficient to low strength of evidence for reducing suicidal outcomes. None of the studies evaluated adverse events. The evidence base on pharmacologic treatment for youths at risk of suicide was largely nonexistent. Conclusions and Relevance This systematic review found that the current evidence on available interventions targeting youths at heightened risk of suicide is uncertain. Medication, neurotherapeutics, and emerging therapies remain unstudied among this population. The limited evidence base calls for the development of novel, developmentally and trauma-informed treatments, as well as multilevel interventions to target the increasing suicide risk among youths.

Purpose: To assess the prevalence, associated conditions, diagnostic and treatment modalities, and provider education regarding the diagnosis and management of keratoconus (KCN) in sub-Saharan Africa (SSA) based on the currently available body of literature. Methods: Peer-reviewed publications from any year and any language were included. The databases included Cochrane Database of Systematic Reviews, Embase, and Ovid. A separate search of African Journals Online was conducted using the same Medical Subject Heading (MeSH) terms as the database search. Additional publications were identified in the references during full-text extraction. The abstracts of all publications were evaluated by two reviewers. The full text was then examined by one reviewer for inclusion. A data extraction tool was used by a single reviewer to document the findings. Results: Sixty-two publications were included in data extraction. Fourteen countries in SSA were represented. Prevalence was reported in eight SSA countries and ranged from 0% to 2.8%. The highest prevalence of 1.2% was found in a cross-sectional study in Banjul, Gambia. Diagnosis in urban areas is often made using slit lamps, although some sites had access to keratometry and/or topography, whereas rural areas use penlight exams alone. Penetrating keratoplasty was reported as an available treatment in 14 manuscripts, glasses and hard contact lenses in 10, and corneal cross-linking in two. Publications discussing provider education reported a knowledge gap. Conclusions: There is a need for increased data on KCN in SSA to better inform public health policy to improve KCN patients’ access to care and quality of life.

Abstract Context Women with preexisting diabetes mellitus (PDM) are at increased risk of pregnancy-related complications. Objective To summarize the available supporting evidence for the Endocrine Society guidelines about management of PDM in pregnancy. Data Sources MEDLINE, EMBASE, Scopus, and other sources through February 2025. Study Selection Studies were selected by pairs of independent reviewers. Data Extraction Data were extracted by pairs of independent reviewers. Data Synthesis We included 17 studies. Meta-analysis showed no significant difference between hybrid closed-loop insulin pump (HCL) and standard of care regarding time in range (TIR), time above range (TAR), and time below range (TBR). HCL had better overnight TIR and TBR. For women with type 2 diabetes mellitus (T2DM), intermittent use of continuous glucose monitoring (CGM) was not associated with a significant change in the risk of large for gestational age (LGA) neonates (2 randomized controlled trials [RCTs], 102 patients). Adding metformin to insulin was associated with a lower risk of LGA (2 RCTs, 1126 patients). Three retrospective studies (1724 patients) suggested increased neonatal complications when delivery was induced before 39 weeks of gestation (particularly before 38 weeks) in women with preexisting type 1 (T1DM) and T2DM, although this evidence was subject to likely confounding. One retrospective study showed no increase in neonatal complications with periconceptional exposure to glucagon-like peptide-1 receptor agonists. We could not identify comparative studies assessing a screening question about the possibility of pregnancy or a carbohydrate restrictive diet. Conclusion This systematic review addresses various aspects of managing PDM in pregnancy and will support the development of the Endocrine Society guidelines.

Abstract The availability of knowledge about the effects of buprenorphine on pain perception in healthy adults could help investigators select experimental tests with evidence of responsiveness to buprenorphine in nondiseased states. The purpose of this meta-narrative systematic review is to summarize the effects of buprenorphine on pain perception in healthy adults. Comprehensive database searches were conducted from inception dates through July 16, 2024. Inclusion criteria included all study designs involving healthy adults receiving buprenorphine and tests of pain perception. Risk of bias was assessed using a tool developed for randomized controlled trials (RCTs). A meta-narrative approach was used due to high levels of clinical heterogeneity. A total of 10 RCTs were included, and healthy adults comprised the comparator groups in all trials. Three RCTs had a low risk of bias, 6 had some concerns, and 1 had a high risk of bias. Six RCTs used intravenous buprenorphine, 3 used transdermal, and 1 study used intravenous and sublingual buprenorphine. The effects of buprenorphine on pain perception are influenced by the route of administration, dose, and pain stimulus modality. Considerable differences exist in the effects of intravenous and transdermal buprenorphine, but only 1 study used sublingual buprenorphine, which limited comparison with the other drug formulations. Based on these findings, recommendations for clinical trials are proposed. These recommendations should be cautiously interpreted due to the clinical heterogeneity, but they provide a framework for advancing the use of experimental pain tests in trials of buprenorphine involving comparator groups of healthy adults.

Abstract Introduction Case reports and series are critical to guide initial decision-making in a pandemic, but may have lower rigor because of the need to publish them quickly. This meta-epidemiologic study compares the methodological quality of case series that described the acute coronavirus disease 2019 (COVID-19) pandemic in 2020 versus those that described long-haul cases. Methods We conducted a systematic review in multiple databases for long-haul case series and reports. We identified early cases of acute COVID-19 synthesized in published systematic reviews. We evaluated the methodological quality by pairs of independent reviewers using a tool dedicated for appraising case series. Results We included 239 original case series (81 published in the first year of the pandemic and 158 published later describing long-haul COVID). The methodological quality of both groups of case series was very good (80–100% of series satisfying quality items) except for two items, the selection approach of cases included in the series and ruling out other causes that can explain the main finding described in the series. The appraisal tool demonstrated high agreement and reliability between reviewers. Conclusion The methodological quality of modern case series is high, except for two quality items that represent an area for potential for improvement for authors of case series describing future pandemics.

Abstract Objectives IBM is characterized by slowly progressive muscle weakness making it challenging to detect significant changes in weakness during a clinical trial. Trial participants receiving placebo may behave differently from in natural history studies. We aimed to quantify the change in muscle strength and IBM Functional Rating Scale (IBMFRS) of IBM patients receiving placebo during clinical trials. Methods Several databases were searched. Randomized, double-blinded, placebo-controlled trials without treatment intervention on the placebo group were included. Standardized mean differences (SMD) for change in muscle strength and mean differences for IBMFRS were used to calculate pooled effects, using DerSimonian-Laird continuous random effect models. Meta-regression determined change in muscle strength. Heterogeneity was evaluated using the I2 indicator. Results Eleven eligible trials were identified with 257 participants receiving placebo and a low risk of bias per the Cochrane Collaboration Risk of Bias 2 (RoB2) tool. Participants receiving placebo on average had a measurable decline in muscle strength with a mean effect size of –0.398 (95% CI –0.652, –0.144) (P = 0.002). SMD changed by –0.009 (–0.016, –0.002) points per week (P = 0.015). Manual muscle testing was associated with higher heterogeneity (I2 = 67.68%) compared with quantitative muscle testing (I2 = 0%). Only three studies reported IBMFRS results. The pooled change in IBMFRS at 12 months was –2.189 points (–3.893, –0.485) on this 0 to 40-point scale (P = 0.012), with relatively high heterogeneity. Conclusion Participants with IBM displayed a measurable decline in their muscle strength and IBMFRS during clinical trials, in keeping with the disease’s slowly progressive nature. These estimates can inform sample size calculations in future studies.

The optimal patient panel size (PPS) in primary care and the factors determining it remain unclear. We conducted a meta-narrative review of the literature to evaluate factors influencing PPS and assess its association with patient outcomes. A comprehensive search of electronic databases was performed from inception through December 2023, focusing on original studies reporting factors used to determine PPS and related outcomes (eg, clinical outcomes, process measures, and resource utilization). A total of 48 studies were included, identifying 7 key factors influencing PPS. Smaller panels were associated with improved patient satisfaction, continuity of care, and health promotion, while clinical outcomes, utilization, and costs showed minimal impact by PPS. Panel size was primarily associated with patient age, sex, comorbidities, and practice type and structure. Community-based centers typically managed smaller panels, often staffed by female clinicians and serving socioeconomically disadvantaged populations with greater health needs than hospital-based practices. Female clinicians were also independently associated with managing smaller panels, higher quality care indicators, fewer emergency department visits, and improved patient satisfaction. Determining the ideal PPS is a multifaceted process influenced by practice setting, patient demographics, and clinician characteristics. While practice-related factors showed limited association with PPS, patient-reported outcomes were more closely linked to it. Primary care practices should tailor panel sizes to their patient populations, emphasizing a patient-centered approach and ensuring adequate infrastructure support to optimize care delivery.

BACKGROUND: Complex regional pain syndrome (CRPS) is a debilitating and painful condition accompanied by sensory, autonomic, trophic, and/or motor abnormalities. Although CRPS is rare in the general population, the prevalence among individuals at higher risk, particularly posttraumatic and postsurgical patients, remains unknown. This study aims to provide a benchmark that quantifies CRPS prevalence in high-risk groups, and offers insights on potential predictors of developing CRPS. METHODS: We conducted a systematic review and meta-analysis to identify studies reporting prevalence of CRPS after an inciting event (eg, fracture, surgery), specifically 12-month and 24-month prevalence (primary outcomes), as well as 3-month and 6-month prevalence (secondary outcomes). Estimates from individual studies were transformed using double-arcsine transformation, and the resulting estimates with 95% confidence interval (CI) were pooled in a meta-analysis using a random-effects model. RESULTS: We included 214 articles with data from 2491,378 participants worldwide (35 countries), of which 16,873 had CRPS. The pooled 12-month and 24-month global prevalence was 3.04% (95% CI, 2.64–3.48) and 6.46% (95% CI, 5.46–7.53), respectively. Subgroup analysis and meta-regression were performed to understand the impact of population-dependent (mechanism of injury, type of CRPS), contextual-dependent (socioeconomic status), and methodological-dependent (study design, publication year) factors. The 12-month prevalence was higher in countries with a high human development index (HDI) compared to those with a medium or very high HDI, was higher in participants with a traumatic inciting injury only versus those with surgical injury only or traumatic/surgical injury, and was higher in prospective versus retrospective studies. Meta-regression analysis showed that publication year was a significant moderator, with more recent articles reporting lower 12-month prevalence. CONCLUSIONS: This study provides a benchmark of the global prevalence of CRPS, which anesthesiologists and pain specialists can use to prioritize early diagnosis and identify those at the highest risk for CRPS.