An exploratory descriptive survey on the use of GRADE and CINeMA: time-consuming, process transparency and subjectivity versus high-speed, practical challenges and poor understanding.

Emergence delirium (ED) is a common complication in pediatric anesthesia. Although intranasal dexmedetomidine (DEX) is widely used, its application is constrained by a slow onset, residual risk of ED in some patients, and risks such as bradycardia and hypotension. Esketamine (ESK), an NMDA receptor antagonist, may provide a faster onset and reduce these side effects. This study compared the efficacy and safety of intranasal DEX-ESK combination versus DEX alone as premedication for anesthesia induction in pediatric patients undergoing surgery. Electronic databases (PubMed, Web of Science, Scopus, CINAHL, and Embase) were systematically searched for randomized controlled trials (RCTs). The primary outcomes included the ED incidence and the onset of sedation. Secondary outcomes included mask acceptance score, FLACC pain score, post-anesthesia care unit (PACU) length of stay, and adverse events. A random-effects model generated pooled effect estimates-risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs) with 95% CIs for continuous outcomes. Prediction intervals were also reported to reflect the expected range of effects in future similar studies. Trial Sequential Analysis was performed. The certainty of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Five RCTs encompassing 466 pediatric patients were included in the quantitative synthesis. The DEX-ESK combination was associated with a reduction in ED incidence (RR = 0.58; 95% CI: 0.35-0.97; p = 0.04) and a shorter time to sedation onset (MD = -3.95 min; 95% CI: -4.77 to -3.14; p < 0.01). Secondary analyses demonstrated improved mask acceptance (MD = -0.77; 95% CI: -1.27 to -0.27; p < 0.01), reduced FLACC pain scores (MD = -0.36; 95% CI: -0.70 to -0.02; p = 0.04), and shorter PACU length of stay (MD = -1.83 min; 95% CI: -2.75 to -0.91; p < 0.01). Adverse event incidence did not differ significantly between groups. The intranasal DEX-ESK combination was associated with improved outcomes compared with DEX monotherapy for pediatric premedication including reductions in ED incidence, a modest acceleration in sedation onset, improved mask acceptance, and slightly shorter PACU length of stay, without an increased risk of adverse events. This combination may represent a feasible and safe premedication option for pediatric patients. PROSPERO: CRD420251236740.

Although dietary pulses are recognized by major clinical practice guidelines to reduce cholesterol and coronary heart disease risk, intake is low. There are no health claims for any pulse for cholesterol reduction, which could support uptake. We therefore conducted a systematic review and dose-response meta-analysis of randomized trials of the effect of different types of whole dietary pulses on lipid targets. MEDLINE, Embase, and the Cochrane Library were searched through March 2025 for trials ≥3 weeks. The primary outcome was low-density lipoprotein-cholesterol. Secondary outcomes were other lipid targets. Independent reviewers extracted data and assessed risk of bias. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Thirty-eight trials (52 trial comparisons, n=2095) with a median of 6 weeks and dose of 130 g/d (0.5-0.67 cup/d) showed that whole dietary pulses decreased low-density lipoprotein-cholesterol (mean difference, -0.14 mmol/L [95% CI, -0.19 to -0.08]), non-high-density lipoprotein-cholesterol (-0.22 mmol/L [95% CI, -0.30 to -0.14]), apoB (apolipoprotein B) (-0.08 g/L [95% CI, -0.13 to -0.03]) and high-density lipoprotein-cholesterol (-0.03 mmol/L [95% CI, -0.05 to -0.01]) with no effects on other lipids. Analyses by pulse type showed similar results. A linear inverse relationship was shown for beans up to 1 cup/d for low-density lipoprotein-cholesterol (coefficient, -0.25 mmol/L/0.5 cup [95% CI, -0.48 to -0.02]) and non-high-density lipoprotein-cholesterol (-0.45 mmol/L/0.5 cup [95% CI, -0.71 to -0.18]). Grading of Recommendations Assessment, Development, and Evaluation was moderate-to-high for all outcomes, except apoB (very low). Whole dietary pulses likely result in small important-to-moderate reductions in lipid targets and trivial reductions in high-density lipoprotein-cholesterol. Similar effects were observed across pulse types with an inverse dose-response gradient for beans up to 1 cup/d. Future studies on chickpeas, dried peas, and lentils are warranted. URL: https://www.crd.york.ac.uk/PROSPERO/view/CRD42023432826; Unique identifier: CRD42023432826.

Several studies have assessed the effects of green tea extract (GTE) supplementation on substrate oxidation. However, no consensus has been reached due to the heterogeneity of the results, and so far no meta-analysis has been conducted on this topic. This systematic review and meta-analysis aimed to critically evaluate the effects of GTE supplementation on substrate oxidation, particularly on fat and carbohydrate oxidation during and after exercise. We conducted a comprehensive search of databases, including PubMed, Web of Science, and Scopus, to identify studies relevant to our research up until December 2024. Eligible randomized controlled trials (RCTs) that reported relevant and adequate data about substrate oxidation were included in this meta-analysis. Also, we rated the evidence certainty using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) method. Nine clinical trials evaluated the effect of GTE supplementation on substrate oxidation during and after exercise. In summary, intervention with GTE significantly increased fat oxidation both during (weighted mean difference [WMD]: 0.2 g/min; 95% CI; 0.04, 0.36; P = .016) and after exercise (WMD: 0.04 g/min; 95% CI; 0.01, 0.08; P = .023). Also, GTE significantly decreased carbohydrate oxidation after exercise (WMD: -0.16 g/min; 95% CI; -0.32, -0.01; P = .04) but did not significantly affect carbohydrate oxidation during exercise (WMD: -0.08 g/min; 95% CI; -0.29, 0.13; P = .468). Furthermore, the results of the dose-response analysis showed that an increase in the dose of GTE could augment fat oxidation after exercise (WMD: 0.03 g/min; 95% CI: 0.01, 0.06, P = .007). The quality of evidence was rated as low to high according to the GRADE criteria. Green tea extract supplementation significantly enhances fat oxidation during and after exercise, with limited effects on carbohydrate oxidation. PROSPERO registration No. CRD42024598165.

BackgroundNeck pain poses a significant and growing public health challenge, with rising prevalence among younger populations and negative impacts on both quality of life and socioeconomic costs. Clinical manifestations are diverse, including restricted movement, muscle spasms, headaches, and upper limb numbness. Although drug therapy is widely used, its long-term use is limited by adverse effects. Traditional Chinese medicine (TCM) exercises offer a promising alternative, but high-quality evidence directly comparing their efficacy and safety to oral medications is currently lacking.ObjectiveThis study aims to compare the efficacy and safety of TCM exercises and oral medication in treating neck pain.MethodsWe will identify relevant randomized controlled trials (RCTs) through a systematic search of multiple databases (including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure [CNKI], Chinese Biomedical Literature Database [CBM], VIP, and Wanfang) from inception through September 2025. Only RCTs directly comparing TCM exercise to oral medication will be included. Study quality will be assessed using the Cochrane RoB2 tool, and the overall evidence will be graded via the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For heterogeneity, the I² statistic and Cochran Q test will be applied. A fixed-effect model will be adopted if I²<50% and P≥.10; otherwise, subgroup analysis will be performed. Should heterogeneity persist, sensitivity analysis or a random-effects model will be employed, leading to a reduction in the GRADE rating.ResultsThis is a study protocol; therefore, no results are available at this stage. The systematic review is scheduled to commence in August 2025, with the literature search from August to September 2025, study screening from September to December 2025, data extraction and analysis from January to May 2026, and manuscript submission by June 2026.ConclusionsThis protocol outlines a systematic review and meta-analysis designed to compare the efficacy and safety of TCM exercises versus oral medications for neck pain. The completed review aims to synthesize the available evidence and clarify whether TCM exercises offer a comparable or superior alternative to pharmacotherapy. By systematically evaluating direct head-to-head RCTs, this study seeks to provide evidence-based insights to inform clinical decision-making. Potential limitations of the forthcoming review may include heterogeneity in exercise protocols, challenges in blinding, and a possible limited number or geographic concentration of available trials, which could affect the generalizability of the findings. These limitations will be considered when interpreting the results.

The Diagnostic Role of Prostate-specific Membrane Antigen Positron Emission Tomography for Patients with Rising PSA After Radical Prostatectomy and Postoperative Radiotherapy: A Systematic Review and Meta-analysis.

Antipsychotics (APs) are not officially approved for the treatment of depressive, anxiety, obsessive-compulsive, emotional dysregulation, or sleep disorders among children and adolescents. Despite this, the treatment of these common and comorbid disorders is likely to partially explain the increased AP use. We assessed all studies reporting changes in symptoms or functioning during antipsychotic treatment for these diagnoses among patients < 18 years old. We systematically searched MEDLINE, EBM reviews and PsycINFO databases for all studies published by October 30, 2025, reporting on the effectiveness of APs for obsessive-compulsive, mood dysregulation, depression, anxiety, and sleep-related disorders among patients < 18 years. We evaluated evidence using the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE). Of the 2237 identified studies, 119 were eligible for full-text review, and 13 were included in the final review. One study compared two antipsychotics, while the rest were uncontrolled open-label studies, case series, or case reports. No randomized controlled trials nor studies on sleep or anxiety disorders were identified. While there were reported changes in standardized mean scores between baseline and endpoint, the level of evidence in obsessive-compulsive, mood dysregulation, and depression related disorders was very low. The identified very low level of evidence stands in stark contrast to clinical practice, where APs are increasingly prescribed. Future methodologically robust studies are needed to demonstrate efficacy. Given the side effects of APs, physicians should carefully consider the benefits and harms when prescribing them for off-label indications.

Heart failure leads to adverse clinical and patient-reported outcomes. Its prevalence has increased markedly among adults aged 60 years and over. Transitional care interventions are recommended to address these issues; however, their effectiveness on health outcomes, particularly in older adults, remains limited and inconclusive. This study aimed to systematically review and synthesise the existing evidence from randomised controlled trials on the effectiveness of transitional care interventions on health outcomes among older adults with heart failure. Only randomised controlled trials were included. This systematic review and meta-analysis were conducted according to the Cochrane Collaboration methodology and were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies from 2001 to the present were identified through searches of PubMed, the Cochrane Library, Web of Science Core Collection, and Cumulative Index to Nursing and Allied Health Literature Plus with full text. Risk ratios, mean differences, and standardised mean differences were calculated. Heterogeneity was evaluated with the I2 statistic. The certainty of the evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation criteria. Eight studies with 967 subjects (483 in the intervention group and 484 in the control group) were included in this systematic review and meta-analysis. Transitional care interventions were associated with improvements in self-care confidence and reductions in heart failure-specific readmission. There were no statistically significant effects on self-care maintenance, self-care management, or heart failure knowledge. Findings for health-related quality of life, functional status, and event-free survival varied across studies. The certainty of the evidence ranged from very low to moderate. Transitional care interventions were associated with improved self-care confidence and reduced heart failure-specific readmissions in older adults with heart failure. However, variations in the certainty of the evidence create uncertainty about the intervention's effect. The limited number of trials included in this review demonstrates an evidence gap in this area. Further high-quality studies with transparent reporting through prospective trial registration should be conducted to determine the optimal content of the transitional care intervention. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021229464). Not applicable.

Despite the growing number of studies comparing active and traditional methodologies, there is a lack of updated systematic syntheses evaluating active methodologies focusing on academic performance in dentistry. Thus, the aim was to systematically evaluate the evidence about the impact of active teaching methodologies compared to the traditional method on the academic performance of undergraduate dental students. The review protocol was registered on PROSPERO (CRD42023472330). Eligibility criteria included randomised clinical trials (RCT) involving undergraduate dental students, comparing at least one active teaching methodology to a traditional, using quantitative methods to evaluate the results. Outcomes were considered successful when they showed statistically significant improvement in knowledge acquisition, skills performance or competency measures compared to traditional teaching. The RevMan software was used for meta-analysis (p < 0.05). Two independent reviewers conducted searches in PubMed/MEDLINE, Embase, Web of Science and Scopus, as well as in grey literature and manual reference lists, published up to December 2024. Risk of bias was assessed using the RoB 2 tool. The certainty of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A total of 1277 studies were identified and 20 met the eligibility criteria. Only 18 were included in the meta-analysis. Active methodologies were associated with higher academic performance after the intervention (p < 0.001) and better retention after 1 month (p < 0.001), compared with traditional teaching. Baseline analysis showed equivalence between groups before the intervention (p = 0.75). The certainty of evidence was rated as low for all outcomes. The use of active methodologies in dental education is related to better academic performance of dental students in comparison to traditional teaching.

The aim of this study was to investigate the prevalence of vestibular and/or postural balance alterations in children with congenital cytomegalovirus (cCMV) and to determine the association between the infection and these impairments compared to a control group. This systematic review was registered with Prospective Register of Systematic Reviews (CRD42024549387) and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines consulted five databases (Embase, LILACS, PubMed/MEDLINE, Scopus, and Web of Science) and gray literature (Google Scholar and ProQuest). It included studies with children aged 0-12 years diagnosed with cCMV by laboratory tests performed in the first 21 days of life. Eligible studies assessed vestibular function and/or postural balance and compared children with cCMV with a control group of children without the infection. Only observational studies were included. A meta-analysis was performed to estimate the association between cCMV and vestibular changes, using a random-effects model and subgroup analysis. The risk of bias was assessed using the Joanna Briggs Institute checklist, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. The qualitative synthesis included eight observational studies of the 2,840 studies identified. All reported vestibular and/or postural balance changes in children with cCMV. The meta-analysis demonstrated an approximately 10-fold increased risk of vestibular changes in this group, especially in symptomatic children. Although the pooled risk ratio suggested a strong association, the certainty of the evidence was rated very low according to GRADE, which considers study quality, consistency, precision, and risk of bias. Children with cCMV, especially those with symptoms, have a significantly increased risk of vestibular and postural balance changes. However, given the very low certainty of the evidence, these results should be interpreted with caution. Future well-designed research should prioritize pediatric vestibular screening to confirm these associations and inform clinical practice.

ObjectivesTo assess the beneficial and harmful effects of regular human insulins versus rapid-acting insulin analogues in children and adolescents with type 1 diabetes.DesignSystematic review of randomised clinical trials with meta-analysis and trial sequential analysis.Data sourcesCENTRAL, MEDLINE, Embase, LILACS and other sources from inception to 30 January 2026.Study selectionRandomised clinical trials comparing regular human insulins versus rapid-acting insulin analogues (insulin aspart, lispro, glulisine) in children and adolescents with type 1 diabetes.AnalysesData were analysed using meta-analysis and trial sequential analysis. Risk of bias was assessed using the Cochrane Risk of Bias tool, V.2, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.Primary outcomesSevere hypoglycaemia, ketoacidosis and serious adverse events.Results10 trials randomising 1107 participants were included. The certainty of evidence was very low mainly due to high risk of bias and small sample sizes. Meta-analysis showed no evidence of a difference between regular human insulins and rapid-acting insulin analogues on severe hypoglycaemia (risk ratio (RR) 1.28, 95% CI 0.81 to 2.03; I2=0.0%; p=0.2851; nine trials), ketoacidosis (RR 0.88, 95% CI 0.26 to 2.93; I2=0.0%; p=0.8593; two trials) and serious adverse events (RR 1.00, 95% CI 0.44 to 2.25; I2=0.0%; p=0.9958; two trials). Trial sequential analysis showed that all meta-analyses of primary outcomes were underpowered.ConclusionsCurrent research shows no differential effects between regular human insulins and rapid-acting insulin analogues for children and adolescents with type 1 diabetes, but the evidence is very uncertain.PROSPERO registration numberCRD42024508625.

AimTo examine the effects of decision aids (DAs) on decision knowledge, conflict, and satisfaction among patients with cancer.BackgroundDAs are frequently used to improve the quality of health decision‐making across various cancer types (e.g., breast, prostate, and colorectal cancer). However, the impact of DAs on decision knowledge, conflict, and satisfaction remains unclear, and the various delivery methods (e.g., telephone, brochure, mixed delivery methods, and web‐based delivery methods) exhibit inconsistent effects.MethodsWe systematically searched eight databases and two search engines from inception to November 30, 2025, for randomized controlled trials (RCTs), evaluating DAs in adult cancer patients facing treatment decisions. A frequentist random‐effects meta‐analysis was conducted using Stata 16.0 to synthesize the primary outcomes of decision knowledge, conflict, and satisfaction. Pooled effects were estimated as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Heterogeneity was explored via subgroup and sensitivity analyses. Publication bias was assessed using funnel plots and Egger’s test, with the trim‐and‐fill method applied when indicated. The methodological quality of individual studies was assessed using the Cochrane Risk‐of‐Bias Tool 2.0 (ROB 2), and the overall certainty of the evidence for each outcome was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.ResultsThirty RCTs with 4303 cancer patients were included. The pooled analysis showed a positive effect on decision knowledge (SMD = 0.91, 95% CI: 0.49–1.33) and a reduction in decision conflict (SMD = −0.23, 95% CI: −0.39 to −0.07). No significant effect was observed on decision satisfaction (SMD = 0.03, 95% CI: −0.42–0.48). In subgroup analyses, all three delivery methods (brochure, web‐based, and mixed) were associated with increased decision knowledge, while only web‐based and mixed methods were associated with reduced decision conflict. DAs designed for both specific and various cancer types were associated with improved knowledge, whereas only those targeting a specific cancer type were associated with reduced conflict.ConclusionDAs are effective in improving decision knowledge and reducing decision conflict, but they do not effectively increase decision satisfaction.Implications for Nursing ManagementNurses should integrate evidence‐based DAs, particularly web‐based and mixed delivery formats, into routine cancer care to enhance patients’ decision knowledge and reduce conflict. To maximize effectiveness, DAs should be tailored based on targeted cancer types, educational levels, and health literacy to achieve unmet needs in decision satisfaction.

Liver transplantation is a life-saving procedure for patients with end-stage liver disease. Risk of post-transplantation infection remains high despite improvement in graft and patient survival. Antibacterial and antifungal prophylaxis plays an important role in reducing infection-related morbidity and mortality, but optimal timing and regimens are not well defined. The Surgical Infection Society's (SIS) Therapeutics and Guidelines Committee and individuals with content expertise convened to develop guidelines on antibacterial and antifungal prophylaxis in liver transplant to prevent surgical site infection and other infections, shorten intensive care unit length of stay, and decrease mortality. PubMed, Embase, Web of Science, and the Cochrane Database were searched using Medical Subject Heading terms including "liver transplantation," "antibiotic prophylaxis," and "antifungal prophylaxis" for studies limited to randomized controlled trials, systematic reviews, meta-analyses, cohort, and case-control studies in adult patients. Evaluation of the published evidence was performed using the Grading of Recommendations Assessment, Development and Evaluation system, and final recommendations were developed by an iterative process. We cannot make a recommendation for or against using pre-operative (more than 1 h before incision) antibiotic agent prophylaxis in liver transplantation with available evidence. We suggest the use of broad-spectrum antibiotic agent prophylaxis in liver transplantation rather than gram-positive antibiotic agent prophylaxis alone (Grade 2B). We recommend limiting administration of antibiotic agent prophylaxis to 24 hours post-operatively after liver transplant (Grade 1B). We recommend against empiric antifungal prophylaxis for patients at low risk for invasive fungal infections (IFIs) after liver transplant; for patients at high risk for IFI, we recommend antifungal prophylaxis (Grade 1B). This guideline summarizes the current SIS recommendations on antibacterial and antifungal prophylaxis in liver transplantation.

BackgroundInadequate alveolar bone is a critical challenge for the placement of implants. The tenting screw technique has been demonstrated to be effective for bone augmentation. However, no previous systematic reviews have addressed the clinical outcomes of the tenting screw technique for guided bone regeneration (TS-GBR). Thus, we aimed to conduct a meta-analysis to systematically assess the clinical outcomes of TS-GBR.Methods and analysisWe will search eight databases to identify relevant studies. Clinical trials that report the outcomes of bone augmentation with the application of the tenting screw technique and that meet the inclusion criteria will be included. Two authors will independently conduct the literature search and data extraction. The risk of bias of the included studies will be assessed with the Cochrane Risk of Bias 2.0 tool, Risk of Bias in Non-randomised Studies of Interventions tool, Newcastle-Ottawa Scale or Joanna Briggs Institute Checklist on the basis of the study design. Weighted means will be calculated. R software will be used to perform the data analysis. A funnel plot will be generated to assess publication bias. The quality of evidence for each outcome will be assessed with the Grading of Recommendations Assessment, Development and Evaluation framework.Ethics and disseminationEthical approval is not applicable since this is a protocol for a systematic review and meta-analysis that does not include actual patients or require data privacy. We will summarise the currently available data related to TS-GBR. The results will be published in a peer-reviewed journal.PROSRERO registration numberCRD420251043324.

BackgroundWalking is associated with many benefits, from improved mental health to a reduced risk of mortality – but can it boost creative thinking? Current evidence suggests a positive effect of physical activity on creative thinking, but the specific effect of walking has not been adequately explored.MethodsWe conducted a systematic search of the PsycINFO, MEDLINE, Scopus, and ProQuest databases from inception to 8 January 2025 using search terms related to walking and creativity. We then performed meta-analyses of Cohen’s d effect sizes to assess the effect of walking on creative thinking, as represented by divergent thinking (the ability to generate novel and useful ideas) and convergent thinking (the ability to analyze and select ideas to find the best solution). We assessed study quality using a creativity-specific tool, and the certainty of the evidence with the Grading of Recommendations Assessment, Development and Evaluation Framework.ResultsWe identified 23 studies (12 randomized experimental studies, nine non-randomized experimental studies, two observational studies) from 16 articles including a total of 1,036 participants, most of whom were post-secondary students. We found moderate certainty evidence of a large effect of walking on divergent thinking (d = 0.93 [95% CI 0.44, 1.42]), and very uncertain evidence of a null effect of walking on convergent thinking (d = 0.16 [95% CI −0.31, 0.63]). Sensitivity analyses of randomized trials only found similarly large effects of walking on divergent thinking ability (d = 0.82 [95% CI 0.35, 1.28]).ConclusionResults suggest that walking likely results in a large increase in divergent thinking, indicating its potential as an intervention to stimulate creative idea generation.

Ketamine and esketamine for the prevention of postpartum depression: A systematic review and network meta-analysis, with an integrated evidence synthesis.

Testicular germ cell tumours (TGCTs) are the most common malignancy in men aged 15-35 years. Management options for men with TGCTs include surgery, radiation and/or chemotherapy, depending on stage. Given TGCTs' excellent survival, most patients live long enough to experience delayed treatment toxicities, warranting careful consideration of therapeutic decisions. An important outcome of interest is the development of secondary leukaemia. A systematic literature search was conducted through a combination of database searches (MEDLINE, EMBASE, and Cochrane library) and manual review. Studies evaluating the incidence of secondary malignant neoplasms in patients following treatment for TGCTs were identified. Our primary outcome was the diagnosis of any leukaemia following treatment, compared to the general population. Meta-analyses were performed using random-effects models, with outcomes reported as standardised incidence ratios (SIRs). Strength of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Six studies including 57 365 patients with 163 secondary leukaemias were included. The weighted-mean follow-up was 12.8 years. The incidence of leukaemia following definitive treatment of TGCTs varied by treatment modality. Chemotherapy was associated with an increase in risk (SIR 5.77, 95% confidence interval [CI] 1.35-24.62; P = 0.03), whereas radiation showed no statistically significant association (SIR 2.55, 95% CI 0.70-9.32; P = 0.11). The certainty of evidence was graded as moderate using the GRADE framework. Chemotherapy is associated with an increase in the relative risk of secondary leukaemias after treatment of TGCTs, although the absolute risk remains small.

Chronic pain is a leading cause of disability, and many affected patients rely on long-term opioid therapy despite its unfavorable adverse effect profile. Spinal cord stimulation is an established therapy for chronic pain that may secondarily reduce opioid consumption by providing sustained analgesia. To quantify changes in opioid use following spinal cord stimulation implantation for the treatment of chronic pain through a systematic review and meta-analysis. We conducted a comprehensive search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus from each database's inception to July 1, 2024. We included studies describing patients who underwent spinal cord stimulator implantation for the treatment of chronic pain. A total of 2,784 potential studies were identified and screened by multiple independent reviewers, yielding a final total of 43 studies included in the systematic review. Data extraction was completed by multiple independent reviewers following Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Meta-analysis Of Observational Studies in Epidemiology guidelines. A random effects model with Hartung-Knapp-Sidik-Jonkman adjustment was used to estimate pooled estimates. Certainty assessment was performed following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The primary outcomes were change in continuous opioid use (ie, morphine milligram equivalent (MME)) and categorical opioid use (yes/no) from preimplantation to 12 months following spinal cord stimulator implantation. Meta-analysis of 12 month continuous MME use comprising 22 study comparisons (1,666 individuals) revealed a weighted mean difference of -18.06 MME (95% CI -24.41 to -11.70; 95% prediction interval -38.29 to 2.17; p<0.001). Meta-analysis of categorical opioid use at 12 months comprising 24 study comparisons (1,527 individuals) revealed an OR of 0.47 (95% CI 0.30 to 0.75; 95% prediction interval 0.10 to 2.11; p=0.003), signifying lower odds of opioid continuation. Spinal cord stimulation is associated with reduced opioid dose consumption and increased odds of opioid cessation at 12 months postimplantation compared with baseline in patients with chronic pain; however, both of these conclusions are supported by evidence of very low GRADE certainty. Properly powered and conducted randomized clinical trial; systematic review with meta-analysis. CRD42024574921.

IntroductionChronic obstructive pulmonary disease (COPD) is frequently accompanied by anxiety, depression and impaired health-related quality of life (HRQoL). Psychological comorbidities worsen symptom burden, daily functioning and self-management and are associated with more frequent exacerbations and higher mortality. Digital cognitive behavioural therapy (dCBT), in which core cognitive behavioural therapy (CBT) content is delivered predominantly via web-based or app-based platforms, offers a potentially scalable approach to addressing these needs. However, no systematic review and meta-analysis has yet synthesised randomised controlled trial (RCT) evidence on the effects of dCBT on patient-reported outcomes (PROs) in adults with COPD. This protocol describes the planned methods for such a review.Methods and analysisWe will include RCTs enrolling adults (≥18 years) with COPD that compare dCBT with usual care, wait-list, attention control, non-CBT psychological or educational interventions, or other non-CBT digital interventions. For this review, dCBT will be defined as an intervention that explicitly states a CBT framework or CBT techniques, delivers most therapeutic content through digital platforms and uses digital CBT as the principal active component. Blended or multicomponent programmes will be eligible only when the dCBT component is clearly identifiable and central to the intervention. The primary outcomes will be PROs assessed by validated PRO measures, including disease-specific or generic HRQoL and psychological symptoms (anxiety and depression). Secondary outcomes will include other PROs such as disease-specific symptom burden, psychological distress or well-being, and self-efficacy where reported. We will search PubMed, Embase, the Cochrane Library, Web of Science, PsycINFO, CNKI, Wanfang Data and SinoMed from inception to 30 November 2025, without language restrictions. Two reviewers will independently screen studies, extract data and assess risk of bias using the Cochrane Risk-of-Bias 2 tool. Where appropriate, we will conduct random-effects meta-analyses, with subgroup, sensitivity and (if feasible) meta-regression analyses to explore heterogeneity. The certainty of evidence for key outcomes will be graded using the Grading of Recommendations Assessment, Development and Evaluation approach.Ethics and disseminationThis systematic review and meta-analysis will use data extracted exclusively from published randomised controlled trials and other publicly available sources. No new data will be collected directly from individual participants, and no identifiable personal information will be obtained; therefore, formal approval from a research ethics committee and informed consent are not required. The review will be carried out in accordance with established methodological guidance for systematic reviews and meta-analyses. The findings will be disseminated through peer-reviewed publication and conference presentations, and review-related data will be curated and made available as appropriate in the final report.PROSPERO registration numberCRD420251246582.

ObjectivesThe predominant concern during pregnancy is musculoskeletal pain, often accompanied by additional discomforts such as anxiety and insomnia. Pilates, as a low-impact mind-body exercise, may be beneficial in managing musculoskeletal pain and associated symptoms in adults. This systematic review and meta-analysis aimed to synthesise the evidence on the effectiveness of Pilates for alleviating musculoskeletal pain and other discomforts during pregnancy.DesignSystematic review and meta-analysis.Data sourcesPubMed, Scopus, TRIP Medical Database, Web of Science and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to 14 January 2026.Eligibility criteriaRandomised controlled trials and prospective non-randomised controlled studies that compared Pilates with other prenatal care modalities for improving musculoskeletal pain and discomfort were eligible.Data extraction and synthesisTwo researchers independently extracted data using standardised forms with subsequent cross-verification. Risk of bias was assessed using the Cochrane Risk of Bias V.2.0 tool. Meta-analyses were performed using random-effects models. The certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach.Results13 studies were included in the systematic review, of which 10 contributed data to the meta-analysis. Primary outcomes were pain intensity and disability level. Pain intensity was assessed using Visual Analogue Scale (range 0–10). Moderate-certainty evidence demonstrated that Pilates significantly reduced musculoskeletal pain during pregnancy (mean differences (MD)=−2.59, 95% CI −4.19 to −1.00; I²=91%, p=0.001). Low-certainty evidence suggested that Pilates reduced pregnancy-related disability (standardised mean differences (SMD)=−1.82, 95% CI −2.99 to −0.66; I² = 93%, p=0.002). Secondary outcomes comprised sleep quality and psychological status. Multivariate meta-analysis showed significant improvements in psychological status (SMD=−0.86, 95% CI −1.31 to −0.42; τ²=0.4, I²=86%, p=0.0005) but did not yield statistically significant improvements in sleep quality (MD=−1.93, 95% CI −4.70 to 0.84; I²=93%, p=0.17). Both secondary outcomes were supported by very low-certainty evidence. Risk of bias assessment rated three studies as high risk, three as unclear risk and seven as low risk. Formal assessment of publication bias was not feasible owing to the limited number of studies (fewer than 10 per outcome).ConclusionThis meta-analysis demonstrates that, compared with standard care, structured prenatal Pilates significantly alleviates musculoskeletal pain and disability while also enhancing psychological status.PROSPERO registration numberCRD42024628027.