Systematic Reviews

BackgroundSelenium is a trace element essential for the normal functions of different human body systems and its deficiency has been associated with different disease states. In recent years, many systematic reviews of randomized clinical trials in humans have demonstrated various properties of selenium such as antioxidant, anti-inflammatory, increased immunity, blocking tumour invasion and metastasis in various pathological conditions. Therefore, there is need to summarize these recent findings in one single paper to facilitate the decision making of clinicians and policy makers regarding the inclusion of selenium supplementation in routine clinical practice, treatment guidelines and essential medicine list. This study would guide researchers towards future research and design of clinical trials. ObjectivesThe objective of this umbrella review is to assess the clinical outcomes of selenium supplementation in different disease states and to determine its therapeutic implications. Eligibility criteriaOnly systematic reviews of randomized clinical trials reporting clinical outcomes after the use of selenium alone as a supplement in the management of diseases will be included. While primary studies, systematic reviews that involved the administration of selenium in combination with other trace elements for the prevention or treatment of diseases will be excluded. MethodsThe following databases will be searched by three independent reviewers: MEDLINE, PUBMED, EMBASE, COCHRANE database of systematic reviews, CINAHL, JBI Evidence synthesis, EPISTEMONIKOS, SCOPUS, Web of Science and TRIP PRO. Unpublished reviews will be searched using ProQuest for dissertations and Theses, Canadian Agency for drugs and Technologies in Health (CADTH) database of Grey matters and GOOGLE scholar. Systematic reviews published in the last 10 years (2013 to 2023). There will be no language restriction. The services of a translator will be employed if studies in other languages were found. Selection of reviews and data extraction will be done by 3 independent reviewers. Summary of findings will be presented in tables accompanied by texts where necessary. Strengths and limitations of this studyThis is the first umbrella review on the use of selenium supplements for disease management. Secondly, the findings from this study would facilitate the decision making of clinicians and policy makers regarding the inclusion of selenium supplementation in routine clinical practice, treatment guidelines and essential medicine list. Nevertheless, a major limitation of this umbrella review would be a reduced scope of eligible studies because only systematic reviews/ or meta-analysis that included randomized clinical trials will be considered.

CONTEXT AND OBJECTIVECoronavirus disease 2019 (COVID-19) has emerged in China in December 2019 and rapidly spread. Although extraordinary efforts have been made on research regarding pharmacological interventions, none have proven effective. This is the protocol for a rapid living systematic review that aims to compare the effectiveness and safety of different pharmacological interventions for the treatment of COVID-19. METHODSrapid living systematic review methodology with Network Meta-Analysis following the recommendations of Cochrane Handbook. We will include randomized controlled trials (RCT) and quasi-RCTs that evaluate single and/or combined pharmacological interventions at any dose for the treatment of COVID-19. We will search PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, Scopus and SciELO to identify potentially eligible studies. No language restrictions will be used in the selection. We will perform the critical appraisal of included studies with the Risk of Bias tool and the certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Importance Non-inferiority trials are becoming increasingly popular in abdominal surgery. The non- inferiority margin is critical in the interpretation and conclusion of these trials. Objective This systematic review aims to assess the methodological and reporting quality of non- inferiority randomized controlled trials in abdominal surgery. Evidence Review Non-inferiority trials were systematically identified by searching Ovid Medline, Embase and the CENTRAL databases from 2006 until December 2025. Randomized controlled trials in adult patients with any type of abdominal surgical intervention in at least one trial arm and a sample size greater than or equal to 100 were eligible for inclusion. The primary outcome was the definition of the non- inferiority margin. Secondary outcomes were the reporting of the non-inferiority margin, the robustness of its estimation, the uncertainty of the point estimate and the adequacy of conclusions. Findings A total of 11 045 trials were identified, of which 101 were eligible, enrolling 44 370 patients. Most trials provided a rationale for the non-inferiority design, while six (5.9%) trials did not. Previous literature was commonly used (n=56; 55.4%), but the non-inferiority margin was most often based on a clinical fixed margin or on historical comparison of the treatment and the active comparator. Based on the margin, investigators tolerated substantially worse outcomes of the treatment compared to the comparator. Conclusions were appropriate based on the confidence interval and the predefined non- inferiority margin in 88 (87.1%) of trials. The clinical judgement of the conclusion was overall adequate. Confidence interval estimations were reported in 16 (15.8%) of trials. Simulation studies were limited by the reporting quality. Conclusions and Relevance Clinical fixed margins are commonly used in abdominal surgery non-inferiority randomized controlled trials, however, substantial shortcomings in reporting limit the interpretability and reproduction of study findings. Based on the findings of this study, guidance on surgical- specific non-inferiority margin definitions is needed.

ObjectivesTo examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons, and whether surgery or the drug intervention was favored. DesignSystematic review of systematic reviews (umbrella review) Data sourcesCochrane Database of Systematic Reviews (CDSR) Eligibility criteria and synthesis of resultsUsing the search term "surg*" in CDSR, we retrieved systematic reviews of surgical interventions. Abstracts were subsequently screened to find systematic reviews that aimed to compare surgical to drug interventions; and then, among them, those that included any randomized controlled trials (RCTs) for such comparisons. Trial results data were extracted manually and synthesized into random-effects meta-analyses. ResultsOverall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs with data) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% confidence intervals, the surgical intervention was favored in 38/103 (37%), and the drugs were favored in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favor of surgery, and 2 (9%) were in favor of drugs. ConclusionsThough the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomized evidence is rare. More randomized trials comparing surgery to drug interventions are needed. Protocol registrationhttps://osf.io/p9x3j FundingThe work of John Ioannidis has been funded by an unrestricted gift from Sue and Bob ODonnell. Anais Rameau is supported by a Paul B. Beeson Emerging Leaders Career Development Award in Aging (K76 AG079040) from the National Institute on Aging and by the Bridge2AI award (OT2 OD032720) from the NIH Common Fund. Anirudh Saraswathula is supported by the National Institute on Deafness and Other Communication Disorders training grant 2T32DC000027. Financial disclosureAnais Rameau is a medical advisor for Perceptron Health, Inc. Summary boxes Section 1: What is already known on this topicO_LIMany conditions and diseases can be managed either with surgery or with drugs. Comparative effectiveness of different treatment options is important to know for shared decision-making. C_LI Section 2: What this study addsO_LIAn assessment of the entire Cochrane Database of Systematic Reviews found 188 reviews that intended to assess surgical versus drug interventions, but only 41 had at least one randomized trial. C_LIO_LIOnly four of the 103 assessed outcomes had high strength of evidence according to GRADE assessments. C_LIO_LIMore evidence is needed to compare the relative merits of surgical and drug interventions and sequestration of these major modes of interventions should be overcome in clinical trial agendas. C_LI

BackgroundThe healthcare sector significantly contributes to environmental degradation and climate change. Implementing sustainable practices, known as "green practices," can mitigate these negative impacts. Healthcare professionals play a crucial role in adopting and promoting green practices, but their perceptions and experiences are not well understood. ObjectiveThis systematic review protocol outlines methods for synthesizing qualitative evidence on healthcare professionals perceptions and experiences regarding green practices in health services. The review aims to identify facilitators, barriers, and strategies for implementing green practices from healthcare professionals perspectives. MethodsWe will search PubMed, Web of Science, Embase, CINAHL, MEDLINE, The Cochrane Library, PsycINFO, and Scopus from each databases inception to July 2025. We will include qualitative studies exploring healthcare professionals perceptions and experiences regarding green practices in health services. Two reviewers will independently screen studies using Covidence, extract data, and assess methodological quality using the Critical Appraisal Skills Programme (CASP) checklist. We will use thematic synthesis to analyze findings. Risk of bias will be assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. DiscussionThis review will provide insights into healthcare professionals perceptions and experiences regarding green practices. Findings will inform strategies for implementing sustainable practices in healthcare, considering key stakeholders perspectives. This may contribute to reducing healthcares environmental impact and improving planetary health. Limitations include English language restriction and potential non-generalizability of qualitative evidence.

BackgroundHealthcare workplaces experience significant interpersonal conflicts affecting staff wellbeing, patient safety, and organizational performance. Traditional punitive approaches to conflict management often fail to address underlying issues, potentially perpetuating cycles of dysfunction. Restorative justice, emphasizing healing, accountability, and relationship repair over punishment, offers promising alternatives for healthcare conflict resolution. Despite growing implementation, systematic evidence synthesis regarding effectiveness, implementation factors, and outcomes remains absent. ObjectivesThis systematic review protocol aims to synthesize evidence on restorative justice approaches for managing workplace conflicts in healthcare settings, examining implementation processes, effectiveness, barriers, facilitators, and impacts on staff wellbeing, patient care, and organizational culture. MethodsFollowing PRISMA-P guidelines, we will search ten databases (PubMed, MEDLINE, CINAHL, PsycINFO, Embase, Scopus, Web of Science, Business Source Premier, Cochrane Library, and ProQuest) from inception to December 2025. The SPIDER framework guides eligibility criteria focusing on healthcare workers involved in restorative justice interventions, their experiences and outcomes across diverse healthcare contexts. Covidence will facilitate study screening and selection. Quality assessment will employ the Mixed Methods Appraisal Tool (MMAT), with risk of bias evaluated using appropriate domain-specific tools. Narrative synthesis and thematic analysis will integrate quantitative and qualitative findings. GRADE-CERQual will assess confidence in qualitative evidence synthesis. DiscussionThis protocol anticipates generating comprehensive evidence regarding restorative justice implementation models, effectiveness indicators, contextual factors influencing success, stakeholder experiences, and comparative advantages over traditional approaches. Evidence generated will inform policy development, implementation guidelines, and training programs for healthcare organizations seeking transformative conflict resolution approaches that prioritize healing, learning, and relationship restoration over punitive measures.

The number of bariatric surgery rises as the prevalence of obesity and metabolic comorbidities consistently increases[1]. Although bariatric surgery was originally developed for glycemic control and weight reduction, increasing evidence suggested extra-metabolic health outcomes are followed by bariatric surgery; incidences on diverse types of cancer[2], perinatal outcomes[3], sexual function[4], and even degree of physical activity[5] are known to be altered after bariatric surgery. We aim to conduct umbrella review for metabolic and other multiple health outcomes following bariatric surgery, and systematically appraise the context and quality of the relevant evidence. Contactminseolike@naver.com; crossing96@yonsei.ac.kr

Importance. Systematic reviews and meta-analyses inform suicide-prevention policy and practice, but broad database searches are difficult to screen manually. This limits capture of upstream interventions, such as economic policies, with indirect effects on suicide. Reliable automated screening could make broader and more comprehensive evidence syntheses feasible. Objective. To develop and validate ScreenAgent, a large language model (LLM) agent for title and abstract screening, and a review-specific method for prospectively estimating screening performance. Design, Setting, and Participants. ScreenAgent was validated internally on a prospective meta-analysis, and externally on two published systematic reviews. The correct include and exclude decisions followed standard systematic-review screening methodology. Exposures. ScreenAgent, an LLM agent returning structured include-or-exclude decisions. Records it marked for inclusion were re-checked by a second, cascade pass using a higher-effort LLM. For the external reviews, the agent's prompt was tuned automatically on a small set of labeled examples. Main Outcomes and Measures. We calculated sensitivity, specificity, workload reduction (the percentage of records removed from human review), and agent-versus-human reliability via Cohen kappa. Sensitivity was estimated by direct comparison (internal) and 5-fold cross-validation (external). Results. In the internal validation, ScreenAgent identified 43 of 44 eligible studies (sensitivity 97.7%; 95% CI, 88.2%-99.6%) with a generic prompt applied without any review-specific optimization, specificity 98.0%, and a measured full-corpus workload reduction of 99.4%. The cost was $855.91 for the full 201,064-record corpus (0.43 US cents per record). Agent-versus-human-consensus agreement exceeded human-versus-human agreement (Cohen kappa 0.75 vs 0.64; percent agreement 97.3% vs 95.4%). For two external validation studies, automatic tuning resulted in a cross-validated sensitivity of 95.9% (95% CI, 90.0%-98.4%) and 97.4% (90.9%-99.3%), with workload reductions of 97.4% and 98.4%. Conclusions and Relevance. Suicide prevention efforts often require rapid consolidation of evidence because of the inherent challenges of single studies trying to prevent rare outcomes. On both internal and external validation sets, ScreenAgent identified nearly all eligible studies with human-level reliability for a fraction of a US cent per record while keeping human reviewers as the final arbiters. By making broad searches feasible and screening performance measurable beforehand, this approach can serve as a transparent methodology to strengthen the speed at which we can inform and advance suicide prevention efforts.

ObjectivesTo develop an organising framework for healthcare decarbonisation research which goes beyond classification schemes based on Scope 1, 2 and 3 emissions or lists of loosely connected themes, and which is intended to support the coordination, funding and application of research into policy and practice. The organising framework should be focused on the NHS in England but enable application to healthcare systems more broadly. DesignAn exploratory manual (non-machine-led) classification study of over 160 research questions derived from a scoping review of 10 systematic reviews (118 screened), 13 stakeholder documents (35 key stakeholder websites searched), two research priority exercises, and four research funder sources (over 430 funding areas screened). The above and a further 21 sources were also used to identify areas without explicit research questions but of clear thematic relevance. SettingPrimarily high-income healthcare systems, with a focus on the NHS in England. ParticipantsNot applicable. Primary outcomeA multi-level thematic framework representing current and missing areas of research in healthcare decarbonisation. ResultsThe framework comprises six top-level themes, grouping 39 sub-themes at level two, and 86 sub-themes at level three. The top-level themes are: Natural resource use and sources of carbon; Healthcare contexts; Solutions; Stakeholders; Organisational levers for change; and Scientific measurement and theory (the "NHS-SOS framework"). ConclusionsThis framework offers a structured, empirically derived representation of the emerging field of healthcare decarbonisation research. It is intended as a living tool to support shared understanding, prioritisation and action, and to foster coherence in a currently fragmented research landscape. Article summaryO_ST_ABSStrengths and limitations of this studyC_ST_ABSO_LIThe study used a transparent and structured process to derive themes from over 160 research questions, sourced from a diverse set of systematic reviews, stakeholder documents, research priority exercises, and funding calls. C_LIO_LIThe inductive approach respected the complexity, breadth and multiple perspectives inherent to healthcare decarbonisation research. C_LIO_LIThe study drew on a wide range of sources selected for conceptual and perspectival breadth but was nonetheless small relative to the volume of publications in the field. C_LIO_LIMany of the research questions were not explicitly stated in the source documents and had to be derived through interpretive analysis. This introduced a potential for bias, which was mitigated through a clearly documented and transparent process outlining how interpretations were made. C_LI

ImportanceEngaging patients and their families has been proposed and promoted as a key strategy for improving patient safety of health systems. However, little is known about the use of this approach in the primary care settings. ObjectiveThis systematic review and meta-analysis assessed the effectiveness of interventions promoting patient and family engagement for patient safety in primary care based on randomised controlled trials (RCTs). Data SourcesFive electronic databases (MEDLINE, CINAHL, Embase, Web of Science, and CENTRAL) were searched from inception to February 2023 with key words structured in four blocks (patient and family engagement; patient safety; primary care; randomised controlled trial). Study SelectionDefinition of patient safety included adverse events and non-recommended practices. Two independent study team members screened each record, with discrepancies resolved by consensus. Data Extraction and SynthesisReporting followed PRISMA standards and included risk of bias and level of certainty assessments. For studies reporting on similar safety outcomes, results were combined into meta-analyses using multi-level random-effects models in case of moderate/substantial heterogeneity (30%[≤]I{superscript 2}[≤]75%), and fixed-effect models when heterogeneity was low (I{superscript 2}[≤]30%). Main Outcome(s) and Measure(s)Expected primary study outcomes were adverse events, non-recommended medical practices, and medical errors. Interventions were considered of interest, if they prompted patients and/or families to take actions, focused on patient education about engagement, or had a significant patient engagement component if they were multifaceted interventions. Interventions were rated based on increasing degrees of patient/family engagement as "Inform about engagement", "Empower", and "Partner/Integrate". ResultsSixteen records were identified, among which eight completed RCTs. No intervention reached the highest engagement level. RCTs primarily targeted medication safety outcomes, with meta-analyses showing no significant effects on adverse drug events (OR=0.73, 95%CI [0.46,1.15]) and medication appropriateness using categorical (OR=0.97, 95%CI [0.73,1.17]) and continuous outcome variables (MD=0.56, 95%CI [-0.61, 1.72]). Overall risk of bias was low and the certainty of evidence ranged from moderate to high for most completed studies. Conclusion and RelevancePatient and family engagement strategies in primary care show inconclusive results based on extant randomised controlled evidence. They should delve into more comprehensive levels of engagement and address more diverse patient safety outcomes. Key pointsO_LIQuestion: Is there randomised controlled evidence supporting the use of patient and family engagement interventions in primary care patient safety? C_LIO_LIFindings: Randomised controlled interventions targeting patient safety through patient and family engagement are scarce in primary care, mostly focus on medication safety, and stay at low to intermediate levels of patient and family engagement. Although their combined effectiveness did not reach significance in meta-analyses, favourable results were reported for several patient safety outcomes. C_LIO_LIMeaning: Patient and family engagement interventions for patient safety in primary care show inconclusive results based on the randomised controlled evidence at hand, yet their scarcity and relatively low level of patient/family engagement underscores the need to further test and refine such approaches in all patient safety domains. C_LI

BackgroundPoor quality in research reporting is a persistent issue that has hindered the advancement of scientific knowledge across all health science disciplines. Similarly, the progress of evidence-based practice has been hampered, as the replication of interventions is often impeded by the incomplete reporting of implementation details. ObjectiveTo map how reports of psychological interventions describe implementation at both the whole intervention level and the level of recipients behaviours or actions (BeA), and to examine whether reporting quality varies by field, guideline use, or indicators of intervention complexity. MethodsThis scoping review followed PRISMA-ScR. Searches were conducted on PsycINFO (ProQuest) and Web of Science (Clarivate) for publications (2014-2024) describing the development and/or implementation of psychological interventions in clinical, public health, social/organizational or educational fields. A random sample of 200 publications per field was screened for inclusion. Following a two-stage selection process involving double screening and consensus resolution, 80 studies were included. Data were extracted using a Delphi-based instrument and analysed using descriptive statistics and {chi}{superscript 2} tests to compare different aspects of reporting across fields, guideline use, and complexity features. ResultsOnly 11.3% reported development-only objectives, while most combined development with effectiveness (40%) and feasibility (48.8%). Reporting quality tools were seldom used (13.8%). Interventions typically targeted a single recipient category (87.5%); multilevel targeting was rare (6.3%). Implementation sequence was often replicable (73.8%), but structured aids were underused (tables/lists 38.8%; diagrams 16.3%). Costs were rarely reported (3.8%). At the BeA level, structural features were usually replicable (e.g., type/form of administration, periodicity, place, timing), whereas content/materials (36.3% and 47.5%), adaptation/customization (35%), and fidelity/adherence (27.5%) were frequently incomplete. Few significant between field differences emerged. Reporting tended to improve as the number of BeA increased. ConclusionsPsychological intervention reports commonly omit critical replicability details, especially provider/evaluator prerequisites, content/materials, adaptation rules, fidelity, and costs, despite available guidance. Routine use of structured representations (e.g., flow diagrams, BeA tables) and established reporting tools (e.g., TIDieR, CONSORT-SPI) could close the most consequential gaps and facilitate replication and implementation at scale. RegistrationINPLASY 2025.7.0098.

StatementThe authors have withdrawn their manuscript owing to a reporting error that we have identified in the conduct of this updated systematic review. On 7th March 2022 we made changes to the original protocol published in F1000, to highlight the need to keep up with the evolving landscape of Covid-19 and Covid-19 research and focus on comparative, controlled studies. The revisions included also changes in data extraction and analysis that would be needed to do so. These changes were done in consultation with members of the Long COVID Support Group. However, we omitted to publicize these changes in an accessible, modified version of our protocol, and/or by updating our preregistered PROSPERO record (CRD42020211131) and F1000 publication, prior to commencing and completing these stages of the process. In this manuscript, which reports the revised analyses, we have consequently also omitted to explicitly describe these changes as important deviations from the published protocol. Additionally, following rapid, sustained, and continuous growth in the conduct and reporting of eligible primary studies, it has become clear that, with or without the changes described above, we do not have sufficient capacity or resources to transition our baseline systematic review to being regularly updated using a living systematic review approach. Therefore, the authors do not wish this work to be cited as reference for the project. If you have any questions, please contact the corresponding author.

Response to the COVID-19 pandemic included a wide range of Public Health and Social Measures (PHSM). PHSM refer to a broad array of nonpharmaceutical interventions implemented by individuals, communities and governments to reduce the risk and scale of transmission of epidemic- and pandemic-prone infectious diseases. In order to inform decisions by the public, health workforce and policy-makers, there is a need to synthesize the large volume of published work on COVID-19. This study protocol describes the methodology for an overview of reviews focusing on the effectiveness and/or unintended health and socio-economic consequences of PHSM implemented during the COVID-19 pandemic. Findings can shape policy and research related to PHSM moving forward.

Independent systematic reviewers may arrive at different conclusions when analyzing evidence addressing the same clinical questions. Similarly, independent expert panels may arrive at different recommendations addressing the same clinical topics. When faced with a multiplicity of reviews or guidelines on a given topic, users are likely to benefit from a structured approach to evaluate concordance, and to explain discordant findings and recommendations. This protocol proposes a methodological survey to evaluate the prevalence of concordance between reviews addressing similar clinical questions, and between clinical practice guidelines addressing similar topics; and to identify methodological frameworks for the evaluation of concordance between related reviews and between related guidelines.

BackgroundThe number of older adults from ethnic minority communities (EMCs) in England and Wales particularly those aged 60 and above is increasing. This demographic change, which is usually coupled with the prevalence of polypharmacy among these populations presents unique challenges in the context of medicine optimisation. Failure in this context can lead to exacerbated health disparities, non-adherence, and inappropriate prescribing (whether over or under). This review builds on the MEMORABLE study which was also a realist study that explored medication management in older people. This study aims to understand the complexities of medicine optimisation and what works and does not work, when and under what circumstances for older adults from EMCs. Key possible areas include cultural backgrounds, traditional beliefs, and systemic barriers that may influence health-seeking behaviours and medicine optimisation. MethodsThe review follows the five-step approach. Firstly, we will establish initial program theories to highlight the expected context, mechanisms, and outcomes. Following this, a formal search for evidence will be conducted. The third step involves the selection and appraisal of studies, studies will be screened by title, abstract/keywords and full text against inclusion and exclusion criteria. In the fourth stage, data from these studies will be extracted, recorded, and coded. The final step will synthesise this information, to test, refine, and expand our initial programme theories to understand how medicine optimisation works or does not work in these populations. DiscussionThis review will be conducted in line with the RAMESES reporting standards. This will include publishing the review in a scientific journal and submitting abstracts for presentation at both national and international primary care and pharmacy practice conferences. Once we improve the understanding of how medicine optimisation works for these populations with polypharmacy in primary care effective interventions can be developed. Systematic review registrationPROSPERO registration number CRD42023432204

Insomnia is a common sleep disorder, and many individuals seek alternative treatments like homeopathy. However, evidence for its effectiveness remains controversial. This systematic review and meta-analysis evaluated the effectiveness of homeopathic interventions for insomnia and sleep-wake disorders. A comprehensive search of PubMed, MEDLINE, CINAHL, and the Cochrane Library was conducted for studies published between 2010 and 2025. We included randomized controlled trials (RCTs) and non-randomized studies involving adults ([≥]18 years) with primary insomnia receiving any homeopathic intervention compared to placebo, no treatment, or active care. Primary outcomes included validated sleep quality measures (e.g., Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI). Four reviewers independently performed study selection, data extraction, and risk of bias assessment using RoB 2.0 and ROBINS-I. A random-effects meta-analysis was conducted for controlled trials, and a narrative synthesis for non-randomized studies. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). The search yielded 1304 records; 12 studies (nine RCTs and three non-randomized) met inclusion criteria. Meta-analysis showed a large, statistically significant positive effect of homeopathy on sleep outcomes (SMD = 0.81, 95% CI [0.24, 1.38], p = 0.0055), with substantial heterogeneity (I{superscript 2} = 86.04%) and publication bias (Eggers test, p = 0.0079). Most studies had high or critical risk of bias, and overall certainty was low. Homeopathic interventions showed a large positive effect on sleep outcomes, but due to high bias, heterogeneity, and publication bias, evidence remains low-certainty and insufficient to support effectiveness. High-quality RCTs are needed. Systematic Review RegistrationPROSPERO CRD42025649926.

BackgroundChronic non-cancer pain (CNCP) is one of the most prevalent health conditions among the elderly, with a considerable impact on the persons physical, mental and social functioning. The use of a bio-psycho-social multidisciplinary approach has become widely recommended for more likely effective management of chronic pain. In recent years, the growing development and application of e-Health (or digital health) within pain medicine has been showing encouraging results. However, the application of such technologies in the field of pain management among elderly is yet understudied, particularly in regard to the potential impacts of multimodal therapies (i.e., interventions which integrate a physical and a psychological component) provided via digital devices. ObjectiveThe overall aim of this scoping review is to systematically map the existing literature about the e-Health multimodal interventions designed for older adults with CNCP. MethodsMultiple electronic databases (PubMed, Cochrane CENTRAL, Web of Science, PsycINFO) will be searched for relevant articles to August 2023. The review will adhere to the Joanna Briggs Institute (JBI) methodology and will utilize the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) reporting guideline and checklist. All eligible studies will be evaluated against the 16-item Quality Assessment Tool (QATSDD). The extracted information will be presented in tabular form along with a narrative summary that is in line with the scoping reviews objective.

This study aimed to systematically review and critically evaluate the risk of bias and applicability of surgical site infection (SSI) risk prediction models after spinal surgery. China National Knowledge Infrastructure, Wanfang Database, China Science and Technology Journal Database (VIP), SinoMed, PubMed, Web of Science, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Embase were searched from inception to April 10, 2025. The prediction model risk of bias assessment tool-artificial intelligence (AI) and transparent reporting of a multivariable prediction model for individual prognosis or diagnosis-AI were used to assess the quality of the included studies, and RevMan software was used to perform a meta-analysis of the odds ratio values for certain model predictors. A total of 37 studies were included, identifying 43 predictive models. The incidence of SSI after spinal surgery ranged from 1.5% to 50%. Among these, 11 studies focused solely on model development, 4 studies included external validation, 22 studies were only internally validated, and 1 study was both internally and externally validated. The area under the curve values ranged from 0.610 to 0.991. The meta-analysis of high-frequency predictors identified statistically significant factors, including diabetes, age, surgery duration, albumin, body mass index, drainage time, smoking history, and American Society of Anesthesiologists score. All studies were rated as having a high risk of bias, primarily due to poor reporting related to study participants and the analysis domain. The evaluation using the prediction model risk of bias assessment tool indicated a considerable risk of bias in current predictive models for postoperative SSI after spinal surgery. Although the predictive model for SSI after spinal surgery is generally acceptable, most studies have methodological flaws. Moreover, studies with larger sample sizes and multicenter external validation are necessary to enhance the robustness of predictive models.

Importance: Social prescribing is implemented to address unmet social needs and improve health, but expansion has outpaced evidence from randomized trials. Objective: To quantify the effects of social prescribing on mental, physical, and social health outcomes in adults. Data Sources: Medline, Embase, Cochrane Central, AMED, CINAHL, PsycInfo, Web of Science, NHS EED, CEA registry, clinicaltrials.gov, OpenGrey, and WHO ICTRP (English language). Trials published from 1992 through 2022 were identified from 23 reviews, supplemented by searches from January 2023 through September 2025. Study Selection: Randomized trials comparing usual care or waitlist with interventions facilitating connection to community-based resources delivered by non-health care professionals. Data Extraction and Synthesis: Pairs of reviewers screened studies, extracted data, and assessed risk of bias using Cochrane Risk of Bias 2. Random-effects meta-analyses pooled mean differences or standardized mean differences as Hedges g with 95% CIs. Main Outcomes and Measures: Mental health, blood pressure, metabolic and anthropometric outcomes, physical activity, loneliness and social isolation, quality of life, health care use, and adverse events. Results: Thirty-three randomized trials involving 13 714 participants were included. High risk of bias was identified in 40% of trials. Social prescribing was associated with reduced depressive symptoms (7 trials; 1087 participants; standardized mean difference [SMD], -0.23; 95% CI, -0.38 to -0.08), lower systolic blood pressure (11 trials; 2817 participants; mean difference, -2.69 mm Hg; 95% CI, -5.36 to -0.02), increased physical activity (7 trials; 3409 participants; SMD, 0.16; 95% CI, 0.06-0.25), and improved quality of life (10 trials; 3134 participants; SMD, 0.15; 95% CI, 0.01-0.29). No clear benefit was found for anxiety, loneliness and social isolation, glycemic control, blood lipids, anthropometric outcomes, or health care use. One trial reported a process evaluation, 7 included economic evaluations, and adverse events were infrequently reported. Conclusions and Relevance: Social prescribing was associated with modest improvements in depressive symptoms, systolic blood pressure, physical activity, and quality of life. Evidence was lacking for other claimed benefits, and process and economic evaluations were uncommon, identifying priorities for future trials.

Background"Nature prescriptions" are gaining popularity as a form of social prescribing and in response to calls for sustainable healthcare. Our review and meta-analysis appraised evidence of effectiveness of nature prescriptions on various health outcomes. In doing so, we sought to determine the factors that are critical for the success of nature prescriptions, based on Social Cognitive Theory. MethodsThis is a scoping review with a nested meta-analysis for a subset of outcomes. Five databases were searched up to July 25, 2021. Randomised and non-randomised controlled studies featuring a nature prescription (i.e. an instruction or organised programme, by a health or social provider, to promote spending time in nature) are included. All health outcomes are eligible, but only key pre-specified outcomes are qualified for meta-analysis. Two reviewers independently conducted all steps of study selection; one reviewer conducted data collection and risk of bias assessment. Summary data was extracted from published reports for analysis. Random-effect models for meta-analysis were conducted using Review Manager 5.4.1. FindingsWe identified 86 unique studies (116 reports), of which 26 studies contributed data to meta-analysis. Compared to control, nature prescription programmes resulted in a greater reduction in systolic blood pressure (MD = -4{middle dot}9mmHg [-9{middle dot}6 to -0{middle dot}1], I2=65%) and diastolic blood pressure (MD = -3{middle dot}6mmHg [-7{middle dot}4 to 0{middle dot}1], I2=67%). They also had a moderate-to-large effect on depression scores (SMD=0{middle dot}5 [0{middle dot}2 to 0{middle dot}8], I2=79%) and anxiety score (SMD=0{middle dot}6 [0{middle dot}1 to 1{middle dot}2], I2=90%). Lastly, they resulted in a greater increase in daily step counts (MD = 900 steps [790-1010], I2=0%), but did not improve weekly time of moderate physical activities (MD = 25{middle dot}9 minutes [-10{middle dot}3 to 62{middle dot}1], I2=53%). Most studies have moderate to high risk of bias, principally due to non-blinding nature of the interventions, small sample size and lack of analysis plan to rule out risks of bias. InterpretationNature prescription programmes may provide cardiometabolic and mental health benefits and increase physical activity. Effective nature prescription programmes can select from a range of natural settings, activities and might be implemented via social and community channels, besides health providers. The Social Cognition Theory is useful in designing future nature prescription programmes. FundingThis work was supported by the Hort Frontiers Green Cities Fund, part of the Hort Frontiers strategic partnership initiative developed by Hort Innovation, with co-investment from the University of Wollongong (UOW) Faculty of Social Sciences, the UOW Global Challenges initiative and contributions from the Australian Government (project number #GC15005). T.A-B. was supported by a National Health and Medical Research Council Boosting Dementia Research Leader Fellowship (#1140317). X.F. was supported by a National Health and Medical Research Council Career Development Fellowship (#1148792). O_TEXTBOXPanel: Research in context Evidence before this studyExtensive evidence indicates contact with nature is associated with social, mental and physical health. However, little evidence exists on the effectiveness of nature prescriptions, which involve a health provider (e.g. general practitioner) recommending a patient to spend a fixed amount of time a week in a natural setting (e.g. a park). Other studies have attempted to evaluate the benefits of food prescription or green prescription programmes, which do not necessarily involve nature exposure. Only one systematic review on nature prescriptions has been conducted to date, which is a qualitative review without meta-analysis. The review concluded that the evidence (studies up to June 2019) was too sparse to discern any clear evidence of health impacts. There was insufficient information to assess the risk of bias or quality of evidence in the review. Moreover, the review included only nature prescriptions dispensed in outpatient settings, which left out prescription programmes implemented by other institutions, such as welfare centres, social services, universities or workplaces. Added value of this studyOur review is the first to provide comprehensive appraisal including meta-analysis of the effectiveness of nature prescription programs on multiple health outcomes. The scoping review identified a range of promising nature-based interventions that were dispensed outside the clinic setting and did not self-label as a nature prescription, but would be effective as one. The nested meta-analyses on key outcomes demonstrated positive benefits on blood pressure, symptoms of depression and anxiety, and physical activity levels. Implications of all the available evidenceOur findings suggest that an effective nature prescription programme can select from a range of natural settings, activities and can be implemented via social and community channels, in addition to health providers. In addition, we also demonstrated that the Social Cognition Theory framework is useful in designing future nature prescription programmes. C_TEXTBOX