Margaret A. Maglione

Purpose: To assess the prevalence, patterns, and consequences of ADHD stimulant medication misuse among adults in the United States. Methods: PubMed and PsycINFO were searched for US-based studies from 2004 to 2024. Cross-sectional and longitudinal studies on stimulant medication misuse among adults were included. Risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist for prevalence studies and the Quality in Prognosis Studies (QUIPS) tool for longitudinal designs. Data were summarized narratively. Findings: Sixty-four studies met inclusion criteria, including several high-quality federally funded national surveys. Many other incidence and prevalence studies were conducted at universities; these had inconsistent quality due to low response, non-representative samples, or unclear methodology. National surveys show that past-year misuse among adults is declining, with 2023 estimates ranging from 1.4% to 3.7% among young adults and 1.9% among adults of all ages. Misuse is most prevalent among younger, White, metropolitan-dwelling individuals, and among college students. Misuse is primarily oral and infrequent, although a subset of high-frequency users obtain stimulants from physicians or dealers and exhibit higher rates of polysubstance use. Consequences of misuse may include psychiatric admission, emergency department visits, and illicit drug use. Long-term studies do not support a link between prescribed stimulant treatment in adolescence and later substance use disorder; unfortunately, no studies collected data on long-term physical health consequences. Conclusions: ADHD stimulant medication misuse among adults, although declining, remains a public health concern, particularly among high-frequency users. Research gaps remain, especially regarding long-term health outcomes.

Bereavement after the death of someone close is universal, and clinicians may be uncertain if or what interventions may be beneficial. To synthesize effects of health care interventions for bereaved children and adults. Eight databases were searched from inception in September 2025, supplemented with screening reviews, guidelines, federal register entries, and expert input. Dual independent reviewers selected randomized controlled trials (RCTs) comparing interventions for bereaved or soon-to-be bereaved persons with usual care, no intervention, or an alternative intervention. Outcomes were evaluated using the abstractor-checker model. Risk of bias was assessed; random-effects meta-analysis was used for effect estimates; multiple effect modifiers were explored; and applicability, generalizability, and strength of evidence (SoE) were determined. A total of 169 RCTs reported in 303 publications evaluated psychotherapy; expert-facilitated support groups; pharmacotherapy; peer support; self-help interventions; writing, music, and art therapy; enhanced provider contact; and integrative medicine for bereaved persons. Risk of bias was substantial, and only 15 RCTs included children. There was moderate SoE that individual psychotherapy improves grief disorder, grief, and depression symptoms and low SoE that expert-facilitated support groups and enhanced contact with health care providers may improve depression symptoms. Other interventions showed conflicting results, indicated no benefit, or had insufficient SoE. Research focused on grief in adults, study populations were complex, and the review may have missed culturally specific interventions. Psychotherapy can improve key outcomes in bereaved adults, and expert-facilitated support groups and enhanced provider contact may also provide benefits. Evidence for other bereavement interventions, approaches for children, and outcomes beyond general grief or grieving, grief disorder, and depression symptoms is limited. Agency for Healthcare Research and Quality. (PROSPERO: CRD42023466057).

Data extraction is a critical but error-prone and labor-intensive task in evidence synthesis. Unlike other artificial intelligence (AI) technologies, large language models (LLMs) do not require labeled training data for data extraction. To compare an AI-assisted versus a traditional, human-only data extraction process. Study within reviews (SWAR) using a prospective, parallel-group comparison with blinded data adjudicators. Workflow validation within 6 ongoing systematic reviews of interventions under real-world conditions. Initial data extraction using an LLM (Claude, versions 2.1, 3.0 Opus, and 3.5 Sonnet) verified by a human reviewer. Concordance, time on task, accuracy, sensitivity, positive predictive value, and error analysis. The 6 systematic reviews in the SWAR yielded 9341 data elements from 63 studies. Concordance between the 2 methods was 77.2% (95% CI, 76.3% to 78.0%). Compared with the reference standard, the AI-assisted approach had an accuracy of 91.0% (CI, 90.4% to 91.6%) and the human-only approach an accuracy of 89.0% (CI, 88.3% to 89.6%). Sensitivities were 89.4% (CI, 88.6% to 90.1%) and 86.5% (CI, 85.7% to 87.3%), respectively, with positive predictive values of 99.2% (CI, 99.0% to 99.4%) and 98.9% (CI, 98.6% to 99.1%). Incorrect data were extracted in 9.0% (CI, 8.4% to 9.6%) of AI-assisted cases and 11.0% (CI, 10.4% to 11.7%) of human-only cases, with corresponding proportions of major errors of 2.5% (CI, 2.2% to 2.8%) versus 2.7% (CI, 2.4% to 3.1%). Missed data items were the most frequent error type in both approaches. The AI-assisted method reduced data extraction time by a median of 41 minutes per study. Assessing concordance and classifying errors required subjective judgment. Consistently tracking time on task was challenging. Data extraction assisted by AI may offer a viable, more efficient alternative to human-only methods. Agency for Healthcare Research and Quality and RTI International.

Clinical practice guidelines (CPGs) may not consistently address racial and ethnic health equity (RHE). This article discusses an audit of CPGs in the ECRI Guidelines Trust (EGT) aiming to summarize the extent and context in which CPGs address RHE, determine use of race-based recommendations, and determine inclusion of patient or public perspectives representing a racially or ethnically diverse group. A working group searched the EGT from 1 January 2020 to 31 January 2025 using RHE-related terms. They included CPGs that were developed by a U.S. organization in an adult population and underpinned by a systematic review that used RHE-related terms. They reviewed included CPGs and their supporting materials, extracted key characteristics, and narratively summarized key findings. The working group identified 137 full-text CPGs. Of these, 105 explicitly addressed RHE terms, whereas the remainder discussed equity or disparities more broadly. When explicitly addressed, RHE was most commonly included as part of the implementation considerations or in the discussion (78.1%). When incorporated into the conduct or methods of developing a guideline recommendation (64.7%), RHE was addressed in the search (8.8%), methods (33.8%), results (41.1%), or EtD or recommendation (39.7%). Although none of the guidelines included a race-based recommendation, 22.8% identified RHE evidence gaps. In total, 84.7% described racial and/or ethnic disparities in the clinical condition and 20% explicitly stated that race is a social construct. Only 3.3% expressly incorporated a racially or ethnically diverse patient or public perspective. However, the search was limited to the EGT, and search terms may not represent the full scope of RHE. Among CPGs addressing health equity, explicit consideration of RHE is mostly addressed in implementation considerations, with less incorporation into the methods or guideline recommendation.

Evidence synthesis and guideline groups have the potential to address health disparities. In June 2024, the Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson Foundation (RWJF) cosponsored a summit to address racial and ethnic health equity in systematic reviews and other syntheses and guidelines, with support from Cochrane US. This article summarizes cross-cutting themes around future directions for systematic reviews and guidelines. Discussions addressed include the rationale for addressing racial health equity in systematic reviews and guidelines; representation of people with lived experience in systematic reviews and guidelines; approaches to developing and addressing equity-focused scope, including frameworks, methods, and thoughtful interpretation in systematic reviews; challenges and opportunities for guideline recommendations; need for standardized language and reporting for race and ethnicity in primary research studies, systematic reviews, and guidelines; and measures to track the progress of incorporating and addressing racial and ethnic health equity in systematic reviews and guidelines. Participants acknowledged that a one-size-fits-all approach was not possible or desired. Consensus priorities for next steps were to develop methods guidance to address equity in systematic reviews and guidelines; develop measures to track the progress of addressing racial and health equity in systematic reviews and guidelines; operationalize engaging representative interest holders in systematic reviews and guidelines; and share resources and learning for advancing health equity.

Background: The coronavirus disease 2019 (COVID-19) pandemic era saw numerous treatments authorized for emergency use by the United States (US) Food and Drug Administration (FDA). The purpose of the review was to determine if convalescent plasma, antivirals, or monoclonal antibodies are associated with serious adverse events (SAEs) and, if so, which specific populations are at risk. Methods: PubMed, ClinicalTrials.gov, and the FDA submission database were searched through December 2023, and the Infectious Diseases Society of America guidelines, international COVID Network Meta-analysis database, and systematic reviews were reference mined to identify controlled studies with at least 1 US site. Reviewers abstracted study characteristics, number of patients experiencing each type of SAE, and methods of adverse event collection and reporting. Results: Fifty-four studies met inclusion criteria, including 31 randomized controlled trials. We found insufficient evidence of association of any SAE with antivirals and spike protein receptor-binding antibodies. In patients hospitalized with COVID-19, the monoclonal antibody tocilizumab, an interleukin 6 inhibitor, may be associated with elevated risk of neutropenia (moderate certainty) and infection (limited certainty). Convalescent plasma may be associated with thrombotic events (limited certainty) as well as bleeding events and infection in patients with hematologic cancers (moderate certainty). Inclusion of studies without a US site could potentially change the findings. Conclusions: Severe COVID-19 infection may have serious consequences, especially in hospitalized patients with comorbidities. These consequences may be confused with toxicities of the interventions. Based on our analysis, approved treatments for COVID-19 should be prescribed as clinically indicated, although continued vigilance is warranted to identify rare and potentially significant toxicities that may arise in clinical practice. Clinical Trials Registration: PROSPERO (CRD42023467821).

To identify baseline patient characteristics (i.e., demographic and psychological factors, military background) associated with better posttraumatic stress disorder (PTSD) treatment retention among veterans, we conducted a systematic review. After an electronic database search for studies of PTSD treatment in veterans, two reviewers independently screened the literature for eligibility, abstracted study‐level information, and assessed risk of bias. As most studies used multivariate models to assess multiple potential predictors of retention simultaneously, the results were described narratively. The GRADE approach, adapted for prognostic literature, was used to assess the overall quality of evidence (QoE). In total, 19 studies reported in 25 publications met the inclusion criteria (n = 6 good quality, n = 9 fair quality, n = 4 poor quality). Definitions of treatment completion and dropout varied, and some studies lumped different therapy approaches together. Older age and higher treatment expectations were associated with better retention (moderate QoE). In 5 of 6 studies, baseline PTSD severity was not associated with retention, and the remaining study reported an association between better retention and more severe PTSD symptoms; the presence of more co‐occurring psychiatric disorders was associated with better retention (moderate QoE). QoE was low or insufficient to support conclusions for any other characteristics due to inconsistent results, imprecision, potential publication bias, possible study population overlap, study limitations, or lack of studies. More research is needed regarding the associations between modifiable factors (e.g., motivation, barriers, expectations) and retention, and consistent definitions of treatment completion and minimally adequate treatment should be adopted throughout the field.

Introduction: Military personnel must prepare for and respond to life-threatening crises on a daily basis. This lifestyle places stress on personnel, and particularly so on deployed service members who are isolated from support systems and other resources. As part of a larger systematic review on the acceptability, efficacy, and comparative effectiveness of interventions designed to prevent, identify, and manage stress reactions, we assessed posttraumatic stress disorder (PTSD) outcomes. Materials and Methods: We searched the electronic databases PsycINFO, PubMed, PTSDPubs, the Defense Technical Information Center, and Cochrane Central, as well as bibliographies of existing systematic reviews, to identify English-language studies evaluating the efficacy or comparative effectiveness of stress control interventions published since 1990. Controlled trials and cohort comparisons of interventions with military, law enforcement, and first responders were included. Two independent reviewers screened literature using predetermined eligibility criteria. Researchers individually abstracted study-level information and outcome data and assessed the risk of bias of included studies; data were reviewed for accuracy by the project leader. Changes in PTSD symptom scores from baseline to post-intervention were converted to standardized mean differences for comparison across studies. Risk ratios were calculated for PTSD case rates post-deployment. When several studies that compared an intervention group with a similar control/comparator reported the same outcome category and measure type, we conducted meta-analysis. We conducted meta-regression by adding a categorical variable, representing setting (i.e., in theater) or population (military vs. law enforcement or first responders) to the meta-analysis model to assess whether this variable was associated with the outcome across studies. The quality of the body of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which considers study limitations (risk of bias), directness, consistency, precision, and publication bias. Results: Sixteen controlled trials and 13 cohort comparisons reporting PTSD outcomes met inclusion criteria. Eight controlled trials and two cohort studies had high risk of bias, primarily due to poor, differential, or unknown response rate at follow-up. Twenty-four of the 29 studies included military personnel. Interventions included Acceptance-based Skills training, Attention Bias Modification training, stress inoculation with biofeedback, Critical Incident Stress Debriefing, group psychological debriefing, Eye Movement Desensitization and Reprocessing for sub-clinical stress, embedding mental health providers in theater, Third Location Decompression, reintegration programs, and a 3-week post-deployment residential program for psychological resource strengthening. Meta-analyses of studies comparing a group that received a stress control intervention to a group that did not receive an intervention found no significant difference in reduction in PTSD symptom scores (moderate QoE) or PTSD case rate post-deployment (low QoE). A meta-analysis of studies comparing a specific stress control intervention to an active comparator (usually standard stress management education) found no significant effect on PTSD symptom scores (moderate QoE). Conclusion: Although combat and operational stress control (COSC) interventions may play a valuable role in decreasing stress, decreasing absenteeism, and enabling return to duty, a systematic review of 29 studies that included a control/comparison group found little evidence that COSC is effective in preventing PTSD or decreasing PTSD symptom scores in military personnel.