BACKGROUND:Approximately 20.4 million Americans met criteria for a substance use disorder (SUD) in 2019; however, only about 12.2% of persons with an SUD receive specialty care. Telehealth offers alternatives to traditional forms of substance use treatment.PURPOSE:To synthesize recent findings on the efficacy of telehealth for SUDs.DATA SOURCES:MEDLINE, Embase, PubMed, and the Cochrane Library from January 2015 through August 2021 (English language only).STUDY SELECTION:Randomized controlled trials (RCTs) of adults with a diagnosis of SUD based on the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases.DATA EXTRACTION:One investigator abstracted data and assessed study quality, and a second checked for accuracy.DATA SYNTHESIS:This rapid review synthesized evidence from 17 RCTs. Evidence is very uncertain that telehealth provided as videoconference therapy (1 RCT) or web-based cognitive behavioral therapy (CBT) (3 RCTs) has similar effects to in-person therapy for improving abstinence from alcohol or cannabis. Low-strength evidence suggests that web-based CBT has similar effects for improving abstinence in multiple SUDs (2 RCTs). Low-strength evidence suggests that adding supportive text messaging to follow-up care improves abstinence and amount of alcohol per day (2 RCTs) but does not improve emergency department visits or frequency of consumption (2 RCTs). Enhanced telephone monitoring likely reduces readmissions for SUD detoxification compared with usual follow-up alone (1 RCT) but does not reduce days of substance use (low-strength evidence).LIMITATION:Narrative synthesis, heterogeneity of telehealth interventions, no assessment of publication bias, and study methodology.CONCLUSION:Evidence is very uncertain that telehealth is similar to in-person care for SUD outcomes. Limited evidence suggests some benefit of adding telehealth to usual SUD care.PRIMARY FUNDING SOURCE:U.S. Department of Veterans Affairs Veterans Health Administration.

Objectives. To review the association between malnutrition and clinical outcomes among hospitalized patients, evaluate effectiveness of measurement tools for malnutrition on clinical outcomes, and assess effectiveness of hospital-initiated interventions for patients diagnosed with malnutrition. Data sources. We searched electronic databases (Embase®, MEDLINE®, PubMed®, and the Cochrane Library) from January 1, 2000, to June 3, 2021. We hand-searched reference lists of relevant studies and searched for unpublished studies in ClinicalTrials.gov. Review methods. Using predefined criteria and dual review, we selected (1) existing systematic reviews (SRs) to assess the association between malnutrition and clinical outcomes, (2) randomized and non-randomized studies to evaluate the effectiveness of malnutrition tools on clinical outcomes, and (3) randomized controlled trials (RCTs) to assess effectiveness of hospital-initiated treatments for malnutrition. Clinical outcomes of interest included mortality, length of stay, 30-day readmission, quality of life, functional status, activities of daily living, hospital acquired conditions, wound healing, and discharge disposition. When appropriate, we conducted meta-analysis to quantitatively summarize study findings; otherwise, data were narratively synthesized. When available, we used pooled estimates from existing SRs to determine the association between malnutrition and clinical outcomes, and assessed the strength of evidence. Results. Six existing SRs (including 43 unique studies) provided evidence on the association between malnutrition and clinical outcomes. Low to moderate strength of evidence (SOE) showed an association between malnutrition and increased hospital mortality and prolonged hospital length of stay. This association was observed across patients hospitalized for an acute medical event requiring intensive care unit care, heart failure, and cirrhosis. Literature searches found no studies that met inclusion criteria and assessed effectiveness of measurement tools. The primary reason studies did not meet inclusion criteria is because they lacked an appropriate control group. Moderate SOE from 11 RCTs found that hospital-initiated malnutrition interventions likely reduce mortality compared with usual care among hospitalized patients diagnosed with malnutrition. Low SOE indicated that hospital-initiated malnutrition interventions may also improve quality of life compared to usual care. Conclusions. Evidence shows an association between malnutrition and increased mortality and prolonged length of hospital stay among hospitalized patients identified as malnourished. However, the strength of this association varied depending on patient population and tool used to identify malnutrition. Evidence indicates malnutrition-focused hospital-initiated interventions likely reduce mortality and may improve quality of life compared to usual care among patients diagnosed with malnutrition. Research is needed to assess the clinical utility of measurement tools for malnutrition.

Background:Suicide is a growing public health problem, with the national rate in the United States increasing by 30% from 2000 to 2016.Purpose:To assess the benefits and harms of nonpharmacologic and pharmacologic interventions to prevent suicide and reduce suicide behaviors in at-risk adults.Data Sources:MEDLINE, EMBASE, PsycINFO, and other databases from November 2011 through May 2018.Study Selection:Systematic reviews (SRs) and randomized controlled trials (RCTs) that assessed nonpharmacologic or pharmacologic therapies for adults at risk for suicide.Data Extraction:One investigator abstracted data and assessed study quality, and a second investigator checked abstractions and assessments for accuracy.Data Synthesis:Eight SRs and 15 RCTs were included. The evidence for psychological interventions suggests that cognitive behavioral therapy (CBT) reduces suicide attempts, suicidal ideation, and hopelessness compared with treatment as usual (TAU). Limited evidence suggests that dialectical behavior therapy (DBT) reduces suicidal ideation compared with wait-list control or crisis planning. The evidence for pharmacologic treatments suggests that ketamine reduces suicidal ideation with minimal adverse events compared with placebo or midazolam. Lithium reduces rates of suicide among patients with unipolar or bipolar mood disorders compared with placebo. However, no differences were observed between lithium and other medications in reducing suicide.Limitation:Qualitative synthesis of new evidence with existing meta-analyses, methodological shortcomings of studies, heterogeneity of nonpharmacologic interventions, and limited evidence for pharmacologic treatments and harms.Conclusion:Both CBT and DBT showed modest benefit in reducing suicidal ideation compared with TAU or wait-list control, and CBT also reduced suicide attempts compared with TAU. Ketamine and lithium reduced the rate of suicide compared with placebo, but there was limited information on harms. Limited data are available to support the efficacy of other nonpharmacologic or pharmacologic interventions.Primary Funding Source:U.S. Department of Veterans Affairs Veterans Health Administration. (PROSPERO: CRD42018104978).

Objective To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD). Methods We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary. Results This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD. Conclusion This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.

Background: Recent clinical trials suggest that treating patients with hypertension to lower blood pressure (BP) targets improves cardiovascular outcomes. Purpose: To summarize the effects of intensive (or targeted) systolic BP (SBP) and diastolic BP (DBP) lowering with pharmacologic treatment on cardiovascular outcomes and harms in adults with hypertension. Data sources: Multiple databases, including MEDLINE and EMBASE, were searched for relevant systematic reviews (SRs) published in English from 15 December 2013 through 25 March 2019, with updated targeted searches through 8 January 2020. Study selection: 8 SRs of randomized controlled trials examining either a standardized SBP target of -10 mm Hg (1 SR) or BP lowering below a target threshold (7 SRs). Data extraction: One investigator abstracted data, assessed study quality, and performed GRADE assessments; a second investigator checked abstractions and assessments. Data synthesis: The main outcome of interest was reduction in composite cardiovascular outcomes. High-strength evidence showed benefit of a 10-mm Hg reduction in SBP for cardiovascular outcomes among patients with hypertension in the general population, patients with chronic kidney disease, and patients with heart failure. Evidence on reducing SBP for cardiovascular outcomes in patients with a history of cardiovascular disease (moderate strength) or diabetes mellitus (high strength) to a lower SBP target was mixed. Low-strength evidence supported intensive lowering to a 10-mm Hg reduction in SBP for cardiovascular outcomes in patients with a history of stroke. All reported harms were considered, including general adverse events, serious adverse events, cognitive impairment, fractures, falls, syncope, hypotension, withdrawals due to adverse events, and acute kidney injury. Safety results were mixed or inconclusive. Limitations: This was a qualitative synthesis of new evidence with existing meta-analyses. Data were sparse for outcomes related to treating DBP to a lower target or for patients older than 60 years. Conclusion: Overall, current clinical literature supports intensive BP lowering in patients with hypertension for improving cardiovascular outcomes. In most subpopulations, intensive lowering was favored over less-intensive lowering, but the data were less clear for patients with diabetes mellitus or cardiovascular disease.

BackgroundEarly rehabilitation after stroke is essential to help reduce disability.PurposeTo summarize evidence on the benefits and harms of nonpharmacologic and pharmacologic treatments for motor deficits and mood disorders in adults who have had stroke.Data SourcesEnglish-language searches of multiple electronic databases from April 2009 through July 2018; targeted searches to December 2018 for studies of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors.Study Selection19 systematic reviews and 37 randomized controlled trials addressing therapies for motor deficits or mood disorders in adults with stroke.Data ExtractionOne investigator abstracted the data, and quality and GRADE assessment were checked by a second investigator.Data SynthesisMost interventions (for example, SSRIs, mental practice, mirror therapy) did not improve motor function. High-quality evidence did not support use of fluoxetine to improve motor function. Moderate-quality evidence supported use of cardiorespiratory training to improve maximum walking speed and repetitive task training or transcranial direct current stimulation to improve activities of daily living (ADLs). Low-quality evidence supported use of robotic arm training to improve ADLs. Low-quality evidence indicated that antidepressants may reduce depression, whereas the frequency and severity of antidepressant-related adverse effects was unclear. Low-quality evidence suggested that cognitive behavioral therapy and exercise, including mind-body exercise, may reduce symptoms of depression and anxiety.LimitationStudies were of poor quality, interventions and comparators were heterogeneous, and evidence on harms was scarce.ConclusionCardiorespiratory training, repetitive task training, and transcranial direct current stimulation may improve ADLs in adults with stroke. Cognitive behavioral therapy, exercise, and SSRIs may reduce symptoms of poststroke depression, but use of SSRIs to prevent depression or improve motor function was not supported.Primary Funding SourceU.S. Department of Veterans Affairs, Veterans Health Administration.

Treatment-resistant depression, a chronic condition that affects 30% of depressed patients on antidepressants, is highly linked to suicidal behavior. Chronic hypoxia exposure via living at altitude (hypobaric hypoxia) or with chronic hypoxic diseases is demographically linked to increased risk for depression and suicide. We previously demonstrated that housing rats at altitude for a week incrementally increases depression-like behavior in the forced swim test (FST) in females, but not males. In animal models, high altitude exposure reduces brain serotonin, and selective serotonin reuptake inhibitors (SSRIs) can lose efficacy when brain serotonin levels are low. To address whether residence at moderate altitude is detrimental to SSRI function, we examined SSRI efficacy in the FST after a week of housing rats at altitudes of 4500 ft. or 10,000 ft. as compared to at sea level. In females, the tricyclic antidepressant desipramine (positive control) functioned well in all groups, increasing latency to immobility and decreasing immobility, by increasing climbing. However, the SSRIs fluoxetine, paroxetine and escitalopram were ineffective in females in all groups: only paroxetine improved swimming in the FST as expected of a SSRI, while all three unexpectedly reduced climbing. Fluoxetine was also ineffective in male rats. Sertraline was the only SSRI with antidepressant efficacy at altitude in both females and males, increasing swimming, climbing and latency to immobility, and reducing immobility. Hypobaric hypoxia thus appears to be detrimental to efficacy of the SSRIs fluoxetine, paroxetine and escitalopram, but not of sertraline. Unlike the other SSRIs, sertraline can improve both serotonergic and dopaminergic transmission, and may be less impacted by a hypoxia-induced serotonin deficit. A targeted approach may thus be necessary for successful antidepressant treatment in patients with depression who live at altitude or with chronic hypoxic diseases, and that sertraline may be the SSRI of choice for prescription for this population.

BACKGROUND:This review will inform updated National Asthma Education and Prevention Program clinical practice guidelines.OBJECTIVE:We sought to evaluate the effectiveness of allergen reduction interventions on asthma outcomes.METHODS:We systematically searched the "gray literature" and 5 bibliographic databases. Eligible studies included systematic reviews, randomized controlled trials, and nonrandomized interventional studies. Risk of bias was assessed by using the Cochrane Risk of Bias instrument and the Newcastle-Ottawa scale. The evidence base was assessed by using the approach of the Agency for Healthcare Research and Quality's Evidence-based Practice Center program.RESULTS:Fifty-nine randomized and 8 nonrandomized trials addressed 8 interventions: acaricide, air purification, carpet removal, high-efficiency particulate air filtration (HEPA) vacuums, mattress covers, mold removal, pest control, and pet removal. Thirty-seven studies evaluated single-component interventions, and 30 studies assessed multicomponent interventions. Heterogeneity precluded meta-analysis. For most interventions and outcomes, the evidence base was inconclusive or showed no effect. No interventions were associated with improvement in validated asthma control measures or pulmonary physiology. Exacerbations were diminished in multicomponent studies that included HEPA vacuums or pest control (moderate strength of evidence [SOE] for both). Quality of life improved in studies of air purifiers (SOE: low) and in multicomponent studies that included HEPA vacuums (SOE: moderate) or pest control (SOE: low).CONCLUSIONS:Single interventions were generally not associated with improvement in asthma measures, with most strategies showing inconclusive results or no effect. Multicomponent interventions improved various outcomes, but no combination of specific interventions appears to be more effective. The evidence was often inconclusive because of a lack of studies. Further research is needed comparing the effect of indoor allergen reduction interventions on validated asthma measures, with sufficient population sizes to detect clinically meaningful differences.

Objectives This review evaluates the effectiveness of allergen reduction interventions on asthma outcomes in adults and children. Data sources We systematically searched the gray literature and five bibliographic databases, MEDLINE®, Embase®, PubMed®, CINAHL®, and the Cochrane Library, through April 21, 2017. Review methods Eligible studies included systematic reviews, meta-analyses, randomized controlled trials (RCTs), and nonrandomized controlled interventional studies. Studies were evaluated for risk of bias using the Cochrane Risk of Bias instrument or the Newcastle-Ottawa scale, and the evidence base was assessed using the methods guidance established by the Evidence-based Practice Center Program. Qualitative comparative analysis was conducted to support the primary analysis. Results Our literature searches identified 72 publications describing interventions to reduce exposure to indoor allergens and their effects on asthma. This included 60 unique RCTs with data published in 64 articles, as well as 8 non-RCTs. Validated measures of asthma control were infrequently reported across studies, and findings were often inconclusive. Thirty-eight studies evaluated single component interventions. Use of acaricides (dust mite pesticides) was not shown to improve pulmonary function (moderate strength of evidence [SOE]). Air purification devices, used alone, improved quality of life (low SOE) but did not reduce exacerbations or health care utilization (low SOE) or improve pulmonary function (low SOE). Impermeable mattress covers were not associated with improved asthma control (moderate SOE) and did not reduce exacerbations or health care utilization (moderate SOE) or improve quality of life (high SOE). Single intervention studies did not adequately examine carpet removal, high-efficiency particulate air-filtration (HEPA) vacuums, mold removal, pet removal, and pest control. Thirty studies assessed multicomponent interventions, but wide differences among study interventions (and combinations of interventions) precluded meta-analysis. When examined as a component within a broader set of interventions, use of air purification reduced school absenteeism (low SOE) but did not improve asthma control (low SOE), reduce exacerbations (high SOE), or improve quality of life (high SOE). HEPA vacuums, when included in a multicomponent approach, reduced exacerbations and improved quality of life (moderate SOE) for children. Mattress covers used within multicomponent interventions reduced school absenteeism and missed activities (low SOE) but had no effect on emergency department visits (low SOE), hospitalizations (high SOE), or quality of life (moderate SOE). Pest control strategies incorporated into multicomponent interventions reduced exacerbations (moderate SOE), improved quality of life (low SOE), and reduced school absenteeism (low SOE) but did not reduce emergency department visits (moderate SOE), hospitalizations (high SOE), or worker absenteeism (low SOE). Other multicomponent interventions included carpet, mold, and pet removal, but the evidence for these strategies was inconclusive. Conclusions Single intervention studies were not associated with improvement in clinical asthma outcomes, with most strategies showing inconclusive results or no effect. Multicomponent intervention studies demonstrated improvement in various outcomes, but no specific combination of interventions was identified as more effective than others. High or moderate strength evidence suggests that multicomponent interventions that include HEPA vacuums or pest control may be effective in reducing exacerbations and improving quality of life. For many primary outcomes for both single and multicomponent interventions, the evidence is inconclusive because of a lack of studies. Further research is needed examining well-defined (standardized) indoor allergen reduction interventions in comparative studies, with sufficient population size of well-characterized patients to detect clinically meaningful differences in validated and relevant asthma outcomes.

Objective This review assesses the effectiveness and safety of bronchial thermoplasty (BT) in adults with asthma. Data sources We systematically searched the gray literature and five bibliographic databases, MEDLINE®, Embase®, PubMed®, CINAHL®, and the Cochrane Library, through April 20, 2017. Review methods Eligible studies included systematic reviews, meta-analyses, randomized controlled trials (RCTs), and nonrandomized interventional studies with concurrent controls. Case reports and series were also considered for describing adverse events. Studies were evaluated for risk of bias using the Cochrane Risk of Bias instrument, and the evidence base was assessed using the methods guidance established by the Evidence-based Practice Center program. Results Fifteen studies, including three RCTs with 5-year single-arm followup in BT-treated patients (n=432 for the RCTs), examined the impact of BT in addition to standard care (continued medical management) on patients with asthma. BT and standard care improved asthma control (defined by the Asthma Control Questionnaire [ACQ] change from baseline to 12 months) and Asthma Quality of Life Questionnaire (AQLQ) scores more than standard care alone to a degree that was statistically significant but not clinically important (low strength of evidence [SOE]). However, BT and standard care, compared with a sham bronchoscopic procedure and standard care, did not improve asthma control (defined as ACQ change from baseline to 12 months), hospitalizations for respiratory symptoms, use of rescue medications, pulmonary physiology measures, or AQLQ scores (in the intention-to-treat analysis) (low SOE). In the same sham-controlled trial, BT reduced severe exacerbations after the 12-week treatment period to a statistically but not clinically important degree (low SOE), and patients undergoing BT had fewer emergency department visits than patients who had the sham bronchoscopic procedure (moderate SOE). In the RCTs comparing BT and standard care to standard care alone, evidence was insufficient to assess if BT reduced rates of severe exacerbations. Common adverse events following BT during the 12-week treatment period in the RCTs included bronchial irritation, chest discomfort, cough, discolored sputum, dyspnea, night awakenings, and wheezing. Hospitalizations were more common in patients undergoing BT than with either standard care alone or sham bronchoscopy during the 12-week treatment period, as were upper respiratory tract infections, wheezing, dyspnea, lower respiratory tract infections, anxiety, and segmental atelectasis, but the events were too infrequent to achieve statistical significance. Severe adverse events (including post-procedure segmental atelectasis due to mucus plugging, hemoptysis, chest infections requiring hospitalization, and bronchial artery pseudoaneurysm) were also reported in six case reports and two small case series. Following the 12-week treatment period, rates of respiratory-related hospitalizations were not significantly different between groups for up to 5 years of followup. No deaths were attributed to BT. Conclusions While asthma control and quality of life measures modestly improved in patients undergoing BT compared to medical management alone in two controlled but nonblinded studies, these measures did not improve in the sham-controlled study. The sham-controlled, blinded study found modest improvements in severe exacerbations and significantly fewer emergency department visits following BT compared to the sham bronchoscopic procedure, but serious adverse events and post-procedure hospitalizations were more common during the 12-week treatment period in patients undergoing BT than in patients undergoing sham treatment. The available body of literature on BT is small and uncertainty remains about appropriate patient selection criteria and the effects of the treatment beyond 5 years.

Rates of depression and suicide are higher in people living at altitude, and in those with chronic hypoxic disorders like asthma, chronic obstructive pulmonary disorder (COPD), and smoking. Living at altitude exposes people to hypobaric hypoxia, which can lower rat brain serotonin levels, and impair brain bioenergetics in both humans and rats. We therefore examined the effect of hypobaric hypoxia on depression-like behavior in rats. After a week of housing at simulated altitudes of 20,000 ft, 10,000 ft, or sea level, or at local conditions of 4500 ft (Salt Lake City, UT), Sprague Dawley rats were tested for depression-like behavior in the forced swim test (FST). Time spent swimming, climbing, or immobile, and latency to immobility were measured. Female rats housed at altitude display more depression-like behavior in the FST, with significantly more immobility, less swimming, and lower latency to immobility than those at sea level. In contrast, males in all four altitude groups were similar in their FST behavior. Locomotor behavior in the open field test did not change with altitude, thus validating immobility in the FST as depression-like behavior. Hypobaric hypoxia exposure therefore induces depression-like behavior in female rats, but not in males.