Review manufactures are an important source of clinical information for family physicians. However, the volume of available reviews is vast and their scientific quality varies enormously. Family physicians must be able to identify trustworthy reviews quickly. This commodity outlines practical and flexible guidelines for critical appraisal and discusses the respective roles of review articles and original research reports in guiding clinical practice.

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SUMMARY

Review

articles

are

an

important

source

of

clinical

information

for

family

physicians.

All the same,

the

book

of

available

reviews

is

vast

and

their

scientific

quality

varies

enormously.

Family

physicians

must

be

able

to

identify

trustworthy

reviews

quickly.

This

article

outlines

practical

and

flexible

guidelines

for

disquisitional

appraisement

and

discusses

the

corresponding

roles

of

review

articles

and

original

enquiry

reports

in

guiding

clinical

practice.

RESUME

Les

articles

de

synthese

sont

une

source

importante

d'informations

cliniques

pour

les

medecins

de

famille.

Toutefois,

le

volume

de

ce

type

d'articles

est

trop

vaste

et

leur

qualite

scientifique

varie

enormement.

Les

medecins

de

famille

se

doivent

d'identifier

rapidement

les

articles

fiables.

Cet

commodity

decrit

united nations

guide

pratique

et

flexible

facilitant

l'evaluation

critique

et

discute

des

roles

respectifs

des

manufactures

de

synthese

et

des

articles

de

nouveautes

en

recherche

pour

mieux

orienter

la

pratique

clinique.

ahn

F

P9yski

133993:139:

seven-1

1102.

Critical

Appraisal

of

Review

Articles

BRIAN

Thousand.

HUTCHISON,

MD,

CCFP

ECAUSE

OF

THE

VAST

SCOPE

OF

family

medicine,

none

of

D

_ _

us

tin can

hope

to

be

aware

of

(much

less

synthesize)

all

of

the

original

research

relevant

to

our

discipline.

As

a

result,

family

physicians,

whether

in

the

course

of

regular

journal

reading

or

when

examining

the

literature

to

resolve

a

clin-

ical

dilemma,

make

extensive

use

of

review

articles

as

well

every bit

reports

of

origi-

nal

research.

Inspired

perhaps

past

the

early on

literature

on

critical

appraisal,'18

which

dealt

exclusively

with

original

research,

physicians

-

peculiarly

acad-

emic

family

physicians

-

have

tended

to

be

apologetic

about

depending

on

review

articles.

Notwithstanding,

neither

original

enquiry

nor

review

articles

have

a

monopoly

on

truth

(or

usefulness).

Each

has

strengths

and

weaknesses,

both

practical

and

sci-

entific.

This

paper

will

hash out

the

place

of

review

articles

for

keeping

up-to-date

and

for

answering

questions

that

arise

in

clinical

do,

and

will

outline

a

prac-

tical

arroyo

to

disquisitional

appraisement

of

review

articles.

Dr

Hutchison

is

an

Associate

Professor

in

the

Department

of

Family

Medicine

and

is

an

associate

member

of

the

Department of

Clinical

Epidemiology

and

Biostatistics

at

McMaster

Academy

in

Hamilton,

Ont.

Original

research

versus

review

articles

Original

inquiry

encountered

during

the

course

of

regular

journal

reading

provides

information

that

is

more than

current

than

that

bachelor

in

review

articles.

In

most

cases,

the

deviation

is

probably

inconsequential.

Nonetheless,

it

assumes

importance

when

a

single

study

provides

strong

prove

on

a

question

with

serious

clinical

implications

or

when

the

report

receives

sensational

cov-

erage

in

the

media

(generating

queries

from

concerned

patients).

Compared

with

review

articles,

origi-

nal

research

reports

are

oftentimes

seen

as

lend-

ing

themselves

more

readily

to

critical

appraisement.

Potentially

relevant

manufactures

reporting

original

research

can

be

screened

methodologically

to

select

stud-

ies

likely

to

yield

valid

results.

For

exam-

ple,

you

can

cull

not

to

read

articles

on

the

effectiveness

of

interventions

unless

they

report

randomized,

controlled

trials.

Having

read

an

article

reporting

original

research,

yous

can

make up one's mind

for

yourself

whether

the

study

results

are

valid

and

applicable

to

your

patients,

using

explicit

and

widely

accepted

criteria.9'10

Representativeness.

Every bit

a

guide

to

clin-

ical

action,

even so,

original

research

reports

have

meaning

limitations.

A

sin-

gle

study

is

rarely

definitive.

More

often,

truth

emerges

from

the

accumulation

of

Canadian

Family unit

Physician

VOL

39:

May

1993

1097

evidence

provided

by

several

studies

addressing

a

particular

upshot.

The

results

of

a

single

report

can

be

misleading

if

they

differ

from

those

obtained

in

other

studies

examining

the

same

question.

The

fre-

quency

with

which

randomized

trials

on

the

same

topic

yield

contradictory

results

is

highlighted

by

Horwitz"'

identification

of

36

topics

with

conflicting

randomized

trial

results

in

a

"nonexhaustive"

search

of

cardiology

and

gastroenterology

literature.

The

consequence

of

representativeness

becomes

very

important

when

we

utilise

research

literature

as

a

source

of

informa-

tion

to

resolve

clinical

doubtfulness

or

to

inform

clinical

policy

development.

Unless

we

conduct

a

comprehensive

search,

using

a

diverseness

of

search

strategies,

nosotros

can

be

misled;

the

results

of

the

studies

in

our

sample

might

non

represent

the

results

of

all

relevant

studies.

Bias.

Similarly,

although

the

authors

of

reports

of

original

inquiry

ofttimes

talk over

their

findings

in

light

of

previous

related

research,

they

cannot

be

counted

upon

to

present

a

comprehensive

and

balanced

review

of

the

relevant

literature.

The

exis-

tence

of

bias

in

citation

of

previous

studies

was

demonstrated

empirically

by

Gotzsche'2

in

a

study

of

the

reference

lists

of

reports

of

double-blind

trials

of

nons-

teroidal

anti-inflammatory

drugs

in

rheumatoid

arthritis.

He

found

an

over-

representation

of

references

to

trials

with

a

positive

outcome

for

the

"new"

drug

in

67%

of

articles

in

which

such

bias

could

have

occurred.

Statistical

ability.

Reports

of

original

research

can

likewise

be

misleading

when,

despite

a

methodologically

strong

design,

they

have

inadequate

sample

sizes

to

detect

(or

dominion

out)

clinically

important

furnishings

or

associations.

Freiman

and

col-

leagues'3

illustrated

how

frequently

this

state of affairs

occurs.

They

analyzed

71

"nega-

tive"

randomized,

controlled

trials

(defined

by

P

>

0.05),

more

than

one-half

of

which

were

published

in

the

New

England

Journal

ofMedicine,

The

Lancet,

or

the

Periodical

of

the

American

Medical

Association.

Fifty-seven

(fourscore%)

of

the

trials

had

a

50%

or

greater

chance

of

missing

a

true

25%

reduction

in

take a chance

of

an

unfavourable

out-

come.

Thirty-ane

trials

(44%)

had

a

50%

or

greater

chance

of

missing

a

chance

reduc-

tion

of

l%.

Viewing

such

negative

trials

in

isolation

can

lead

to

the

erroneous

con-

clusion

that

an

intervention

is

ineffective

or

that

no

association

exists

between

a

putative

causal

factor

and

a

condition

of

interest,

whereas

an

overview

of

all

rele-

vant

studies

might

lead

to

an

contrary

(and

correct)

conclusion.

For

example,

in

an

overview

past

Yusuf

et

al'four

of

randomized

trials

of

long-term

>-receptor

blockade

following

myocardial

infarction,

19

of

23

private

trials

failed

to

evidence

a

statistical-

ly

significant

reduction

in

bloodshed.

However,

the

aggregated

results

of

all

tri-

als

showed

that

n-receptor

blockade

was

associated

with

a

highly

statistically

signif-

icant

23%

reduction

in

take chances

of

death

(ii-sided

P

<

0.0001).

Meta-analysis.

This

type

of

review,

which

aggregates

the

results

of

several

1098

Canadian

Family

Physician

VOL

39:

May

1993

Table

1.

Published

guidelines

for

assessing

enquiry

reviews

MULROW

I7

ane.

Was

the

specific

purpose

of

the

review

stated?

two.

Were

sources

and

methods

of

the

citation

search

identified?

3.

Were

explicit

guidelines

provided

that

determined

the

textile

included

in,

and

excluded

from,

the

review?

.................................................................................................................................I...............

4.

Was

a

methodologic

validity

assessment

of

material

in

the

review

performed?

.............I...................................................................................................................................

5.

Was

the

information

systematically

integrated

with

explication

of

data

limitations

and

inconsistencies?

six.

Was

the

information

weighted

or

pooled?

................................................................................................................................................

vii.

Was

a

summary

of

pertinent

findings

provided?

............I..........................................................................................................I........................

8.

Were

specific

directions

for

new

inquiry

initiatives

proposed?

.................................................................................................................................................

OXMAN

AND

GUYAU

18

..................................I..............................................................................................................

1.

Were

the

questions

and

method

clearly

stated?

..................................................................I..............................................I................................

2.

Were

comprehensive

search

methods

used

to

locate

relevant

studies?

.................................................................................................................................................

three.

Were

explicit

methods

used

to

decide

which

articles

to

include

in

the

review?

.................................................................................................................................................

four.

Was

the

validity

of

the

main

studies

assessed?

..................I..........................................................................................................................

5.

Was

the

assessment

of

the

primary

studies

reproducible

and

complimentary

from

bias?

.................................................................................................................................................

half dozen.

Was

variation

in

the

findings

of

the

relevant

studies

analyzed?

.................................................................................................................................................

seven.

Were

the

findings

of

the

main

studies

combined

appropriately?

................................................................................................................................................

8.

Were

the

reviewers'

conclusions

supported

past

the

data

cited?

trials,

is

called

a

"meta-analysis."

Such

reviews

are

appearing

with

increasing

(but

still

low)

frequency

in

the

health

care

liter-

ature.

They

provide

a

quantitative

synthe-

sis

of

the

results

of

all

relevant

primary

studies

that

encounter

predetermined

inclusion

criteria

in

guild

to

produce

an

overall

esti-

mate

of,

for

case,

the

event

of

an

inter-

vention,

the

sensitivity

and

specificity

of

a

diagnostic

test,

or

the

strength

of

an

asso-

ciation

between

a

medical

condition

and

a

possible

prognostic

or

etiologic

gene.

Such

inquiry

overviews

have

advantages

over

both

original

research

reports

and

traditional

narrative

reviews

as

sources

of

data

to

resolve

clinical

dilemmas.

Properly

done,

meta-analysis

elimi-

nates

much

of

the

subjectivity

and

potential

for

bias

from

the

process

of

reviewing

principal

research.

Rigorous

methodologic

standards

designed

to

minimize

bias

and

ensure

validity

in

the

conduct

of

quantitative

research

overviews

have

been

published.'v

By

quantitatively

combining

results

from

more

than

one

study,

meta-analysis

increases

statistical

ability

to

detect

clin-

ically

important

furnishings

or

associations

(reduces

type

II

or

,B

error)

and

increas-

es

the

precision

(narrows

the

confidence

interval)

of

estimates

of

the

magnitude

of

an

intervention's

effect,

the

sensitivity

and

specificity

of

a

diagnostic

test,

or

the

force

of

an

association.

Meta-analysis

is

most

helpful

when

a

large

number

of

studies

(especially

small

studies)

employing

the

same

(preferably

potent)

methodology

accept

variable,

conflicting,

or

statistically

nonsignifi-

cant

results.

Offsetting

the

obvious

strength

of

meta-analysis

is

the

fact

that

only

a

handful

of

primary

care

issues

accept

been

addressed

to

date

with

this

method.

Since

1989,

meta-analysis

has

been

a

medical

subject

heading

(MeSH)

in

the

MEDLINE

database

and

can

be

used

as

a

search

term

in

computerized

literature

searches.

At

their

best,

review

articles

are

valu-

able

guides

to

action

because

they

rep-

resent

a

comprehensive,

unbiased

assessment

and

synthesis

of

the

primary

enquiry

relevant

to

a

clinical

question.

At

a

applied

level,

perhaps

the

most

important

reward

of

review

articles

is

that

someone

else

does

the

laborious

work

of

identifying,

critically

apprais-

ing,

and

synthesizing

the

relevant

pri-

mary

research.

Unfortunately,

the

quality

of

review

articles

is

often

poor.

(Of

form

the

aforementioned

can

be

said

for

the

quality

of

original

research.)'6

Because

the

methods

are

rarely

stated,

review

articles

are

somewhat

harder

to

appraise

critically

than

original

enquiry.

However,

criteria

for

assessing

review

articles

accept

recently

been

devel-

oped;

Mulrow'vii

and

Oxman

and

Guyatt'8

accept

published

similar

sets

of

guidelines

for

assessing

the

scientific

quality

of

review

articles

(Table

ane).

An

instrument

for

assessing

the

scien-

tific

quality

of

review

articles,29

based

on

Oxman

and

Guyatt's

criteria,

has

been

shown

to

have

satisfactory

reliability

(inter-assessor

agreement)

when

used

past

experts

in

research

methodology,

Assessing

potentially

relevant

reviews:

Critical

appraisal

tin can

ident;

applicable

studies

in the

vast

medical

literature.

clinicians

with

inquiry

training,

and

enquiry

administration.

Manufactures

that

satisfy

the

instrument's

guidelines

tin

be

expected

to

provide

valid

answers

to

the

questions

addressed

by

the

reviews.

Unfortunately,

but

a

pocket-sized

fraction

of

current

reviews

meet

these

standards.

Until

the

overall

quality

of

review

arti-

cles

improves

substantially,

a

set

of

less

stringent

and

more

flexible

guidelines

are

required

to

assist

physicians

to

dis-

card

reviews

of

mediocre

or

inferior

quality

quickly

after

scanning.

A

prepare

of

such

guidelines

are

presented

beneath

and

summarized

in

Table

2.

Canadian

Family

Medico

VOL

39:

May

1993

1099

Exaiining

a

review

article

Is

the

question

being

addressed

clearly

defined?

Expect

for

a

articulate

country-

ment

of

the

target

population,

the

inter-

vention

or

exposure

of

interest,

and

the

outcome(s)

(eg,

"Does

acetysalicylic

acid

reduce

bloodshed

in

patients

with

myocardial

infarction?").

When

ques-

tions

are

formulated

in

this

fashion,

you

can

brand

a

decision

quickly

and

confi-

dently

about

the

relevance

to

your

clini-

cal

practise.

Does

the

reviewfocus

on

a

specific

question

or

address

a

wide,

gener-

al

topic?

The

author

of

a

review

that

addresses

a

specific

question

(eg,

continu-

ous

electronic

fetal

monitoring

in

low-risk

obstetric

patients)

tin can

-

but

might

not

-

identify,

critically

review,

summarize,

and

synthesize

all

the

relevant

master

inquiry

bearing

on

that

question.

This

thoroughness

is

clearly

unattainable

in

a

review

addressing

a

general

topic

(eg,

depression-

gamble

obstetrics)

that

could

contain

within

information technology

numerous

questions

related

to

etiology,

pathophysiology,

epidemiology,

diagnosis,

and

treatment.

Each

question

has,

of

necessity,

to

be

dealt

with

briefly

and

ordinarily

superficially.

(This

is

non

to

deny

the

usefulness

of

broad

overviews

as

an

intro-

duction

or

orientation

to

an

area

of

knowl-

border.

Still,

the

specific

"answers"

such

an

overview

provides

should

not

be

accept-

ed

uncritically

as

valid).

Is

the

author

obviously

biased?

Unrestrained

author

bias

sometimes

becomes

credible

in

the

first

few

sen-

tences

of

a

review.

Pass

over

such

articles

unless

you

enjoy

polemic

writing

for

its

amusement

value.

Are

the

methods

used

to

bear

the

search

for

relevant

original

research

described?

Search

methods

used

to

place

original

research

are

rarely

described.

As

a

reader,

you

have

no

way

of

knowing

(unless

the

author

tells

you)

whether

he

or

she

simply

pulled

a

haphazard

accumulation

of

articles

from

a

file

drawer

or

conducted

a

systematic,

comprehensive

search.

When

search

methods

are

described,

you

can

judge

for

yourself

how

probable

it

is

that

all

(or

virtually)

relevant

primary

studies

have

been

included

in

the

review.

Are

references

absent

or

scanty?

Lack

of

references

is

acceptable

nether

cer-

tain

circumstances,

such

as

articles

describing

an

established

technique

or

procedure

(eg,

aspiration

of

the

knee

joint)

and

descriptions

of

"new"

diseases.

The

main

trouble

with

unreferenced

or

scant-

ily

referenced

review

articles

is

that

you

are

completely

at

the

mercy

of

the

author.

You

have

no

way

of

verifying

the

author's

statements.

Y'all

cannot

know

whether

they

are

based

on

conventional

wisdom,

personal

clinical

feel,

"common

sense,"

or

scientific

evidence.

This

situa-

tion

is

especially

mutual

in

commer-

cial

(throwaway)

journals.

Are

primary

studies

critically

appraised?

Critical

appraisement

preferably

should

use

explicit

methodologic

criteria.

Features

other

than

basic

research

design

have

important

effects

on

the

validity

of

the

results

of

chief

studies.

Explicit

methodologic

criteria

are

available

for

evaluating

the

scientific

validity

of

various

types

of

studies.'

-8

When

authors

of

review

articles

assess

primary

studies

against

such

1100

Canadian

Family

Physician

VOL

39:

Alay

1993

Table

2.

Framework

for

quality

cess

of

review

articles

POSITIVE

FEATURES

Focuses

on

a

specific

question.

Clearly

defines

the

question(s)

being

addressed.

.........................................................................................................................................

Methods

of

conducting

search

for

relevant

main

studies

are

described.

.......................................................................................................................................

Primary

studies

are

critically

appraised,

preferably

in

relation

to

explicit

methodologic

criteria.

...I.................................................I..................................................................................

When

results

of

primary

studies

are

being

presented,

inquiry

design

and

population

studied

are

described.

.....................................................................................................................I..........................

Quantitative

data

from

primary

studies

are

summarized,

preferably

with

confidence

intervals

or

P

values.

......I......................................................................................I..................................................

NEGATIVE

FEATURES

...............................................................................................................................................

Addresses

a

broad

or

general

topic.

....................................................................................................................

Writer

patently

biased.

...............................................................................................................................................

No

references

or

a

scanty

list

of

references.

...........................................I.....................................................................

Summary

statements

regarding

of import

problems

are

only

followed

by

one

or

more than

references

(or

no

references)

without

further

description

of

the

studies

or

their

results.

...........................................................................................................................................

Magnitude

of

event

is

not

discussed.

criteria,

our

power

to

make

rational

deci-

sions

about

the

clinical

application

of

the

findings

is

enhanced.

When

results

of

pimary

studies

are

beingness

presented,

are

the

research

design

and

population

studied

described?

Research

design

and

subjects

preferably

should

be

described

in

a

sum-

mary

table;

summary

statements

regarding

important

problems

should

non

only

exist

fol-

lowed

by

one

or

more

citations

(or

no

ref-

erences)

without

further

description

of

the

studies

or

their

results.

"Inactivated

whole

virus

vaccine

reduces

the

run a risk

of

flu

in

the

elderly

by

50%

to

70%."25

What

are

nosotros

to

make

of

statements

such

as

this?

We

cannot

know

(unless

the

tides

offer

a

clue)

whether

the

studies

cited

provide

strong

or

weak

evidence

(were

they

instance

control,

cohort,

or

randomized,

controlled

studies?)

or

whether

the

written report

populations

were

sim-

ilar

to

our

patient

population

(were

they

healthy

elderly

or

chronically

ill,

institu-

tionalized

elderly?).

On

the

other

hand,

when

such

information

is

presented,

nosotros

can

judge

for

ourselves

the

strength

of

the

evidence

and

how

well

the

results

apply

to

our

patients.

Are

quantitative

information

from

primary

studies

summarized?

Data

preferably

should

be

summarized

in

a

table,

and

preferably

with

Pvalues,

or

better

still,

con-

fidence

limits.

Nonquantitative

statements

about

an

association

(eg,

"Passive

exposure

to

cigarette

fume

is

associated

with

an

increased

risk

of

lung

cancer")

or

the

effect

of

an

intervention

(eg,

"Propranolol

is

use-

ful

for

beneficial

familial

tremor")

are

of

limit-

ed

clinical

usefulness.

In

order

to

talk

sensibly

with

our

patients

and

to

make

rational

clinical

decisions,

we

demand

an

esti-

mate

of

the

magnitude

of

an

event

or

the

strength

of

an

association

and

an

indication

of

the

precision

of

that

estimate,

such

as

a

Pvalue

or,

preferably,

confidence

limits

(eg,

"Mortality

was

10%

in

the

handling

group

and

20%

in

the

control

group.

The

95%

conviction

interval

for

the

difference

in

mortality

between

treated

and

command

sub-

jects

was

7%

to

xv%").

Presentation

of

information

in

a

table

or

effigy

helps

to

ensure

a

sys-

tematic

and

uniform

arroyo

to

summa-

rizing

information

and

facilitates

comparisons

across

studies.

Putting

guidelines

into

practise

These

guidelines

tin can

be

used

in

a

variety

of

ways

in

regular

journal

reading.

For

instance,

you

could

select

a

cluster

of

cri-

teria

confronting

which

to assess

potentially

relevant

reviews.

Tabular array

3

shows

how

such

criteria

can

exist

applied.

The

criteria

are

bundled

in

society

of

the

ease

with

which

they

can

be

applied.

Failure

to

meet

whatever

1

of

the

criteria

disqualifies

an

article.

The

offset

benchmark

can

be

applied

past

examining

the

tide

or,

at

most,

the

intro-

duction;

the

second

by

examining

the

ref-

erence

listing;

and

the

third

past

reading

the

writer'due south

introduction.

Awarding

of

the

final

two

criteria

commonly

requires

scanning

the

tables

and

text.

Boosted

criteria

could

be

added:

for

example,

a

require-

ment

for

a

description

of

the

methods

used

to

identify

the

main

studies

included

in

the

review.

This

would

profoundly

enhance

the

quality

and

trustworthiness

of

the

reviews

you lot

ultimately

read

but,

given

the

deplorable

state

of

the

current

review

literature,

would

accept

the

effect

of

excluding

all

but

a

few

articles

on

clinically

relevant

topics.

For

literature

searches

designed

to

respond

questions

that

arise

in

clinical

practice,

the

guidelines

can

be

used

to

place

the

best

reviews

that

are

(readily)

available.

Where

relevant

review

manufactures

are

plentiful,

stringent

criteria

are

appro-

priate.

Where

trivial

is

available,

you

may

take

to

loosen

your

selection

criteria

(or,

alternatively,

search

for

articles

reporting

loftier-quality

original

enquiry).

The

advent

of

"structured

abstracts"

of

review

articles,

pioneered

by

the

Annals

of

Internal

Medicine,xx'ii'

promises

(if

their

utilize

becomes

widespread)

to

simplify

the

disquisitional

appraisal

of

review

articles.

Structured

abstracts

summarize

information

virtually

review

articles

under

the

following

head-

ings:

objective(southward),

data

sources,

study

selec-

tion,

information

extraction,

data

synthesis,

and

conclusions.

Detailed

instructions

for

preparing

structured

abstracts

have

been

developed.20

Structured

abstracts

are

not

truncated

in

the

MEDLINE

database,

even

when

they

exceed

the

usual

250-give-and-take

limit.22

Because

structured

abstracts

high-

light

the

key

methodologic

issues

related

to

the

deport

and

reporting

of

inquiry

overviews,

improvement

in

the

overall

quality

of

review

articles

could

be

expected

to

follow

if

structured

abstracts

are

adopted

Canadian

Family

Physician

VOL

39:

May

1993

1101

Tabular array

3.

Deciding

whether

to

read

a

"relevant"

review

commodity:

The

commodity

should

be

rejected

ifthefollouning

are

true.

*

It

addresses

a

broad

topic

*

Information technology

has

no

references

or

scanty

references

*

The

author

is

obviously

biased

*

Information technology

has

no

description

or

minimal

description

of

primary

studies

*

The

magnitude

of

effect

is

not

discussed

widely

past

periodical

editors.

However,

a

struc-

tured

abstruse

is

no

more than

a

guarantee

of

high

quality

than

a

methods

section.

Readers

still

need

to

be

critical.

Review

articles

have

a

vital

office

in

fam-

ily

physicians'

efforts

to

keep

upwards-to-date

through

regular

journal

reading

and

to

resolve

clinical

dilemmas

past

examining

the

accumulated

health

intendance

literature.

Disquisitional

appraisal

of

review

articles

based

on

criteria

of

scientific

quality

is

both

desirable

and

feasible.

H

Requests

for

reprints

to:

Dr

B.Thou.

Hutchison,

First

Identify

Family unit

Medical

Centre,

350

K:ing

St

E,

Suite

106,

Hamilton,

ON

L8N3Y3

Acknowledgment

I

thank

DrAndy

Oxman

of

the

Departments

of

Family

Medicine

and

Clinical

Epidemiology

and

Biostatistics

at

McMaster

Universiy

for

his

meaning

contribu-

tions

to

this

work

through

discussion

of

key

issues

and

comments

on

earlier

drafts.

References

1.

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of

Clinical

Epidemiology

and

Biostatistics,

McMaster

University

Health

Sciences

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How

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1981;

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1984;130:377-81.

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Clinical

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McMaster

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1984;

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VII.

To

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economic

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(office

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Med

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1984;

130:

1542-9.

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DL,

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RB,

Tugwell

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RH,

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SW,

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TA,

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CD.

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GH,

SingerJ,

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CD,

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Ann

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1988;

108:613-five.

21.

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RB,

Mulrow

CD,

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EJ,

Altman

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MJ.

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JVZAi

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1102

Canadian

Family

Physician

VOI.

39:

May

1993

... In looking at the medical faculty, Hutchison (1993) fi nds that many postgraduate students who were expected to produce a thesis or dissertation lacked the knowledge in writing a proficient literature review. He mentions that many of the participants in his study were not prepared to deal with knowing what previous research had done and what current enquiry is doing. ...

... However, this claim was not supported by whatever bear witness although it may exist presumed that the participants were not prepared considering of their weakness in reading and comprehension that has been accentuated by their language profi ciency. Hutchison (1993) as well notes that those who had successfully completed their thesis or dissertation could have done so through modeling other peoples' work. This is likely to be the primary reason because most postgraduate students are not really taught how to write a thesis or dissertation so what amend strategy to do this other than to 'model' another person's work or way. ...

... This is probable to be the primary reason because most postgraduate students are non really taught how to write a thesis or dissertation so what improve strategy to do this other than to 'model' another person's work or style. This biasness is farther exaggerated when Hutchison (1993) asserts that of the many who had already completed their postgraduate degrees, many do not fifty-fifty know how to synthesise, a claim which needs to be justifi ed and substantiated with tangible evidence. ...

A affiliate to help trainers

... While a multitude of studies demonstrating biological effects of ocean acidification has been relatively apace clustered, syntheses of the discrete primary research studies tin enhance the insight they provide (Hutchison, 1993). Such syntheses are condign increasingly possible through the evolution of online databases that host information (e.g., those associated with journals such as Figshare for Frontiers, or that are contained such as Pangaea). ...

... The frameworks provided by literature review approaches have often been used when synthesizing existing primary research into comprehensive, contextualized overviews (Hutchison, 1993). These approaches range from the traditional qualitative narrative to the quantitative meta-analysis, with each approach having its own features, advantages, and disadvantages. ...

Understanding links between the abiotic surroundings and organism fitness and office is a central claiming of biology, and an outcome of growing relevance due to anthropogenic environmental changes. To date, our understanding of these links has largely been based on the findings of isolated experimental studies. This command may, however, exist enhanced where currently disparate data are synthesized. Past outlining a range of approaches advisable in bringing together the findings of studies considering bounding main acidification effects, we promise to provide insight every bit to how they may be used in the futurity. Specifically, approaches discussed in this narrative literature review include established literature review methods, likewise as emerging schemes structured around biological theories (i.east., dynamic energy budget, DEB; oxygen- and capacity-limited thermal tolerance, OCLTT; multiple functioning-multiple optima, MPMO), and strategies adult in other disciplines (i.e., adverse outcome pathways, AOP). In the future approaches to use such frameworks in creative combinations may exist developed. Here we discuss some of these potential combinations, specifically the utilize of: AOPs to identify key steps that can be explored in more detail through literature review frameworks; OCLTT and DEB frameworks to consider effects on both energy supply and resource allotment; MPMO frameworks to place the performance curves of organisms whose interactions are considered in an ecosystem model. Regardless of the approach taken, synthesizing scientific literature represents a potentially powerful method to enhance understanding of the influence of the abiotic environment on whole organism fitness.

... Narrative reviews are besides known as unsystematic narrative reviews, which may provide critique of the literatures being reviewed, simply are not essential (5). This format is close to an educational article to keep clinicians upwards to date with low-scientific level, and is far from the articles that should derive objective results or design specific studies (6)(7)(8). Therefore, we will elaborate on the latest views and our experiences in the form of a narrative review. ...

... Systematic reviews involve comprehensive syntheses of collections of databases on specific topic. Proficient review reading may remain one of the utmost resourceful ways toward getting acquainted with avant-garde inquiry besides every bit do on several precise ecology/public health topics [76,77]. The usage of explicit and consistent systematic methods (i.e., decision-making rules) in reviews decrease bias equally well every bit decrease'due south chance impacts, hence providing a more trustworthy outcomes on which decisions are made [78]. ...

Given the unprecedented novel nature and calibration of coronavirus and the global nature of this public wellness crisis, which upended many public/environmental research norms virtually overnight. Nevertheless, with farther waves of the virus expected and more pandemics anticipated. The COVID-19 pandemic of 2020 opened our optics to the ever-changing conditions and uncertainty that exists in our earth today, particularly with regards to ecology and public health practices disruption. This newspaper explores environmental and public wellness evidence-based practices toward responding to Covid-19. A literature review tried to practise a deep dive through the utilize of various search engines such as Mendeley, Research Gate, CAB Abstruse, Google Scholar, Summon, PubMed, Scopus, Hinari, Dimension, OARE Abstract, SSRN, Academia search strategy toward retrieving research publications , "gray literature" likewise as reports from good working groups. To reach enhanced population wellness, it is recommended to adopt widespread evidence-based strategies, particularly in this uncertain fourth dimension. As but together tin can testify-informed decision-making (EIDM) tin become a reality which include effective policies and practices, transparency and accountability of decisions, and equity outcomes; these are all more relevant in resource-constrained contexts, such as Nigeria. Effective and ethical EIDM though requires the production too every bit utilise of loftier-quality evidence that are timely, appropriate and structured. One fashion to practise so is through co-production. Co-production (or co-creation or co-design) of envi-ronmental/public health show considered as a key tool for addressing circuitous global crises such as the high take chances of severe COVID-19 in different nations. A significant show-based component of environmental/public health (EBEPH) consist of decisions making based on best accessible, evidence that is peer-reviewed; using data as well equally systematic information systems; community engagement in policy making; conducting sound evaluation; do a thorough program-planning frameworks; too equally disseminating what is being learned. Equally researchers, scientists , statisticians, journal editors, practitioners, as well every bit decision makers strive to improve population health, having a natural tendency toward scrutinizing the scientific literature aimed at novel inquiry findings serving as the foundation for intervention also as prevention programs. The main inspiration behind conducting inquiry ought to be toward stimulating and collaborating appropriately on Bear witness-Based Approaches to Effectively Answer to Public Health Emergencies 2 public/ecology health action. Hence, at that place is need for a "Programme B" of effective behavioral, environmental, social besides equally systems interventions (BESSI) toward reducing transmission.

... Systematic reviews involve comprehensive syntheses of collections of databases on specific topic. Good review reading may remain one of the utmost resourceful ways toward getting acquainted with advanced research as well as practice on several precise environmental/public health topics [69,70]. The usage of explicit and consistent systematic methods (i.e., determination-making rules) in reviews subtract bias as well every bit subtract'due south risk impacts, hence providing a more trustworthy outcomes on which decisions are made [71]. ...

COVID-xix demonstrated a global ending that touched everybody, including the scientific community. As we respond and recover rapidly from this pandemic, there is an opportunity to guarantee that the fabric of our society includes sustainability, fairness, and care. Still, approaches to environmental wellness try to decrease the populations burden of COVID-19, toward saving patients from becoming ill forth with preserving the allocation of clinical resource and public safety standards. This paper explores ecology and public health evidence-based practices toward responding to Covid-19. A literature review tried to do a deep dive through the utilise of various search engines such as Mendeley, Research Gate, CAB Abstract, Google Scholar, Summon, PubMed, Scopus, Hinari, Dimension, OARE Abstruse, SSRN, Academia search strategy toward retrieving enquiry publications, "greyness literature" as well as reports from skilful working groups. To achieve enhanced population health, it is recommended to adopt widespread prove-based strategies , particularly in this uncertain fourth dimension. As only together can evidence-informed conclusion-making (EIDM) can get a reality which include effective policies and practices, transparency and accountability of decisions, and equity outcomes; these are all more than relevant in resource-constrained contexts, such equally Nigeria. Constructive and ethical EIDM though requires the product every bit well equally use of high-quality evidence that are timely, appropriate and structured. One way to do so is through co-product. Co-production (or co-creation or co-design) of ecology/public health show considered as a key tool for addressing circuitous global crises such as the high risk of severe COVID-19 in unlike nations. A significant evidence-based component of ecology/public health (EBEPH) consist of decisions making based on best accessible, evidence that is peer-reviewed; using data as well as systematic information systems; community engagement in policy making; conducting sound evaluation; practise a thorough program-planning frameworks; besides equally disseminating what is being learned. Equally researchers, scientists, statisticians, journal editors, practitioners, as well as determination makers strive to improve population wellness, having a natural trend toward scrutinizing the scientific literature aimed at novel enquiry findings serving equally the foundation for intervention as well equally prevention programs. The primary inspiration behind conducting research ought to be toward stimulating and collaborating appropriately on public/environmental health action. Hence, there is need for a "Plan B" of constructive behavioural, environmental, social besides equally systems interventions (BESSI) toward reducing transmission.

... This review is an overview of the most pertinent studies of US-guidance in the handling of cervical radicular pain and is therefore prone to a higher degree of bias when compared to a meta-analysis [fourscore,81]. Nosotros attempted to reduce bias through appropriate writing and inquiry techniques [82][83][84][85][86] as well as involving the Health Sciences Informationist at the Eskind Biomedical Library of Vanderbilt University to conduct the final database review in search of relevant literature. Additionally, we have provided the search strategy equally part of the supplementary fabric for readers. ...

Purpose of Review This newspaper aims to review the bachelor literature addressing the safety, accuracy, and efficacy of ultrasound-guided injections for cervical radicular pain. Recent Findings Ultrasound-guided injections remain a "partially bullheaded technique" due to the inability to visualize relevant structures and the distribution of injectate. In that location remains a need for adequately powered studies evaluating the safety, accuracy, and effectiveness of ultrasound-guided steroid injections in the cervical spine. Fluoroscopy remains the best evidence-based image-guidance modality for injections into the cervical epidural space to care for cervical radicular pain. Summary If ultrasound guidance is planned for treatment of cervical radicular pain, the authors recommend concomitant utilise of fluoroscopy guidance. Given the chance of inaccurate needle placement, physicians should retain fluoroscopic images prior to contrast injection to document the proper vertebral segment and concluding needle tip position. Equally epidural flow cannot exist fully visualized with ultrasound, it is recommended to utilize fluoroscopy and, if needed, digital subtraction imaging to confirm the absence of intravascular injection. At a minimum, images should be saved post-contrast injection to document epidural menses.

Groundwork: Given the unprecedented novel nature and scale of coronavirus and the global nature of this public health crunch, which upended many public/ecology inquiry norms almost overnight. However, with further waves of the virus expected and more pandemics anticipated. The COVID-19 pandemic of 2020 opened our eyes to the e'er-changing conditions and uncertainty that exists in our world today, particularly with regards to environmental and public health practices disruption. Objectives: This paper explores environmental and public health evidence-based practices toward Responding to Covid-19. Methods: A literature review tried to do a deep dive by using a diversity of search engines including Research Gate, Google Scholar, Summon, PubMed, Scopus, Hinari, Dimension, CAB Abstract, OARE Abstruse, Academia, Mendeley, SSRN search strategy to retrieve research publications, "grayness literature" and expert working group reports. Results: To reach improved population health, more widespread adoption of evidence-based strategies is recommended, particularly in this uncertain time. As simply together tin evidence-informed decision-making (EIDM) can become a reality which include effective policies and practices, transparency and accountability of decisions, and disinterestedness outcomes; these are all more relevant in resources-constrained contexts, such equally Nigeria. Effective and upstanding EIDM though requires the production and apply of loftier-quality evidence that are timely, relevant and structured. Ane way to do so is through co-production. Co-product (or co-creation or co-design) of ecology/public health prove considered as a central tool for addressing complex global crises such as the high run a risk of severe COVID-nineteen in unlike nations. Discussion: A significant prove-based component of environmental/public health (EBEPH) consist of decisions making based on all-time attainable, evidence that is peer-reviewed; using information besides equally systematic information systems; community engagement in policy making; conducting sound evaluation; do a thorough programme-planning frameworks; as well as disseminating what is beingness learned. Every bit researchers, scientists, statisticians, journal editors, practitioners, too as decision makers strive to better population health, having a natural tendency toward scrutinizing the scientific literature aimed at novel enquiry findings serving as the foundation for intervention likewise as prevention programs. The main inspiration behind conducting research ought to be toward stimulating and collaborating appropriately on public/environmental health activity. Hence, in that location is demand for a "Programme B" of effective behavioural, ecology, social and systems interventions (BESSI) to reduce manual.

Humans answer cognitively and emotionally to the congenital surround. The modernistic possibility of recording the neural activeness of subjects during exposure to environmental situations, using neuroscientific techniques and virtual reality, provides a promising framework for time to come pattern and studies of the built environment. The discipline derived is termed "neuroarchitecture". Given neuroarchitecture's transdisciplinary nature, it progresses needs to be reviewed in a contextualised way, together with its forerunner approaches. The present commodity presents a scoping review, which maps out the broad areas on which the new discipline is based. The limitations, controversies, benefits, impact on the professional sectors involved, and potential of neuroarchitecture and its precursors' approaches are critically addressed.

Background/Importance Ultrasound (US)-guided cervical selective nerve root injections (CSNRI) have been proposed as an alternative to fluoroscopic (FL) -guided injections. When choosing US guidance, the proceduralist should be enlightened of potential problems confirming vertebral level, exist clear regarding terminology, and upwards to appointment regarding the advantages and disadvantages of US-guided CSNRI. Objective Review the accuracy and effectiveness of United states of america guidance in avoiding vascular puncture (VP) and/or intravascular injection (IVI) during CSNRI. Evidence Review Queries included PubMed, CINAHL and Embase databases from 2005 to 2019. Three authors reviewed references for eligibility, bathetic information, and appraised quality. Findings The literature demonstrates singled-out safety considerations and limited evidence of the effectiveness of US guidance in detecting VP and/or IVI. As vascular flow and desired injectate spread cannot be visualized with US, the use of real-fourth dimension fluoroscopy, and if needed digitial subraction imaging, is indicated in cervical transforaminal epidural injections (CTFEIs). Given the take chances of VP and/or IVI, the ability to perform and to retain FL images to certificate that the procedure was safely conducted is valuable in CTFEIs. Conclusion US guidance remains to be proven as a non-inferior culling to FL guidance or other imaging modalities in the prevention of VP and/or IVI with CTFEIs or cervical selective nerve root blocks. There is a paucity of adequately powered clinical studies evaluating the accuracy and effectiveness of United states guidance in avoiding VP and/or IVI. US-guided procedures to treat cervical radicular pain has limitations in visualization of anatomy, and currently with the bear witness available is best used in a combined approach with FL guidance.

  • Cynthia Mulrow Cynthia Mulrow

This proposal presents guidelines for preparing informative abstracts of review articles. Six guidelines are proposed: ane. The abstract should brainstorm with a precise statement of the primary objective of the review. two. The data sources for the review should be succinctly summarized. 3. The criteria used to select studies from the data sources and the method by which these criteria were practical should be specified. 4. The guidelines used for abstracting data and assessing information quality should be described. five. The main results of the review and the methods used to obtain these results should exist stated. 6. Conclusions and potential applications of the review's results should be clearly and succinctly stated. Awarding of these guidelines can pb to efficient identification of relevant, scientifically sound review manufactures, a greater awareness of the vital elements of a good review article, more precise computerized literature searches, and improved peer-review processes.

Objective: To assess the consistency of an index of the scientific quality of enquiry overviews. Pattern: Understanding was measured among 9 judges, each of whom assessed the scientific quality of 36 published review manufactures. Detail Selection: An iterative process was used to select ten criteria relative to v fundamental tasks entailed in conducting a research overview. Sample: The review articles were fatigued from three sampling frames: articles highly rated past criteria external to the study; meta-analyses; and a broad spectrum of medical journals. JUDGES: Three categories of judges were used: research assistants; clinicians with research training; and experts in research methodology; with three judges in each category. Results: The level of understanding inside the three groups of judges was similar for their overall cess of scientific quality and for six of the ix other items. With four exceptions, agreement among judges within each group and across groups, as measured past the intraclass correlation coefficient (ICC), was greater than 0.5, and threescore% (24/40) of the ICCs were greater than 0.7. Conclusions: It was possible to reach reasonable to excellent agreement for all of the items in the index, including the overall assessment of scientific quality. The implications of these results for practising clinicians and the peer review organisation are discussed.

  • Shazzid Yusuf Shazzid Yusuf
  • Richard Peto
  • John Lewis
  • Peter Sleight

Long-term beta blockade for perchance a year or so following discharge after an MI is now of proven value, and for many such patients mortality reductions of about 25% can be achieved. No important differences are clearly credible amidst the benefits of unlike beta blockers, although some are more than user-friendly than others (or have slightly fewer side furnishings), and it appears that those with appreciable intrinsic sympathomimetic activeness may confer less do good. If monitored, the side effects of long-term therapy are non a major problem, as when they occur they are easily reversible past changing the beta blocker or past discontinuation of treatment. By contrast, although very early Four brusk-term beta occludent can definitely limit infarct size, more reliable information about the effects of such treatment on mortality will not be available until a large trial (ISIS) reports later this year, with information on some thousands of patients entered within less than 4 hours of the onset of pain. Our aim has been not merely to review the 65-odd randomized beta blocker trials but also to demonstrate that when many randomized trials have all applied one general approach to treatment, it is often non advisable to base inference on individual trial results. Although in that location will normally exist important differences from one trial to another (in eligibility, treatment, end-point assessment, so on), physicians who wish to decide whether to adopt a detail treatment policy should try to make their determination in the light of an overview of all these related randomized trials and non just a few item trial results. Although most trials are too pocket-sized to be individually reliable, this defect of size may be rectified by an overview of many trials, equally long as appropriate statistical methods are used. Fortunately, robust statistical methods exist--based on direct, unweighted summation of ane O-East value from each trial--that are elementary for physicians to employ and understand yet provide full statistical sensitivity. These methods allow combination of information from different trials while avoiding the unjustified directly comparing of patients in one trial with patients in another. (Moreover, they tin be extended of such information that there is no existent need for the introduction of any more complex statistical methods that might exist more difficult for physicians to trust.) Their robustness, sensitivity, and avoidance of unnecessary complication brand these particular methods an important tool in trial overviews.