Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Systematic Reviews: Synthesis of Best Evidence for Clinical Decisions Measures of Reliability in Sports Medicine and Science Effectiveness of exercise interventions on physical function in community-dwelling frail older people: an umbrella review of systematic reviews Effect of vitamin D supplementation on inflammation: protocol for a systematic review Resting blood pressure reductions following isometric handgrip exercise training and the impact of age and sex: protocol for a systematic review Systematic strength training as a model of therapeutic intervention. A controlled trial in postmenopausal women with osteopenia. All in the Family: systematic reviews, rapid reviews, scoping reviews, realist reviews, and more Balancing the strengths of systematic and narrative reviews. Determinants of weight loss maintenance: a systematic review. Nonpharmacological interventions to prevent type 2 diabetes in women diagnosed with gestational diabetes mellitus: a systematic overview Rehabilitation in rheumatoid arthritis: a critical review. An international registry of systematic-review protocols Dietetic guidelines: diet in secondary prevention of cardiovascular disease. Effect of dietary interventions in mild cognitive impairment: a systematic review. The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature Enhancing the usability of systematic reviews by improving the consideration and description of interventions The immediate and long-term effects of exercise and patient education on physical, functional, and quality-of-life outcome measures after single-level lumbar microdiscectomy: a randomized controlled trial protocol Wasted research when systematic reviews fail to provide a complete and up-to-date evidence synthesis: the example of lung cancer Room for improvement? A survey of the methods used in systematic reviews of adverse effects Research gaps identified during systematic reviews of clinical trials: glass-ionomer cements The effects of a systematically developed photo-novella on knowledge, attitudes, communication and behavioural intentions with respect to sexually transmitted infections among secondary school learners in South Africa. Assessing the complexity of interventions within systematic reviews: development, content and use of a new tool (iCAT_SR) Paediatrician's responses to an evidence summary about renal tract imaging tests in children after urinary tract infection The effects on knowledge of the systematic education of patients with joint diseases treated with NSAIDs and diuretics. Ascertainment of cause-specific mortality in COPD: operations of the TORCH Clinical Endpoint Committee Systematic Reviews of Diagnostic Test Accuracy UK clinical guideline for the prevention and treatment of osteoporosis Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review. Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Overview of Systematic Reviews: Yoga as a Therapeutic Intervention for Adults with Acute and Chronic Health Conditions Use of upper limb exercise to assess breathlessness in patients with cancer: tolerability, repeatability, and sensitivity. The Effectiveness of Exercise Interventions for the Management of Frailty: A Systematic Review Efficiency and Contribution of Strategies for Finding Randomized Controlled Trials: A Case Study from a Systematic Review on Therapeutic Interventions of Chronic Depression Knowledge Translation in Family Nursing The clinical effectiveness of different parenting programmes for children with conduct problems: a systematic review of randomised controlled trials Foot orthoses for adults with flexible pes planus: a systematic review
BACKGROUND Multiple sclerosis ( MS ) is a major cause of chronic , neurological disability , with a significant long-term disability burden , often requiring comprehensive rehabilitation . OBJECTIVES To systematic ally evaluate evidence from published Cochrane Review s of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS ( pwMS ) , to improve patient outcomes , and to highlight current gaps in knowledge . METHODS We search ed the Cochrane Data base of Systematic Review s up to December 2017 , to identify Cochrane Review s that assessed the effectiveness of organised rehabilitation interventions for pwMS . Two review ers independently assessed the quality of included review s , using the Revised Assessment of Multiple Systematic Review s ( R-AMSTAR ) tool , and the quality of the evidence for reported outcomes , using the GRADE framework . MAIN RESULTS Overall , we included 15 review s published in the Cochrane Library , comprising 164 r and omised controlled trials ( RCTs ) and four controlled clinical trials , with a total of 10,396 participants . The included review s evaluated a wide range of rehabilitation interventions , including : physical activity and exercise therapy , hyperbaric oxygen therapy ( HBOT ) , whole-body vibration , occupational therapy , cognitive and psychological interventions , nutritional and dietary supplements , vocational rehabilitation , information provision , telerehabilitation , and interventions for the management of spasticity . We assessed all review s to be of high to moderate method ological quality , based on R-AMSTAR criteria .Moderate- quality evidence suggested that physical therapeutic modalities ( exercise and physical activities ) improved functional outcomes ( mobility , muscular strength ) , reduced impairment ( fatigue ) , and improved participation ( quality of life ) . Moderate- quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation , and interventions that provided information improved patient knowledge . Low-qualitty evidence suggested that neuropsychological interventions , symptom-management programmes ( spasticity ) , whole body vibration , and telerehabilitation improved some patient outcomes . Evidence for other rehabilitation modalities was inconclusive , due to lack of robust studies . AUTHORS ' CONCLUSIONS The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit , although the certainty of evidence varies across the different types of interventions evaluated by the review s. Structured , multidisciplinary rehabilitation programmes and physical therapy ( exercise or physical activities ) can improve functional outcomes ( mobility , muscle strength , aerobic capacity ) , and quality of life . Overall , the evidence for many rehabilitation interventions should be interpreted cautiously , as the majority of included review s did not include data from current studies . More studies , with appropriate design , which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge At the end of a long week in the office , you sink back into your chair , reflecting on some of the more memorable patients you cared for and counseled . Through gentle history taking , you discovered that urinary incontinence is the underlying cause of an elderly patient 's increasing social isolation . During a careful physical examination , you detected bruising on the torso of a woman with chronic headaches and began to explore the longst and ing abusive relationship between the woman and her alcoholic partner . You discontinued procainamide therapy in a 72-year-old man who had asymptomatic premature ventricular contractions after myocardial infa rct ion . To prevent bleeding from esophageal varices , you started -blocker therapy in a woman with long-st and ing cryptogenic cirrhosis and portal hypertension . In couples ' therapy , discussing the future quality of life of a middle-aged gay man with human immunodeficiency virus infection , you journeyed through emotionally intense dialogue about advance directives . You presented the risk factors for major and minor bleeding to a 39-year-old woman who was considering warfarin therapy because of recently diagnosed atrial fibrillation and valvular heart disease . You listened to , made diagnoses for , treated , advised , and comforted many patients . Yet there were some hiccoughs in your practice along the way . You stumbled while debating the pros and cons of breast cancer screening with a healthy 48-year-old woman who has been staying current with information on the Internet . You question ed the merits of a personalized walking program suggested to you by a motivated 66-year-old man with severe claudication . Explaining that you wanted to review the best current evidence on these issues , you resolved to address your uncertainties before these patients made their next office visits , in a week 's time . Sighing deeply , you acknowledge that you have little time to read . You subscribe to three journals , which you browse months after they arrive-either when your journal stack becomes precariously high or when your guilt is sufficiently motivational . You sometimes find the conclusions of individual articles conflicting or confusing . You know that some of the decisions and suggestions you made this week , specifically your decisions about stopping procainamide therapy and starting -blocker therapy and your advice about bleeding risks from anticoagulant therapy , were based on the best current research evidence [ 1 - 3 ] . On the other h and , your patients ' inquiries about breast cancer screening and exercise treatment for claudication highlight your need for a concise , current , rigorous synthesis of the best available evidence on each of these topics : in brief , a systematic review [ 4 , 5 ] . Incorporating Research Evidence into Clinical Decision Making The foregoing scenario is familiar to practitioners . In a typical week , we encounter patients with diverse problems ; exercise numerous clinical , interpersonal , and technical skills ; and make many decisions . The factors that affect these decisions and their outcomes are complex . For instance , each patient has unique sociodemographic characteristics , cultural circumstances , and personal preferences . Each physician has unique knowledge , experiences , and values . Moreover , practitioners and their patients make decisions within the context of a rapidly changing health care system that influences the availability , accessibility , and cost of diagnostic tests and therapies [ 6 ] . Timely , useful evidence from the biomedical literature should be an integral component of clinical decision making . If one treatment has been shown to be better than another , we need to know , so that we can recommend the treatment to the appropriate patients . The worldwide effort to develop new tests and treatments , and to determine their usefulness , has never been stronger , and our patients and their families expect us to be fonts of the knowledge that results from this effort [ 7 ] . Unfortunately , it is easy for current best research evidence to pass us by [ 8 ] . We may lack the time , motivation , and basic skills needed to find , critically appraise , and synthesize information , all of which we must do if we are to integrate the results of original studies into our practice . Fortunately , several potent methods are emerging that can greatly enhance our ability to interpret and apply research evidence ; foremost among them is the systematic review . This article begins a series in Annals that will examine systematic review s in detail and explore their many applications . Systematic review s represent the best chance that most practitioners will have to underst and and accurately apply the key signals arising from the robust and increasingly productive search for solutions to medical problems . A properly conducted systematic review faithfully summarizes the evidence from all relevant studies on the topic of interest , and it does so concisely and transparently . What Is a Systematic Review ? Systematic review s are scientific investigations in themselves , with pre-planned methods and an assembly of original studies as their subjects . They synthesize the results of multiple primary investigations by using strategies that limit bias and r and om error [ 9 , 10 ] . These strategies include a comprehensive search of all potentially relevant articles and the use of explicit , reproducible criteria in the selection of articles for review . Primary research design s and study characteristics are appraised , data are synthesized , and results are interpreted . When the results of primary studies are summarized but not statistically combined , the review may be called a qualitative systematic review . A quantitative systematic review , or meta- analysis , is a systematic review that uses statistical methods to combine the results of two or more studies . The term overview is sometimes used to denote a systematic review , whether quantitative or qualitative . Summaries of research that lack explicit descriptions of systematic methods are often called narrative review s. Review articles are one type of integrative publication ; practice guidelines , economic evaluations , and clinical decision analyses are others . These other types of integrative articles often incorporate the results of systematic review s. For example , practice guidelines are systematic ally developed statements intended to assist practitioners and patients with decisions about appropriate health care for specific clinical circumstances [ 11 ] . Evidence -based practice guidelines are based on systematic review s of the literature , appropriately adapted to local circumstances and values . Economic evaluations compare both the costs and the consequences of different courses of action ; the knowledge of consequences that are considered in these evaluations is often generated by systematic review s of primary studies . Decision analyses quantify both the likelihood and the valuation of the expected outcomes associated with competing alternatives . Differences between Systematic and Narrative Review s All review s , narrative and systematic alike , are retrospective , observational research studies and are therefore subject to systematic and r and om error . Accordingly , the quality of a review - and thus its worth-depends on the extent to which scientific review methods have been used to minimize error and bias . This is the key feature that distinguishes traditional narrative review s from systematic review s ( Table 1 ) . If a review is prepared according to the steps outlined in the right column of Table 1 , it is more likely to be systematic and to provide unbiased conclusions . If review methods approximate those found in the middle column of Table 1 , the article is more likely to be a narrative review , and the conclusions are less likely to be based on an unbiased summary of all relevant evidence . Table 1 . Differences between Narrative Review s and Systematic Review s Systematic review s are generated to answer specific , often narrow , clinical questions in depth . These questions can be formulated explicitly according to four variables : a specific population and setting ( such as elderly out patients ) , the condition of interest ( for example , hypertension ) , an exposure to a test or treatment ( such as pharmacologic management ) , and one or more specific outcomes ( such as cardiovascular and cerebrovascular events and mortality ) [ 12 ] . Thus , an example of a well-formulated , clinical ly relevant question is , Does pharmacologic treatment of hypertension in the elderly prevent strokes and myocardial infa rct ions or delay death ? If the question that is driving the review is not clear from the title , abstract , or introduction , or if no methods section is included , the paper is more likely to be a narrative review than a systematic review [ 13 ] . Most narrative review articles deal with a broad range of issues related to a given topic rather than addressing a particular issue in depth [ 9 ] . For example , a narrative review on diabetes ( such as that which might be found in a textbook chapter ) might include sections on the physiology and pathophysiology of carbohydrate , lipid , and protein metabolism ; the epidemiology of and prognosis associated with diabetes ; diagnostic and screening approaches ; and preventive , therapeutic , rehabilitative , and palliative interventions . Thus , narrative review s may be most useful for obtaining a broad perspective on a topic ; they are less often useful in furnishing quantitative answers to specific clinical questions . Narrative review s are appropriate for describing the history or development of a problem and its management . Narrative review s may better describe cutting-edge developments if research is scant or preliminary or if studies are very limited by flawed design or execution [ 13 ] . They may be particularly useful for discussing data in light of underlying theory and context . Narrative review s can draw analogies and can conceptually integrate two independent fields of research , such as Abstract Reliability refers to the reproducibility of values of a test , assay or other measurement in repeated trials on the same individuals . Better reliability implies better precision of single measurements and better tracking of changes in measurements in research or practical setting s. The main measures of reliability are within-subject r and om variation , systematic change in the mean , and retest correlation . A simple , adaptable form of within-subject variation is the typical ( st and ard ) error of measurement : the st and ard deviation of an individual ’s repeated measurements . For many measurements in sports medicine and science , the typical error is best expressed as a coefficient of variation ( percentage of the mean ) . A biased , more limited form of within-subject variation is the limits of agreement : the 95 % likely range of change of an individual ’s measurements between 2 trials . Systematic changes in the mean of a measure between consecutive trials represent such effects as learning , motivation or fatigue ; these changes need to be eliminated from estimates of within-subject variation . Retest correlation is difficult to interpret , mainly because its value is sensitive to the heterogeneity of the sample of participants . Uses of reliability include decision-making when monitoring individuals , comparison of tests or equipment , estimation of sample size in experiments and estimation of the magnitude of individual differences in the response to a treatment . Reasonable precision for estimates of reliability requires approximately 50 study participants and at least 3 trials . Studies aim ed at assessing variation in reliability between tests or equipment require complex design s and analyses that research ers seldom perform correctly . A wider underst and ing of reliability and adoption of the typical error as the st and ard measure of reliability would improve the assessment of tests and equipment in our disciplines Objectives : This umbrella review aim ed to determine the effectiveness of exercise interventions , alone or in combination with other interventions , in improving physical function in community-dwelling older people identified as pre-frail or frail . Introduction : Exercise is said to have a positive impact on muscle mass and strength which improves physical function and hence is beneficial for the treatment of frailty . Several systematic review s discuss the effects of exercise interventions on physical function parameters , such as strength , mobility , gait , balance and physical performance , and indicate that multi-component exercise , including resistance , aerobic , balance and flexibility training , appears to be the best way in which to improve physical function parameters in frail older people . However , there is still uncertainty as to which exercise characteristics ( type , frequency , intensity , duration and combinations ) are the most effective and sustainable over the long-term . Inclusion criteria : Participants were adults , 60 years or over , living in the community and identified as pre-frail or frail . Quantitative systematic review s , with or without meta- analysis that examined the effectiveness of exercise interventions of any form , duration , frequency and intensity , alone or in combination with other interventions design ed to alter physical function parameters in frail older people , were considered . The quantitative outcome measures were physical function , including muscular strength , gait , balance , mobility and physical performance . Methods : An iterative search strategy for ten bibliometric data bases and gray literature was developed . Critical appraisal of seven systematic review s was conducted independently by two review ers using a st and ard Joanna Briggs Institute tool . Data was extracted independently by two review ers using a st and ard Joanna Briggs Institute data extraction tool and summarized using a narrative synthesis approach . Results : Seven systematic review s were included in this umbrella review , with a total of 58 relevant r and omized controlled trials and 6927 participants . Five systematic review s examined the effects of exercise only , while two systematic review s reported on exercise in combination with a nutritional approach , including protein supplementations , as well as fruit and dairy products . The average  exercise frequency was 2–3 times per week ( mean 3.0 ± 1.5 times per week ; range 1–7 weekly ) for 10–90 minutes per session ( mean of 52.0 ± 16.5 mins ) and a total duration of 5–72 weeks with the majority lasting a minimum of 2.5 months ( mean 22.7 ± 17.7 weeks ) . Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength , gait speed , balance and physical performance , including resistance , aerobic , balance and flexibility tasks . Resistance training alone also appeared to be beneficial , in particular for improving muscular strength , gait speed and physical performance . Other types of exercise were not sufficiently studied and their effectiveness is yet to be established . Conclusions : Interventions for pre-frail and frail older adults should include multi-component exercises , including in particular resistance training , as well as aerobic , balance and flexibility tasks . Future research should adopt a consistent definition of frailty and investigate the effects of other types of exercise alone or in combination with nutritional interventions so that more specific recommendations can be made Introduction The extraskeletal role of vitamin D is being increasingly recognised . This has important clinical implication s , as vitamin D deficiency has reached epidemic proportions worldwide . Vitamin D has proposed anti-inflammatory properties , yet the role of vitamin D supplementation in reducing inflammation remains largely unknown . The purpose of this review is to investigate the impact of vitamin D supplementation on inflammation , and to identify relevant knowledge gaps in the field . Methods and analysis Medline , CINAHL , EMBASE and All EBM will be systematic ally search ed for r and omised controlled trials ( RCTs ) and systematic review s of RCTs , comparing vitamin D supplementation with placebo , usual care or other pharmacological or non-pharmacological interventions . One review er will assess articles for eligibility according to prespecified selection criteria , after which 2 independent review ers will perform data extraction and quality appraisal . Meta-analyses will be conducted where appropriate . Ethics and dissemination Formal ethical approval is not required as no primary data is collected . This systematic review will identify potential clinical implication s of vitamin D deficiency and supplementation , and will be disseminated through a peer- review ed publication and at conference meetings , to inform future research on the efficacy of vitamin D supplementation for inflammation and inflammatory diseases . PROSPERO registration number CRD42016037104 Background The risk of developing cardiovascular disease is directly correlated to one ’s resting blood pressure ( BP ) , age , and biological sex . Resting BP can be reduced using h and grip exercise training , but the impact of age and sex on the effectiveness of training is not well documented . Methods / design A systematic search of the literature will be conducted for all experimental studies ( including r and omized controlled trials and prospect i ve experiments ) that report the influence of isometric h and grip exercise training on resting systolic blood pressure . The data bases Medline , Embase , Cochrane Review s , Cumulative Index to Nursing and Allied Health Literature ( CINAHL ) , SPORTD iscus , Web of Science , Allied and Complementary Medicine ( AMED ) , PubMed , and Scopus will be search ed until 1 December 2015 . Screening of potential articles , data abstract ion , and quality appraisal will be completed in duplicate independently . When necessary , corresponding authors will be contacted in order to facilitate the separation of pooled data into age and sex categories . Method ological quality will be determined using the Quality Assessment Framework developed by the Cochrane Collaboration and the Newcastle-Ottawa Quality Assessment Scale as appropriate . Any discrepancies will be resolved by a third author . Findings will be presented in accordance with the preferred reporting items for systematic review s and meta- analysis ( PRISMA ) guidelines . Discussion This systematic review will determine the overall effectiveness  of h and grip exercise training in improving resting blood pressure . A novel , focused assessment will contrast  effectiveness of h and grip training  based on the age ( younger 18–54 years , older > 55 years ) and the sex ( men , women ) of study participants . This information is essential to consoli date before moving forward with the development and implementation of h and grip exercise training programmes which are design ed to best meet the needs of particular cohorts . Systematic review registration PROSPERO Physical exercise is often recommended as a therapeutic tool to combat pre- and postmenopausal loss of bone density . However , the relationship between training dosage ( intensity , duration , frequency ) and the effect on bone density still is undergoing discussion . Furthermore , the exercise quantification programs are often described so inadequately that they are neither quantitatively nor qualitatively reproducible . The aim of this investigation was to determine whether a clearly defined training of muscle strength , under defined safety aspects , performed only twice weekly , can counteract bone density loss in women with postmenopausal osteopenia . Data from 16 women in the training group ( age , 63.6 + /- 6.2 yr ) and 15 women in the control group ( age , 67.4 + /-9.7 yr ) , of comparable height and weight , were evaluated .  Strength training was performed for 6 mo as continually adapted strength training , providing an intensity of about 70 % of each test person 's one repetition maximum . Bone mineral density of lumbar vertebrae 2 to 4 and the femoral neck was measured by dual-energy x-ray absorptiometry . Maximum performance in watts and parameters of hemodynamics were controlled with a bicycle ergometer test to maximal effort . In addition , metabolic data were assessed . In the lumbar spine and femoral neck , the training group showed no significant changes , whereas the control group demonstrated a significant loss of bone mineral density , especially in the femoral neck ( P<0.05 ) . The strength increase was highly significant in all exercised muscle groups , rising to about 70 % above the pretraining status ( P<0.001 ) . Heart rate and blood pressure data indicated a slight economization , metabolism was not significantly influenced . Based on these findings , we conclude that continually adapted strength training is an effective , safe , reproducible , and adaptable method of therapeutic strength training , following only two exercise sessions per week Three years ago , we founded this journal focusing on publishing systematic review s , systematic review protocol s , and associated method ological development papers . Systematic review s , which developed in the social sciences in the 1970s , began to gain rapid momentum during the 1990s in response to concerns by policymakers and clinicians about the scientific validity of the prevailing paradigm of traditional narrative review s written by authoritative experts . What distinguished systematic review s was the use of formal explicit methods , in other words pre-specification , of what exactly was the question to be answered , how evidence was search ed for and assessed , and how it was synthesized in order to reach the conclusion . Importantly , these formal methods were described as part of the review itself in a Methods section . In turn , these methods themselves became the subject of hypothesis-testing studies , as investigators sought how best to search for evidence , assess studies for quality or risk of bias , determine under what conditions meta- analysis was justified , and how to best determine and characterize our confidence in the conclusions . The results of these hypothesis-testing studies led over time to improvements in the methods we use for systematic review s. Thus , systematic review s and this journal are part of an ever-evolving process whose foundations are rooted in the scientific method . Today , new forms of review s are appearing . These have emerged in response to policymakers and other stakeholders ’ needs for information , sometimes emergently or urgently , for which the existing systematic review model does not quite fit . Hence , the rapid review , when time is of the essence ; the scoping review , when what is needed is not detailed answers to specific questions but rather an overview of a broad field ; the evidence map , a cousin of scoping review s that commonly has a specific visual presentation of the evidence across a broad field ; and the realist review , where the question of interest includes how and why complex social interventions work in certain situations , rather than assume they either do or do not work at all . As Editors , we regularly get contacted by prospect i ve authors asking whether realist review s , or scoping review s , etc . , are “ within the scope ” for Systematic Review s , and therefore we judge it an opportune time to state our position on this matter . It is our view that all of these new forms of review s are related to systematic review s , similar to the way that different biological Species within the same Family are related to each other . We consider “ systematic review s ” to be the Family and the different forms of review s to be the different species . Just as in the biological classification , where the related organisms must share certain characteristics , so too must the different types of review s share a common characteristic . In this case , what is shared is their foundation in the scientific method , with their methods articulated in advance in sufficient detail that the review can be reproduced by others . A further defining feature is that there are scholars devoted to improving the methods over time via hypothesis-testing studies . Systematic Review s has responded to these emerging techniques and already publishes papers reporting methods and findings from the systematic review family and has for example published an extremely popular series on rapid review s. We would like to consoli date this position and invite su bmi ssion of these new species of review s , as long as they meet the qualifications just listed . We expect this process of evolution to continue and to refine the methods such that in 10 years ’ time , there will appear new , as yet unimagined species of review s— and perhaps some current species of review will become extinct . Thus , it is with the scientific method , which we believe is the foundation that unites the Family of systematic review The m and ate of Human Reproduction Up date involves several roles : ( i ) to provide a synthesis of evidence that can aid scientists and clinicians in their daily work ; ( ii ) to help reproductive specialists underst and concepts from related disciplines ; and ( iii ) to summarize current knowledge generated by basic science as the foundation of future scientific and clinical advancement . Given that review and synthesis are central to good scientific and clinical practice , and that a grasp of the current state of knowledge is a prerequisite to design ing new studies , it is pertinent to ask which review s are most likely to fulfil the needs of readers . A related question concerns whether systematic review s meet the needs of all review topics and all readers . Summarizing evidence or knowledge is a difficult problem in reproductive medicine , as in other branches of science and medical care ( Eddy et al. , 1992 ) . For each question there may be multiple studies that use different design s and inclusion criteria . For clinical questions , the interventions , outcomes and measures of effect may vary : the effect measures in treatment studies include odds ratios , relative risks and absolute differences . For scientific questions , the experimental species , models and design s may differ . Moreover , it is always uncertain whether all of the relevant evidence has been evaluated . Even when the search has been exhaustive , there are no simple guides on how to interpret conflicting results and whether to accept apparently outlying studies . The choices that the review er makes to address the variable conditions and uncertainties may be conservative , strict and exclusive , or liberal , open and inclusive . The decisions made by the review er may not be consistent throughout and these choices may or may not satisfy the reader who seeks out the review to address a clinical or research question . Faced with uncertainty and doubt , readers nonetheless must form an impression of the evidence and synthesize the state of knowledge in order to address the clinical or research question that stimulated their interest in the review . We argue that the reader is better served when the choices made in the review , regardless of whether they are strict or open , should be explicit , transparent , clearly stated and reproducible by interested readers . This list of objectives for review s is more easily satisfied by systematic review s , which use explicit methods to method ically search , critically appraise and synthesize the available literature on a specific issue . The question or issue need not be clinical : indeed , the concept evolved primarily in psychology studies ( Light and Pillemer , 1984 ) . The systematic review attempts to reduce review er bias through the use of objective , reproducible criteria to select relevant individual publications and assess their validity . A systematic review may include a meta- analysis or statistical summary of the individual study results : the aggregate of effects from several studies yields an average treatment effect that is more precise than the individual study results ( Schlesselman and Collins , 2003 ) . Thus , the systematic review involves explicit , transparent methods which are clearly stated , and reproducible by others . Whether a systematic review of r and omized controlled trials adheres to the guidelines can easily be evaluated by means of a widely used checklist ( the QUORUM statement ) ( Moher et al. , 1999 ) . The strengths of the systematic review include the narrow focus of the question , the comprehensive search for evidence , the criterion-based selection of relevant evidence , the rigorous appraisal of validity , the objective or quantitative summary , and the evidence -based inferences ( Cook et al. , 1997 ) . For some review topics , however , the strengths of the systematic review may turn into weaknesses . The primary problem is that the narrow focus and prescribed methods of the systematic review do not allow for comprehensive coverage . For example , the historical review is an irreplaceable means of tracing the development of a scientific principle or clinical concept , but the narrative thread could be lost in the strict rules of systematic review . As other examples , it would be burdensome to apply systematic methods to a survey on  aneuploidy and fertility in the aging female or to an assessment of mouse knockout models and polycystic ovarian phenotype . Such topics would require the wider scope of a traditional narrative review , in Human Reproduction Up date , Vol.11 , No.2 pp . 103–104 , 2005 doi:10.1093/humupd/dmh058 Advance Access publication December 23 , BACKGROUND Discerning the determinants of weight loss maintenance is important in the planning of future interventions and policies regarding overweight and obesity . We have therefore systematic ally synthesized recent literature on determinants of weight loss maintenance for individuals with overweight and obesity . METHODS With the use of the Preferred Reporting Items for Systematic Review s and Meta-Analyses statement , prospect i ve studies were identified from search es in PubMed and PsycINFO from 2006 to 2016 . We included articles investigating adults with overweight and obesity undergoing weight loss without surgery or medication .  Included articles were scored on their method ological quality , and a best- evidence synthesis was applied to summarize the results . RESULTS Our search result ed in 8,222 articles of which 67 articles were selected . In total , 124 determinants were identified of which 5 were demographic , 59 were behavioural , 51 were psychological/cognitive and 9 were social and physical environmental determinants . We found consistent evidence that demographic determinants were not predictive of weight loss maintenance . Behavioural and cognitive determinants that promote a reduction in energy intake , an increase in energy expenditure and monitoring of this balance are predictive determinants . CONCLUSION This review identifies key determinants in weight loss maintenance . However , more research regarding cognitive and environmental determinants of weight loss maintenance is needed to advance our knowledge on determinants of weight loss maintenance This systematic overview summarizes the relevant evidence from multiple systematic review s of the benefits of nonpharmacological interventions for preventing  type 2 diabetes mellitus ( T2MD ) in women diagnosed with gestational diabetes mellitus ( GDM ) . A comprehensive search using the Cochrane Library , CINAHL , EMBASE and MEDLINE via Ovid SP , and PubMed data bases was completed on 18 November 2015 . Any systematic review s that evaluated r and omized controlled trials ( RCTs ) with defined nonpharmacological interventions for preventing T2DM in women diagnosed with GDM were eligible for inclusion . The authors independently performed critical appraisal s and quality assessment s of the included review s using the AMSTAR tool , and extracted data were converted to coherent values for tabular summarization . Six eligible review s of diet and /or exercise , breastfeeding , and reminder interventions were identified ; however , the method ologies of the review s varied greatly , and the majority of the evidence suggested unclear bias . We found inconsistent reporting on the rates at which diet and exercise interventions reduced the risk of T2DM progression , but these interventions were found to be effective at reducing glycemic load . Combined diet , exercise , and breastfeeding interventions proved to be effective at returning women to their postpartum weight . Neither diet alone nor exercise alone proved to be effective at lowering the risk of T2DM . Overall , there was no robust evidence to support the hypothesis that nonpharmacological interventions are effective at lowering the risk of T2DM in women diagnosed with GDM , and there was no consistent evidence showing that these interventions improved the predictor outcomes of T2DM , such as glycemic load or anthropometric changes This article considers the evidence for effectiveness and timing of rehabilitation  for people with rheumatoid arthritis ( RA ) . The Cochrane Library , DARE , Medline , Embase , CINAHL and AMED were search ed to identify systematic review s and r and omized controlled trials evaluating rehabilitation interventions for people with rheumatoid arthritis . Many trials identified had method ological limitations ( e.g. short follow-up periods , small sample sizes ) . Evidence to date is that symptomatic relief results from thermotherapy , laser therapy , acupuncture and assistive devices . In the short-term , comprehensive occupational therapy ( in established rheumatoid arthritis ) , orthoses , and mind-body approaches can help maintain function . Over at least a one-year period , the following are effective in reducing pain and maintaining function :  patient education and joint protection training using behavioural approaches ; dynamic exercise therapy , h and exercises and hydrotherapy ; and cognitive-behavioural therapy ( in people with poorer psychological status ) . Many trials have recruited people with moderate to severe , established RA and relatively little is known about the long-term effectiveness of early rehabilitation , although this is becoming much more common in practice . Despite the increased availability of guidelines and systematic review s , most conclude there is insufficient evidence for many areas of rheumatology rehabilitation . Further well- design ed clinical trials are needed recruiting people with early disease using patient-centred outcomes Support for prospect i ve registration of protocol s for systematic review s has been gathering momentum . The PRISMA statement , a guideline for reporting systematic review s and meta-analyses of studies that evaluate health-care interventions , advocates registration . Well-conducted systematic review s are accepted as the best- quality evidence to inform policy and practice , and the dramatic upward trend in the number of systematic review s published annually ( fi gure ) is set to continue . However , there is currently no single facility for identifying this type of research in advance of the appearance of the results of the review . There is concern about and evidence of publication and selective outcome -reporting biases associated with systematic review s. An open registry of review s captured at the protocol stage would facilitate good practice in systematic review s by providing transparency of the review process and outcomes . Discrepancies between the methods of the published review and those planned in the registered protocol could be more readily identifi ed . Registration might also encourage full publication of the review ’s fi ndings and transparency in changes to methods that could bias fi ndings . In both the prevention and revelation of potential bias , registration should improve quality and increase confi dence that policy or practice informed by the fi ndings of systematic review s are indeed drawing on best- quality evidence . A registry of protocol s of systematic review s could assist those planning new review s and updating existing ones . Easy access to information about ongoing review s should help to optimise the use of fi nite re sources by enabling funding and commissioning agencies to avoid unnecessary duplication and encourage collaboration . A comprehensive registry could also create opportunities for method ological and other research , both within and across disciplines . Existing access to systematic - review protocol s is limited to the outputs of individual organisations , such as the Cochrane and Campbell Collaborations and the Joanna Briggs Institute . The National Public Health Service for Wales is piloting an All Wales Systematic Review s Register , but , up to now , there has been no central ised comprehensive registry of systematic - review protocol s. We are developing an international facility to register the details of ongoing systematic review s in health and social care . Our registry is being established with the existing platform and infrastructure that supports the Data base of Abstract s of Review s of Eff ects ( DARE ) , the NHS Economic Evaluations Data base ( NHS EED ) and the Health Technology Assessment ( HTA ) data base produced by the Centre for Review s and Dissemination . The initial scope of the registry will be limited to systematic review s of the eff ectiveness of health interventions . However , the longterm aim is for the registry to include details of all ongoing systematic review s with a health-related outcome in the broadest sense . Ultimately , inclusion will encompass systematic review s of health-care interventions , and review s of the social determinants of health , of service delivery , and of risk factors and genetic associations . Our web-based registry will off er free public access , be electronically search able , and open to all prospect i ve registrants . Registration will require the provision of a minimum data set , the completeness of which will be checked automatically before registration . After acceptance , the registry ’s entry and protocol for the review , if available , will be loaded on the data base as a permanent entry and a unique identifi cation number issued . An audit trail for any amendments to the information will be available within the record . Links to result ing publications will be added . These provisions ensure that the registry will match the relevant criteria required of clinical trials registries AIM To produce dietetic guidelines summarizing the systematic review evidence on dietary advice for secondary prevention of cardiovascular disease . METHODS The Cochrane Library , MEDLINE and EMBASE were comprehensively search ed for systematic review s on aspects of diet and heart health . Review s were included if they search ed systematic ally for r and omised controlled trials relating to diet and secondary prevention of cardiovascular disease . Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review . The quality and results of each review were discussed and summarized in a whole group meeting . The guidelines were trialled in seven dietetic departments and modified where necessary . RESULTS Providing evidence -based dietary information ( including increasing omega-3 fat plus fruit and vegetable intake ) to all people after myocardial infa rct ion will save more lives than concentrating dietary advice on those in need of weight loss or lipid lowering . The practice of prioritizing dietetic time to those with raised lipids is out of date since the advent of statin therapy . CONCLUSION There is good systematic review evidence that dietary advice to those with cardiovascular disease can reduce mortality and morbidity as well as modify risk factors .  Dietary advice that does this most effectively should be prioritized Diet has been investigated in relation to its ability to promote cognitive function . However , evidence is currently limited and has rarely been systematic ally review ed , particularly in a mild cognitive impairment ( MCI ) population . This review examined the effect of diet on cognitive outcomes in MCI patients . A total of five data bases were search ed to find r and omised controlled trial ( RCT ) studies , with diet as the main focus , in MCI participants . The primary outcome was incident dementia and /or Alzheimer 's disease ( AD ) and secondary outcomes included cognitive function across different domains using vali date d neuropsychological tests .  Sixteen studies met the inclusion criteria . There was a high degree of heterogeneity relating to the nature of the dietary intervention and cognitive outcomes measured , thus making study comparisons difficult . Supplementation with vitamin E ( one study , n 516 ) , ginkgo biloba ( one study , n 482 ) or Fortasyn Connect ( one study , n 311 ) had no significant effect on progression from MCI to dementia and /or AD . For cognitive function , the findings showed some improvements in performance , particularly in memory , with the most consistent results shown by B vitamins , including  folic acid  ( one study , n 266 ) ,  folic acid alone  ( one study , n 180 ) ,  DHA and EPA  ( two studies , n 36 and n 86 ) ,  DHA  ( one study , n 240 ) and  flavonol supplementation  ( one study , n 90 ) . The findings indicate that dietary factors may have a potential benefit for cognitive function in MCI patients . Further well- design ed trials are needed , with st and ardised and robust measures of cognition to investigate the influence of diet on cognitive status Introduction Currently , no therapeutic intervention is universally accepted , and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined . This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness . Source of data A systematic review of literature according to the PRISMA guidelines was performed . A comprehensive search of PubMed , Medline , CINAHL , Cochrane , Embase , Ovid and Google Scholar data bases using various combinations of the keywords ' shoulder ' ,  ' shoulder stiffness ' ,  ' stiff shoulder ' ,  '  conservative  '  , since inception of data bases to June 2018 was performed . Areas of agreement Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications , corticosteroid injections , or transcutaneous electrical nerve stimulation , manipulation under anaesthesia , and arthroscopic capsular release . Areas of controversy No therapeutic intervention is universally accepted , and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined . Growing points The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group . Areas timely for developing research There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness . Prospect i ve , r and omized studies are needed to establish whether surgical or conservative management produce a clinical ly relevant difference in functional outcome The importance of adequate intervention descriptions in minimising research waste and improving research usability and reproducibility has gained attention in the past few years . Nearly all focus to date has been on intervention reporting in r and omised trials . Yet clinicians are encouraged to use systematic review s , whenever available , rather than single trials to inform their practice . This article explores the problem and implication s of incomplete intervention details during the planning , conduct , and reporting of systematic review s and makes recommendations for review authors , peer review ers , and journal Background Low back pain remains a costly quality -of-life-related health problem . Microdiscectomy is often the surgical procedure of choice for a symptomatic , single-level , lumbar disc herniation in younger and middle-aged adults . The question of whether a post-microdiscectomy exercise program enhances function , quality of life , and disability status has not been systematic ally explored . Thus , the overall purpose of this study is to assess immediate and long-term outcomes of an exercise program , developed at University of Southern California ( USC ) , targeting the trunk and lower extremities ( USC Spine Exercise Program ) for persons who have undergone a single-level microdiscectomy for the first time . Methods / design One hundred individuals between the ages of 18 and 60 who consent to undergo lumbar microdiscectomy will be recruited to participate in this study . Subjects will be r and omly assigned to one of two groups : 1 ) one session of back care education , or 2 ) a back care education session followed by the 12-week USC Spine Exercise Program . The outcome examiners ( evaluators ) , as well as the data managers , will be blinded to group allocation . Education will consist of a one-hour " one-on-one " session with the intervention therapist , guided by an educational booklet specifically design ed for post-microdiscectomy care . This session will occur four to six weeks after surgery . The USC Spine Exercise Program consists of two parts : back extensor strength and endurance , and mat and upright therapeutic exercises . This exercise program is goal -oriented , performance-based , and periodized . It will begin two to three days after the education session , and will occur three times a week for 12 weeks . Primary outcome measures include the Oswestry Disability Question naire , Rol and -Morris Disability Question naire , SF-36 ® quality of life assessment , Subjective Quality of Life Scale , 50-foot Walk , Repeated Sit-to-St and , and a modified Sorensen test . The outcome measures in the study will be assessed before and after the 12-week post-surgical intervention program . Long-term follow up assessment s will occur every six months beginning one year after surgery and ending five years after surgery . Immediate and long-term effects will be assessed using repeated measures multivariate analysis of variance ( MANOVA ) . If significant interactions are found , one-way ANOVAs will be performed followed by post-hoc testing to determine statistically significant pairwise comparisons . Discussion We have presented the rationale and design for a r and omized controlled trial evaluating the effectiveness of a treatment regimen  for people who have undergone a single-level lumbar microdiscectomy Background Multiple treatments are frequently available for a given condition , and clinicians and patients need a comprehensive , up-to- date synthesis of evidence for all competing treatments . We aim ed to quantify the waste of research related to the failure of systematic review s to provide a complete and up-to- date evidence synthesis over time . Methods We performed a series of systematic overviews and networks of r and omized trials assessing the gap between evidence covered by systematic review s and available trials of second-line treatments for advanced non-small cell lung cancer . We search ed the Cochrane Data base of Systematic Review s , Data base of Abstract s of Review s of Effects , MEDLINE , EMBASE , and other re sources sequentially by year from 2009 to March 2 , 2015 . We sequentially compared the amount of evidence missing from systematic review s to the r and omized evidence available for inclusion each year . We constructed cumulative networks of r and omized evidence over time and evaluated the proportion of trials , patients , treatments , and treatment comparisons not covered by systematic review s on December 31 each year from 2009 to 2015 . Results We identified 77 trials ( 28,636 patients ) assessing 47 treatments with 54 comparisons and 29 systematic review s ( 13 published after 2013 ) . From 2009 to 2015 , the evidence covered by existing systematic review s was consistently incomplete : 45 % to 70 % of trials ; 30 % to 58 % of patients ; 40 % to 66 % of treatments ; and 38 % to 71 % of comparisons were missing . In the cumulative networks of r and omized evidence , 10 % to 17 % of treatment comparisons were partially covered by systematic review s and 55 % to 85 % were partially or not covered . Conclusions We illustrate how systematic review s of a given condition provide a fragmented , out-of- date panorama of the evidence for all treatments . This waste of research might be reduced by the development of live cumulative network meta-analyses Background Although the methods for conducting systematic review s of efficacy are well established , there is much less guidance on how systematic review s of adverse effects should be performed . Methods In order to determine where method ological research is most needed to improve systematic review s of adverse effects of health care interventions , we conducted a descriptive analysis of systematic review s published between 1994 and 2005 . We search ed the Data base of Abstract s of Review s of Effects ( DARE ) and The Cochrane Data base of Systematic Review s ( CDSR ) to identify systematic review s in which the primary outcome was an adverse effect or effects . We then extracted data on many of the elements of the systematic review process including : types of interventions studied , adverse effects of interest , re sources search ed , search strategies , data sources included in review s , quality assessment of primary data , nature of the data analysis , and source of funding . Results 256 review s were included in our analysis , of which the majority evaluated drug interventions and pre-specified the adverse effect or effects of interest . A median of 3 re sources were search ed for each review and very few review s ( 13/256 ) provided sufficient information to reproduce their search strategies . Although more than three quarters ( 185/243 ) of the review s sought to include data from sources other than r and omised controlled trials , fewer than half ( 106/256 ) assessed the quality of the studies that were included . Data were pooled quantitatively in most of the review s ( 165/256 ) but heterogeneity was not always considered . Less than half ( 123/256 ) of the review s reported on the source of funding . Conclusion There is an obvious need to improve the methodology and reporting of systematic review s of adverse effects . The methodology around identification and quality assessment of primary data is the main concern Background To report the results of an audit concerning research gaps in clinical trials that were accepted for appraisal in authored and published systematic review s regarding the application of glass-ionomer cements ( GIC ) in dental practice Methods Information concerning research gaps in trial precision was extracted , following a framework that included classification of the research gap reasons : ‘ imprecision of information ( results ) ’ , ‘ biased information ’ , ‘ inconsistency or unknown consistency ’ and ‘ not the right information ’ , as well as research gap characterization using PICOS elements : population ( P ) , intervention ( I ) , comparison ( C ) , outcomes ( O ) and setting ( S ) . Internal trial validity assessment was based on the underst and ing that successful control for systematic error can not be assured on the basis of inclusion of adequate methods alone , but also requires empirical evidence about whether such attempt was successful . Results A comprehensive and interconnected coverage of GIC-related clinical topics was established . The most common reasons found for gaps in trial precision were lack of sufficient trials and lack of sufficient large sample size . Only a few research gaps were ascribed to ‘ Lack of information ’ caused by focus on mainly surrogate trial outcomes . According to the chosen assessment criteria , a lack of adequate r and omisation , allocation concealment and blinding/masking in trials covering all review ed GIC topics was noted ( selection - and detection/performance bias risk ) . Trial results appear to be less affected by loss-to-follow-up ( attrition bias risk ) . Conclusion This audit represents an adjunct of the systematic review articles it has covered . Its results do not change the systematic review ’s conclusions but highlight existing research gaps concerning the precision and internal validity of review ed trials in detail . These gaps should be addressed in future GIC-related clinical research A pre-post test follow-up design was used to test the effects of a systematic ally developed photo-novella ( Laduma ) on knowledge , attitudes , communication and behavioural intentions with respect to sexually transmitted infections , after a single reading by 1168 secondary school learners in South Africa . The reading result ed in an increase in knowledge on the spread of sexually transmitted infections ( STIs ) , change in attitude to condom use and towards people with STIs and /or HIV/AIDS , as well as increased intention to practice safe sex . Laduma did not influence communication about sexually transmitted infections and reported sexual behaviour and condom use . While print media proved to be an effective strategy to reach large numbers of youth and prepare them for adequate preventive behaviours , the study also identified the need to combine print media with other planned theory-based interventions that build confidence and skills to initiate the preventive behaviour Background Health interventions fall along a spectrum from simple to more complex . There is wide interest in methods for review ing ‘ complex interventions ’ , but few transparent approaches for assessing intervention complexity in systematic review s. Such assessment s may assist review authors in , for example , systematic ally describing interventions and developing logic models . This paper describes the development and application of the intervention Complexity Assessment Tool for Systematic Review s ( iCAT_SR ) , a new tool to assess and categorise levels of intervention complexity in systematic review s. Methods We developed the iCAT_SR by adapting and extending an existing complexity assessment tool for r and omized trials . We undertook this adaptation using a consensus approach in which possible complexity dimensions were circulated for feedback to a panel of method ologists with expertise in complex interventions and systematic review s. Based on these inputs , we developed a draft version of the tool . We then invited a second round of feedback from the panel and a wider group of systematic review ers . This informed further refinement of the tool . Results The tool comprises ten dimensions : ( 1 ) the number of active components in the intervention ; ( 2 ) the number of behaviours of recipients to which the intervention is directed ; ( 3 ) the range and number of organizational levels targeted by the intervention ; ( 4 ) the degree of tailoring intended or flexibility permitted across sites or individuals in applying or implementing the intervention ; ( 5 ) the level of skill required by those delivering the intervention ; ( 6 ) the level of skill required by those receiving the intervention ; ( 7 ) the degree of interaction between intervention components ; ( 8) the degree to which the effects of the intervention are context dependent ; ( 9 ) the degree to which the effects of the interventions are changed by recipient or provider factors ; ( 10 ) and the nature of the causal pathway between intervention and outcome . Dimensions 1–6 are considered ‘ core ’ dimensions . Dimensions 7–10 are optional and may not be useful for all interventions . Conclusions The iCAT_SR tool facilitates more in-depth , systematic assessment of the complexity of interventions in systematic review s and can assist in undertaking review s and interpreting review findings . Further testing of the tool is now needed Introduction Renal tract imaging after urinary tract infection ( UTI ) has been widely recommended but clinical practice varies substantially among paediatricians . Aim To describe changes in knowledge and reported ordering practice s of paediatricians in response to an evidence based summary about prevalence of abnormalities and test performance of renal tract imaging , in the setting of UTI in children . Methods 354 paediatricians were r and omly selected from a register of Australasian physicians and surveyed 14 months before , and concurrent with , a summary of a relevant systematic review . Respondents ' estimates were dichotomised and labelled as correct when within 5 % of the evidence -based value . Frequency of correct responses was compared using McNemar 's test for paired proportions . Results Response rate for the return of both surveys was 61 % ( 215/354 ) . Provision of the evidence summary significantly improved knowledge of the frequencies of associated renal tract abnormalities ( vesicoureteric reflux and kidney damage ) , with an increase in correct responses of about 30 % post summary ( p<0.001 for reflux and damage ) . Prior to the summary , clinicians underestimated the sensitivity of all imaging tests for the diagnosis of renal damage and reflux by about 30 % , with an increase in correct responses of 30–50 % for all tests after the summary ( p<0.001 for all ) . In contrast , reported imaging practice s for all tests showed no significant change in practice after receipt of the evidence summary . Conclusions Provision of evidence based information on rates of abnormality and test sensitivity improved knowledge but did not result in any significant change in reported practice . Properties of diagnostic tests conventionally thought to modify use , sensitivity and likelihood of detecting abnormalities , did not influence test ordering practice In a r and omised , controlled trial , patients with joint diseases and concomitant treatment with NSAIDs and diuretics received systematic education . The intervention group was given information by a self-conducted , interactive Kodak Photo-CD program in addition to personal drug information and non-commercial drug leaflets . Awareness of drug interactions and encouragement of self-adjustment of treatment was focused on . Control patients received conventional information . Three months after r and omisation , knowledge was tested by means of a question naire . At 3 months there was a significant difference in attained score between the intervention group and the control group . Greater knowledge was achieved , especially on drug interaction , in the intervention group . In conclusion , less than 1 h of systematic education significantly improved  patients ' knowledge on essential issues of concomitant treatment with NSAIDs and diuretics . Knowledge of effects , side-effects and interactions of drugs is essential for self-adjustment of treatment . The method employed , which is st and ardised and produces a reproducible quantity of education , might be applicable to several other medical conditions Background : TORCH ( Towards a Revolution in COPD Health ) is an international multicentre , r and omised , placebo-controlled clinical trial of inhaled fluticasone propionate/salmeterol combination treatment and its monotherapy components for maintenance treatment of moderately to severely impaired patients with chronic obstructive pulmonary disease ( COPD ) . The primary outcome is all-cause mortality . Cause-specific mortality and deaths related to COPD are additional outcome measures , but systematic methods for ascertainment of these outcomes have not previously been described . Methods : A Clinical Endpoint Committee ( CEC ) was tasked with categorising the cause of death and the relationship of deaths to COPD in a systematic , unbiased and independent manner . The key elements of the operation of the committee were the use of predefined principles of operation and definitions of cause of death and COPD -relatedness ; the independent review of cases by all members with development of a consensus opinion ; and a substantial infrastructure to collect medical information . Results : 911 deaths were review ed and consensus was reached in all . Cause-specific mortality was : cardiovascular 27 % , respiratory 35 % , cancer 21 % , other 10 % and unknown 8 % . 40 % of deaths were definitely or probably related to COPD . Adjudications were identical in 83 % of blindly re-adjudicated cases ( κ = 0.80 ) . COPD -relatedness was reproduced 84 % of the time ( κ = 0.73 ) . The CEC adjudication was equivalent to the primary cause of death recorded by the site investigator in 52 % of cases . Conclusion : A CEC can provide st and ardised , reliable and informative adjudication of COPD mortality that provides information which frequently differs from data collected from assessment by site investigators Diagnosis is a critical component of health care , and clinicians , policymakers , and patients routinely face a range of questions regarding diagnostic tests . They want to know whether testing improves outcome ; what test to use , purchase , or recommend in practice guidelines ; and how to interpret test results . Well- design ed  diagnostic test accuracy studies can help in making these decisions , provided that they transparently and fully report their participants , tests , methods , and results as facilitated , for example , by the STARD ( St and ards for Reporting of Diagnostic Accuracy ) statement ( 1 ) . That 25-item checklist was published in many journals and is now adopted by more than 200 scientific journals worldwide . As in other areas of science , systematic review s and meta- analysis of accuracy studies can be used to obtain more precise estimates when small studies addressing the same test and patients in the same setting are available . Review s can also be useful to establish whether and how scientific findings vary by particular subgroups , and may provide summary estimates with a stronger generalizability than estimates from a single study . Systematic review s may help identify the risk for bias that may be present in the original studies and can be used to address questions that were not directly considered in the primary studies , such as comparisons between tests . The Cochrane Collaboration is the largest international organization preparing , maintaining , and promoting systematic review s to help people make well-informed decisions about health care ( 2 ) . The Collaboration decided in 2003 to make preparations for including systematic review s of diagnostic test accuracy in their Cochrane Data base of Systematic Review s. To enable this , a working group ( Appendix ) . was formed to develop methodology , software , and a h and book The first diagnostic test accuracy review was published in the Cochrane Data base in October 2008 . In this paper , we review recent method ological developments concerning problem formulation , location of literature , quality assessment , and meta- analysis of diagnostic accuracy studies by using our experience from the work on the Cochrane H and book . The information presented here is based on the recent literature and up date s previously published guidelines by Irwig and colleagues ( 3 ) . Definition of the Objectives of the Review Diagnostic test accuracy refers to the ability of a test to distinguish between patients with disease ( or more generally , a specified target condition ) and those without . In a study of test accuracy , the results of the test under evaluation , the index test , are compared with those of the reference st and ard determined in the same patients . The reference st and ard is an agreed-on and accurate method for identifying patients who have the target condition . Test results are typically categorized as positive or negative for the target condition . By using such binary test outcomes , the accuracy is most often expressed as the test 's sensitivity ( the proportion of patients with positive results on the reference st and ard that are also positive on the index test ) and specificity ( the proportion of patients with negative results on the reference st and ard that are also negative on the index test ) . Other measures have been proposed and are in use ( 46 ) . It has long been recognized that test accuracy is not a fixed property of a test . It can vary between patient subgroups , with their spectrum of disease , with the clinical setting , or with the test interpreters and may depend on the results of previous testing . For this reason , inclusion of these elements in the study question is essential . In order to make a policy decision to promote use of a new index test , evidence is required that using the new test increases test accuracy over other testing options , including current practice , or that the new test has equivalent accuracy but offers other advantages ( 79 ) . As with the evaluation of interventions , systematic review s need to include comparative analyses between alternative testing strategies and should not focus solely on evaluating the performance of a test in isolation . In relation to the existing situation , 3 possible roles for a new test can be defined : replacement , triage , and add-on ( 7 ) . If a new test is to replace an existing test , then comparing the accuracy of both tests on the same population and with the same reference st and ard provides the most direct evidence . In triage , the new test is used before the existing test or testing pathway , and only patients with a particular result on the triage test continue the testing pathway . When a test is needed to rule out disease in patients who then need no further testing , a test that gives a minimal proportion of falsenegative results and thus a relatively high sensitivity should be used . Triage tests may be less accurate than existing ones , but they have other advantages , such as simplicity or low cost . A third possible role of a new test is add-on . The new test is then positioned after the existing testing pathway to identify false-positive or false-negative results after the existing pathway . The review should provide data to assess the incremental change in accuracy made by adding the new test . An example of a replacement question can be found in a systematic review of the diagnostic accuracy of urinary markers for primary bladder cancer ( 10 ) . Clinicians may use cytology to triage patients before they undergo invasive cystoscopy  , the reference st and ard for bladder cancer . Because cytology combines high specificity with low sensitivity ( 11 ) , the goal of the review was to identify a tumor marker with sufficient accuracy to either replace cytology or be used in addition to cytology . For a marker to replace cytology , it has to achieve equally high specificity with improved sensitivity . New markers that are sensitive but not specific may have roles as adjuncts to conventional testing . The review included studies in which the test under evaluation ( several different tumor markers and cytology ) was evaluated against cystoscopy or histopathology . Included studies compared 1 or more of the markers , cytology only , or a combination of markers and cytology . Although information on accuracy can help clinicians make decisions about tests , good diagnostic accuracy is a desirable but not sufficient condition for the effectiveness of a test ( 8) . To demonstrate that using a new test does more good than harm to patients tested , r and omized trials of test- and -treatment strategies and review s of such trials may be necessary . However , with the possible exception of screening , in most cases , such r and omized trials are not available and systematic review s of test accuracy may provide the most useful evidence available to guide clinical and health policy decision making and use as input for decision and cost-effectiveness analysis ( 12 ) . Identification and Selection of Studies Identifying test accuracy studies is more difficult than search ing for r and omized trials ( 13 ) . There is not a clear , unequivocal keyword or indexing term for an accuracy study in literature data bases comparable with the term r and omized , controlled trial . The Medical Subject Heading sensitivity and specificity may look suitable but is inconsistently applied in most electronic bibliographic data bases . Furthermore , data on diagnostic test accuracy may be hidden in studies that did not have test accuracy estimation as their primary objective . This complicates the efficient identification of diagnostic test accuracy studies in electronic data bases , such as MEDLINE . Until indexing systems properly code studies of test accuracy , search ing for them will remain challenging and may require additional manual search es , such as screening reference lists . In the development of a comprehensive search strategy , review authors can use search strings that refer to the test(s ) under evaluation , the target condition , and the patient description or a subset of these . For tests with a clear name that are used for a single purpose , search ing for publications in which those tests are mentioned may suffice . For other review s , adding the patient description may be necessary , although this is also often poorly indexed . A search strategy in MEDLINE should contain both Medical Subject Headings and free text words . A search strategy for articles about tests for bladder cancer , for example , should include as many synonyms for bladder cancer as possible in the search strategy , including neoplasm , carcinoma , transitional cell , and hematuria . Several method ological electronic search filters for diagnostic test accuracy studies have been developed , each attempting to restrict the search to articles that are most likely to be test accuracy studies ( 1316 ) . These filters rely on indexing terms for research methodology and text words used in reporting results , but they often miss relevant studies and are unlikely to decrease the number of articles one needs to screen . Therefore , they are not recommended for systematic review s ( 17 , 18 ) . The incremental value of search ing in language s other than English and in the gray literature has not yet been fully investigated . In systematic review s of intervention studies , publication bias is an important and well-studied form of bias in which the decision to report and publish studies is linked to their findings . For clinical trials , the magnitude and determinants of publication bias have been identified by tracing the publication history of cohorts of trials review ed by ethics committees and research boards ( 19 ) . A consistent observation has been that studies with significant results are more likely to be published than studies with nonsignificant findings ( 19 ) . Investigating publication bias for diagnostic tests is problematic , because many studies are done without ethical review or study registration ; therefore , identification of cohorts of studies from registration to final publication status Introduction In 2008 , the UK National Osteoporosis Guideline Group ( NOGG ) produced a guideline on the prevention and treatment of osteoporosis , with an up date in 2013 . This paper presents a major up date of the guideline , the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over . Methods Where available , systematic review s , meta-analyses and r and omised controlled trials were used to provide the evidence base . Conclusions and recommendations were systematic ally grade d according to the strength of the available evidence . Results Review of the evidence and recommendations are provided for the diagnosis of osteoporosis , fracture-risk assessment , lifestyle measures and pharmacological interventions , duration and monitoring of bisphosphonate therapy , glucocorticoid-induced osteoporosis , osteoporosis in men , postfracture care and intervention thresholds . Conclusion The guideline , which has received accreditation from the National Institute of Health and Care Excellence ( NICE ) , provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management PURPOSE We systematic ally review ed r and omized and quasi-r and omized clinical trials in the literature to assess the efficacy of neck stabilization and postural exercises on pain , neck range of motion , and time off work in adults with acute whiplash-associated disorders . METHODS Electronic data bases , reference lists of relevant Cochrane review s , reference lists of studies selected for inclusion , and tables of contents of relevant journals were systematic ally search ed for r and omized and quasi-r and omized controlled trials . Two independent review ers selected studies for inclusion , assessed method ological quality , and extracted data . Because of the heterogeneity of the interventions , a qualitative synthesis was performed using " levels of evidence " as recommended by van Tulder et al. RESULTS Eight studies representing five clinical trials were selected for inclusion . Two trials were grade d as high quality , two as moderate quality , and one as low quality . Many of these studies had mixed results , demonstrating significant differences on some outcome measures but not on others . CONCLUSIONS There is moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders . However , no evidence exists to support the use of postural exercises for increasing neck range of motion . There is conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders Abstract Purpose To evaluate the effectiveness of non-steroidal anti-inflammatory drugs ( NSAIDs ) for the management of neck pain and associated disorders ( NAD ) , whiplash-associated disorders , and non-specific low back pain ( LBP ) with or without radiculopathy . Methods We systematic ally search ed six data bases from 2000 to 2014 . R and om pairs of independent review ers critically appraised eligible systematic review s using the Scottish Intercollegiate Guidelines Network criteria . We included systematic review s with a low risk of bias in our best evidence synthesis . Results We screened 706 citations and 14 systematic review s were eligible for critical appraisal . Eight systematic review s had a low risk of bias . For recent-onset NAD , evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy . For NAD ( duration not specified ) , oral NSAIDs may be more effective than placebo . For recent-onset LBP , evidence suggests that : ( 1 ) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant ; and ( 2 ) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest . For persistent LBP , evidence suggests that : ( 1 ) oral NSAIDs are more effective than placebo ; and ( 2 ) oral NSAIDs may be more effective than acetaminophen . For recent-onset LBP with radiculopathy , there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo . Finally , different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy . Conclusions For NAD , oral NSAIDs may be more effective than placebo . Oral NSAIDs are more effective than placebo for persistent LBP , but not for recent-onset LBP . Different oral NSAIDs lead to similar outcomes for neck pain and LBP Objectives . Overview the quality , direction , and characteristics of yoga interventions for treatment of acute and chronic health conditions in adult population s. Methods . We search ed for systematic review s in 10 online data bases , bibliographic references , and h and - search es in  yoga-related  journals . Included review s satisfy Oxman criteria and specify yoga as a primary intervention in one or more r and omized controlled trials for treatment in adults . The AMSTAR tool and GRADE approach evaluated the method ological quality of review s and quality of evidence . Results . We identified 2202 titles , of which 41 full-text articles were assessed for eligibility and 26 systematic review s satisfied inclusion criteria . Thirteen systematic review s include quantitative data and six papers include meta- analysis . The quality of evidence is generally low . Sixteen different types of health conditions are included . Eleven review s show tendency towards positive effects of yoga intervention , 15 review s report unclear results , and no , review s report adverse effects of yoga . Yoga appears most effective for reducing symptoms in anxiety , depression , and pain . Conclusion . Although the quality of systematic review s is high , the quality of supporting evidence is low . Significant heterogeneity and variability in reporting interventions by type of yoga , setting s , and population characteristics limit the generalizability of results We report the development of an arm exercise test to assess breathlessness in patients with lung cancer who are breathless at low levels of exertion .  Exercise consisted of raising the arm over 40 cm , either the dominant arm only ( n=10 ) or both arms alternating at minute intervals ( n=12 ) . Subjects breathed through a mouthpiece , and ventilation ( VE ) and oxygen uptake ( VO(2 ) ) were measured . Following familiarization , three tests were performed over one week to explore repeatability , and sensitivity was assessed in a fourth test . Arm exercise was generally well tolerated and increased breathlessness , VE , and VO(2 ) . The commonest factor limiting exercise was arm fatigue , although four patients in the two-arm test also reported breathlessness . Repeatability for breathlessness score and VE was best in the two-arm test . The added resistance used to assess sensitivity could not be detected . The two-arm test offers a potential means of assessing the effects of an intervention on breathlessness and E in patients for whom a cycle or treadmill exercise test is unsuitable This systematic review examines the effectiveness of current exercise interventions for the management of frailty . Eight electronic data bases were search ed for r and omized controlled trials that identified their participants as “ frail ” either in the title , abstract , and /or text and included exercise as an independent component of the intervention . Three of the 47 included studies utilized a vali date d definition of frailty to categorize participants . Emerging evidence suggests that exercise  has a positive impact on some physical determinants and on all functional ability outcomes reported in this systematic review . Exercise programs that optimize the health of frail older adults seem to be different from those recommended for healthy older adults . There was a paucity of evidence to characterize the most beneficial exercise program for this population . However , multicomponent training interventions , of long duration ( ≥5 months ) , performed three times per week , for 30–45 minutes per session , generally had superior outcomes than other exercise programs . In conclusion , structured exercise training seems to have a positive impact on frail older adults and may be used for the management of frailty Background Identifying all existing evidence is a crucial aspect in conducting systematic review s. Since the retrieval of electronic data base search es alone is limited , guidelines recommend the use of additional search strategies . The aim of this investigation was to assess the efficiency and contribution of additional search strategies for identifying r and omized controlled trials in conducting a systematic review on interventions after performing a sensitive electronic data base search . Design and Methods Seven electronic data bases , 3 journals and 11 systematic review s were search ed . All first authors of the included studies were contacted ; citation tracking and a search in clinical trial registers were performed . A priori defined evaluation criteria were calculated for each search strategy . Results A total of 358 full-text articles were identified ; 50 studies were included in the systematic review , wherefrom 84.0 % ( 42 ) were acquired by the sensitive electronic data base search and 16.0 % ( 8) through additional search strategies . Screening reference lists of related systematic review s was the most beneficial additional search strategy , with an efficiency of 31.3 % ( 5 ) and a contribution of 10.0 % ( 5/50 ) , whereas h and - search ing and author contacts contributed two and one additional studies , respectively . Citation tracking and search ing clinical trial registers did not lead to any further inclusion of primary studies . Conclusions Based on our findings , h and - search ing contents of relevant journals and screening reference lists of related systematic review s may be helpful additional strategies to identify an extensive body of evidence . In case of limited re sources , a sensitive electronic data base search may constitute an appropriate alternative for identifying relevant trials . Significance for public health Systematic review s provide the strongest form of evidence synthesis for therapeutic interventions and are of high relevance for decision makers in public health . Preparing high quality systematic review s can be very time-consuming since all existing evidence should be identified , but the retrieval of electronic data base search es is limited and therefore additional search strategies are recommended . However , the time needed for conducting full systematic review s does often not address the need for urgent evidence . Thus , priorities of summarizing all available evidence and providing fast evidence -based recommendations may conflict . So far , no consensus exists regarding which additional search strategies are beneficial and sparsely time-consuming for conducting systematic review s. We examined the efficiency and contribution of additional search strategies performed after a sensitive electronic data base search . Our results provide highly relevant information for research ers conducting systematic review s in various fields of public health research and for establishing guidelines for conducting rapid review In an effort to examine translation of family nursing knowledge to practice , the L and spitali University Hospital Family Nursing Implementation Project ( 2007 - 2011 ) , was thoughtfully initiated in Reykjavik , Icel and and systematic ally evaluated . The mission was to implement family nursing in every department of the hospital . This publication is the first formal research report from this l and mark project . The purpose of this research was to evaluate the effectiveness of a short-term therapeutic conversation intervention  with families who were receiving health care services at the Children ’s Hospital at L and spitali University Hospital in Icel and related to childhood and adolescent acute and chronic illnesses . The therapeutic conversation was guided by Family Systems Nursing and used the Calgary Family Assessment and Intervention Models ( Wright & Leahey , 2005 , 2009 ) . Families ( N = 76 ) were r and omly assigned to either an experimental group ( short-term therapeutic conversation : n = 41 ) or to a control group ( traditional care : n = 35 ) . Parents in the experimental group reported significantly higher family support after the intervention , compared to the parents in the control group . Differences were noted between families experiencing acute versus chronic illnesses . Recommendations are made for conducting and design ing intervention research with families experiencing the hospitalization of a child or adolescent Background Conduct problems are common , disabling and costly . The prognosis for children with conduct problems is poor , with outcomes in adulthood including criminal behaviour , alcoholism , drug abuse , domestic violence , child abuse and a range of psychiatric disorders . There has been a rapid expansion of group based parent-training programmes for the treatment of children with conduct problems  in a number of countries over the past 10 years . Existing review s of parent training have method ological limitations such as inclusion of non-r and omised studies , the absence of investigation for heterogeneity prior to meta- analysis or failure to report confidence intervals . The objective of the current study was to systematic ally review r and omised controlled trials of parenting programmes for the treatment of children with conduct problems .  Methods St and ard systematic review methods were followed including duplicate inclusion decisions , data extraction and quality assessment . Twenty electronic data bases from the fields of medicine , psychology , social science and education were comprehensively search ed for RCTs and systematic review s to February 2006 . Inclusion criteria were : r and omised controlled trial ; of structured , repeatable parenting programmes ; for parents/carers of children up to the age of 18 with a conduct problem ; and at least one measure of child behaviour . Meta- analysis and qualitative synthesis were used to summarise included studies . Results 57 RCTs were included . Studies were small with an average group size of 21 . Meta-analyses using both parent ( SMD -0.67 ; 95 % CI : -0.91 , -0.42 ) and independent ( SMD -0.44 ; 95 % CI : -0.66 , -0.23 ) reports of outcome showed significant differences favouring the intervention group . There was insufficient evidence to determine the relative effectiveness of different approaches to delivering parenting programmes . Conclusion Parenting programmes are an effective treatment for children with conduct problems . The relative effectiveness of different parenting programmes requires further research Background Foot orthoses are widely used in the management of flexible pes planus , yet the evidence to support this intervention has not been clearly defined . This systematic review aim ed to critically appraise the evidence for the use of foot orthoses for flexible pes planus in adults . Methods Electronic data bases ( Medline , CINAHL , Cochrane , Web of science , SportD iscus , Embase ) were systematic ally search ed in June 2013 for r and omised controlled , controlled clinical and repeated measure trials where participants had identified flexible pes planus using a vali date d and reliable measure of pes planus and the intervention was a rigid or semi-rigid orthoses with the comparison being a no-orthoses ( shoes alone or flat non-posted insert ) condition . Outcomes of interest were foot pain , rearfoot kinematics , foot kinetics and physical function . Results Of the 2,211 articles identified by the search es , 13 studies met the inclusion criteria ; two were r and omised controlled trials , one was a controlled trial and 10 were repeated measure studies . Across the included studies , 59 relevant outcome measures were reported with 17 calculated as statistically significant large or medium effects observed with use of foot orthoses compared to the no orthoses condition ( SMD range 1.13 to -4.11 ) . Conclusions No high level evidence supported the use of foot orthoses for flexible pes planus . There is good to moderate level evidence that foot orthoses improve physical function ( medial-lateral sway in st and ing ( level II ) and energy cost during walking ( level III ) ) . There is low level evidence ( level IV ) that foot orthoses  improve pain , reduce rearfoot eversion , alter loading and impact forces ; and reduce rearfoot inversion and eversion moments in flexible pes planus . Well- design ed r and omised controlled trials that include appropriate sample sizes , clinical cohorts and involve a measure of symptom change are required to determine the efficacy of foot orthoses to manage adult flexible pes planus
Good repeatability ( for the 6MWT and ESWT ) and reproducibility ( for the 6MWT , 12-minute walk test , ISWT , ESWT , and incremental cycle ergometer test ) were reported by most studies assessing these tests , providing patients were familiarized with them beforeh and .
The 6MWT , ISWT , and particularly the ESWT were reported to be sensitive to therapeutic intervention .
Exercise tests are often used to evaluate the functional status of patients with COPD .
However , to the best of our knowledge , a comprehensive systematic comparison of these tests has not been performed .
We systematic ally review ed studies reporting the repeatability and /or reproducibility of these tests , and studies comparing their sensitivity to therapeutic intervention .