Effectiveness of Conservative, Surgical, and Postsurgical Interventions for Trigger Finger, Dupuytren Disease, and De Quervain Disease: A Systematic Review. A systematic review of randomized controlled trials on curative and health enhancement effects of forest therapy Bias in Systematic Reviews? Rating the strength of scientific evidence: relevance for quality improvement programs. INVITED COMMENTARY: Rating the Quality of Trials in Systematic Reviews of Physical Therapy Interventions Driving up the Quality and Relevance of Research Through the Use of Agreed Core Outcomes Systematic review automation technologies Allergen immunotherapy for the treatment of allergic rhinitis and/or asthma: an umbrella review. Effectiveness of exercise interventions on physical function in community-dwelling frail older people: an umbrella review of systematic reviews Mixed treatment comparison analysis provides internally coherent treatment effect estimates based on overviews of reviews and can reveal inconsistency. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: Methods of a decision-maker-researcher partnership systematic review Dietetic guidelines: diet in secondary prevention of cardiovascular disease. The effect of night extension orthoses following surgical release of Dupuytren contracture: a single-center, randomized, controlled trial. Effectiveness of Different Commercial Chlorhexidine-Based Mouthwashes After Periodontal and Implant Surgery: A Systematic Review Evidence-based behavioral medicine: What is it and how do we achieve it? Bias due to selective inclusion and reporting of outcomes and analyses in systematic reviews of randomised trials of healthcare interventions. Systematic Reviews: Synthesis of Best Evidence for Clinical Decisions Evidence-based medicine and the challenge of low back pain: where are we now? Components of effective randomized controlled trials of hydrotherapy programs for fibromyalgia syndrome: A systematic review Nonoperative Management or ‘Watch and Wait’ for Rectal Cancer with Complete Clinical Response After Neoadjuvant Chemoradiotherapy: A Critical Appraisal Digital Games, Design, and Learning Exercise and Motor Training in People with Parkinson's Disease: A Systematic Review of Participant Characteristics, Intervention Delivery, Retention Rates, Adherence, and Adverse Events in Clinical Trials Improving practice in community-based settings: a randomized trial of supervision – study protocol Spine surgery research: on and beyond current strategies.
OBJECTIVES To provide an evidence -based overview of the effectiveness of conservative and (post)surgical interventions for trigger finger , Dupuytren disease , and De Quervain disease . DATA SOURCES Cochrane Library , Physiotherapy Evidence Data base , PubMed , Embase , and CINAHL were search ed to identify relevant systematic review s and r and omized controlled trials ( RCTs ) . DATA SELECTION Two review ers independently applied the inclusion criteria to select potential studies . DATA EXTRACTION Two review ers independently extracted the data and assessed the method ologic quality . DATA SYNTHESIS A best- evidence synthesis was performed to summarize the results . Two review s ( trigger finger and De Quervain disease ) and 37 r and omized controlled trials ( RCTs ) ( trigger finger : n=8 ; Dupuytren disease : n=14 , and De Quervain disease : n=15 ) were included . The trials reported on oral medication ( Dupuytren disease ) , physiotherapy ( De Quervain disease ) , injections and surgical treatment ( trigger finger , Dupuytren disease , and De Quervain disease ) , and other conservative ( De Qervain disease ) and postsurgical treatment ( Dupuytren disease ) . Moderate evidence was found for the effect of corticosteroid injection  on the very short term for trigger finger , De Quervain disease , and for injections with collagenase ( 30d ) when looking at all joints , and no evidence was found when looking at the PIP joint for Dupuytren disease . A thumb splint as additive to a corticosteroid injection seems to be effective ( moderate evidence ) for De Quervain disease ( short term and midterm ) . For Dupuytren disease , use of a corticosteroid injection within a percutaneous needle aponeurotomy in the midterm and tamoxifen versus a placebo before or after a fasciectomy seems to promising ( moderate evidence ) . We also found moderate evidence for splinting after Dupuytren surgery in the short term . CONCLUSIONS In recent years , more and more RCTs have been conducted to study treatment of the aforementioned h and disorders . However , more high- quality RCTs are still needed to further stimulate evidence -based practice for patients with trigger finger , Dupuytren disease , and De Quervain disease Objective To summarize the evidence for curative and health enhancement effects through  forest therapy  and to assess the quality of studies based on a review of r and omized controlled trials ( RCTs ) . Study design A systematic review based on RCTs . Methods Studies were eligible if they were RCTs . Studies included one treatment group in which forest therapy was applied .  The following data bases – from 1990 to November 9 , 2010 – were search ed : MEDLINE via PubMed , CINAHL , Web of Science , and Ichushi- Web . All Cochrane data bases and Campbell Systematic Review s were also search ed up to November 9 , 2010 . Results Two trials met all inclusion criteria . No specific diseases were evaluated , and both studies reported significant effectiveness in one or more outcomes for health enhancement . However , the results of evaluations with the CONSORT ( Consoli date d St and ards of Reporting Trials ) 2010 and CLEAR NPT ( A Checklist to Evaluate a Report of a Nonpharmacological Trial ) checklists generally showed a remarkable lack of description in the studies . Furthermore , there was a problem of heterogeneity , thus a meta- analysis was unable to be performed . Conclusion Because there was insufficient evidence on forest therapy due to poor method ological and reporting quality and heterogeneity of RCTs , it was not possible to offer any conclusions about the effects of this intervention . However , it was possible to identify problems with current RCTs of forest therapy , and to propose a strategy for strengthening study quality and stressing the importance of study feasibility and original check items based on characteristics of forest therapy as a future research agenda At an orthodontic meeting in recent years , a colleague recounted to me that when a presenter had finished their presentation on a systematic review , the person beside leaned over and said to my colleague ‘ not another systematic review where it ’s not possible to draw any firm conclusions ’ . So an element of frustration was clear based on the screening of a large volume of evidence to arrive at such a low point for a conclusion . This , however , is now a familiar outcome for many orthodontic systematic review s. In this short editorial , I have attempted to give a brief outline of the proposed benefits of systematic review s but more importantly , to highlight , some issues we all need to bear in mind in their regard . The increasing focus on evidence -based healthcare , including orthodontics , has shunned the narrative review and spawned the systematic review . Aim ing to identify , evaluate and summarize the findings of all relevant studies on a specific topic , its exacting systematic approach should minimize bias and provide conclusions based on reliable findings . Meta-analyses of r and omized clinical trials with low risk of bias are considered the highest level of evidence available for evaluating the effects of an intervention . Systematic review s are also important tools in setting the research agenda via their recommendations for future research and authors can alert research ers to the most pertinent outcomes in clinical practice . But systematic review s like any other study type are not without their variability , both in dentistry in general and specifically in orthodontics . Large differences have also been observed in the quality of reporting of several characteristics between Cochrane and non-Cochrane systematic review s. A key question that must be asked when looking at all Cochrane review s is whether the review has been undertaken in a way to avoid bias and whether the data and results from the included studies are valid . Conclusions may be distorted if bias is introduced to the review process at any stage . For example , incomplete search ing for all relevant studies may lead to publication bias ; there is strong association between publication and studies reporting significant or positive findings in medicine and also within orthodontics . With regard to studies included within the review , these need to be assessed to ensure that they are undertaken and reported in a manner that is free of bias ( systematic error ) . Outcome reporting bias ( ORB ) may also be relevant , e.g. in a study identified as relevant to a review , where data exist on the outcome of interest but only selected findings have been given based on the results . Although systematic review s have emphasized ‘ assessment of method ological quality ’ of included studies , the Cochrane h and book recommends a focus on ‘ risk of bias assessment ’ instead . The justifications are four-fold : it targets whether the results of included studies should be credible ; despite being carried out to the highest st and ards , a study may have risk of bias due to , e.g. impracticality/impossibility of blinding of participants / study personnel ; some quality markers , e.g. a power calculation is unlikely to directly affect risk of bias ; it overcomes ambiguity between quality of reporting and quality of the underlying research OBJECTIVE To summarize an extensive review of systems for grading the quality of research articles and rating the strength of bodies of evidence , and to highlight for health professionals and decision-makers concerned with quality measurement and improvement the available " best practice s " tools by which these steps can be accomplished . DESIGN Drawing on an extensive review of checklists , question naires , and other tools in the field of evidence -based practice , this paper discusses clinical , management , and policy rationale s for rating strength of evidence in a quality improvement context , and documents best practice s methods for these tasks . RESULTS After review of 121 systems for grading the quality of articles , 19 systems , mostly STUDY DESIGN specific , met a priori scientific st and ards for grading systematic review s , r and omized controlled trials , observational studies , and diagnostic tests ; eight systems ( of 40 review ed ) met similar st and ards for rating the overall strength of evidence . All can be used as is or adapted for particular types of evidence reports or systematic review s. CONCLUSIONS Formally grading study quality and rating overall strength of evidence , using sound instruments and procedures , can produce reasonable levels of confidence about the science base for parts of quality improvement programs . With such information , health care professionals and administrators concerned with quality improvement can underst and better the level of science ( versus only clinical consensus or opinion ) that supports practice guidelines , review criteria , and assessment s that feed into quality assurance and improvement programs . New systems are appearing and research is needed to confirm the conceptual and practical underpinnings of these grading and rating systems , but the need for those developing systematic review s , practice guidelines , and quality or audit criteria to underst and and undertake these steps is becoming increasingly clear & NA ; Physical therapists seeking to use evidence to guide their practice may have limited time to read research reports . One way to reduce the time required to identify and read about the research that is relevant to a particular clinical question is to read a systematic review that summarizes multiple studies . This paper explains the process that is used to conduct systematic review s , which includes the establishment of a protocol , comprehensive search ing , appraisal of the quality of the included studies , data extraction and meta analysis , and consideration of the clinical and research implication s of the findings . We also consider how the reader of a systematic review can determine whether the review is likely to provide an unbiased ( believable ) estimate of the treatment effect . A systematic review of r and omized trials of a  cardiopulmonary physical therapy intervention is used as an example . The issue of appraisal of quality is then discussed further , with a demonstration of how one vali date d tool for quality appraisal ‐‐the PEDro scale‐‐can be used to evaluate a r and omized trial in cardiopulmonary physical therapy There is a growing recognition that insufficient attention has been paid to the selection of the outcomes to measure in clinical trials and clinical audit . Outcomes need to be relevant to patients , clinicians , purchasers and policy-makers if the findings of research are to influence practice and future research . In addition , st and ardization of outcomes is needed to combine data from different studies to allow evidence synthesis and to compare data sets . Inconsistent choice of outcome measures means that many meta-analyses are unable to include data from all the relevant studies . For example , the five most accessed Cochrane review s in 2009 , together with the top cited review in that year , all described inconsistencies in the outcomes reported in eligible trials . A call for the st and ardization of outcomes is a regular conclusion of systematic review s. Furthermore , outcome reporting bias , defined as the bias arising from selecting outcomes for publication based on the results , affects many r and omized trials and ‘ is an under-recognized problem that affects the conclusions in a substantial proportion of Cochrane review s ’ . That bias is likely to affect systematic review s more widely as well as affecting individual studies when considered on their own . Similar problems occur with clinical audit , highlighting the importance of establishing national audits that use and report the same outcomes for all participants . All these issues could be addressed with the development and application of agreed st and ardized sets of outcomes that have been termed ‘ core outcome sets ’ . These should be measured and reported , as a minimum , in all relevant clinical trials and national clinical audits for a specific condition . Adopting a core outcome set does not imply that a particular study , review or audit should be restricted to only those outcomes . Rather , the expectation is that , as a minimum , core outcomes will always be collected and reported to allow the results of trials to be compared , contrasted and combined as appropriate . The adoption of core outcomes would have implication s across all areas of research in health and health care , reduce heterogeneity between trials , and lead to research that is more likely to have measured relevant outcomes . Importantly , they would enhance the value of evidence synthesis by reducing the risk of outcome reporting bias and ensuring that all trials contribute usable information . In addition , they will increase the efficiency and value of research . An important rationale for core outcome sets is that outcomes currently reported for trials do not consistently reflect endpoints that are meaningful for patients . Examples exist where trials failed to include all outcomes important to patients and where involvement of patients has identified an outcome that might not have been considered by practitioners on their own . Despite increasing recognition of the importance of incorporating patients ’ opinions , their involvement has been limited . Recent regulatory guidance in the USA requires documented evidence of patient input during the development of instruments to measure  patient reported outcomes ( PROs ) . However , measurement of PROs in clinical trials is hampered by the multiplicity and heterogeneity of tools currently available . Many generic , disease and domain-specific instruments have been developed and vali date d , each containing multiple scales and items . As a result , synthesis of PRO data from trials is difficult and review s aim ing to summarize treatment effect according to PROs may fail . There is synergy between the development of core outcome sets for trials and work to select up to seven outcomes that are important to patients for inclusion in Summary of Findings tables in systematic review s. Developed by the GRADE group ( http://www . grade workinggroup.org ) , Cochrane review s have featured such tables since 2008 , and they play a key role in presenting research in guidelines , such as those produced by the World Health Organization ( WHO ) . The development of core outcome sets needs to be accelerated and undertaken in ways that maximize efficiency . The COMET ( Core Outcome Measures in Effectiveness Trials , http://www.comet-initiative.org ) Initiative in the UK brings together research ers interested in the development and application of core outcome sets . These include key participants in a collaboration of research ers in rheumatology who have done the most notable work to date in this area . The COMET Initiative was launched in January 2010 , with a second meeting in July 2011 . Attendees included trialists , systematic review ers , patients , clinicians , journal editors , research funders , policy-makers , people responsible for trials registries and regulators . Data on individual studies , both published and ongoing , are being included in a free , publically available internet-based re source . This will be up date d periodically , to minimize the risk of duplication . Seventy-eight published or ongoing studies have already been entered into the repository . In addition , published review s of outcomes used in clinical trials or studies examining patients ’ views , will be entered Systematic review s , a cornerstone of evidence -based medicine , are not produced quickly enough to support clinical practice . The cost of production , availability of the requisite expertise and timeliness are often quoted as major contributors for the delay . This detailed survey of the state of the art of information systems design ed to support or automate individual tasks in the systematic review , and in particular systematic review s of r and omized controlled clinical trials , reveals trends that see the convergence of several parallel research projects . We surveyed literature describing informatics systems that support or automate the processes of systematic review or each of the tasks of the systematic review . Several projects focus on automating , simplifying and /or streamlining specific tasks of the systematic review . Some tasks are already fully automated while others are still largely manual . In this review , we describe each task and the effect that its automation would have on the entire systematic review process , summarize the existing information system support for each task , and highlight where further research is needed for realizing automation for the task . Integration of the systems that automate systematic review tasks may lead to a revised systematic review workflow . We envisage the optimized workflow will lead to system in which each systematic review is described as a computer program that automatically retrieves relevant trials , appraises them , extracts and synthesizes data , evaluates the risk of bias , performs meta- analysis calculations , and produces a report in real time BACKGROUND Allergic rhinitis and asthma are important public health concerns , yet there is no consensus about the benefits and harms of allergen-specific immunotherapy to treat these conditions . We performed an umbrella review of systematic review s summarizing the current evidence for the benefits and harms of subcutaneous immunotherapy ( SCIT ) and sublingual immunotherapy ( SLIT ) . METHODS We search ed MEDLINE , Embase , the Cochrane Library and the grey literature from Jan. 1 , 2010 to Nov. 20 , 2016 for systematic review s of r and omized controlled trials or prospect ively controlled studies involving children or adults with allergic rhinitis or asthma . Outcomes were summarized narratively ( benefits : total combined symptom-medication score , symptom score , medication score , disease-specific quality of life , adherence ; harms : anaphylaxis , death , local and systemic reactions ) . RESULTS Twenty-three systematic review s were included . SCIT and SLIT were more effective than placebo for most outcomes . SCIT was better than SLIT at improving medication and symptom scores , with no differences in quality of life ; however , data were limited for this comparison . Anaphylaxis and death were infrequently reported . Few review s assessed benefits or harms among children . INTERPRETATION Allergen immunotherapy appears to be effective among patients with allergic rhinitis and asthma . The safety of allergen immunotherapy is not conclusively established , although death and anaphylaxis appear to be rare . PROSPERO no. : CRD42015024590 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 OBJECTIVES To propose methods for mixed treatment comparisons ( MTC ) based on pooled summaries of the type produced in overviews of review s. STUDY DESIGN AND SETTING Overviews of review s ( umbrella review s ) summarize the results of multiple systematic review s into a single document . They report the summary estimates from the original pairwise meta-analyses and discuss them in narrative form , with the intention of identifying the most effective treatment . We present methods for MTC synthesis , tailored for use with overviews of review s. These generate a single internally consistent summary of all the relative treatment effects and assessment s of whether the summary is consistent with the data . These methods are applied to a published overview of treatments for childhood nocturnal enuresis . We apply the methods to both fixed-effect ( FE ) and r and om-effects ( RE ) meta-analyses of the original trials . RESULTS The summary relative risks based on FE meta-analyses , as originally published , were highly inconsistent . Those based on RE meta-analyses were consistent and could , given st and ard assumptions on comparability of treatment effects in meta- analysis , form a basis for coherent decision making . CONCLUSION Along with the summaries from systematic review s , MTC methods should be used in overviews to provide a single coherent analysis of all treatment comparisons and to check for evidence consistency Background Computerized clinical decision support systems are information technology-based systems design ed to improve clinical decision-making . As with any healthcare intervention with cl aims to improve process of care or patient outcomes , decision support systems should be rigorously evaluated before widespread dissemination into clinical practice . Engaging healthcare providers and managers in the review process may facilitate knowledge translation and uptake . The objective of this research was to form a partnership of healthcare providers , managers , and research ers to review r and omized controlled trials assessing the effects of computerized decision support for six clinical application areas : primary preventive care , therapeutic drug monitoring and dosing , drug prescribing , chronic disease management , diagnostic test ordering and interpretation , and acute care management ; and to identify study characteristics that predict benefit . Methods The review was undertaken by the Health Information Research Unit , McMaster University , in partnership with Hamilton Health Sciences , the Hamilton , Niagara , Haldim and , and Brant Local Health Integration Network , and pertinent healthcare service teams . Following agreement on information needs and interests with decision-makers , our earlier systematic review was up date d by search ing Medline , EMBASE , EBM Review data bases , and Inspec , and review ing reference lists through 6 January 2010 . Data extraction items were exp and ed according to input from decision-makers . Authors of primary studies were contacted to confirm data and to provide additional information . Eligible trials were organized according to clinical area of application . We included r and omized controlled trials that evaluated the effect on practitioner performance or patient outcomes of patient care provided with a  computerized clinical decision support system compared with patient care without such a system . Results Data will be summarized using descriptive summary measures , including proportions for categorical variables and means for continuous variables . Univariable and multivariable logistic regression models will be used to investigate associations between outcomes of interest and study specific covariates . When reporting results from individual studies , we will cite the measures of association and p-values reported in the studies . If appropriate for groups of studies with similar features , we will conduct meta-analyses . Conclusion A decision-maker- research er partnership provides a model for systematic review s that may foster knowledge translation and uptake 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 PURPOSE To clarify the efficacy and detrimental effects of orthoses used to maintain finger extension following surgical release of Dupuytren contracture . METHODS We conducted a single-center , r and omized , controlled trial to investigate the effect of night extension orthoses on finger range of motion and h and function for 3 months following surgical release of Dupuytren contracture . We also wanted to determine how well finger extension was maintained in the total sample . We r and omized 56 patients to receive a night extension orthosis plus h and therapy  ( n = 26 ) or h and therapy alone ( n = 30 ) . The primary outcome was total active extension of the operated fingers ( ° ) . Secondary outcomes were total active flexion of the operated fingers ( ° ) , active distal palmar crease ( cm ) , grip strength ( kg ) , and self-reported h and function using the Disabilities of the Arm , Shoulder , and H and question naire ( 0 - 100 scale ) . RESULTS There were no statistically significant differences between the no-orthosis and orthosis groups for total active extension or for any of the secondary outcomes . Between the first postoperative measure and 3 months after surgery , 62 % of little fingers had maintained or improved total active extension . CONCLUSIONS The use of a night extension orthosis in combination with st and ard h and therapy has no greater effect on maintaining finger extension than h and therapy alone in the 3 months following surgical release of Dupuytren contracture . Our results indicate that the practice of providing every patient with a night extension orthosis following surgical release of Dupuytren contracture may not be justified except for cases in which extension loss occurs after surgery . Our results also challenge clinicians to research ways of maintaining finger extension in a greater number of patients Objectives : The aim of the present study was to review the effectiveness , side effects , and patient acceptance of different concentrations and formulation of chlorhexidine-based mouthwashes used after periodontal and implant surgery . Material s and Methods : The PRISMA guideline was adopted in the search strategy using electronic data bases PubMed and MEDLINE to identify r and omized and case – control prospect i ve studies on humans written in English language and published up to September 2017 . Results : A total of 10 articles were selected for a total of 344 patients . Because of the significant heterogeneity of the outcome measures , meta- analysis was not performed , and the data were summarized in a table . A positive relationship between the use of chlorhexidine  and reduction of plaque was found , demonstrating the effectiveness of the substance in terms of antisepsis and decrease of inflammation after periodontal and implant surgery . Conclusion : Chlorhexidine is recognized as the primary agent for plaque control and the gold st and ard in preventing infection , although the presence of largely known side effects would affect patient compliance . Future research should be directed at finding chlorhexidine formulation with negligible adverse effects , without compromising or even increasing its effectiveness as the antiseptics and antiplaque agent The goal of evidence -based medicine is ultimately to improve patient outcomes and quality of care .  Systematic review s of the available published evidence are required to identify interventions that lead to improvements in behavior , health , and well-being . Authoritative literature review s depend on the quality of published research and research reports . The Consoli date d St and ards for Reporting Trials ( CONSORT ) Statement ( www.consort-statement.org ) was developed to improve the design and reporting of interventions involving r and omized clinical trials ( RCTs ) in medical journals . We describe the 22 CONSORT guidelines and explain their application to behavioral medicine research and to evidence -based practice . Additional behavioral medicine-specific guidelines ( e.g. , treatment adherence ) are also presented . Use of these guidelines by clinicians , educators , policymakers , and research ers who design , report , and evaluate or review RCTs will strengthen the research itself and accelerate efforts to apply behavioral medicine research to improve the processes and outcomes of behavioral medicine practice BACKGROUND Systematic review s may be compromised by selective inclusion and reporting of outcomes and analyses . Selective inclusion occurs when there are multiple effect estimates in a trial report that could be included in a particular meta- analysis ( e.g. from multiple measurement scales and time points ) and the choice of effect estimate to include in the meta- analysis is based on the results ( e.g. statistical significance , magnitude or direction of effect ) . Selective reporting occurs when the reporting of a subset of outcomes and analyses in the systematic review is based on the results ( e.g. a protocol -defined outcome is omitted from the published systematic review ) . OBJECTIVES To summarise the characteristics and synthesis e the results of empirical studies that have investigated the prevalence of selective inclusion or reporting in systematic review s of r and omised controlled trials ( RCTs ) , investigated the factors ( e.g. statistical significance or direction of effect ) associated with the prevalence and quantified the bias . SEARCH METHODS We search ed the Cochrane Methodology Register ( to July 2012 ) , Ovid MEDLINE , Ovid EMBASE , Ovid PsycINFO and ISI Web of Science ( each up to May 2013 ) , and the US Agency for Healthcare Research and Quality ( AHRQ ) Effective Healthcare Program 's Scientific Re source Center ( SRC ) Methods Library ( to June 2013 ) . We also search ed the abstract books of the 2011 and 2012 Cochrane Colloquia and the article alerts for method ological work in research synthesis published from 2009 to 2011 and compiled in Research Synthesis Methods . SELECTION CRITERIA We included both published and unpublished empirical studies that investigated the prevalence and factors associated with selective inclusion or reporting , or both , in systematic review s of RCTs of healthcare interventions . We included empirical studies assessing any type of selective inclusion or reporting , such as investigations of how frequently RCT outcome data is selectively included in systematic review s based on the results , outcomes and analyses are discrepant between protocol and published review or non-significant outcomes are partially reported in the full text or summary within systematic review s. DATA COLLECTION AND ANALYSIS Two review authors independently selected empirical studies for inclusion , extracted the data and performed a risk of bias assessment . A third review author resolved any disagreements about inclusion or exclusion of empirical studies , data extraction and risk of bias . We contacted authors of included studies for additional unpublished data . Primary outcomes included overall prevalence of selective inclusion or reporting , association between selective inclusion or reporting and the statistical significance of the effect estimate , and association between selective inclusion or reporting and the direction of the effect estimate . We combined prevalence estimates and risk ratios ( RRs ) using a r and om-effects meta- analysis model . MAIN RESULTS Seven studies met the inclusion criteria . No studies had investigated selective inclusion of results in systematic review s , or discrepancies in outcomes and analyses between systematic review registry entries and published systematic review s. Based on a meta- analysis of four studies ( including 485 Cochrane Review s ) , 38 % ( 95 % confidence interval ( CI ) 23 % to 54 % ) of systematic review s added , omitted , up grade d or down grade d at least one outcome between the protocol and published systematic review . The association between statistical significance and discrepant outcome reporting between protocol and published systematic review was uncertain . The meta-analytic estimate suggested an increased risk of adding or upgrading ( i.e. changing a secondary outcome to primary ) when the outcome was statistically significant , although the 95 % CI included no association and a decreased risk as plausible estimates ( RR 1.43 , 95 % CI 0.71 to 2.85 ; two studies , n = 552 meta-analyses ) . Also , the meta-analytic estimate suggested an increased risk of downgrading ( i.e. changing a primary outcome to secondary ) when the outcome was statistically significant , although the 95 % CI included no association and a decreased risk as plausible estimates ( RR 1.26 , 95 % CI 0.60 to 2.62 ; two studies , n = 484 meta-analyses ) . None of the included studies had investigated whether the association between statistical significance and adding , upgrading or downgrading of outcomes was modified by the type of comparison , direction of effect or type of outcome ; or whether there is an association between direction of the effect estimate and discrepant outcome reporting . Several secondary outcomes were reported in the included studies . Two studies found that reasons for discrepant outcome reporting were infrequently reported in published systematic review s ( 6 % in one study and 22 % in the other ) . One study ( including 62 Cochrane Review s ) found that 32 % ( 95 % CI 21 % to 45 % ) of systematic review s did not report all primary outcomes in the abstract . Another study ( including 64 Cochrane and 118 non-Cochrane review s ) found that statistically significant primary outcomes were more likely to be completely reported in the systematic review abstract than non-significant primary outcomes ( RR 2.66 , 95 % CI 1.81 to 3.90 ) . None of the studies included systematic review s published after 2009 when reporting st and ards for systematic review s ( Preferred Reporting Items for Systematic review s and Meta-Analyses ( PRISMA ) Statement , and Method ological Expectations of Cochrane Intervention Review s ( MECIR ) ) were disseminated , so the results might not be generalisable to more recent systematic review s. AUTHORS ' CONCLUSIONS Discrepant outcome reporting between the protocol and published systematic review is fairly common , although the association between statistical significance and discrepant outcome reporting is uncertain . Complete reporting of outcomes in systematic review abstract s is associated with statistical significance of the results for those outcomes . Systematic review outcomes and analysis plans should be specified prior to seeing the results of included studies to minimise post-hoc decisions that may be based on the observed results . Modifications that occur once the review has commenced , along with their justification , should be clearly reported . Effect estimates and CIs should be reported for all systematic review outcomes regardless of the results . The lack of research on selective inclusion of results in systematic review s needs to be addressed and studies that avoid the method ological weaknesses of existing research are also needed 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 Low  back pain  has long been described as a challenge for both primary care physicians and specialists . Management of  low back pain  has also been criticized as frequently arbitrary , inappropriate , or ineffective . Contributing factors have been an inadequate evidence base and a need for more rigorous appraisal s of the available literature . Evidence -based medicine , an approach to clinical problem solving , is predicated on the premise that high- quality health care will result from practice s consistent with the best evidence . In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion , authority , and un systematic clinical observations , evidence -based medicine emphasizes the need for rigorous critical appraisal s of the scientific literature to inform medical decision making . Evidence -based medicine places strong weight on the requirement for valid studies , particularly r and omized controlled trials , to appropriately evaluate the effectiveness of health care interventions . Because of the rapidly increasing volume of medical literature , however , most clinicians are unable to keep up-to- date with all the new data . Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic review s and evidence -based clinical practice guidelines . Like primary studies , systematic review s and clinical practice guidelines must adhere to high method ologic st and ards to reduce error and bias . As in other areas of medicine , the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings . In addition to more rigorous primary studies , an increasing number of high- quality systematic review s and evidence -based clinical practice guidelines for low back pain are also available . Although some research gaps and method ologic shortcomings persist , the richer evidence base has greatly improved our underst and ing of what does and does not work for low back pain . Despite these advances , the best available evidence often does not inform everyday clinical decisions for low back pain . Nonetheless , there is widespread agreement that adherence to evidence -based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care . This article review s basic principles of evidence -based medicine , discusses evidence -based medicine in the context of low back pain management , and summarizes some useful evidence -based medicine re sources Aim Previous systematic review s have found hydrotherapy to be an effective management strategy for  fibromyalgia syndrome ( FMS ) .  The aim of this systematic review was to summarize the components of hydrotherapy programs used in r and omized controlled trials . Method A systematic review of r and omized controlled trials was conducted . Only trials that have reported significant FMS-related outcomes were included . Data relating to the components of hydrotherapy programs ( exercise type , duration , frequency and intensity , environmental factors , and service delivery ) were analyzed . Results Eleven r and omized controlled trials were included in this review . Overall , the quality of trials was good . Aerobic exercise featured in all 11 trials and the majority of hydrotherapy programs included either a strengthening or flexibility component . Great variability was noted in both the environmental components of hydrotherapy programs and service delivery . Conclusions Aerobic exercise , warm up and cool-down periods and relaxation exercises are common features of hydrotherapy programs that report significant FMS-related outcomes . Treatment duration of 60 minutes , frequency of three sessions per week and an intensity equivalent to 60%–80 % maximum heart rate were the most commonly reported exercise components . Exercise appears to be the most important component of an effective hydrotherapy program for FMS , particularly when considering mental health-related outcomes Background There is increasing interest in nonoperative management ( NOM ) for rectal cancer with complete clinical response ( cCR ) after neoadjuvant chemoradiation ( nCRT ) . Objective The aim of this systematic review was to summarize the available data on NOM , with the intention of formulating st and ardized protocol s on which to base future investigations . Methods A systematic review following the Preferred Reporting Items for Systematic Review s and Meta-Analyses ( PRISMA ) guidelines was conducted . A highly sensitive literature search identified all relevant studies published between January 2004 and December 2016 . Data extraction and quality assessment was performed independently by two authors , and resolved by consensus with a third review er . Results In total , 15 studies , including 920 patients , met the inclusion criteria ; 575 ( 62.5 % ) of these patients underwent NOM after cCR , with the remaining patients forming a surgical control group . The weighted mean follow-up was 39.4 ( 12.7 ) months in the NOM group and 39.8 ( 5.1 ) months in the surgery group . The pooled regrowth rate in the NOM group was 21.3 % at a mean of 15.6 ( 7.0 ) months . Surgical salvage was possible and was undertaken in 93.2 % of these patients . Overall survival in the NOM group was 91.7 % , while disease-free survival was 82.7 % . For the comparison proctectomy group , pooled rates of local recurrence , overall survival , and disease-free survival were 8.4 , 92.4 , and 87.5 % , respectively . Conclusion NOM may be a feasible option for surgically eligible rectal cancer patients with cCR after nCRT . Before such a strategy can be widely implemented , further prospect i ve data are required with st and ardized definitions , diagnostic criteria , and management protocol s , with an emphasis on shared patient – provider decision making and patient-centered outcomes In this meta- analysis , we systematic ally review ed research on digital games and learning for K–16 students . We synthesized comparisons of game versus nongame conditions ( i.e. , media comparisons ) and comparisons of augmented games versus st and ard game design s ( i.e. , value-added comparisons ) . We used r and om-effects meta-regression models with robust variance estimates to summarize overall effects and explore potential moderator effects . Results from media comparisons indicated that digital games significantly enhanced student learning relative to nongame conditions ( g ¯ = 0.33 , 95 % confidence interval [ 0.19 , 0.48 ] , k = 57 , n = 209 ) . Results from value-added comparisons indicated significant learning benefits associated with augmented game design s ( g ¯ = 0.34 , 95 % confidence interval [ 0.17 , 0.51 ] , k = 20 , n = 40 ) . Moderator analyses demonstrated that effects varied across various game mechanics characteristics , visual and narrative characteristics , and research quality characteristics . Taken together , the results highlight the affordances of games for learning as well as the key role of design beyond medium There is research evidence that exercise and motor training are beneficial for people with Parkinson 's disease ( PD ) , and clinicians seek to implement optimal programs . This paper summarizes important factors about the nature and reporting of r and omized controlled trials of exercise and /or motor training for people with PD which are likely to influence the translation of research into clinical practice . Search es identified 53 relevant trials with 90 interventions conducted for an average duration of 8.3 ( SD 4.2 ) weeks . Most interventions were fully supervised ( 74 % ) and conducted at a facility ( 79 % ) . Retention rates were high with 69 % of interventions retaining ≥85 % of their participants ; however adherence was infrequently reported , and 72 % of trials did not report adverse events . Overall , the labor-intensive nature of most interventions tested in these trials and the sparse reporting of adherence and adverse events are likely to pose difficulties for therapists attempting to balance benefits and costs when selecting protocol s that translate to sustainable clinical practice for people with PD Background Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy  Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes . Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes . Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes . Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes . Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes . Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes . Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes . Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes . Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes . Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision or consultation is required . Supervision is notably under-investigated , particularly as provided in public mental health . The degree to which supervision in this setting includes ‘ gold st and ard ’ supervision elements from efficacy trials ( e.g. , session review , model fidelity , outcome monitoring , skill-building ) is unknown . The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practice s and test the impact of systematic implementation of gold st and ard supervision strategies on treatment fidelity and clinical outcomes .  Evidence -based treatments for child mental health problems are not consistently available in public mental health setting s. Exp and ing availability requires workforce training . However , research has demonstrated that training alone is not sufficient for changing provider behavior , suggesting that ongoing intervention-specific supervision BACKGROUND CONTEXT Systematic review s of the literature are powerful tools in evidence -based medicine . However , the design and report of systematic review s in spinal surgery contain many aspects amenable to improvement . PURPOSE To discuss the issues especially relevant for systematic review s in spinal surgery . METHODS From our experience of systematic review s and meta-analyses of clinical trials in  spinal surgery  , we infer guidance for the design and execution of systematic literature review s. RESULTS There are many difficulties associated with the design as well as conduct of clinical trials and consequently appraising evidence in spinal surgery . New treatments should be compared with the gold st and ard before other comparisons are investigated . Studies should present data as thoroughly as possible regarding all subgroups and follow-up moments , possibly in supplementary material . To provide the highest level of evidence , systematic review s should be as rigorously design ed as possible . CONCLUSIONS Gathering information on clinical effectiveness in spinal surgery can be improved both at the clinical study level and at the systematic review level . Alternatives to r and omized controlled trials such as comparative studies can be valuable tools on the clinical effectiveness of treatments in spinal surgery . The experience reflected in this article can support the scientific efforts in this field
Outcomes , such as range of motion , recurrence , and clinical success , were frequently defined , however many different definitions were used .
This systematic review summarizes the outcome reporting st and ards in Dupuytren ’s disease treatment research .