Issues related to the conduct of systematic reviews: a focus on the nutrition field. Systematic Reviews of Animal Studies; Missing Link in Translational Research? Epidemiology and Reporting Characteristics of Systematic Reviews of Biomedical Research: A Cross-Sectional Study Scoping review of systematic reviews of complementary medicine for musculoskeletal and mental health conditions A comprehensive approach to rehabilitation interventions following breast cancer treatment - a systematic review of systematic reviews Efficacy, tolerability and safety of cannabis‐based medicines for chronic pain management – An overview of systematic reviews Updating Systematic Reviews: An International Survey Reporting of Sex Effects by Systematic Reviews on Interventions for Depression, Diabetes, and Chronic Pain Outcome Measures of Chinese Herbal Medicine for Hypertension: An Overview of Systematic Reviews Key Steps in Conducting Systematic Reviews for Underpinning Clinical Practice Guidelines: Methodology of the European Association of Urology. How do systematic reviews incorporate risk of bias assessments into the synthesis of evidence? A methodological study Efficacy and safety of acupuncture for hypertension: An overview of systematic reviews. Setting Priorities for Comparative Effectiveness Research on Management of Primary Angle Closure: A Survey of Asia-Pacific Clinicians The most important tasks for peer reviewers evaluating a randomized controlled trial are not congruent with the tasks most often requested by journal editors Dual computer monitors to increase efficiency of conducting systematic reviews. Assessing the complexity of interventions within systematic reviews: development, content and use of a new tool (iCAT_SR) How effective and safe is medical cannabis as a treatment of mental disorders? A systematic review Association between progression-free survival and health-related quality of life in oncology: a systematic review protocol Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Systematic reviews of evaluations of prognostic variables What do review papers conclude about food and dietary patterns? SYRCLE’s risk of bias tool for animal studies Cluster Randomised Trials in Cochrane Reviews: Evaluation of Methodological and Reporting Practice
Systematic review s ( SRs ) are an increasingly popular evidence -based tool and are often used to answer complex research questions across many different research domains . Early SR methodology was advanced by social scientists , and the term meta- analysis was coined by a social scientist who also conducted research in psychology . SRs have recently become popular in healthcare and are likely to be beneficial in any field . The aim of this report is to highlight issues in SR conduct with a focus on the field of nutrition and to make recommendations on improving SR conduct in this area . Development of the research question is probably the most important step in conducting an SR . The 4 main components of an answerable question are 1 ) the patient , population , or problem ; 2 ) the intervention , independent variable , or exposure ; 3 ) the comparators ; and 4 ) the dependent variables or outcomes of interest . The question will be used to determine the optimal methods for conducting the SR . SRs often include study design s beyond r and omized trials and do not always include a meta- analysis of the results . Other topics explored include underst and ing and interpreting discordant review s and the importance of reporting tools [ eg , QUality Of Reporting Of Meta-analyses ( QUOROM Statement ) or CONsoli date d St and ards Of Reporting of Trials ( CONSORT Statement ) ] . Recommendations are then provided , such as developing a capacity-building program , search ing the primary literature for research gaps , and extending reporting tools such as the QUOROM Statement to the field of nutrition Background The method ological quality of animal studies is an important factor hampering the translation of results from animal studies to a clinical setting . Systematic review s of animal studies may provide a suitable method to assess and thereby improve their method ological quality . Objectives The aims of this study were : 1 ) to evaluate the risk of bias assessment in animal-based systematic review s , and 2 ) to study the internal validity of the primary animal studies included in these systematic review s. Data Sources We systematic ally search ed Pubmed and Embase for SRs of pre clinical animal studies published between 2005 and 2012 . Results A total of 91 systematic review s met our inclusion criteria . The risk of bias was assessed in 48 ( 52.7 % ) of these 91 systematic review s. Thirty-three ( 36.3 % ) SRs provided sufficient information to evaluate the internal validity of the included studies . Of the evaluated primary studies , 24.6 % was r and omized , 14.6 % reported blinding of the investigator/caretaker , 23.9 % blinded the outcome assessment , and 23.1 % reported drop-outs . Conclusions To improve the translation of animal data to clinical practice , systematic review s of animal studies are worthwhile , but the internal validity of primary animal studies needs to be improved . Furthermore , risk of bias should be assessed by systematic review s of animal studies to provide insight into the reliability of the available evidence Background Systematic review s ( SRs ) can help decision makers interpret the deluge of published biomedical literature . However , a SR may be of limited use if the methods used to conduct the SR are flawed , and reporting of the SR is incomplete . To our knowledge , since 2004 there has been no cross-sectional study of the prevalence , focus , and completeness of reporting of SRs across different specialties . Therefore , the aim of our study was to investigate the epidemiological and reporting characteristics of a more recent cross-section of SRs . Methods and Findings We search ed MEDLINE to identify potentially eligible SRs indexed during the month of February 2014 . Citations were screened using prespecified eligibility criteria . Epidemiological and reporting characteristics of a r and om sample of 300 SRs were extracted by one review er , with a 10 % sample extracted in duplicate . We compared characteristics of Cochrane versus non-Cochrane review s , and the 2014 sample of SRs versus a 2004 sample of SRs . We identified 682 SRs , suggesting that more than 8,000 SRs are being indexed in MEDLINE annually , corresponding to a 3-fold increase over the last decade . The majority of SRs addressed a therapeutic question and were conducted by authors based in China , the UK , or the US ; they included a median of 15 studies involving 2,072 participants .  Meta- analysis was performed in 63 % of SRs , mostly using st and ard pairwise methods . Study risk of bias/ quality assessment was performed in 70 % of SRs but was rarely incorporated into the analysis ( 16 % ) . Few SRs ( 7 % ) search ed sources of unpublished data , and the risk of publication bias was considered in less than half of SRs . Reporting quality was highly variable ; at least a third of SRs did not report use of a SR protocol , eligibility criteria relating to publication status , years of coverage of the search , a full Boolean search logic for at least one data base , methods for data extraction , methods for study risk of bias assessment , a primary outcome , an abstract conclusion that incorporated study limitations , or the funding source of the SR . Cochrane SRs , which accounted for 15 % of the sample , had more complete reporting than all other types of SRs . Reporting has generally improved since 2004 , but remains suboptimal for many characteristics . Conclusions An increasing number of SRs are being published , and many are poorly conducted and reported . Strategies are needed to help reduce this avoidable waste in research Objective To identify potentially effective complementary approaches for musculoskeletal (MSK)–mental health ( MH ) comorbidity , by synthesis ing evidence on effectiveness , cost-effectiveness and safety from systematic review s ( SRs ) . Design Scoping review of SRs . Methods We search ed literature data bases , registries and reference lists , and contacted key authors and professional organisations to identify SRs of r and omised controlled trials for complementary medicine for MSK or MH . Inclusion criteria were : published after 2004 , study ing adults , in English and scoring > 50 % on Assessing the Method ological Quality of Systematic Review s ( AMSTAR ) ; quality appraisal checklist ) . SRs were synthesis ed to identify research priorities , based on moderate/good quality evidence , sample size and indication of cost-effectiveness and safety . Results We included 84 MSK SRs and 27 MH SRs . Only one focused on MSK – MH comorbidity . Meditative approaches and yoga may improve MH outcomes in MSK population s. Yoga and tai chi had moderate/good evidence for MSK and MH conditions . SRs reported moderate/good quality evidence ( any comparator ) in a moderate/large population for :  low back pain ( LBP )  ( yoga , acupuncture , spinal manipulation/mobilisation , osteopathy ) , osteoarthritis ( OA ) ( acupuncture , tai chi ) , neck pain  ( acupuncture , manipulation/manual therapy ) , myofascial trigger point pain ( acupuncture ) , depression ( mindfulness-based stress reduction ( MBSR ) , meditation , tai chi , relaxation ) , anxiety ( meditation/MBSR , moving meditation , yoga ) , sleep disorders ( meditative/mind – body movement ) and stress/distress ( mindfulness ) . The majority of these complementary approaches had some evidence of safety — only three had evidence of harm . There was some evidence of cost-effectiveness for spinal manipulation/mobilisation and acupuncture for LBP , and manual therapy/manipulation for neck pain , but few SRs review ed cost-effectiveness and many found no data . Conclusions Only one SR studied MSK – MH comorbidity . Research priorities for complementary medicine for both MSK and MH ( LBP , OA , depression , anxiety and sleep problems ) are yoga , mindfulness and tai chi . Despite the large number of SRs and the prevalence of comorbidity , more high- quality , large r and omised controlled trials in comorbid population s are needed Background Breast cancer ( BC ) is the most common type of cancer in women worldwide . Post-treatment , patients suffer from side effects and have various rehabilitation needs , which means that individualization is fundamental for optimal rehabilitation . This systematic review ( SR ) of SRs aims to evaluate the current evidence on rehabilitation interventions in female patients following BC treatment . Methods Full-text SRs published in English from 2009 were search ed in Embase , PubMed , Cinahl Complete , PsycINFO , AMED , SCOPUS , and Cochrane Library . Inclusion criteria : SRs of r and omized or non-r and omized controlled trials investigating the effects of  rehabilitation interventions in women following BC treatment . All outcomes were considered . Method ological quality was evaluated using the AMSTAR 2 tool and interrater agreement was evaluated . Out of 1269 citations retrieved , 37 SRs were included . Results Five rehabilitation areas were identified : exercise and physical activity ( PA ) , complementary and alternative medicine ( CAM ) , yoga , lymphoedema treatment , and psychosocial interventions . The most solid evidence was found in exercise/PA and yoga . Exercise interventions improved outcomes such as shoulder mobility , lymphoedema , pain , fatigue and quality of life ( QoL ) . Effects of yoga were shown on QoL , anxiety , depression , sleep disturbance , fatigue and gastrointestinal symptoms . The effect of CAM was shown on nausea , pain , fatigue , anger and anxiety but these results need to be interpreted with caution because of low method ological quality in included studies in the SRs . Among the lymphoedema treatments , positive effects were seen for resistance training on volume reduction and muscle strength and psychosocial interventions such as cognitive behavioural therapy had positive effects on QoL , anxiety , depression and mood disturbance . Conclusions This SR of SRs show solid positive effects of exercise/PA and yoga for women following BC treatment , and provides extended knowledge of the effects of CAM , yoga , lymphoedema treatment and psychosocial interventions . It is evident that more than one intervention could have positive effects on a specific symptom and that the effects depend not only on intervention type but also on how and when the intervention is provided . The results can be used as a foundation for individualized rehabilitation and aid health care professionals in meeting patients ’ individual needs and preferences . Trial registration PROSPERO ( CRD42017060912 ) Medicinal cannabis has already entered mainstream medicine in some countries . This systematic review ( SR ) aim ed at evaluating the efficacy , acceptability and safety of cannabis-based medicines for chronic pain management . Qualitative systematic review of SRs of r and omized controlled trials with cannabis-based medicines for chronic pain management . The Cochrane data bases of SRs , Data base of Abstract s of Review s of Effects and PubMed were search ed for SR published in the period January 2009 to January 2017 . Assessment of the method ological quality of SR was performed by the AMSTAR checklist . Out of 748 papers identified , 10 SRs met the inclusion criteria . The method ological quality was high in four and moderate in six SRs . There were inconsistent findings of four SRs on the efficacy of cannabis-based medicines in neuropathic pain and of one SR for painful spasms in multiple sclerosis . There were consistent results that there was insufficient evidence of any cannabis-based medicine for pain management in patients with rheumatic diseases ( three SRs ) and in cancer pain ( two SRs ) . Cannabis-based medicines undoubtedly enrich the possibilities of drug treatment of chronic pain conditions . It remains the responsibility of the health care community to continue to pursue rigorous study of cannabis-based medicines to provide evidence that meets the st and ard of 21st century clinical care . SIGNIFICANCE We provide an overview of systematic review s on the efficacy , tolerability and safety of cannabis-based medicines for chronic pain management . There are inconsistent findings of the efficacy of cannabinoids in neuropathic pain and painful spasms in multiple sclerosis . There are inconsistent results on tolerability and safety of cannabis-based medicines for any chronic pain Background Systematic review s ( SRs ) should be up to date to maintain their importance in informing healthcare policy and practice . However , little guidance is available about when and how to up date SRs . Moreover , the updating policies and practice s of organizations that commission or produce SRs are unclear . Methodology /Principal Findings The objective was to describe the updating practice s and policies of agencies that sponsor or conduct SRs . An Internet-based survey was administered to a purposive non-r and om sample of 195 healthcare organizations within the international SR community . Survey results were analyzed using descriptive statistics . The completed response rate was 58 % ( n = 114 ) from across 26 countries with 70 % ( 75/107 ) of participants identified as producers of SRs . Among responders , 79 % ( 84/107 ) characterized the importance of updating as high or very-high and 57 % ( 60/106 ) of organizations reported to have a formal policy for updating . However , only 29 % ( 35/106 ) of organizations made reference to a written policy document . Several groups ( 62/105 ; 59 % ) reported updating practice s as irregular , and over half ( 53/103 ) of organizational respondents estimated that more than 50 % of their respective SRs were likely out of date . Authors of the original SR ( 42/106 ; 40 % ) were most often deemed responsible for ensuring SRs were current . Barriers to updating included re source constraints , review er motivation , lack of academic credit , and limited publishing formats . Most respondents ( 70/100 ; 70 % ) indicated that they supported central ization of updating efforts across institutions or agencies . Furthermore , 84 % ( 83/99 ) of respondents indicated they favoured the development of a central registry of SRs , analogous to efforts within the clinical trials community . Conclusions / Significance Most organizations that sponsor and /or carry out SRs consider updating important . Despite this recognition , updating practice s are not regular , and many organizations lack a formal written policy for updating SRs . This research marks the first baseline data available on updating from an organizational perspective Differences in disease prevalence , clinical manifestations , and health outcomes exist between men and women . Sources for this variation range from biological differentiation at the cellular level to behavioral differences influenced by societal gender norms . Typically , biologically based differences between men and women are called sex differences , whereas gender differences describe health differences related , at least in part , to societal constructs of gender ( 13 ) . For example , biological events unique to women , such as pregnancy and menopause , are probably associated with sex differences in occurrence of certain conditions or in response to some medical therapies ( 48 ) . Gender differences probably exist in health-related perceptions and behaviors for women and men with medical conditions that are prevalent for both sexes ( for example , heart disease and chronic pain ) ( 9 –16 ) . Although sex and gender differences are theoretically distinct , they remain difficult to disentangle when differences between men and women in health outcomes and treatment effectiveness are being examined . For this reason , and for brevity , we hereafter refer to sex and gender differences collectively as sex effects . In the past 2 decades , recognition of the importance of sex effects for health outcomes and treatment heterogeneity has been growing . Beginning in 1993 , the National Institutes of Health has issued policies requiring the inclusion of women and minorities in all clinical research and trial design s with valid analysis of sex effects or differences between racial and ethnic groups ( 17 , 18 ) . Since then , the inclusion of women in clinical trials has increased ( 19 , 20 ) , and sex effects have been identified for medications , such as nicotine replacement therapy , analgesics , and aspirin ( 13 , 14 , 21 ) . Recently , sex effects in adverse reactions led to sex-specific dosage recommendations for a widely used sedative ( 7 ) . Despite this progress , representation of women in clinical studies remains inadequate for many conditions ( 22 ) . Further , published clinical trials infrequently report sex effects or discuss the appropriateness of sex-specific analyses ( 19 , 20 , 23 ) . To advance the clinical evidence base and improve health outcomes for women , clinical research must include adequate numbers of women , appropriately conduct sex-specific analyses , and consistently report sex effects . Systematic review s ( SRs ) are a key source of information for clinicians , research ers , and guideline panels . By synthesizing the overall body of evidence for key clinical and research questions , SRs could potentially make a unique contribution to the evaluation of sex effects . To our knowledge , however , the reporting of sex effects by SRs has not been previously examined . Here , we use evidence mapping to systematic ally evaluate the reporting of sex effects by SRs examining a diverse set of interventions for chronic conditions common to women ( that is , depression , diabetes , and chronic pain ) . Evidence mapping is an emerging approach that describes key characteristics of studies for a broad area of medicine ( 2426 ) . Our evidence map addresses the volume and characteristics of eligible SRs , including the representation of women in primary studies , whether and how review s reported sex effects , and findings about sex effects . Methods This work was part of a larger report for the Veterans Health Administration ( VHA ) Evidence -based Synthesis Program ( ESP ) . The complete technical report is available online ( www.hsrd . research .va.gov/publications/esp ) and includes additional information on our methods . We focused on SRs to determine the reporting of sex effects , provide high-level information about the volume of current clinical evidence , and summarize information about actual sex effects . Prioritization of Conditions for Inclusion We used forced-ranking prioritization ( 27 ) with our VHA stakeholders to determine our conditions of interest . These stakeholders included representatives from the Health Services Research & Development Center for the Study of Healthcare Innovation , Implementation and Policy ; Health Services Research & Development Women 's Health Research Network ; Women 's Health Research in the Office of Research & Development ; Women 's Health Services ; and Mental Health Services . We initially selected 34 conditions ( Appendix Table 1 ) based on disease prevalence in women , disease burden in women , availability and breadth of effective treatments for men or women , and women veterans ' priorities for gender-specific care . Stakeholders ranked this initial set of conditions , discussed the rankings , and reranked conditions that initially received intermediate priority rankings . After 2 rounds of iterative prioritization , the following conditions were selected : depressive disorders , type 2 diabetes mellitus , and chronic pain ( that is , chronic low back pain , fibromyalgia , and chronic knee pain due to osteoarthritis ) . Appendix Table 1 . Conditions Presented to Stakeholders for Prioritization * Data Sources and Search es In collaboration with an expert reference librarian , we search ed PubMed and Cochrane Data base of Systematic Review s to identify eligible SRs published after 1 October 2009 through 31 October 2014 for depression , 13 February 2015 for diabetes , and 27 February 2015 for chronic pain . Search strategies used Medical Subject Headings and free-text terms for the conditions of interest , eligible interventions , and SRs ( Appendix Table 2 ) . We restricted the search to the past 6 years because SRs are typically out date d within 5 years of publication ( 28 ) , and our goal was to describe the current state of the clinical literature . In addition to electronic search ing , we screened published review s of review s for eligible articles . Appendix Table 2 . Search Strategies Study Selection and Quality Assessment Eligible SRs evaluated interventions in several broad categories ( that is , medications , behavioral interventions , supervised exercise , and quality improvement or organizational interventions ) . We also included condition-specific interventions , such as bariatric surgery for diabetes . Review s that evaluated mixed conditions or multiple interventions must have reported results separately for at least 1 eligible condition or intervention . We included review s of interventions in any setting , with any type of active or inactive comparator , and with any duration of follow-up . Detailed inclusion and exclusion criteria are provided in Appendix Table 3 . Appendix Table 3 . Detailed Inclusion and Exclusion Criteria for Review Eligibility Two investigators screened citations for eligibility , and citations that were considered to be relevant by either person were retained for full-text review . Full-text articles were review ed by 2 investigators , and disagreements were resolved through discussion or adjudicated by a third person . Formal assessment of review quality was beyond the scope of this project . However , we noted whether review s originated from organizations known for high- quality review s ( that is , Cochrane Collaboration , Agency for Healthcare Research and Quality Evidence -based Practice Centers , and VHA ESP ) . For review s reporting sex effects , we also assessed industry funding and whether statistical power was considered . Data Abstract ion Data were abstract ed by 1 investigator and review ed by a second person . Disagreements were resolved by discussion or by a third review er . Abstract ed data included the analysis method ( that is , qualitative synthesis , meta- analysis , network meta- analysis , or individual-patient data [ IPD ] meta- analysis ) ; clinical conditions ; interventions ; main outcomes ; number and design of primary studies ( for example , r and omized , controlled trials [ RCTs ] or observational cohorts ) ; proportion of women in the included primary studies ; and if sex effects were part of the study aims , analysis plan , or results . For review s reporting sex effects , we also recorded the number of primary studies used for sex-specific analyses , effect estimates , and the method used ( for example , metaregression , subgroup analysis , or IPD meta- analysis ) . All eligible review s on depressive disorders and chronic pain conditions were fully abstract ed . All diabetes review s of nonpharmacologic interventions were also fully abstract ed . For eligible diabetes medication review s ( n= 120 ) , we applied an additional prioritization procedure before full abstract ion . We prioritized review s that examined multiple classes of medications or evaluated a single class of medications when 6 or fewer eligible review s were identified . For SRs evaluating a single class ( > 6 eligible review s were identified ) , we used additional prioritization criteria ( for example , the most recent review published in a high-impact journal or work done by an organization known for high- quality review s ) . The remaining unselected but eligible review s ( n= 58 ) had a keyword text search for sex effects and were fully abstract ed only when this search yielded positive results ( n= 13 ) . Data Synthesis and Analysis of SRs We grouped eligible review s by intervention category and described the overall volume of clinical literature for interventions addressing each condition of interest . We also determined the number of review s reporting sex effects and summarized these results . Time trends for the proportion of these review s were examined for depression and diabetes . Examination of Primary RCTs for Selected Interventions We anticipated that some interventions for each condition would have few or no eligible SRs that addressed sex effects . Thus , for a subset of interventions for each condition , we evaluated primary RCTs to determine the feasibility of conducting a future review to evaluate sex effects . Specifically , we examined  quality improvement interventions and psychotherapy for depression ; diet , physical activity , and culturally tailored psychoeducation for diabetes ; behavioral interventions for chronic low back pain ; and exercise interventions Objective . The aim of this overview was to summarize the outcome measures of Chinese herbal medicine ( CHM ) for the treatment of hypertension based on available systematic review s ( SRs ) , so as to evaluate the potential benefits and advantages of CHM on hypertension . Methods . Literature search es were conducted in the Cochrane Data base of Systematic Review s , MEDLINE , and 4 data bases in Chinese . SRs of CHM for hypertension were included . Two independent review ers ( J. Wang and X. J. Xiong ) extracted the data . Results . 10 SRs were included . 2 SRs had primary endpoints , while others focused on secondary endpoints to evaluate CHM for hypertension such as blood pressure ( BP ) and Traditional Chinese Medicine ( TCM ) syndrome . 6 SRs have reported the adverse effects , whereas the other 4 SRs have not mentioned it at all . Many CHM appeared to have significant effect on improving BP , TCM syndrome , and so on . However , most SRs failed to make a definite conclusion for the effectiveness of CHM for hypertension due to poor evidence . Conclusion . Primary endpoints have not been widely used currently . The benefits of CHM for hypertension need to be confirmed in the future with r and omized controlled trials ( RCTs ) of more persuasive primary endpoints and high- quality SRs CONTEXT The findings of systematic review s ( SRs ) and meta-analyses ( MAs ) are used for clinical decision making . The European Association of Urology has committed increasing re sources into the development of high quality clinical guidelines based on such SRs and MAs . OBJECTIVE In this paper , we have summarised the process of conducting SRs for underpinning clinical practice guidelines under the auspices of the European Association of Urology Guidelines Office . EVIDENCE ACQUISITION The process involves explicit methods and the findings should be reproducible . When conducting a SR , the essential first step is to formulate a clear and answerable research question . An extensive literature search lays the foundation for evidence synthesis . Data are extracted independently by two review ers and any disagreements are resolved by discussion or arbitration by a third review er . EVIDENCE SYNTHESIS In SRs , data for particular outcomes in individual r and omised controlled trials may be combined statistically in a meta- analysis to increase power when the studies are similar enough . Biases in studies included in a SR/MA can lead to either an over estimation or an under estimation of true intervention effect size , result ing in heterogeneity in outcome between studies . A number of different tools are available such as Cochrane Risk of Bias assessment tool for r and omised controlled trials . In circumstances where there is too much heterogeneity , or when a review has included nonr and omised comparative studies , it is more appropriate to conduct a narrative synthesis . The GRADE tool for assessing quality of evidence strives to be a structured and transparent system , which can be applied to all evidence , regardless of quality . A SR not only identifies , evaluates , and summarises the best available evidence , but also the gaps to be targeted by future studies . CONCLUSIONS SRs and MAs are integral in developing sound clinical practice guidelines and recommendations . PATIENT SUMMARY Clinical practice guidelines should be evidence based , and systematic review s and meta-analyses are essential in their production . We have discussed the key steps of conducting systematic review s and meta-analyses in this paper Background Systematic review s ( SRs ) are expected to critically appraise included studies and privilege those at lowest risk of bias ( RoB ) in the synthesis . This study examines if and how critical appraisal s inform the synthesis and interpretation of evidence in SRs . Methods All SRs published in March – May 2012 in 14 high-ranked medical journals and a sample from the Cochrane library were systematic ally assessed by two review ers to determine if and how : critical appraisal was conducted ; RoB was summarised at study , domain and review levels ; and RoB appraisal s informed the synthesis process . Results Of the 59 SRs studied , all except six ( 90 % ) conducted a critical appraisal of the included studies , with most using or adapting existing tools . Almost half of the SRs reported critical appraisal in a manner that did not allow readers to determine which studies included in a review were most robust . RoB assessment s were not incorporated into synthesis in one-third ( 20 ) of the SRs , with their consideration more likely when review s focused on r and omised controlled trials . Common methods for incorporating critical appraisal s into the synthesis process were sensitivity analysis , narrative discussion and exclusion of studies at high RoB. Nearly half of the review s which investigated multiple outcomes and carried out study -level RoB summaries did not consider the potential for RoB to vary across outcomes . Conclusions The conclusions of the SRs , published in major journals , are frequently uninformed by the critical appraisal process , even when conducted . This may be particularly problematic for SRs of public health topics that often draw on diverse study design BACKGROUND AND PURPOSE Acupuncture is widely used in the treatment of hypertension , yet its efficacy and safety for hypertension remain controversial . This overview aim ed to summarize the evidence on acupuncture for hypertension . METHODS Eight data bases were search ed . The Assessment of Multiple Systematic Review s ( AMSTAR ) tool and the Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach were performed . RESULTS Fifteen systematic review s ( SRs ) were identified . Method ological quality and quality of evidence were unsatisfactory . Acupuncture combined with Western medicine ( WM ) was superior to WM in systolic blood pressure ( SBP ) and diastolic blood pressure ( DBP ) , efficacy rate , and traditional Chinese medicine ( TCM ) syndrome .  Acupuncture was more effective in treating SBP and DBP than sham acupuncture plus WM . Evidence regarding the benefit of acupuncture alone for SBP and DBP , efficacy rate and TCM syndrome was inconsistent . No serious adverse effects were identified . CONCLUSION High- quality SRs and r and omized controlled trials ( RCTs ) are required Purpose : To set priorities for new systematic review s ( SRs ) and r and omized clinical trials on the management of primary angle closure ( PAC ) using clinical practice guidelines and a survey of Asia-Pacific clinicians . Methods : We restated the American Academy of Ophthalmology ’s Preferred Practice Patterns recommendations for management of PAC into answerable clinical questions . We asked participants at the Asia-Pacific Joint Glaucoma Congress 2010 in Taipei to rate the importance of having an answer to each question for providing effective patient care , using a Likert-type scale and scoring from 0 ( not important at all ) to 10 ( highly important ) . We identified relevant SRs and mapped the evidence to clinical questions to identify evidence gaps . Results : We generated 42 clinical questions . One hundred seventy-five individuals agreed to participate in the survey , 132 responded ( 75.4 % response rate ) and 96 completed the question naire ( 54.9 % usable response rate ) . Questions rated important include laser iridotomy for the prevention of angle closure in primary angle-closure suspects , further therapies in eyes with plateau iris syndrome after laser iridotomy , and evaluation of the fellow eye in acute angle-closure patients for improving prognosis . Up-to- date and conclusive SR evidence was not available for any of the 42 clinical questions . Conclusions : We identified high priority clinical questions on the management of PAC , none of which had reliable SR evidence available . New SRs and r and omized clinical trials can be initiated to address these evidence gaps Background The peer review process is a cornerstone of biomedical research publications . However , it may fail to allow the publication of high- quality articles . We aim ed to identify and sort , according to their importance , all tasks that are expected from peer review ers when evaluating a manuscript reporting the results of a r and omized controlled trial ( RCT ) and to determine which of these tasks are clearly requested by editors in their recommendations to peer review ers . Methods We identified the tasks expected of peer review ers from 1 ) a systematic review of the published literature and 2 ) recommendations to peer review ers for 171 journals ( i.e. , 10 journals with the highest impact factor for 14 different medical areas and all journals indexed in PubMed that published more than 15 RCTs over 3 months regardless of the medical area ) . Participants who had peer- review ed at least one report of an RCT had to classify the importance of each task relative to other tasks using a Q-sort technique . Finally , we evaluated editors ’ recommendations to authors to determine which tasks were clearly requested by editors in their recommendations to peer review ers . Results The Q-sort survey was completed by 203 participants , 93 ( 46 % ) with clinical expertise , 72 ( 36 % ) with method ological/statistical expertise , 17 ( 8 % ) with expertise in both areas , and 21 ( 10 % ) with other expertise . The task rated most important by participants ( evaluating the risk of bias ) was clearly requested by only 5 % of editors . In contrast , the task most frequently requested by editors ( provide recommendations for publication ) , was rated in the first tertile only by 21 % of all participants . Conclusions The most important tasks for peer review ers were not congruent with the tasks most often requested by journal editors in their guidelines to review ers OBJECTIVE Systematic review s ( SRs ) are the cornerstone of evidence -based medicine . In this study , we evaluated the effectiveness of using two computer screens on the efficiency of conducting SRs . STUDY DESIGN AND SETTING A cohort of review ers before and after using dual monitors were compared with a  control group that did not use dual monitors .  The outcomes were time spent for abstract screening , full-text screening and data extraction , and inter-rater agreement . We adopted multivariate difference-in-differences linear regression models . RESULTS A total of 60 SRs conducted by 54 review ers were included in this analysis . We found a significant reduction of 23.81 minutes per article in data extraction in the intervention group relative to the control group ( 95 % confidence interval : -46.03 , -1.58 , P = 0.04 ) , which was a 36.85 % reduction in time . There was no significant difference in time spent on abstract screening , full-text screening , or inter-rater agreement between the two groups . CONCLUSION Using dual monitors when conducting SRs is associated with significant reduction of time spent on data extraction . No significant difference was observed on time spent on abstract screening or full-text screening . Using dual monitors is one strategy that may improve the efficiency of conducting SRs 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 We conducted a review of systematic review s ( SRs ) and r and omized-controlled trials ( RCTs ) to analyze efficacy and safety of cannabis-based medication in patients with mental disorders . Five data bases were systematic ally search ed ( 2006—August 2018 ) ; 4 SRs ( of 11 RCTs ) and 14 RCTs ( 1629 participants ) were included . Diagnoses were : dementia , cannabis and opioid dependence , psychoses/schizophrenia , general social anxiety , posttraumatic stress disorder , anorexia nervosa , attention-deficit hyperactivity disorder , and Tourette`s disorder . Outcome variables were too heterogeneous to conduct a meta- analysis . A narrative synthesis method was applied . The study quality was assessed using the risk-of-bias tool and SIGN-checklists . THC- and CBD-based medicines , given as adjunct to pharmaco- and psychotherapy , were associated with improvements of several symptoms of mental disorders , but not with remission . Side effects occurred , but severe adverse effects were mentioned in single cases only . In order to provide reliable treatment recommendations , more and larger RCTs with follow-up assessment s , consistent outcome measures and active comparisons are needed Introduction There is an increasing number of new oncology drugs being studied , approved and put into clinical practice based on improvement in progression-free survival , when no overall survival benefits exist . In oncology , the association between progression-free survival and health-related quality of life is currently unknown , despite its importance for patients with cancer , and the unverified assumption that longer progression-free survival indicates improved health-related quality of life . Thus far , only 1 study has investigated this association , providing insufficient evidence and inconclusive results . The objective of this study protocol is to provide increased transparency in supporting a systematic summary of the evidence bearing on this association in oncology . Methods and analysis Using the OVID platform in MEDLINE , Embase and Cochrane data bases , we will conduct a systematic review of r and omised controlled human trials addressing oncology issues published starting in 2000 . A team of review ers will , in pairs , independently screen and abstract data using st and ardised , pilot-tested forms . We will employ numerical integration to calculate mean incremental area under the curve between treatment groups in studies for health-related quality of life , along with total related error estimates , and a 95 % CI around incremental area . To describe the progression-free survival to health-related quality of life association , we will construct a scatterplot for incremental health-related quality of life versus incremental progression-free survival . To estimate the association , we will use a weighted simple regression approach , comparing mean incremental health-related quality of life with either median incremental progression-free survival time or the progression-free survival HR , in the absence of overall survival benefit . Discussion Identifying direction and magnitude of association between progression-free survival and health-related quality of life is critically important in interpreting results of oncology trials . Systematic evidence produced from our study will contribute to improvement of patient care and practice of evidence -based medicine in oncology 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 This is the last in a series of four articles Prognostic studies include clinical studies of variables predictive of future events as well as epidemiological studies of aetiological risk factors . As multiple similar studies accumulate it becomes increasingly important to identify and evaluate all of the relevant studies to develop a more reliable overall assessment . For prognostic studies this is not straightforward . Box 1 summarises the clinical importance of information on prognostic factors . Many of the issues discussed are also relevant to aetiological studies , especially cohort ones . Some features of prognostic studies lead to particular difficulties for the systematic review er . Firstly , in most clinical prognostic studies the outcome of primary interest is the time to an event , often death . Meta- analysis of such studies is rather more difficult than that for binary data or continuous measurements . Secondly , in many context s the prognostic variable of interest is often one of several prognostic variables . When examining a variable of interest research ers should consider other prognostic variables with which it might be correlated . Thirdly , many prognostic factors are continuous variables , for which research ers use a wide variety of methods of analysis . # # # # Summary points Systematic review s are applicable to all types of research design , and studies of prognostic variables are an important additional area where appropriate methodology should be applied Prognostic variables should be evaluated in a representative sample of patients assembled at a common point in the course of their disease — ideally they should all have received the same medical treatment or been in a r and omised trial When examined critically , a high proportion of prognostic studies are found to be method ologically poor Meta- analysis of published data is hampered by difficulties in extraction of data and variation in the characteristics of the study and patients The poor quality of the published literature is a strong argument in favour Nutrients and other bioactive constituents of foods may interact with each other and the surrounding food matrix in complex ways . Therefore , associations between single nutrients and chronic disease may be difficult to identify and interpret , but when dietary patterns ( DPs ) are examined the combination of many food factors will be considered . An explorative literature search of published review articles was conducted to obtain a fuller underst and ing of current DPs in epidemiological research , to discuss pros and cons of DPs in nutrition research , and to identify results of studies linking DPs to chronic disease risk in adults . R and omized feeding trials providing the experimental diets to study participants have repeatedly demonstrated that diets based on current dietary recommendations are associated with important health benefits . Systematic review s of feeding trials and prospect i ve population studies of DPs and chronic disease risk reach similar conclusions regardless of the methodology used to construct DPs . However , to date only a few review articles of DP studies have followed a systematic process using independent review ers with strict inclusion , exclusion , and study quality criteria . Diets with plenty of plants foods , fish , and seafood that preferably include vegetable oils and low-fat dairy products are associated with a lower risk of most chronic diseases . In contrast , Western-type DPs with food products low in essential nutrients and high in energy , like sugar-sweetened beverages , sweets , refined cereals and solid fats ( e.g. butter ) , and high in red and processed meats , are associated with adverse health effects . An emphasis on high- quality original research , and systematic review s following a structured process to objective ly select and judge studies , is needed in order to enforce a strong future knowledge base regarding DPs and chronic disease Background Systematic Review s ( SRs ) of experimental animal studies are not yet common practice , but awareness of the merits of conducting such SRs is steadily increasing . As animal intervention studies differ from r and omized clinical trials ( RCT ) in many aspects , the methodology for SRs of clinical trials needs to be adapted and optimized for animal intervention studies . The Cochrane Collaboration developed a Risk of Bias ( RoB ) tool to establish consistency and avoid discrepancies in assessing the method ological quality of RCTs . A similar initiative is warranted in the field of animal experimentation . Methods We provide an RoB tool for animal intervention studies ( SYRCLE ’s RoB tool ) . This tool is based on the Cochrane RoB tool and has been adjusted for aspects of bias that play a specific role in animal intervention studies . To enhance transparency and applicability , we formulated signalling questions to facilitate judgment . Results The result ing RoB tool  for animal studies contains 10 entries . These entries are related to selection bias , performance bias , detection bias , attrition bias , reporting bias and other biases . Half these items are in agreement with the items in the Cochrane RoB tool . Most of the variations between the two tools are due to differences in design between RCTs and animal studies . Shortcomings in , or unfamiliarity with , specific aspects of experimental design of animal studies compared to clinical studies also play a role . Conclusions SYRCLE ’s RoB tool is an adapted version of the Cochrane RoB tool . Widespread adoption and implementation of this tool will facilitate and improve critical appraisal of evidence from animal studies . This may subsequently enhance the efficiency of translating animal research into clinical practice and increase awareness of the necessity of improving the method ological quality of animal studies Objective Systematic review s can include cluster-r and omised controlled trials ( C- RCTs ) , which require different analysis compared with st and ard individual-r and omised controlled trials . However , it is not known whether review authors follow the method ological and reporting guidance when including these trials . The aim of this study was to assess the method ological and reporting practice of Cochrane review s that included C- RCTs against criteria developed from existing guidance . Methods Criteria were developed , based on method ological literature and personal experience supervising review production and quality . Criteria were grouped into four themes : identifying , reporting , assessing risk of bias , and analysing C- RCTs . The Cochrane Data base of Systematic Review s was search ed ( 2nd December 2013 ) , and the 50 most recent review s that included C- RCTs were retrieved . Each review was then assessed using the criteria . Results The 50 review s we identified were published by 26 Cochrane Review Groups between June 2013 and November 2013 . For identifying C- RCTs , only 56 % identified that C- RCTs were eligible for inclusion in the review in the eligibility criteria . For reporting C- RCTs , only eight ( 24 % ) of the 33 review s reported the method of cluster adjustment for their included C- RCTs . For assessing risk of bias , only one review assessed all five C- RCT -specific risk-of-bias criteria . For analysing C- RCTs , of the 27 review s that presented unadjusted data , only nine ( 33 % ) provided a warning that confidence intervals may be artificially narrow . Of the 34 review s that reported data from unadjusted C- RCTs , only 13 ( 38 % ) excluded the unadjusted results from the meta-analyses . Conclusions The method ological and reporting practice s in Cochrane review s incorporating C- RCTs could be greatly improved , particularly with regard to analyses . Criteria developed as part of the current study could be used by review authors or editors to identify errors and improve the quality of published systematic review s incorporating C- RCTs
The reporting quality of SRs has improved 3 y after publication of SR reporting st and ards , but the reporting of nutrition variables has not .
Improved adherence to consensus methods and reporting st and ards should improve the utility of nutrition SRs
BACKGROUND The quality of nutrition-related systematic review s ( SRs ) is an unstudied but important factor affecting their usefulness .
OBJECTIVES The objectives were to evaluate the reporting quality of published SRs and to identify areas of improvement .