To conduct a systematic survey on the extent of the use of the grading of recommendations, assessment, development, and evaluations (GRADE) and other evidence grading systems in Campbell systematic reviews (SRs). Campbell SRs published before January 1st, 2024, that used evidence grading systems were included. General characteristics and details of a summary of findings (SoF) table and an evidence profile (EP) were independently extracted by two investigators. Among 234 SRs retrieved, 46 (19.66%) used evidence grading systems, all of which were GRADE. One used GRADE erroneously to rate the quality of individual studies rather than the body of evidence. The 45 SRs used GRADE to assess the certainty of a body of evidence and included 858 outcomes. Of them, the certainty in evidence for 32 were rated as high (3.73%), 170 were moderate (19.81%), 291 were low (33.92%), and 365 were very low (42.54%). Among the 1860 instances of downgrading and upgrading, the certainty in evidence was mostly downgraded for risk of bias (ROB) (1026, 55.16%) and imprecision (408, 21.94%). The large magnitude of effect (14, 0.75%) and plausible confounding (10, 0.54%) were the main upgraded factors. The proportions for higher certainty in evidence (including high and moderate) were larger in the international development (9.59%) and social welfare (7.55%) groups than in the other groups (1.37%). Most Campbell SRs do not assess the GRADE certainty in evidence. Where evidence is evaluated, the quality of that evidence is mainly low or very low, and this is most commonly due to serious ROB or imprecision.
BackgroundLarge language models (LLMs) may reduce the burden associated with performing systematic reviews by prescreening abstracts from a literature search for eligibility for inclusion in full-text review.MethodsWe developed an iterative, LLM-based workflow for screening abstracts: after manual specification of eligibility criteria and seed examples, an ensemble of five LLMs deliberates through a Delphi process to classify a batch of abstracts; these labels are used to train a logistic regression model that ranks the remaining abstracts and identifies a new batch of abstracts for LLM escalation until all abstracts are labelled by the LLM or probability thresholds. We tested our workflow on abstracts screened in three published systematic reviews in psychiatry. Our primary endpoint was the recall metric, and secondary endpoint was the work saved over sampling at 95% recall metric (WSS@95%).ResultsIn a dataset on autism biomarkers, 1,655 (35%) of 4,745 retrieved abstracts were judged to be relevant by the original authors. The Delphi-LLM workflow correctly identified 1,605 (97.0%) of these 1,655 abstracts (precision = 54.2%, WSS@95% = 38.1%). The performance metrics were better than non-LLM approaches (recall ≤ 91%, WSS@95 ≤ 26%), and, overall, balanced these metrics optimally compared to single-LLM agents (recall = 84.9-99.9%, WSS@95% = 16.7-39.8%). The recall and work saved metrics were similarly reliable and among the top in two low-prevalence datasets on an attention-deficit hyperactivity disorder treatment review (10% of 2,891 relevant) and a posttraumatic stress disorder trajectory review (7% of 4,453 relevant). For these two datasets, recall was 100.0% and 96.4%, and the WSS@95% was 17.3% and 18.5%, respectively.ConclusionsWe presented the design and validation of a novel abstract screening workflow that centres around a Delphi-style aggregation process to harness the strengths of five open-source LLMs that can be run on consumer-level workstations. This multi-LLM workflow showed acceptable and reliable performance for use as an automated prescreening method to facilitate systematic reviews. A new algorithm to debate a team of AI language models for improving the screening process of article abstracts in psychiatry.Plain Language SummaryLarge language models (LLMs) can now understand and write complex scientific texts. Systematic reviews, which demand significant time and resources, can greatly benefit from the use of LLMs, which can process thousands of articles much faster and cheaper than human researchers.We built an automated workflow inspired by the Delphi method, where five different LLMs communicate with each other to reach a consensus decision on the relevance of a given abstract for a specific systematic review. In essence, the five-LLM Delphi ensemble serves as a teacher model that processes a small batch of difficult abstracts, which are also used to train a student classifier model that can clear similar abstracts. This two-stage cycle repeats until all abstracts are labelled, either by the LLM–Delphi teacher ensemble, or by the student classifier.We tested this workflow on three systematic reviews in psychiatry. In the first review containing 4,745 abstracts, the original authors determined 1,655 (35%) to be truly relevant. The workflow automatically determined 62% of the dataset as relevant and 38% as irrelevant, saving significant labour. The positively labelled abstracts contained 97% of the truly relevant abstracts, demonstrating the workflow’s competence (i.e., recall). The workflow showed similarly high recall (96–100%) but reduced labour savings (17–18%) in the other two reviews, which contained a lower proportion of relevant abstracts (i.e., 7% of 4,453 total in one, and 10% of 2,891 in another). Overall, the five-LLM model produced a more well-rounded and reliably excellent performance compared to using just a single-LLM model as the teacher, and better performance compared to not using LLMs to label the difficult cases.The entire workflow can run on a consumer-grade computer without sending data to costly cloud-based models. By achieving high recall ability and substantial labour savings, this approach could make systematic reviews faster and cheaper to conduct. Les grands modèles de langage (GML) peuvent réduire le fardeau associé à la réalisation de revues systématiques en effectuant une présélection des résumés issus d’une recherche documentaire pour déterminer s’ils peuvent être inclus dans une revue de texte intégral. Nous avons mis au point un flux de travail itératif fondé sur des GML en vue de la sélection des résumés; après avoir précisé manuellement les critères d’admissibilité et fourni des exemples initiaux, un ensemble de cinq GML délibère selon un processus Delphi afin de classer un lot de résumés; ces étiquettes servent ensuite à entraîner un modèle de régression logistique qui classe les résumés restants et identifie un nouveau lot de résumés à soumettre aux GML jusqu’à ce que tous les résumés aient été classés par les GML ou sur la base de seuils de probabilité. Nous avons testé notre flux de travail sur des résumés examinés sélectionnés dans le cadre de trois revues systématiques publiées en psychiatrie. Notre critère d’évaluation principal était la mesure du rappel, et notre critère d’évaluation secondaire était la quantité de travail évité par rapport à l’échantillonnage (work saved over sampling [WSS]) pour atteindre un rappel de 95% (WSS à 95%). Dans un ensemble de données portant sur les biomarqueurs de l’autisme, 1 655 (35%) des 4 745 résumés récupérés ont été jugés pertinents par les auteurs originaux. Le flux de travail Delphi-GML a correctement identifié 1 605 (97,0%) de ces 1 655 (précision = 54,2%, WSS à 95% = 38,1%). Les indicateurs de rendement se sont révélés supérieurs à ceux des approches ne faisant pas appel aux GML (rappel ≤ 91%, WSS à 95% ≤ 26%), tout en étant plus équilibrés que les meilleurs agents utilisant un seul GML (rappel = 84,9 à 99,9%, WSS à 95% = 16,7 à 39,8%). Les paramètres relatifs au rappel et à la quantité de travail évité (work saved) étaient tout aussi fiables et figuraient parmi les meilleurs résultats dans le cadre de deux ensembles de données à faible prévalence, l’un portant sur une revue du traitement du trouble du déficit de l’attention avec hyperactivité (10% des 2 891 résumés étant pertinents) et l’autre sur une revue des trajectoires du trouble de stress post-traumatique (7% des 4 453 résumés étant pertinents). Pour ces deux ensembles de données, le rappel était de 100,0% et de 96,4%, et les WSS à 95% étaient de 17,3% et de 18,5%, respectivement. Nous avons présenté la conception et la validation d’un nouveau flux de travail relatif à la sélection de résumés axé sur un processus d’agrégation de style Delphi et visant à exploiter les atouts de cinq GML à code source ouvert pouvant être utilisés sur des postes de travail grand public. Ce flux de travail multi-GML a montré un rendement acceptable et fiable en vue de son utilisation comme méthode de présélection automatisée pour faciliter les revues systématiques.
The Public Health Review Team, University of Sheffield, was commissioned to deliver a programme of public health evidence synthesis projects. The review programme (2019-25) provided a unique opportunity to develop effective and efficient processes to maximise the value and impact of evidence synthesis for public health practitioners, policy-makers, commissioners and research funders. The overall purpose of the programme was to deliver evidence reviews that could inform the commissioning of further primary research and directly inform public health policy and practice. This synopsis summarises the programme content and reflects on lessons learnt. Diverse appropriate methods were used for individual reviews to ensure the timely and efficient production of evidence synthesis products that were as useful as possible to the relevant stakeholders and decision-makers. These included an umbrella review (review of reviews), mapping reviews, systematic reviews, rapid reviews and evidence briefings. The majority of reviews were informed by both public and practitioner involvement, from defining the review questions and identification of relevant evidence to interpreting and disseminating the findings. Both established public panels and topic-specific groups with relevant lived experience recruited for individual projects were involved in the review process. This synopsis was produced by collating and synthesising information from across all 11 commissioned review topics. The review team informally reflected on the learning and generated a number of recommendations for future review programmes. All review projects across the programme used online database searches to identify relevant peer-reviewed journal articles. For many topics, relevant data were identified from grey literature identified by topic experts and other stakeholders and from website searches. Evidence synthesis outputs were generated across 11 different topics prioritised by the Public Health Research Programme Prioritisation Committee: gambling-related harm, working in later life, working from home, access to services for ethnic minority populations, parenting programmes, warmer homes, student mental health, housing insecurity, alcohol licensing, local interventions to reduce air pollution, health impact assessment to inform spatial planning. Individual project outputs were used to inform both primary research commissioning calls and public health policy development. Research reports, research summaries and other outputs, such as animations, webinars, posters and presentations, were widely shared with both public and professional audiences. The programme benefited from high levels of engagement from public panels and professional involvement as well as close engagement with topic experts and policy-makers. Experience from this programme is informing commissioning of further national evidence synthesis teams, and we continue to build on the learning to develop efficient approaches to the delivery of timely, high-quality reviews which are of maximum value to decision-makers. This synopsis can only summarise some key aspects of the programme. Further work is underway to disseminate learning on the value of stakeholder engagement and other methodological aspects of public health evidence synthesis. Commissioning flexible evidence synthesis teams and ensuring effective engagement with stakeholders are efficient approaches to the delivery of timely, high-quality reviews that can optimise impact on population health and health inequalities. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR127659. From 2019 to 2025, the Public Health Review Team at the University of Sheffield completed reviews of available research evidence across 11 topics of importance to population health. Their main goal was to create useful, high-quality reports to help make decisions about public health and guide future research. We used different methods for the reviews depending on what was most feasible and useful to the information users. These included systematic reviews (which carefully look at all the evidence), rapid reviews (which are quicker but still thorough), and umbrella reviews (which analyse the findings of existing reviews). The team asked for ongoing feedback from both the public and people working in public health to make sure the reviews answered the right questions and were helpful. The reviews used data from many sources, mainly from research papers, but also from reports and documents that are not always published in academic journals (known as ‘grey literature’). This report summarises the review projects completed during the programme and the review team’s reflections of what was learnt about how to produce reviews that are as useful as possible to different evidence users. Outputs: the 11 featured topics comprised: gambling-related harm, working in later life, working from home, access to services for ethnic minority groups, parenting programs, warmer homes, student mental health, alcohol licensing, local actions to reduce air pollution, and health impact assessments for planning spaces. Findings from these reviews helped guide future research and shape public health policies. The team shared their findings in different ways, including journal articles, research reports, conference presentations, animations and blogs. By working closely with both the public and practitioners, the review team was able to ensure the reviews were of high quality and value to decision-makers. The programme has demonstrated the value of an experienced and well-co-ordinated team that is able to respond rapidly by producing information to influence policy and thus improve the health of the population and reduce health inequalities.
Health inequities are unnecessary, avoidable and unjust differences in health across social groups. Addressing them is a priority for governments and health systems worldwide, requiring not only specific interventions targeting inequity but also embedding equity across all decision-making. Systematic reviews of interventions underpin health decision-making and could, therefore, be a key mechanism to address inequities, but most reviews are limited in their approach to considering equity and often only conclude data for subgroup analyses are unavailable. While some guidance is available, it largely focuses on reviews of interventions specifically seeking to reduce inequities and is published in disparate literature. We describe approaches to incorporate an equity perspective relevant to all systematic reviews of interventions, even when equity is not the primary review focus.Consideration of equity may be needed at all stages of the review process. Planning the review involves examining theory, using logic models, involving relevant people and organisations, and considering if additional sources of evidence are needed. Investigating the data requires examining the external validity of primary studies, including who was involved in the primary studies, and the reach of interventions. The synthesis process includes selecting appropriate analysis, considering the implications of reporting absolute or relative equity effects of the intervention, exploring and understanding mechanisms and assessing certainty of the evidence in relation to equity. Interpreting results involves linking theory with evidence and discussing implications and limitations. We hope this article helps review authors make best use of the available evidence to incorporate equity into systematic reviews.
Electronic cigarettes (EC) are considered a smoking cessation tool in some countries, such as the United Kingdom, but uncertainty remains internationally over whether their benefits outweigh potential harms when used for this purpose. This overview (1) synthesised existing evidence from systematic reviews (SR) on the effectiveness and safety of ECs to explore and address these uncertainties and disagreements and (2) mapped primary intervention studies to identify priorities for further research. Overview of SRs published from 1 January 2015 and meeting the inclusion criteria of the Cochrane review of EC for smoking cessation. We searched seven databases to April 2024. We followed Cochrane screening and data extraction methods. We adapted Campbell Collaboration and 3ie methods for the Evidence and Gap Map (EGM). We assessed review quality using AMSTAR-2. We included 14 reviews of intervention studies (7 high quality; 7 low quality), with search dates from 2014 to 2023, in adult populations including the general population, people at risk of lung cancer, with comorbid health conditions and pregnant people. Eighteen studies were included across multiple reviews, some of which included multiple meta-analyses. Across 21 meta-analytic comparisons of nicotine EC versus other interventions, all reported point estimates favouring nicotine EC for smoking cessation, with relative risks/odds ratios typically in the range 1.17-1.67 versus nicotine replacement therapy and 1.46-2.09 versus non-nicotine EC, with higher-quality reviews giving more consistent estimates. Of 13 reviews that meta-analysed serious adverse events (SAEs), two reported point estimates suggesting increased SAEs with nicotine EC; other estimates included the possibility of no difference. For adverse events, pooled estimates generally indicated little or no difference between groups. Our EGM mapped 90 primary, complete studies and identified absolute gaps in evidence comparing the effects of nicotine EC to cytisine, bupropion and nicotine pouches. Most studies used collected data from high-income countries. Meta-analyses of electronic cigarettes (EC) for smoking cessation report point estimates favouring higher ≥6-month smoking cessation rates with nicotine EC compared with nicotine replacement therapy, non-nicotine EC/placebo, behavioural or no support and mixed support. Evidence on serious adverse events (SAEs) remains inconclusive. Evidence gaps were identified in SAE data and in studies from low- and middle-income countries.
Cognitive capacity and function affect daily activities, independence, and overall well-being across the life course. To map and synthesise evidence on interventions that measured cognitive capacity at any life stage across the life course from Cochrane and Campbell systematic reviews. Mapping review. The Cochrane and Campbell libraries were searched up to 1 May 2024 for systematic reviews of interventions that measured cognitive capacity across all ages. Data on interventions and outcomes were coded using the International Classification of Function and the International Classification of Health Interventions. We coded for equity characteristics using PROGRESS-Plus. Methodological quality was assessed with AMSTAR2. We included 34 Campbell and 31 Cochrane reviews, with over half (55%) rated as high quality. Most reviews (80%) included studies from high-income countries, with only 12% including studies from low-income countries. Of the 30 reviews that planned a subgroup analysis across equity characteristics, only eight did so. Most reviews included multiple age groups (63%), but none evaluated differences in cognitive outcomes across more than two age categories. Practical support interventions (60%) and intellectual function outcomes (51%) were most common; however, the interventions and outcomes varied at different life stages, reflecting a focus on development in younger ages and on maintaining cognitive function or prevention of decline in older ages. This work highlights the need for a comprehensive life course approach to cognitive interventions, incorporating equity considerations and age-appropriate outcome measures.
Self-regulation is critical yet inconsistently defined across neurodevelopmental conditions (NDCs). This preregistered (CRD42023350582), PRISMA-aligned overview of reviews aimed to (1) review and summarize definitions and models of self-regulation, (2) synthesize key self-regulation-related constructs and (3) identify common self-regulation measures in NDC populations. We searched Ovid Medline/PsycINFO/Embase, Web of Science-Core Collection and Cochrane Databases (inception to September 2024). We included 35 narrative, 2 scoping, 7 systematic and 3 meta-analytic peer-reviewed reviews of human studies on autism, attention-deficit/hyperactivity disorder and intellectual disability that addressed self-regulation across emotional, cognitive and behavioural domains. We found that, despite varied terminology, elevated dysregulation was consistently reported across the included reviews. Inductive content analysis of the included reviews identified core psychological constructs related to self-regulation and their developmental and environmental-contextual interplays; the findings converged into a domain-general, transdiagnostic self-regulation framework emphasizing interdependent integration of emotional, cognitive and behavioural processes across contexts. Finally, a meta-summary from 332 primary empirical studies from the included scoping, systematic and meta-analytic reviews (69 autism, 130 intellectual disability and 133 attention-deficit/hyperactivity disorder) revealed measurement gaps with 521 identified measurements relying heavily on parent-report questionnaires. Risk of bias assessed through the Joanna Briggs Institute checklist revealed methodological heterogeneity. This overview of reviews offers guidance for aligning research, assessments and interventions with a domain-general, developmental understanding of self-regulation across NDCs.
Mapping reviews are valuable tools for synthesizing and visualizing research evidence, providing a comprehensive overview of studies within a specific field. Their visual approach enhances accessibility, enabling researchers, policymakers, and practitioners to efficiently identify key findings, trends, and knowledge gaps. These reviews are particularly significant in guiding future research, informing funding decisions, and shaping evidence-based policymaking. In environmental science-similar to health and social sciences-mapping reviews play a crucial role in identifying effective conservation strategies, tracking interventions, and supporting targeted programs.Unlike systematic reviews, which assess intervention effectiveness, mapping reviews focus on broad research questions, aiming to chart the existing evidence on a given topic. They use structured methodologies to identify patterns, gaps, and trends, often employing visual tools to enhance data accessibility. A well-defined scope, guided by inclusion and exclusion criteria, ensures a transparent study selection process. Comprehensive search strategies, often spanning multiple databases, maximize evidence capture. Effective screening, combining automated and manual processes, ensures relevance, while data extraction emphasizes high-level categories such as study design and population demographics. Advanced software tools, including EPPI-Reviewer and MindMeister, support data extraction and visualization, with evidence gap maps highlighting robust areas and research voids.Despite their advantages, mapping reviews present challenges. The categorization and coding of studies can introduce subjective biases, and the process demands substantial resources. Automation and artificial intelligence offer promising solutions, improving efficiency while addressing integration and multilingual limitations. As methodological advancements continue, interdisciplinary collaboration will be essential to fully realize the potential of mapping reviews across scientific disciplines.
To map and characterize, systematically, the volume, scope and distribution of systematic review evidence on virtual clinical simulation in healthcare education, describing the educational outcomes assessed, the contexts and modalities where virtual simulations have been implemented and the main evidence gaps identified. Virtual clinical simulations are increasingly used to support healthcare education and training. However, existing evidence on their effectiveness remains fragmented, with variations in methodological quality and scope. Evidence and Gap Map (EGM) following Campbell Collaboration Guidance. A systematic search was conducted across nine databases and two gray literature sources. Eligible studies included systematic reviews examining healthcare professionals or students using virtual simulations. Data were extracted using the PICOS framework and reviewed independently by two researchers. Methodological quality was assessed using AMSTAR-2 and confidence in findings was appraised using CERQual. A total of 118 reviews met inclusion criteria: 91 systematic, 25 scoping and 2 umbrella reviews. Most were published within the past four years and originated from high-income countries. We identified seven categories across the results: (1) Learning and Knowledge Acquisition; (2) User Perception; (3) Development of Technical Skills; (4) Simulation Performance; (5) Development of Practical Skills; (6) Transfer to Real Clinical Practice; and (7) Program Effectiveness. More than half of the systematic reviews were rated as low or critically low quality, with only 10 % achieving high methodological rigour. Virtual clinical simulations demonstrate potential to enhance learning outcomes in healthcare education. However, evidence is limited by uneven methodological quality, concentration in high-income settings and a lack of research on emerging technologies and long-term educational impacts. Future high-quality, comparative studies are needed to strengthen the evidence base.
Cancer care in Ethiopia imposes a significant financial burden, with high direct costs (eg, treatment and hospital stays) and indirect costs (eg, lost productivity). Despite the growing cancer burden, comprehensive data on its economic impact and cost-effectiveness remain limited. This systematic review assesses the economic burden of cancer care and the cost-effectiveness of interventions in Ethiopia, focusing on both adult and pediatric cancers. A systematic search was conducted in PubMed, Embase, Scopus, and the Cochrane Library following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting Ethiopian-specific cost data, including direct and indirect costs, catastrophic health expenditure, and cost-effectiveness, were included. Economic evaluations and observational studies covering prevention to palliative care were considered. Cost data were standardized to 2019 values using the Campbell and Cochrane Economics Methods Group and the Evidence for Policy and Practice Information and Coordinating-Centre cost converter. Two independent reviewers' extracted data, with quality assessment using the Consolidated Health Economic Evaluation Reporting Standards checklist. Of 656 identified records, 11 studies met the inclusion criteria. Cancer care costs were substantial, with medications, treatment, and hospital stays being the primary cost drivers. Lost productivity further exacerbated the burden. Pediatric oncology care and human papillomavirus vaccination were consistently cost-effective. Methodological approaches included decision trees, Markov models, and cost-effectiveness analyses. Gaps in uncertainty analysis, discount rates, and sensitivity analysis were noted. Cancer care in Ethiopia remains a financial challenge, but cost-effective interventions, such as pediatric oncology programs and human papillomavirus vaccination, can mitigate costs. Strengthening financial protection mechanisms and conducting more detailed economic evaluations are crucial to informing policy and improving cancer care affordability.
Childhood obesity is a major public health concern worldwide, yet the best way to prevent it remains unknown. To determine what types of intervention strategy are most effective at preventing the development of obesity in children aged 5-18 years, as measured by change in body mass index, and to determine whether interventions work differentially in children with different characteristics associated with inequities. Systematic reviews and statistical evidence syntheses. Randomised controlled trials of dietary and/or activity interventions that aimed to prevent overweight or obesity in children and young people aged 5-18 years and reported outcomes at least 12 weeks after baseline. Non-randomised evidence was identified through an overview of systematic reviews. Sources of inequity of interest were those defined by the PROGRESS (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital) acronym: place, race/ethnicity, occupation (of parents), gender/sex, religion, education (of parents), socioeconomic status and social capital. Updating of an existing Cochrane Review, searching bibliographic databases up to February 2023, including MEDLINE, EMBASE, PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials on the Cochrane Library, international trial registers and grey literature databases, and examining reference lists. Results subgrouped by inequity factors were sought directly from trialists. Cochrane Reviews followed standard Cochrane procedures. The main statistical synthesis was informed by a novel analytic framework developed iteratively through discussions with children and young people, schoolteachers and public health professionals. Methodology was developed to analyse the data using multilevel metaregression. To examine the impact of inequity factors, we performed a two-stage meta-analysis of interactions, based on subgroup-level aggregate data collected directly from the trialists. We collected available information on intervention costs. We included 172 trials in ages 5-11 and 74 in ages 12-18. In the main synthesis, of 204 trials from both reviews, we found interventions were effective on average (mean difference in standardised body mass index -0.037, 95% credible interval -0.053 to -0.022, which would correspond to a reduction in a proportion of 2.3% with obesity to a proportion of approximately 2.1%). Larger effects were associated with physical activity rather than dietary interventions, after 12 months of follow-up and in the older age group. The overview of non-randomised evidence included 24 systematic reviews, yielding mixed results. The investigation of inequity did not identify substantial differences in effectiveness according to place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital characteristics, and there was very limited information about costs. We were able to examine only the interventions that had been evaluated in studies identified for inclusion in the systematic reviews, which does not cover all possible intervention approaches. Interventions to prevent obesity in children aged 5-18 have a small beneficial effect on body mass index on average but with considerable variation. A novel re-analysis of existing randomised trials failed to identify general intervention characteristics driving this variation. No evidence was identified to suggest that interventions increase (or decrease) health inequities. Future studies of the effects of interventions to prevent childhood obesity should routinely collect baseline characteristics around potential inequities. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131572. One in five children in England are living with obesity at age 12. It affects children unequally, with higher levels of obesity seen in children from more deprived areas. Obesity is known to lead to numerous diseases such as diabetes and cancer. The United Kingdom government aims to halve childhood obesity by 2030. Over the last 30 years, many different strategies have been tried around the world to prevent childhood obesity. We wanted to work out which types of strategies work best and in which groups of children. We brought together as many studies of different strategies as we could find, in two Cochrane Reviews. At the heart of our project was a statistical analysis of the results of all the studies we found. We identified important features of the strategies that we could compare across all the different studies. The method allows us to learn about what types of strategies work best. We also looked closely at the gender, ethnic backgrounds and socioeconomic backgrounds of the children involved in the studies to see if these aspects affected how well the different strategies worked. We found 172 studies in the 5- to 11-year age group and 74 studies in the 12- to 18-year age group. The strategies typically had a beneficial impact on preventing the gain of excess body fat, though there was a lot of variation between studies. Unfortunately, we were unable to find features of the strategies that convincingly explained why some worked better than others, although we did see greater effects from strategies aiming to increase physical activity rather than to improve diet. We found that the strategies worked similarly well irrespective of the gender, ethnic backgrounds and socioeconomic backgrounds of the children. Strategies to prevent obesity in children aged 5–18 years generally work, but only to a very small extent on average. In future, we suggest that more focus is put on promoting an increase in physical activity alongside an improvement in diet. The evidence suggests that strategies aiming to prevent obesity in children do not increase health inequities.
Systematic review and meta-analysis. To perform a comprehensive meta-analysis comparing clinical outcomes of uniportal versus biportal endoscopic spine surgery across decompression procedures in patients with lumbar degenerative disease (LDD). Uniportal endoscopic spine surgery has been a widely adopted minimally invasive technique, whereas biportal endoscopy has recently emerged as a promising alternative with potential advantages in surgical outcomes. A systematic review and meta-analysis of comparative studies was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Embase, and Scopus databases were searched to identify relevant studies. Eleven studies encompassing 374 uniportal and 368 biportal patients were included. Outcomes analyzed were Oswestry Disability Index (ODI), Visual Analog Scale (VAS) scores for back and leg pain, complication rates, operative time, and length of hospital stay. Biportal endoscopic surgery was associated with a significantly lower ODI at 1-3 months and at final follow-up compared with uniportal surgery. However, uniportal discectomy demonstrated significantly shorter operative time and length of hospital stay than biportal discectomy. No significant differences were observed between approaches in terms of VAS scores, complication rates, or ODI at other time points. Both uniportal and biportal endoscopic spine surgeries yield comparable postoperative outcomes in LDD. Although biportal surgery showed a modest advantage in ODI improvement, it did not reach the minimal clinically important difference. Uniportal surgery demonstrated greater efficiency in terms of operative time and recovery, particularly for discectomy procedures.
Red meat intake (RMI) is implicated in promoting inflammation and compromising immune function. We conducted a systematic review and meta-analysis assessing how RMI influences inflammation and immune function biomarkers in adults with any health status. Twenty-two randomized controlled trials (RCTs; 1152 adults) and 10 observational studies (OBS; 438,925 adults) were included from literature published through May 2024 using PubMed, Scopus, CINAHL, and Cochrane databases. Sufficient data were obtained for meta-analyses of blood C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), leptin, and adiponectin. Overall, greater total RMI led to higher CRP across 18 RCTs (weighted mean difference 0.23, 95% CI 0.08-0.39). Subgroup analyses indicated similar findings for participants diagnosed with, but not without, cardiometabolic diseases; unspecified or mixed RMI, but not unprocessed RMI; studies without, but not with, energy restriction; and RMI ≥, but not <, 0.5 servings/day (3.5 servings/week). Limited RCTs suggest total RMI did not influence IL-6, TNF-α, leptin, or adiponectin. Among 10 OBS, no associations were shown between RMI and these biomarkers. Conservatively, these results are consistent with recommendations for people who choose to consume red meat to limit or avoid consuming processed red meat, especially among individuals with cardiometabolic diseases. Registry and registry number for systematic reviews or meta-analyses: PROSPERO CRD42021256264.
This systematic review examined the duration of measles virus airborne transmissibility after a source case is no longer present to identify evidence gaps in measles contact tracing exposure window guidelines. A systematic literature review following PRISMA guidelines was conducted using PubMed, EMBASE, Web of Science, and SCOPUS databases for publications from January 1988 to July 2024. Additional sources were identified through reference list reviews and Google Scholar searches. Studies examining how long the measles virus survives in the air or remains transmissible after an infectious case leaves a public space were included, while editorials, opinion pieces, non-evidence-based recommendations, mathematical models, and publications unrelated to airborne transmission of measles in public environments or not available in English were excluded. Researchers extracted summary data. Initial database searches identified 1054 studies, with none meeting initial inclusion criteria after screening. Supplemental searches identified five relevant articles (1964-1987). Two experimental studies and three real-world studies demonstrated measles virus survival between 29 and 120 min, with increasing survival time for lower humidity levels. Current guidelines for measles contact tracing exposure windows rely on limited research from 1964 to 1987. Additional studies are urgently needed to understand how long the virus is transmissible in real-world settings, particularly given the implications for contact tracing efficiency and resource allocation during outbreak responses. U.S. Centers for Disease Control & Prevention (Cooperative Agreement #NU38FT000004).
Orthopaedic surgeons face increasing pressure to align clinical decision making with evidence-based practices. However, the adoption of such practices can be inconsistent because of variability in surgical techniques, patient factors, and entrenched habits. This systematic review evaluates interventions designed to change orthopaedic surgeons' clinical decision making across cost optimization, diagnostic ordering, and prescribing behaviors. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses and MECIR-adherent search was conducted across seven databases (MEDLINE, PsycINFO, EMBASE, Cochrane Library, Business Source Premier, SPORTDiscus, and Scopus) to identify studies from the United States and Canada reporting interventions aimed at modifying orthopaedic surgeons' clinical decision making. Studies were included if they evaluated changes in practice patterns in at least one of the three domains: procedure costs, orders (tests/procedures), or medication prescribing. Two independent reviewers conducted screening, data extraction, and quality assessment using the Effective Public Health Practice Project tool. Of 9,065 records identified, 28 studies met inclusion criteria: education (n = 24), physician reminders (n = 3), and incentive systems (n = 1). Most used before-and-after designs (n = 23) and were of moderate quality (n = 21). Three of five studies (60%) on procedure costs demonstrated statistical significance in cost reduction after intervention (P ≤ 0.05), with the largest from a surgeon "scorecard" initiative ($694 per total knee arthroplasty case, P < 0.001). Four of 14 studies (29%) on diagnostic/procedural ordering demonstrated statistical significance in clinical decision-making change. All nine studies on prescribing behaviors, predominantly opioid stewardship, showed statistically significant clinical decision-making change, including reductions in morphine milligram equivalents and improved guideline compliance. Evidence-based interventions, particularly education combined with audit and feedback, can meaningfully shift orthopaedic surgeons' clinical decision making. Sustained change is less well studied, highlighting the need for prospective trials with long-term follow-up. This synthesis provides a framework for designing future interventions that improve adherence to best practices. Level III.
Reverse shoulder arthroplasty (rTSA) has become a foundational procedure in shoulder surgery, with utilization expanding across all age groups. As case volumes have risen, attention has shifted toward patient-specific factors that may influence outcomes and complication rates. Sex-based differences are increasingly recognized in orthopedics, yet the extent to which rTSA literature reports and analyzes outcomes by sex remains unclear. As surgical care moves toward more personalized care, understanding the influence of sex on rTSA outcomes and revision risk is critical. This review aims to assess the extent of sex-specific reporting in rTSA studies and identify trends and gaps in the analysis of outcomes and complications by sex. A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, and Scopus were searched for English-language studies from 2007 to 2024 involving patients undergoing rTSA. Eligible studies reported sex-disaggregated baseline characteristics, outcomes, or complications. Extracted data included study design, demographics, procedure type, and sex-specific reporting of functional outcomes, complications, and revision rates. Of 10,805 studies screened, 356 met inclusion criteria, comprising 345,154 patients (63% female). Only 10 studies (2.8%) reported sex-disaggregated outcomes, covering 14,694 patients (9,338 females; 5,354 males). Females presented with lower preoperative scores but showed similar improvements postoperatively, while males showed greater postoperative external rotation and abduction. No significant difference was found between final American Shoulder and Elbow Surgeons scores. Females had a significantly increased risk of acromial stress fractures (odds ratio 2.32, 95% confidence interval: 1.26-4.28, P < .05). rTSA benefits both male and female patients; our review underscores persistent disparities in outcomes and a critical underreporting of sex-disaggregated data. Female patients exhibited a significantly higher risk of acromial stress fractures, consistent with trends previously described in the rTSA literature. With only 2.8% of studies reporting sex-specific outcomes, a substantial evidence gap remains. Surgeons should consider potential sex-based differences during preoperative planning, and future research must prioritize comprehensive, sex-disaggregated analyses to guide equitable, personalized care.
We conducted a systematic review and meta-analysis to compare continuous ketamine infusion to other analgosedatives in critically ill children receiving invasive mechanical ventilation (IMV). We searched four electronic databases and trial registries to September 1, 2025. We searched published conference abstracts from two major critical care conferences (2022 to 2025). We preregistered the protocol on PROSPERO (CRD42025631768). Reviewers screened abstracts and full texts independently and in duplicate. We included randomized controlled trials (RCTs) and nonrandomized studies comparing ketamine to other analgosedatives in critically ill children receiving IMV. Independently and in duplicate, we conducted data extraction. We assessed risk of bias using the Risk Of Bias instrument for Use in SysTematic reviews for RCTs or Risk Of Bias In Nonrandomized Studies of Interventions tool, and certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluation. We pooled data using random-effects models. We included three RCTs and five nonrandomized studies (n = 1436 participants). Pooled analysis demonstrated that ketamine may have no effect on IMV duration (mean difference, 0.00 d; 95% CI, 0.03 d fewer to 0.03 d more; low certainty) and may reduce opioid exposure (mean difference, -8.88 µg/kg cumulative fentanyl equivalents; 95% CI, -6.99 to -10.77; low certainty). We found an uncertain effect of ketamine on delirium, withdrawal, length of stay, clinically important hypotension, and mortality compared with other analgosedatives. Long-term outcomes were not measured in included studies. There is a paucity of studies examining ketamine analgosedation in children receiving IMV, yielding mostly very low certainty evidence for patient-important outcomes due to imprecision and issues related to serious risk of bias of included studies. Methodologically rigorous RCTs are needed to better understand the potential role of ketamine analgosedation in the PICU.
To evaluate the efficacy of active pedagogical strategies for teaching the nursing process compared to traditional teaching methods. Systematic review with meta-analyses performed according to the recommendations of Cochrane Handbook and reported according to Preferred Reporting Items for Systematic Reviews and Metanalyses (PRISMA) Statement. Searches were carried out in February 2024 and updated in October 2025 in the databases Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Literature on Health Sciences, Excerpta Medica Database, Medical Literature Analysis and Retrieval System Online, Scopus and Web of Science. Free searches and searches in gray literature were performed in Google Scholar. The selection of studies and data extraction was performed independently by two reviewers. Data synthesis was performed through narrative synthesis and meta-analytic methods. Meta-analyses were conducted for knowledge, clinical reasoning, critical thinking and attitudinal skills. Thirty-four studies involving undergraduate and graduate nursing students were included to evaluate the effectiveness of active teaching strategies in developing nursing process related competencies. The meta-analyses demonstrated that active learning strategies significantly improved knowledge (SMD = 0.95; p < 0.001; I2 = 80%), clinical reasoning (SMD = 0.48; p < 0.001; I2 = 43%), and attitudinal skills (SMD = 0.39; p = 0.004; I2 = 81%) when compared to traditional methods. There was no difference in critical thinking (SMD = 0.92; p = 0.074; I2 = 95%). Subgroup analyses showed that among the strategies evaluated, simulation consistently showed favorable results for knowledge, clinical reasoning, and attitudinal skills. This study supports the effectiveness of active teaching strategies - particularly simulation - in enhancing learning outcomes associated with the nursing process. The findings emphasize the value of integrating structured, student-centered pedagogies in nursing curricula to foster core competencies.
Mechanical thrombectomy is a critical intervention for patients with acute ischemic stroke with large vessel occlusion. However, significant barriers remain in its widespread implementation, particularly in low- to middle-income countries, including a shortage of trained physicians and limited access to advanced medical technologies. This systematic review and meta-analysis aimed to comprehensively evaluate current mechanical thrombectomy training methodologies and assess their effectiveness in improving procedural skills among neurointerventional teams. We conducted a systematic review following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, searching PubMed, Scopus, and Web of Science. Eight studies were included, with 3 studies eligible for meta-analysis. We assessed training approaches, participant demographics, and procedural outcomes using the Risk of Bias in Non-randomized Studies of Interventions tool and performed statistical analysis using OpenMetaAnalyst software. Various training modalities, including virtual reality simulations and hands-on workshops, consistently demonstrated positive effects on procedural skills and professional confidence, demonstrating significant improvements across multiple metrics. Our systematic review and meta-analysis revealed statistically significant reductions in total procedure time (average decrease of 17.84 minutes, 95% CI: [-22.19 to -13.48]), number of handling errors (decreased by 6.34 errors, 95% CI: [-13.16 to 0.48]), contrast volume (decreased by 27.35 mL, 95% CI: [-45.11 to -9.60]), and fluoroscopy time (reduced by 8.07 minutes, 95% CI: [-10.71 to -5.44]). Participants showed increased procedural steps completed, with an average increase of 6.52 steps (95% CI: [3.99-9.05]). Structured, simulation-based mechanical thrombectomy training programs can significantly enhance procedural skills, clinical decision-making, and professional confidence among neurointerventional teams, potentially improving stroke care.
'The climate emergency is also a health emergency' (England 2024). Climate change directly impacts the health of the human population through events such as earthquakes, flooding, heatwaves and drought, which increase the risk of injury, displacement, disruption of food supplies, infectious diseases and mental ill health (England 2024; Lenzen et al. 2020; Tennison et al. 2021; The Lancet Respiratory Medicine 2023). The impact on population health of these climate events, alongside indirect health consequences such as increased prevalence of respiratory conditions due to air pollution, places an increased burden on health services (Royal College of Physicians 2017). The environmental footprint of healthcare services contributes between 1% and 5% towards total global environmental impacts (Lenzen et al. 2020; Tennison et al. 2021). Reducing the impact of the healthcare system on climate change has the potential to benefit population health through improved air quality and diet, and increased activity levels (Mailloux et al. 2021). Due to the lack of systematic reviews which consider carbon emissions associated with the patient pathway within individual specialities, further research is needed to enable the identification and transformation of the most carbon-intensive clinical pathways, while ensuring future models of care can be delivered in a cost-effective manner without increasing emissions or compromising patient care. In 2008, the Climate Change Act set national targets for the 100% reduction of carbon emissions in England to 1990 levels by 2050 ('Climate Change Act' 2008). Within the United Kingdom, the National Health Service (NHS) has an important role in helping to achieve these targets, as the organisation accounts for 4% of England's carbon footprint (NHS England 2022). The UK government's Greener NHS team from NHS England asked the Exeter Policy Research Programme Evidence Review Facility to bring together and analyse research which assesses different ways carbon emissions resulting from hospital-led care can be reduced, without affecting the care patients receive in hospitals, at home and in clinics. Work focusing on identifying and delivering interventions to reduce carbon emissions within known carbon hotspots, such as NHS estates and facilities, travel and transport, supply chain, and certain medicines and medical and anaesthetic gases that have high global warming potential is already underway, alongside examining the effectiveness of different models of care delivery across all specialities (NHS England 2022; NHS Shared Business Services 2022). Evidence focusing on the effectiveness of interventions in reducing carbon emissions within secondary healthcare would be a useful complement to this work. An approach which considers the patient pathway may be beneficial in identifying interventions which consider wider healthcare systems and thus have a meaningful impact on reducing carbon emissions. This review was commissioned by the Greener NHS team and could serve as a useful case study for wider net-zero ambitions elsewhere in the world. We aimed to carry out a systematic review examining the effectiveness of interventions in reducing the carbon footprint within specific medical specialities in secondary healthcare and explored where this evidence could inform the patient care pathway. In July 2023, we searched a selection of bibliographic databases with coverage of both health care and environmental science journals, including MEDLINE, Embase and Environment Complete, which we supplemented by inspecting the HealthcareLCA database, conducting forwards and backwards citation chasing on all studies which met our inclusion criteria, searching reference lists of topically relevant reviews, and searching Google Scholar and a selection of relevant websites. We included studies using any comparative study design evaluating any intervention intended to reduce the environmental impact of a procedure, process, treatment, or pathway delivered within secondary healthcare in the following specialities: cardiology, gastroenterology, obstetrics, oncology, ophthalmology, orthopaedics and trauma, radiology, renal, respiratory and high volume, low complexity surgeries (specifically: ear, nose, and throat [ENT], gynaecology and urology). We extracted descriptive data regarding study sample, intervention/control group, carbon emission methodology, PROGRESS-PLUS criteria (related to equity) and environmental, patient and cost outcomes. We appraised the quality of studies using life cycle assessment (LCA) methods with a predetermined scoring system informed by Weidema's (1997) guidelines (B.P.W. 1997). We synthesised findings from studies drawing on LCA methods and non-LCA studies separately using narrative synthesis. Within each group, studies were clustered into five broad intervention categories: (1) Accessing care, (2) Product level, (3) Care delivery, (4) Setting and (5) Multiple components. We examined and explained patterns across studies within the same speciality which evaluated similar interventions. We also developed an evidence and gap map (EGM) to highlight where evidence relevant to the review aims could inform a generic patient care pathway for each speciality and future research on lower carbon pathways. Input from the Greener NHS team at NHS England, LCA methods experts and patient and public representatives was incorporated throughout. Eighty-eight studies (92 articles) met eligibility criteria, 28 used LCA-informed methods to calculate carbon emissions (19 of these utilised a full LCA approach). Of the LCA studies, 9 were of Low risk of bias, 14 of Medium risk of bias and 5 of High risk of bias. Urology (n = 14), gastroenterology (n = 13), oncology/radiation oncology (n = 13) and renal (n = 11) were the most common specialities represented. Across different specialities, most evidence was found in the first three stages of the patient care pathway (Initial assessment/diagnostic tests, initial treatment, or routine follow-up). The exception was the renal speciality, where most evidence was within 'Ongoing care' segment. There was limited evidence within the 'Discharge' segment of the care pathway across all specialities. Evidence relating to the wider healthcare setting was clustered within gastroenterology (n = 5) and radiology specialities (n = 5). The two largest groups of evidence were for studies evaluating telehealth (n = 26) and reuseable equipment (n = 13) interventions. Telehealth interventions were predominantly evaluated using non-LCA methods (n = 23). While carbon-emissions favoured telemedicine interventions versus face-to-face care, these calculations often only considered patient-travel saved and did not account for carbon emissions associated with other parts of the delivery of the service, such as digital technology used or energy use of building or clinic equipment for face-to-face appointments, or wider impact on the patient care pathway such as potential need to travel for additional primary care appointments. The majority of patient and cost outcomes favoured telemedicine interventions, although most were based on non-statistical analyses. Interventions comparing carbon emissions associated with the use of reuseable versus disposable surgical equipment represented the largest group of studies using LCA methods. For studies within gastroenterology, reuseable equipment was associated with reduced carbon emissions. Within urology, this finding was reversed, although questions regarding the accuracy of use of characterisation factors, quantity of materials used in disposable versus reuseable equipment packs and how carbon emissions were assigned to the reprocessing of reuseable equipment mean confidence in this finding is uncertain. While waste management/reduction interventions were associated with reduced carbon emissions, interventions were highly heterogeneous, with limited consideration of patient or cost outcomes. Eight non-LCA studies found that reduced carbon emissions were associated with energy conservation interventions, such as turning equipment off when not in use or choosing imaging techniques with lower energy use, the majority of which were conducted within radiology/radiotherapy settings. This systematic review synthesises quantitative evidence evaluating the effectiveness of interventions intended to reduce carbon emissions within high-volume secondary healthcare specialities. It highlights a highly heterogeneous evidence base, and the methodological limitations associated with studies based on LCA and non-LCA methods. While we identified several large clusters of studies evaluating similar interventions within the same speciality, future research needs to address these methodological limitations to support confident decision-making within policy commissioning and clinical practice. Our EGM displays the included evidence according to individual speciality along the patient pathway, enabling evidence users to identify research which meets their requirements as well as identifying potential gaps where further research may be required.