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International Journal of Nursing Studies Dec 2023Pressure injuries are a fundamental safety concern in older people living in nursing homes. Recent studies report a disparate body of evidence on pressure injury... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pressure injuries are a fundamental safety concern in older people living in nursing homes. Recent studies report a disparate body of evidence on pressure injury prevalence and incidence in this population.
OBJECTIVES
To systematically quantify the prevalence and incidence of pressure injuries among older people living in nursing homes, and to identify the most frequently occurring PI stage(s) and anatomical location(s).
DESIGN
Systematic review and meta-analysis.
SETTING(S)
Nursing homes, aged care, or long-term care facilities.
PARTICIPANTS
Older people, 60 years and older.
METHODS
Cross-sectional and cohort studies reporting on either prevalence or incidence of pressure injuries were included. Studies published in English from 2000 onwards were systematically searched in Medline, PubMed, Embase, Cochrane Library, CINAHL and ProQuest. Screening, data extraction and quality appraisal were undertaken independently by two or more authors and adjudicated by another. Outcomes included pressure injury point prevalence, cumulative incidence, and nursing home acquired pressure injury rate. In meta-analyses, Cochrane's Q test and the I statistic were used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Sources of heterogeneity were investigated by subgroup analyses and meta-regression.
RESULTS
3384 abstracts were screened, and 47 full-text studies included. In 30 studies with 355,784 older people, the pooled pressure injury prevalence for any stage was 11.6 % (95 % CI 9.6-13.7 %). Fifteen studies with 5,421,798 older people reported the prevalence of pressure injury excluding stage I and the pooled estimate was 7.2 % (95 % CI 6.2-8.3 %). The pooled incidence for pressure injury of any stage in four studies with 10,645 older people was 14.3 % (95 % CI 5.5-26.2 %). Nursing home acquired pressure injury rate was reported in six studies with 79,998 older people and the pooled estimate was 8.5 % (95 % CI 4.4-13.5 %). Stage I and stage II pressure injuries were the most common stages reported. The heel (34.1 %), sacrum (27.2 %) and foot (18.4 %) were the three most reported locations of pressure injuries. Meta-regression results indicated a reduction in pressure injury prevalence over the years of data collection.
CONCLUSION
The burden of pressure injuries among older people in nursing homes is similar to hospitalised patients and requires a targeted approach to prevention as is undertaken in hospitals. Future studies using robust methodologies focusing on epidemiology of pressure injury development in older people are needed to conduct as the first step of preventing pressure injuries.
REGISTRATION NUMBER
PROSPERO CRD42022328367.
TWEETABLE ABSTRACT
Pressure injury rates in nursing homes are comparable to hospital rates indicating the need for targeted programmes similar to those in hospitals.
Topics: Humans; Aged; Pressure Ulcer; Incidence; Prevalence; Cross-Sectional Studies; Nursing Homes
PubMed: 37801939
DOI: 10.1016/j.ijnurstu.2023.104605 -
The Lancet. Global Health Jan 2019Global child mortality reduced substantially during the Millennium Development Goal period (2000-15). We aimed to estimate morbidity, mortality, and prevalence of risk...
BACKGROUND
Global child mortality reduced substantially during the Millennium Development Goal period (2000-15). We aimed to estimate morbidity, mortality, and prevalence of risk factors for child pneumonia at the global, regional, and national level for developing countries for the Millennium Development Goal period.
METHODS
We estimated the incidence, number of hospital admissions, and in-hospital mortality due to all-cause clinical pneumonia in children younger than 5 years in developing countries at 5-year intervals during the Millennium Development Goal period (2000-15) using data from a systematic review and Poisson regression. We estimated the incidence and number of cases of clinical pneumonia, and the pneumonia burden attributable to HIV for 132 developing countries using a risk-factor-based model that used Demographic and Health Survey data on prevalence of the various risk factors for child pneumonia. We also estimated pneumonia mortality in young children using data from multicause models based on vital registration and verbal autopsy.
FINDINGS
Globally, the number of episodes of clinical pneumonia in young children decreased by 22% from 178 million (95% uncertainty interval [UI] 110-289) in 2000 to 138 million (86-226) in 2015. In 2015, India, Nigeria, Indonesia, Pakistan, and China contributed to more than 54% of all global pneumonia cases, with 32% of the global burden from India alone. Between 2000 and 2015, the burden of clinical pneumonia attributable to HIV decreased by 45%. Between 2000 and 2015, global hospital admissions for child pneumonia increased by 2·9 times with a more rapid increase observed in the WHO South-East Asia Region than the African Region. Pneumonia deaths in this age group decreased from 1·7 million (95% UI 1·7-2·0) in 2000 to 0·9 million (0·8-1·1) in 2015. In 2015, 49% of global pneumonia deaths occurred in India, Nigeria, Pakistan, Democratic Republic of the Congo, and Ethiopia collectively. All key risk factors for child pneumonia (non-exclusive breastfeeding, crowding, malnutrition, indoor air pollution, incomplete immunisation, and paediatric HIV), with the exception of low birthweight, decreased across all regions between 2000 and 2015.
INTERPRETATION
Globally, the incidence of child pneumonia decreased by 30% and mortality decreased by 51% during the Millennium Development Goal period. These reductions are consistent with the decrease in the prevalence of some of the key risk factors for pneumonia, increasing socioeconomic development and preventive interventions, improved access to care, and quality of care in hospitals. However, intersectoral action is required to improve socioeconomic conditions and increase coverage of interventions targeting risk factors for child pneumonia to accelerate decline in pneumonia mortality and achieve the Sustainable Development Goals for health by 2030.
FUNDING
Bill & Melinda Gates Foundation.
Topics: Child Mortality; Child, Preschool; Global Health; Humans; Infant; Pneumonia
PubMed: 30497986
DOI: 10.1016/S2214-109X(18)30408-X -
International Journal of Stroke :... Mar 2023The epidemiology of stroke is evolving in China as the population undergoes demographic, lifestyle, and economic transitions. An updated review is pertinent to providing... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The epidemiology of stroke is evolving in China as the population undergoes demographic, lifestyle, and economic transitions. An updated review is pertinent to providing feedback on current, and in planning future, prevention and management strategies.
AIMS
To identify high-quality epidemiological studies for quantifying the prevalence, incidence, mortality, and case fatality for stroke in China.
METHODS
A search was undertaken across a range of bibliographic databases on 30 November 2021 without time limitation. Assessments were made of the risk of bias of the included studies. The outcomes were synthesized using a random-effects model. Subgroup analysis and meta-regression models were used to define the source of heterogeneity.
RESULTS
Of 9407 identified records, 26 population-based studies were included. Due to significant heterogeneity across the studies, the original range for crude rates of indices was wide. The pooled annual prevalence was 1329.5/100,000 (95% confidence interval (CI) 713.6-2131.9, p < 0.001), incidence 442.1/100,000 (327.6-573.8, p < 0.001), mortality 154.1/100,000 (52.6-308.8, I = 100%, p < 0.001), and case fatality 35.8% (26.1% to 46.1%, I = 97%, p < 0.001). The prevalence and incidence of stroke have increased, but stroke-related case fatality has declined in China over recent decades. There are significant regional and rural-urban differences in incidence rates.
CONCLUSION
Despite improved public health policies and healthcare delivery, the burden of stroke remains high in China. Further coordinated efforts are required in prevention and community care to offset the likelihood of further expansion in the absolute number of stroke cases in this large population.
Topics: Humans; Stroke; Incidence; Prevalence; Rural Population; China
PubMed: 36274585
DOI: 10.1177/17474930221135983 -
The Lancet. Psychiatry Apr 2017Several studies and meta-analyses have shown that mortality in people with schizophrenia is higher than that in the general population but have used relative measures,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Several studies and meta-analyses have shown that mortality in people with schizophrenia is higher than that in the general population but have used relative measures, such as standardised mortality ratios. We did a systematic review and meta-analysis to estimate years of potential life lost and life expectancy in schizophrenia, which are more direct, absolute measures of increased mortality.
METHODS
We searched MEDLINE, PsycINFO, Embase, Cinahl, and Web of Science for published studies on years of potential life lost and life expectancy in schizophrenia. Data from individual studies were combined in meta-analyses as weighted averages. We did subgroup analyses for sex, geographical region, timing of publication, and risk of bias (estimated with the Newcastle-Ottawa Scale).
FINDINGS
We identified 11 studies in 13 publications covering all inhabited continents except South America (Africa n=1, Asia n=1, Australia n=1, Europe n=7, and North America n=3) that involved up to 247 603 patients. Schizophrenia was associated with a weighted average of 14·5 years of potential life lost (95% CI 11·2-17·8), and was higher for men than women (15·9, 13·8-18·0 vs 13·6, 11·4-15·8). Loss was least in the Asian study and greatest in Africa. The overall weighted average life expectancy was 64·7 years (95% CI 61·1-71·3), and was lower for men than women (59·9 years, 95% CI 55·5-64·3 vs 67·6 years, 63·1-72·1). Life expectancy was lowest in Asia and Africa. Timing of publication and risk of bias had little effect on results.
INTERPRETATION
The effects of schizophrenia on years potential life lost and life expectancy seem to be substantial and not to have lessened over time. Development and implementation of interventions and initiatives to reduce this mortality gap are urgently needed.
FUNDING
None.
Topics: Adult; Aged; Aged, 80 and over; Cause of Death; Female; Global Health; Humans; Life Expectancy; Male; Middle Aged; Schizophrenia; Sex Factors
PubMed: 28237639
DOI: 10.1016/S2215-0366(17)30078-0 -
The European Respiratory Journal Sep 2019In 1999, the World Health Organization (WHO) estimated that one-third of the world's population had latent tuberculosis infection (LTBI), which was recently updated to... (Meta-Analysis)
Meta-Analysis
In 1999, the World Health Organization (WHO) estimated that one-third of the world's population had latent tuberculosis infection (LTBI), which was recently updated to one-fourth. However, this is still based on controversial assumptions in combination with tuberculin skin test (TST) surveys. Interferon-γ release assays (IGRAs) with a higher specificity than TST have since been widely implemented, but never used to estimate the global LTBI prevalence.We conducted a systematic review and meta-analysis of LTBI estimates based on both IGRA and TST results published between 2005 and 2018. Regional and global estimates of LTBI prevalence were calculated. Stratification was performed for low, intermediate and high TB incidence countries and a pooled estimate for each area was calculated using a random effects model.Among 3280 studies screened, we included 88 studies from 36 countries with 41 IGRA (n=67 167) and 67 TST estimates (n=284 644). The global prevalence of LTBI was 24.8% (95% CI 19.7-30.0%) and 21.2% (95% CI 17.9-24.4%), based on IGRA and a 10-mm TST cut-off, respectively. The prevalence estimates correlated well to WHO incidence rates (Rs=0.70, p<0.001).In the first study of the global prevalence of LTBI derived from both IGRA and TST surveys, we found that one-fourth of the world's population is infected. This is of relevance, as both tests, although imperfect, are used to identify individuals eligible for preventive therapy. Enhanced efforts are needed targeting the large pool of latently infected individuals, as this constitutes an enormous source of potential active tuberculosis.
Topics: Algorithms; Communicable Disease Control; Global Health; Humans; Incidence; Interferon-gamma Release Tests; Latent Tuberculosis; Prevalence; Tuberculin Test; World Health Organization
PubMed: 31221810
DOI: 10.1183/13993003.00655-2019 -
European Journal of Public Health Feb 2019A recent study has shown that close to one in six older adults have experienced elder abuse in a community setting in the past year. It is thought that abuse in... (Meta-Analysis)
Meta-Analysis
BACKGROUND
A recent study has shown that close to one in six older adults have experienced elder abuse in a community setting in the past year. It is thought that abuse in institutions is just as prevalent. Few systematic evidence of the scale of the problem exists in elder care facilities. The aim of this review is to conduct a systematic review and meta-analysis of the problem in institutional settings and to provide estimates of the prevalence of elder abuse in the past 12 months.
METHODS
Fourteen academic databases and other online platforms were systematically searched for studies on elder abuse. Additionally, 26 experts in the field were consulted to identify further studies. All studies were screened for inclusion criteria by two independent reviewers. Data were extracted, and meta-analysis was conducted. Self-reported data from older residents and staff were considered separately.
RESULTS
Nine studies met the inclusion criteria from an initial of 55 studies identified for review. Overall abuse estimates, based on staff reports, suggest that 64.2% of staff admitted to elder abuse in the past year. There were insufficient studies to calculate an overall prevalence estimate based on self-reported data from older residents. Prevalence estimates for abuse subtypes reported by older residents were highest for psychological abuse (33.4%), followed by physical (14.1%), financial (13.8%), neglect (11.6%), and sexual abuse (1.9%).
CONCLUSIONS
The prevalence of elder abuse in institutions is high. Global action to improve surveillance and monitoring of institutional elder abuse is vital to inform policy action to prevent elder abuse.
Topics: Aged; Aged, 80 and over; Elder Abuse; Female; Homes for the Aged; Humans; Male; Nursing Homes; Prevalence
PubMed: 29878101
DOI: 10.1093/eurpub/cky093 -
BMC Musculoskeletal Disorders Jun 2020Running is one of the most popular sports worldwide. Despite low back pain (LBP) represents the most common musculoskeletal disorder in population and in sports, there...
BACKGROUND
Running is one of the most popular sports worldwide. Despite low back pain (LBP) represents the most common musculoskeletal disorder in population and in sports, there is currently sparse evidence about prevalence, incidence and risk factors for LBP among runners. The aims of this systematic review were to investigate among runners: prevalence and incidence of LBP and specific risk factors for the onset of LBP.
METHODS
A systematic review has been conducted according to the guidelines of the PRISMA statement. The research was conducted in the following databases from their inception to 31st of July 2019: PubMed; CINAHL; Google Scholar; Ovid; PsycINFO; PSYNDEX; Embase; SPORTDiscus; Scientific Electronic Library Online; Cochrane Library and Web of Science. The checklists of The Joanna Briggs Institute Critical Appraisal tools were used to investigate the risk of bias of the included studies.
RESULTS
Nineteen studies were included and the interrater agreement for full-text selection was good (K = 0.78; 0.61-0.80 IC 95%). Overall, low values of prevalence (0.7-20.2%) and incidence (0.3-22%) of LBP among runners were reported. Most reported risk factors were: running for more than 6 years; body mass index > 24; higher physical height; not performing traditional aerobics activity weekly; restricted range of motion of hip flexion; difference between leg-length; poor hamstrings and back flexibility.
CONCLUSIONS
Prevalence and incidence of LBP among runners are low compared to the others running related injuries and to general, or specific population of athletes. View the low level of incidence and prevalence of LBP, running could be interpreted as a protective factor against the onset of LBP.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42018102001.
Topics: Humans; Incidence; Low Back Pain; Prevalence; Risk Factors; Running
PubMed: 32493481
DOI: 10.1186/s12891-020-03357-4 -
Annals of the Rheumatic Diseases Nov 2019To provide the level and trends of prevalence, incidence and disability adjusted life years (DALYs) for rheumatoid arthritis (RA) in 195 countries from 1990 to 2017 by...
OBJECTIVES
To provide the level and trends of prevalence, incidence and disability adjusted life years (DALYs) for rheumatoid arthritis (RA) in 195 countries from 1990 to 2017 by age, sex, Socio-demographic Index (SDI; a composite of sociodemographic factors) and Healthcare Access and Quality (an indicator of health system performance) Index.
METHODS
Data from the Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2017 were used. GBD 2017 modelled the burden of RA for 195 countries from 1990 to 2017, through a systematic analysis of mortality and morbidity data to estimate prevalence, incidence and DALYs. All estimates were presented as counts and age-standardised rates per 100 000 population, with uncertainty intervals (UIs).
RESULTS
Globally, the age-standardised point prevalence and annual incidence rates of RA were 246.6 (95% UI 222.4 to 270.8) and 14.9 (95% UI 13.3 to 16.4) in 2017, which increased by 7.4% (95% UI 5.3 to 9.4) and 8.2% (95% UI 5.9 to 10.5) from 1990, respectively. However, the age-standardised rate of RA DALYs per 100 000 population was 43.3 (95% UI 33.0 to 54.5) in 2017, which was a 3.6% (95% UI -9.7 to 0.3) decrease from the 1990 rate. The age-standardised prevalence and DALY rates increased with age and were higher in females; the rates peaked at 70-74 and 75-79 age groups for females and males, respectively. A non-linear association was found between age-standardised DALY rate and SDI. The global age-standardised DALY rate decreased from 1990 to 2012 but then increased and reached higher than expected levels in the following 5 years to 2017. The UK had the highest age-standardised prevalence rate (471.8 (95% UI 428.9 to 514.9)) and age-standardised incidence rate (27.5 (95% UI 24.7 to 30.0)) in 2017. Canada, Paraguay and Guatemala showed the largest increases in age-standardised prevalence rates (54.7% (95% UI 49.2 to 59.7), 41.8% (95% UI 35.0 to 48.6) and 37.0% (95% UI 30.9 to 43.9), respectively) and age-standardised incidence rates (48.2% (95% UI 41.5 to 55.1), 43.6% (95% UI 36.6 to 50.7) and 36.8% (95% UI 30.4 to 44.3), respectively) between 1990 and 2017.
CONCLUSIONS
RA is a major global public health challenge. The age-standardised prevalence and incidence rates are increasing, especially in countries such as Canada, Paraguay and Guatemala. Early identification and treatment of RA is vital especially among females, in order to reduce the ongoing burden of this condition. The quality of health data needs to be improved for better monitoring of disease burden.
Topics: Age Distribution; Arthritis, Rheumatoid; Female; Global Burden of Disease; Humans; Incidence; Male; Prevalence; Quality-Adjusted Life Years; Risk Factors; Sex Distribution
PubMed: 31511227
DOI: 10.1136/annrheumdis-2019-215920 -
The Cochrane Database of Systematic... Jan 2019General health checks are common elements of health care in some countries. They aim to detect disease and risk factors for disease with the purpose of reducing... (Meta-Analysis)
Meta-Analysis
BACKGROUND
General health checks are common elements of health care in some countries. They aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used individual screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is therefore important to assess whether general health checks do more good than harm. This is the first update of the review published in 2012.
OBJECTIVES
To quantify the benefits and harms of general health checks.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, two other databases and two trials registers on 31 January 2018. Two review authors independently screened titles and abstracts, assessed papers for eligibility and read reference lists. One review author used citation tracking (Web of Knowledge) and asked trial authors about additional studies.
SELECTION CRITERIA
We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening for more than one disease or risk factor in more than one organ system.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and assessed the risk of bias in the trials. We contacted trial authors for additional outcomes or trial details when necessary. When possible, we analysed the results with a random-effects model meta-analysis; otherwise, we did a narrative synthesis.
MAIN RESULTS
We included 17 trials, 15 of which reported outcome data (251,891 participants). Risk of bias was generally low for our primary outcomes. Health checks have little or no effect on total mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.97 to 1.03; 11 trials; 233,298 participants and 21,535 deaths; high-certainty evidence, I = 0%), or cancer mortality (RR 1.01, 95% CI 0.92 to 1.12; 8 trials; 139,290 participants and 3663 deaths; high-certainty evidence, I = 33%), and probably have little or no effect on cardiovascular mortality (RR 1.05, 95% CI 0.94 to 1.16; 9 trials; 170,227 participants and 6237 deaths; moderate-certainty evidence; I = 65%). Health checks have little or no effect on fatal and non-fatal ischaemic heart disease (RR 0.98, 95% CI 0.94 to 1.03; 4 trials; 164,881 persons, 10,325 events; high-certainty evidence; I = 11%), and probably have little or no effect on fatal and non-fatal stroke (RR 1.05 95% CI 0.95 to 1.17; 3 trials; 107,421 persons, 4543 events; moderate-certainty evidence, I = 53%).
AUTHORS' CONCLUSIONS
General health checks are unlikely to be beneficial.
Topics: Adult; Cause of Death; Diagnosis; Disease; Health Promotion; Humans; Morbidity; Primary Prevention; Randomized Controlled Trials as Topic
PubMed: 30699470
DOI: 10.1002/14651858.CD009009.pub3 -
The Cochrane Database of Systematic... Apr 2019Non-invasive positive pressure ventilation (NPPV) has been used to treat respiratory distress due to acute cardiogenic pulmonary oedema (ACPE). We performed a systematic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Non-invasive positive pressure ventilation (NPPV) has been used to treat respiratory distress due to acute cardiogenic pulmonary oedema (ACPE). We performed a systematic review and meta-analysis update on NPPV for adults presenting with ACPE.
OBJECTIVES
To evaluate the safety and effectiveness of NPPV compared to standard medical care (SMC) for adults with ACPE. The primary outcome was hospital mortality. Important secondary outcomes were endotracheal intubation, treatment intolerance, hospital and intensive care unit length of stay, rates of acute myocardial infarction, and adverse event rates.
SEARCH METHODS
We searched CENTRAL (CRS Web, 20 September 2018), MEDLINE (Ovid, 1946 to 19 September 2018), Embase (Ovid, 1974 to 19 September 2018), CINAHL Plus (EBSCO, 1937 to 19 September 2018), LILACS, WHO ICTRP, and clinicaltrials.gov. We also reviewed reference lists of included studies. We applied no language restrictions.
SELECTION CRITERIA
We included blinded or unblinded randomised controlled trials in adults with ACPE. Participants had to be randomised to NPPV (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care (SMC) compared with SMC alone.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened and selected articles for inclusion. We extracted data with a standardised data collection form. We evaluated the risks of bias of each study using the Cochrane 'Risk of bias' tool. We assessed evidence quality for each outcome using the GRADE recommendations.
MAIN RESULTS
We included 24 studies (2664 participants) of adult participants (older than 18 years of age) with respiratory distress due to ACPE, not requiring immediate mechanical ventilation. People with ACPE presented either to an Emergency Department or were inpatients. ACPE treatment was provided in an intensive care or Emergency Department setting. There was a median follow-up of 13 days for hospital mortality, one day for endotracheal intubation, and three days for acute myocardial infarction. Compared with SMC, NPPV may reduce hospital mortality (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.82; participants = 2484; studies = 21; I = 6%; low quality of evidence) with a number needed to treat for an additional beneficial outcome (NNTB) of 17 (NNTB 12 to 32). NPPV probably reduces endotracheal intubation rates (RR 0.49, 95% CI 0.38 to 0.62; participants = 2449; studies = 20; I = 0%; moderate quality of evidence) with a NNTB of 13 (NNTB 11 to 18). There is probably little or no difference in acute myocardial infarction (AMI) incidence with NPPV compared to SMC for ACPE (RR 1.03, 95% CI 0.91 to 1.16; participants = 1313; studies = 5; I = 0%; moderate quality of evidence). We are uncertain as to whether NPPV increases hospital length of stay (mean difference (MD) -0.31 days, 95% CI -1.23 to 0.61; participants = 1714; studies = 11; I = 55%; very low quality of evidence). Adverse events were generally similar between NPPV and SMC groups, but evidence was of low quality.
AUTHORS' CONCLUSIONS
Our review provides support for continued clinical application of NPPV for ACPE, to improve outcomes such as hospital mortality and intubation rates. NPPV is a safe intervention with similar adverse event rates to SMC alone. Additional research is needed to determine if specific subgroups of people with ACPE have greater benefit of NPPV compared to SMC. Future research should explore the benefit of NPPV for ACPE patients with hypercapnia.
Topics: Adult; Continuous Positive Airway Pressure; Hospital Mortality; Humans; Intensive Care Units; Intubation, Intratracheal; Length of Stay; Noninvasive Ventilation; Pulmonary Edema; Randomized Controlled Trials as Topic
PubMed: 30950507
DOI: 10.1002/14651858.CD005351.pub4