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Circulation Apr 2019
2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Topics: Adolescent; Adult; Age Factors; Cardiology; Consensus; Evidence-Based Medicine; Heart Defects, Congenital; Humans; Middle Aged; Treatment Outcome; Young Adult
PubMed: 30586767
DOI: 10.1161/CIR.0000000000000603 -
The Cochrane Database of Systematic... Nov 2018The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010.
OBJECTIVES
To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.
MAIN RESULTS
We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.
AUTHORS' CONCLUSIONS
Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.
Topics: Abdominal Abscess; Acute Disease; Adult; Appendectomy; Appendicitis; Child; Female; Humans; Laparoscopy; Male; Pain, Postoperative; Randomized Controlled Trials as Topic; Recovery of Function; Surgical Wound Infection; Time Factors
PubMed: 30484855
DOI: 10.1002/14651858.CD001546.pub4 -
BMJ (Clinical Research Ed.) Sep 2018
Topics: Aged; Decision Making; Early Detection of Cancer; Follow-Up Studies; Humans; Lower Urinary Tract Symptoms; Male; Mass Screening; Middle Aged; Practice Patterns, Physicians'; Prostate-Specific Antigen; Prostatic Neoplasms; Randomized Controlled Trials as Topic
PubMed: 30185545
DOI: 10.1136/bmj.k3581 -
Journal of Surgical Case Reports Jun 2018Appendicular mucocele is a rare well-described clinico-pathological occurrence. It denotes an obstructive dilatation of the appendicular lumen by mucinous secretions.
INTRODUCTION
Appendicular mucocele is a rare well-described clinico-pathological occurrence. It denotes an obstructive dilatation of the appendicular lumen by mucinous secretions.
CASE REPORT
A 60-year-old patient presented with right lower abdominal pain and nausea for 2 years. Abdominal CT scan suggested a diagnosis of a appendicular mucocele. Following informed consent, surgical exploration revealed a cystic mass arising from the body of the appendix with inflamed walls with no evidence of perforation. Simple appendectomy was performed as the caecum and the mesenteric nodes were free of pathological involvement. The final diagnosis of mucinous cystadenoma was confirmed by histopathology. Postoperative course was uneventful. The patient was in good health during a four years regular follow-up.
DISCUSSION
Appendicular mucocele is a rare disease with vague symptoms. Abdominal imaging is an important diagnostic tool, but histopathology is the standard for definitive diagnosis. Surgery for benign appendicular mucoceles has an excellent long-term prognosis.
PubMed: 29991998
DOI: 10.1093/jscr/rjy102 -
BMJ Open Jun 2018To quantify the duration of each step of the diagnostic pathway for patients with multiple myeloma from symptom onset to confirmation of diagnosis. (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To quantify the duration of each step of the diagnostic pathway for patients with multiple myeloma from symptom onset to confirmation of diagnosis.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES AND SELECTION CRITERIA
The MEDLINE and Embase databases were searched up until January 2018 to identify articles that reported time intervals from onset of symptoms to diagnosis. Articles focusing on children or adolescents and on the asymptomatic form of the disease (monoclonal gammopathies and smouldering myeloma) were excluded.
DATA COLLECTION AND DATA ANALYSIS
Data were extracted independently by two reviewers. Weighted estimates of the median and IQR were calculated. Risk of bias was assessed using the Aarhus checklist.
MAIN RESULTS
Nine studies were included. The patient interval (first symptom to first presentation) had a median of 26.3 days (IQR: 1-98, n=465, two studies). Subsequently, the primary care interval (first presentation to first referral) was 21.6 days (IQR: 4.6-55.8, n=326, two studies), the diagnostic interval (first presentation to diagnosis) was 108.6 days (IQR: 33.3-241.7, n=5395, seven studies) and the time to diagnosis (first symptom to diagnosis) interval was 163 days (IQR: 84-306, n=341, one study). No studies reported data for the referral to diagnosis interval.
CONCLUSION
The review demonstrates that there is scope for significant reductions in the time to myeloma diagnosis. At present, many patients experience a diagnostic interval longer than 3 months until diagnosis is confirmed.
REVIEW REGISTRATION
Not available. Protocol available in the appendix.
Topics: Humans; Multiple Myeloma; Primary Health Care; Referral and Consultation; Time Factors
PubMed: 29934381
DOI: 10.1136/bmjopen-2017-019758 -
The Cochrane Database of Systematic... May 2018Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer from postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.This is an update of the review first published in 2015.
OBJECTIVES
To assess the safety and efficacy of abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 6), Ovid MEDLINE (1946 to 30 June 2017), Ovid Embase (1974 to 30 June 2017), Science Citation Index Expanded (1900 to 30 June 2017), World Health Organization International Clinical Trials Registry Platform (30 June 2017), ClinicalTrials.gov (30 June 2017) and Chinese Biomedical Literature Database (CBM) (1978 to 30 June 2017).
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) that compared abdominal drainage and no drainage in people undergoing emergency open appendectomy for complicated appendicitis.
DATA COLLECTION AND ANALYSIS
Two review authors identified the trials for inclusion, collected the data, and assessed the risk of bias independently. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). We used GRADE to rate the quality of evidence.
MAIN RESULTS
We included six RCTs (521 participants), comparing abdominal drainage and no drainage in patients undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia and Africa. The majority of the participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was at low risk of bias.There was insufficient evidence to determine the effects of abdominal drainage and no drainage on intra-peritoneal abscess at 14 days (RR 1.23, 95% CI 0.47 to 3.21; 5 RCTs; 453 participants; very low-quality evidence) or for wound infection at 14 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-quality evidence). The increased risk of 30-day overall complication rate (morbidity) in the drainage group was rated as very low-quality evidence (RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants). There were seven deaths in the drainage group (N = 183) compared to one in the no drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio (OR) 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; moderate-quality evidence). There is 'very low-quality' evidence that drainage increases hospital stay compared to the no drainage group by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants).Other outlined outcomes, hospital costs, pain, and quality of life, were not reported in any of the included studies.
AUTHORS' CONCLUSIONS
The quality of the current evidence is very low. The effect of abdominal drainage on the prevention of intra-peritoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to no drainage group is also subject to great uncertainty. Thus, there is no evidence for any clinical improvement by using abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 people recruited to the studies. Larger studies are needed to determine the effects of drainage on morbidity and mortality outcomes more reliably.
Topics: Abdominal Abscess; Appendectomy; Appendicitis; Drainage; Emergencies; Humans; Length of Stay; Peritoneal Diseases; Postoperative Complications; Randomized Controlled Trials as Topic
PubMed: 29741752
DOI: 10.1002/14651858.CD010168.pub3 -
The Cochrane Database of Systematic... Nov 2017Laparoscopic appendectomy is amongst the most common general surgical procedures performed in the developed world. Arguably, the most critical part of this procedure is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Laparoscopic appendectomy is amongst the most common general surgical procedures performed in the developed world. Arguably, the most critical part of this procedure is effective closure of the appendix stump to prevent catastrophic intra-abdominal complications from a faecal leak into the abdominal cavity. A variety of methods to close the appendix stump are used worldwide; these can be broadly divided into traditional ligatures (such as intracorporeal or extracorporeal ligatures or Roeder loops) and mechanical devices (such as stapling devices, clips, or electrothermal devices). However, the optimal method remains unclear.
OBJECTIVES
To compare all surgical techniques now used for appendix stump closure during laparoscopic appendectomy.
SEARCH METHODS
In June 2017, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6) in the Cochrane Library, MEDLINE Ovid (1946 to 14 June 2017), Embase Ovid (1974 to 14 June 2017), Science Citation Index - Expanded (14 June 2017), China Biological Medicine Database (CBM), the World Health Organization International Trials Registry Platform search portal, ClinicalTrials.gov, Current Controlled Trials, the Chinese Clinical Trials Register, and the EU Clinical Trials Register (all in June 2017). We searched the reference lists of relevant publications as well as meeting abstracts and Conference Proceedings Citation Index to look for additional relevant clinical trials.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) that compared mechanical appendix stump closure (stapler, clips, or electrothermal devices) versus ligation (Endoloop, Roeder loop, or intracorporeal knot techniques) for uncomplicated appendicitis.
DATA COLLECTION AND ANALYSIS
Two review authors identified trials for inclusion, collected data, and assessed risk of bias independently. We performed the meta-analysis using Review Manager 5. We calculated the odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).
MAIN RESULTS
We included eight randomised studies encompassing 850 participants. Five studies compared titanium clips versus ligature, two studies compared an endoscopic stapler device versus ligature, and one study compared an endoscopic stapler device, titanium clips, and ligature. In our analyses of primary outcomes, we found no differences in total complications (OR 0.97, 95% CI 0.27 to 3.50, 8 RCTs, very low-quality evidence), intraoperative complications (OR 0.93, 95% CI 0.34 to 2.55, 8 RCTs, very low-quality evidence), or postoperative complications (OR 0.80, 95% CI 0.21 to 3.13, 8 RCTs, very low-quality evidence) between ligature and all types of mechanical devices. However, our analyses of secondary outcomes revealed that use of mechanical devices saved approximately nine minutes of total operating time when compared with use of a ligature (mean difference (MD) -9.04 minutes, 95% CI -12.97 to -5.11 minutes, 8 RCTs, very low-quality evidence). However, this finding did not translate into a clinically or statistically significant reduction in inpatient hospital stay (MD 0.02 days, 95% CI -0.12 to 0.17 days, 8 RCTs, very low-quality evidence). Available information was insufficient for reliable comparison of total hospital costs and postoperative pain/quality of life between the two approaches. Overall, evidence across all analyses was of very low quality, with substantial potential for confounding factors. Given the limitations of all studies in terms of bias and the low quality of available evidence, a clear conclusion regarding superiority of any one particular type of mechanical device over another is not possible.
AUTHORS' CONCLUSIONS
Evidence is insufficient at present to advocate omission of conventional ligature-based appendix stump closure in favour of any single type of mechanical device over another in uncomplicated appendicitis.
Topics: Abdominal Wound Closure Techniques; Appendectomy; Appendix; Humans; Intraoperative Complications; Laparoscopy; Length of Stay; Operative Time; Postoperative Complications; Randomized Controlled Trials as Topic; Surgical Instruments; Surgical Staplers; Sutures
PubMed: 29190038
DOI: 10.1002/14651858.CD006437.pub3 -
The Cochrane Database of Systematic... Aug 2017Please see Appendix 4 for a glossary of terms.The outcome of patients with esophageal cancer is generally poor. Although multimodal therapy is standard, there is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Please see Appendix 4 for a glossary of terms.The outcome of patients with esophageal cancer is generally poor. Although multimodal therapy is standard, there is conflicting evidence regarding the addition of esophagectomy to chemoradiotherapy.
OBJECTIVES
To compare the effectiveness and safety of chemoradiotherapy plus surgery with that of chemoradiotherapy alone in people with nonmetastatic esophageal carcinoma.
SEARCH METHODS
We performed a computerized search for relevant studies, up to Feburary 2017, on the CENTRAL, MEDLINE, and Embase databases using MeSH headings and keywords. We searched five online databases of clinical trials, handsearched conference proceedings, and screened reference lists of retrieved papers.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) comparing chemoradiotherapy plus esophagectomy with chemoradiotherapy alone for localized esophageal carcinoma. We excluded RCTs comparing chemotherapy or radiotherapy alone with esophagectomy.
DATA COLLECTION AND ANALYSIS
Two authors independently selected studies, extracted data, and assessed risk of bias and the quality of the evidence, using standardized Cochrane methodological procedures. The primary outcome was overall survival (OS), estimated with Hazard Ratio (HR). Secondary outcomes, estimated with risk ratio (RR), were local and distant progression-free survival (PFS), quality of life (QoL), treatment-related mortality and morbidity, and use of salvage procedures for dysphagia. Data were analyzed using a random effects model in Review Manager 5.3 software.
MAIN RESULTS
From 2667 references, we identified two randomized studies, in six reports, that included 431 participants. All participants were clinically staged to have at least T3 and/or node positive thoracic esophageal carcinoma, 93% of which was squamous cell histology. The risk of methodological bias of the included studies was low to moderate.High-quality evidence found the addition of esophagectomy had little or no difference on overall survival (HR 0.99, 95% CI 0.79 to 1.24; P = 0.92; I² = 0%; two trials). Neither study reported PFS, therefore, freedom from loco-regional relapse was used as a proxy. Moderate-quality evidence suggested that the addition of esophagectomy probably improved freedom from locoregional relapse (HR 0.55, 95% CI 0.39 to 0.76; P = 0.0004; I² = 0%; two trials), but low-quality evidence suggested it may increase the risk of treatment-related mortality (RR 5.11, 95% CI 1.74 to 15.02; P = 0.003; I² = 2%; two trials).The other pre-specified outcomes (quality of life, treatment-related toxicity, and use of salvage procedures for dysphagia) were reported by only one study, which found very low-quality evidence that use of esophagectomy was associated with reduced short-term QoL (MD 0.93, 95% CI 0.24 to 1.62), and low-quality evidence that it reduced use of salvage procedures for dysphagia (HR 0.52, 95% CI 0.36 to 0.75). Neither study compared treatment-related morbidity between treatment groups.
AUTHORS' CONCLUSIONS
Based on the available evidence, the addition of esophagectomy to chemoradiotherapy in locally advanced esophageal squamous cell carcinoma, provides little or no difference on overall survival, and may be associated with higher treatment-related mortality. The addition of esophagectomy probably delays locoregional relapse, however, this end point was not well defined in the included studies. It is undetermined whether these results can be applied to the treatment of adenocarcinomas, tumors involving the distal esophagus and gastro-esophageal junction, and to people with poor response to chemoradiation.
Topics: Carcinoma; Carcinoma, Squamous Cell; Chemoradiotherapy; Cisplatin; Combined Modality Therapy; Deglutition Disorders; Esophageal Neoplasms; Esophagectomy; Fluorouracil; Humans; Neoplasm Recurrence, Local; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 28829911
DOI: 10.1002/14651858.CD010511.pub2 -
Journal of the West African College of... 2017The known complications of appendicitis include perforated appendicitis with generalised peritonitis, appendiceal mass, appendiceal abscess, sepsis, adhesion formation... (Review)
Review
BACKGROUND
The known complications of appendicitis include perforated appendicitis with generalised peritonitis, appendiceal mass, appendiceal abscess, sepsis, adhesion formation and in a few occasions, small bowel intestinal obstruction.
AIM
To review published cases of intestinal obstruction due to appendicitis with a view to better understand the pathophysiology of this complication.
METHODOLOGY
A search of the literature in the MEDLINE database, using PubMed and OvidSP, Scopus, Google Scholar and Cochrane Databases with the following MeSH terms: was done. Also, these searches were restricted according to the following MeSH limits: (a) January 1, 1950 to July 31, 2016, (b) English articles (c) Human.
RESULTS
Overall, 27 articles reported 45 patients with intestinal obstruction due to appendicitis. Of the 30 (66.7%) patients that the gender was indicated, 22 (48.9%) were male while 8 (17.8%) were female. In 38 (84.4%) cases the cause was mechanical obstruction resulting from one or a combination of the following: (a) appendix laid across loops of bowel bound down by adhesions, (b) herniation through a ring or gap formed by the appendix tip being attached to its base, (c) appendix tip attached to the bowel causing a torsion, (d) kinking of the bowel, (e) complex knotting. Pre-operative diagnosis was a major challenge and so, none was approached through incision based on the McBurney's point.The outcome of treatment which was mostly achieved by immediate appendectomy followed by adhesiolysis was sufficient and often gave good results.
CONCLUSION
This study has shown that appendicitis is an important cause of intestinal obstruction. Even though pre-operative diagnosis is still a major challenge, clinical evaluation and a high index of suspicion are key to diagnosis.
PubMed: 30525005
DOI: No ID Found -
Diagnostic and Prognostic Research 2017Diagnostic clinical prediction rules (CPRs) are worthwhile if they improve patient outcomes or provide benefits such as reduced resource use, without harming patients.... (Review)
Review
BACKGROUND
Diagnostic clinical prediction rules (CPRs) are worthwhile if they improve patient outcomes or provide benefits such as reduced resource use, without harming patients. We conducted a systematic review to assess the effects of diagnostic CPRs on patient and process of care outcomes.
METHODS
We searched electronic databases and a trial registry and performed citation and reference checks, for randomised trials comparing a diagnostic strategy with and without a CPR. Included studies were assessed for risk of bias and similar studies meta-analysed.
RESULTS
Twenty-seven studies evaluating diagnostic CPRs for 14 conditions were included. A clinical management decision was the primary outcome in the majority of studies. Most studies were judged to be at high or uncertain risk of bias on ≥3 of 6 domains. Details of study interventions and implementation were infrequently reported.For suspected Group A throat infection, diagnostic CPRs reduced symptoms (1 study) and antibiotic prescriptions (5 studies, RR 0.86, 95% CI 0.75 to 0.99). For suspected cardiac chest pain, diagnostic strategies incorporating a CPR improved early discharge rates (1 study), decreased objective cardiac testing (1 study) and decreased hospitalisations (1 study). For ankle injuries, Ottawa Ankle Rules reduced radiography when used with clinical examination (1 study) but had no effect on length of stay as a triage test (1 study). For suspected acute appendicitis, CPRs had no effect on rates of perforated appendix (1 study) or the number of non-therapeutic operations (5 studies, RR 0.68, 95% CI 0.43 to 1.08). For suspected pneumonia, CPRs reduced antibiotic prescribing without unfavourable outcomes (3 studies). For children with possible serious bacterial infection, diagnostic CPRs did not improve process of care outcomes (3 studies).
CONCLUSION
There are few randomised trials of diagnostic CPRs, and patient outcomes are infrequently reported. Diagnostic CPRs had a positive effect on process outcomes in some clinical conditions; however, many studies were at unclear or high risk of bias and the results may be context specific. Future studies should seek to detail how the CPR might alter the diagnostic pathway, report effects on both patient and process outcomes, and improve reporting of the study interventions and implementation.
TRIAL REGISTRATION
The protocol for this review was not registered with PROSPERO, the international prospective register of systematic review protocols. The review was conceived and protocol prepared prior to the launch of PROSPERO in February 2011.
PubMed: 31093542
DOI: 10.1186/s41512-017-0013-2