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TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both.
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility
criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions
and implications of key findings; systematic review registration number.
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known.
Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions,
comparisons, outcomes, and study design (PICOS).
METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide
registration information including registration number.
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered,
language, publication status) used as criteria for eligibility, giving rationale.
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify
additional studies) in the search and date last searched.
Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be
repeated.
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable,
included in the meta-analysis).
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any
processes for obtaining and confirming data from investigators.
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and
simplifications made.
Risk of bias in individual 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was
studies done at the study or outcome level), and how this information is to be used in any data synthesis.
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means).
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of
consistency (e.g., I2) for each meta-analysis.
Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective
reporting within studies).
Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done,
indicating which were pre-specified.
RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions
at each stage, ideally with a flow diagram.
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period)
and provide the citations.
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome-level assessment (see Item 12).
Results of individual 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each
studies intervention group and (b) effect estimates and confidence intervals, ideally with a forest plot.
Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency.
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15).
Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).
DISCUSSION
Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their
relevance to key groups (e.g., health care providers, users, and policy makers).
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review level (e.g., incomplete retrieval of
identified research, reporting bias).
Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future
research.
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for
the systematic review.
doi:10.1371/journal.pmed.1000100.t001
Item 16: ADDITIONAL ANALYSES. Describe methods of Explanation. Authors should report, ideally with a flow
additional analyses (e.g., sensitivity or subgroup analyses, meta- diagram, the total number of records identified from electronic
regression), if done, indicating which were pre-specified. bibliographic sources (including specialized database or registry
searches), hand searches of various sources, reference lists, citation
indices, and experts. It is useful if authors delineate for readers the
Example. ‘‘Sensitivity analyses were pre-specified. The
number of selected articles that were identified from the different
treatment effects were examined according to quality
sources so that they can see, for example, whether most articles were
components (concealed treatment allocation, blinding of identified through electronic bibliographic sources or from references
patients and caregivers, blinded outcome assessment), time or experts. Literature identified primarily from references or experts
to initiation of statins, and the type of statin. One post-hoc may be prone to citation or publication bias [131,132].
sensitivity analysis was conducted including unpublished The flow diagram and text should describe clearly the process of
data from a trial using cerivastatin.’’ [124] report selection throughout the review. Authors should report:
unique records identified in searches; records excluded after
Explanation. Authors may perform additional analyses to preliminary screening (e.g., screening of titles and abstracts);
help understand whether the results of their review are robust, all reports retrieved for detailed evaluation; potentially eligible reports
of which should be reported. Such analyses include sensitivity that were not retrievable; retrieved reports that did not meet
analysis, subgroup analysis, and meta-regression [125]. inclusion criteria and the primary reasons for exclusion; and the
studies included in the review. Indeed, the most appropriate layout Examples. In text:
may vary for different reviews. ‘‘Characteristics of included studies
Authors should also note the presence of duplicate or Methods
supplementary reports so that readers understand the number of All four studies finally selected for the review were randomised
individual studies compared to the number of reports that were controlled trials published in English. The duration of the
included in the review. Authors should be consistent in their use of intervention was 24 months for the RIO-North America and
terms, such as whether they are reporting on counts of citations, 12 months for the RIO-Diabetes, RIO-Lipids and RIO-
records, publications, or studies. We believe that reporting the Europe study. Although the last two described a period of 24
number of studies is the most important. months during which they were conducted, only the first 12-
A flow diagram can be very useful; it should depict all the months results are provided. All trials had a run-in, as a single
studies included based upon fulfilling the eligibility criteria, blind period before the randomisation.
whether or not data have been combined for statistical analysis. Participants
A recent review of 87 systematic reviews found that about half
The included studies involved 6625 participants. The main
included a QUOROM flow diagram [133]. The authors of this
inclusion criteria entailed adults (18 years or older), with a
research recommended some important ways that reviewers can
body mass index greater than 27 kg/m2 and less than 5 kg
improve the use of a flow diagram when describing the flow of
variation in body weight within the three months before
information throughout the review process, including a separate
flow diagram for each important outcome reported [133]. study entry.
Intervention
Item 18: STUDY CHARACTERISTICS. For each study, All trials were multicentric. The RIO-North America was
present characteristics for which data were extracted (e.g., study conducted in the USA and Canada, RIO-Europe in Europe
size, PICOS, follow-up period) and provide the citation. and the USA, RIO-Diabetes in the USA and 10 other
different countries not specified, and RIO-Lipids in eight Explanation. For readers to gauge the validity and
unspecified different countries. applicability of a systematic review’s results, they need to know
The intervention received was placebo, 5 mg of rimonabant something about the included studies. Such information includes
or 20 mg of rimonabant once daily in addition to a mild PICOS (Box 2) and specific information relevant to the review
hypocaloric diet (600 kcal/day deficit). question. For example, if the review is examining the long-term
Outcomes effects of antidepressants for moderate depressive disorder, authors
Primary should report the follow-up periods of the included studies. For
each included study, authors should provide a citation for the
In all studies the primary outcome assessed was weight
source of their information regardless of whether or not the study
change from baseline after one year of treatment and the
is published. This information makes it easier for interested
RIO-North America study also evaluated the prevention of
readers to retrieve the relevant publications or documents.
weight regain between the first and second year. All studies
Reporting study-level data also allows the comparison of the
evaluated adverse effects, including those of any kind and
main characteristics of the studies included in the review. Authors
serious events. Quality of life was measured in only one
should present enough detail to allow readers to make their own
study, but the results were not described (RIO-Europe). judgments about the relevance of included studies. Such
Secondary and additional outcomes information also makes it possible for readers to conduct their
These included prevalence of metabolic syndrome after one own subgroup analyses and interpret subgroups, based on study
year and change in cardiometabolic risk factors such as characteristics.
blood pressure, lipid profile, etc. Authors should avoid, whenever possible, assuming information
No study included mortality and costs as outcome. when it is missing from a study report (e.g., sample size, method of
The timing of outcome measures was variable and could randomization). Reviewers may contact the original investigators
include monthly investigations, evaluations every three to try to obtain missing information or confirm the data extracted
months or a single final evaluation after one year.’’ [134] for the systematic review. If this information is not obtained, this
In table: See Table 2. should be noted in the report. If information is imputed, the reader
should be told how this was done and for which items. Presenting do not generally allow for the quantity of information available in
study-level data makes it possible to clearly identify unpublished electronic journals or Cochrane reviews, this should not be
information obtained from the original researchers and make it accepted as an excuse for omission of important aspects of the
available for the public record. methods or results of included studies, since these can, if necessary,
Typically, study-level characteristics are presented as a table as be shown on a Web site.
in the example in Table 2. Such presentation ensures that all Following the presentation and description of each included
pertinent items are addressed and that missing or unclear study, as discussed above, reviewers usually provide a narrative
information is clearly indicated. Although paper-based journals summary of the studies. Such a summary provides readers with an
No. of
Source Setting Patients Age Range Inclusion Criteria Antiemetic Agent Route Follow-Up
Freedman et al., 2006 ED 214 6 months–10 years GE with mild to moderate Ondansetron PO 1–2 weeks
dehydration and vomiting
in the preceding 4 hours
Reeves et al., 2002 ED 107 1 month–22 years GE and vomiting requiring IV Ondansetron IV 5–7 days
rehydration
Roslund et al., 2007 ED 106 1–10 years GE with failed oral rehydration Ondansetron PO 1 week
attempt in ED
Stork et al., 2006 ED 137 6 months–12 years GE, recurrent emesis, mild Ondansetron and IV 1 and 2 days
to moderate dehydration, dexamethasone
and failed oral hydration
overview of the included studies. It may for example address the Cochrane Collaboration’s new tool for assessing the risk of bias
languages of the published papers, years of publication, and also requests that authors substantiate these assessments with any
geographic origins of the included studies. relevant text from the original studies [11]. It is often easiest to
The PICOS framework is often helpful in reporting the narrative provide these data in a tabular format, as in the example.
summary indicating, for example, the clinical characteristics and However, a narrative summary describing the tabular data can
disease severity of the participants and the main features of the also be helpful for readers.
intervention and of the comparison group. For non-pharmacolog-
ical interventions, it may be helpful to specify for each study the key Item 20: RESULTS OF INDIVIDUAL STUDIES. For all
elements of the intervention received by each group. Full details of outcomes considered (benefits and harms), present, for each study:
the interventions in included studies were reported in only three of (a) simple summary data for each intervention group and (b) effect
25 systematic reviews relevant to general practice [84]. estimates and confidence intervals, ideally with a forest plot.
Item 19: RISK OF BIAS WITHIN STUDIES. Present data Examples. See Table 4 and Figure 3.
on risk of bias of each study and, if available, any outcome-level
assessment (see Item 12). Explanation. Publication of summary data from individual
studies allows the analyses to be reproduced and other analyses
Example. See Table 3. and graphical displays to be investigated. Others may wish to
assess the impact of excluding particular studies or consider
Explanation. We recommend that reviewers assess the risk of subgroup analyses not reported by the review authors. Displaying
bias in the included studies using a standard approach with the results of each treatment group in included studies also enables
defined criteria (see Item 12). They should report the results of any inspection of individual study features. For example, if only odds
such assessments [89]. ratios are provided, readers cannot assess the variation in event
Reporting only summary data (e.g., ‘‘two of eight trials rates across the studies, making the odds ratio impossible to
adequately concealed allocation’’) is inadequate because it fails interpret [138]. Additionally, because data extraction errors in
to inform readers which studies had the particular methodological meta-analyses are common and can be large [139], the
shortcoming. A more informative approach is to explicitly report presentation of the results from individual studies makes it easier
the methodological features evaluated for each study. The to identify errors. For continuous outcomes, readers may wish to
Table 3. Example Table: Quality measures of the randomized controlled trials that failed to fulfill any one of six markers of validity.
Figure 3. Example Figure: Overall failure (defined as failure of assigned regimen or relapse) with tetracycline-rifampicin versus
tetracycline-streptomycin. CI, confidence interval. Reproduced with permission from [137].
doi:10.1371/journal.pmed.1000100.g003
iate meta-regression showed no significant difference in Example. ‘‘Overall, the evidence is not sufficiently robust
CMV [cytomegalovirus] disease after allowing for potential to determine the comparative effectiveness of angioplasty
confounding or effect-modification by prophylactic drug (with or without stenting) and medical treatment alone. Only
used, organ transplanted or recipient serostatus in CMV 2 randomized trials with long-term outcomes and a third
positive recipients and CMV negative recipients of CMV randomized trial that allowed substantial crossover of
positive donors.’’ [149] treatment after 3 months directly compared angioplasty
and medical treatment…the randomized trials did not
Explanation. Authors should report any subgroup or evaluate enough patients or did not follow patients for a
sensitivity analyses and whether or not they were pre-specified sufficient duration to allow definitive conclusions to be made
(see Items 5 and 16). For analyses comparing subgroups of about clinical outcomes, such as mortality and cardiovascu-
studies (e.g., separating studies of low- and high-dose aspirin), the lar or kidney failure events.
authors should report any tests for interactions, as well as Some acceptable evidence from comparison of medical
estimates and confidence intervals from meta-analyses within
treatment and angioplasty suggested no difference in long-
each subgroup. Similarly, meta-regression results (see Item 16)
term kidney function but possibly better blood pressure
should not be limited to p-values, but should include effect sizes
and confidence intervals [150], as the first example reported control after angioplasty, an effect that may be limited to
above does in a table. The amount of data included in each patients with bilateral atherosclerotic renal artery stenosis.
additional analysis should be specified if different from that The evidence regarding other outcomes is weak. Because the
considered in the main analyses. This information is especially reviewed studies did not explicitly address patients with
relevant for sensitivity analyses that exclude some studies; for rapid clinical deterioration who may need acute interven-
example, those with high risk of bias. tion, our conclusions do not apply to this important subset of
Importantly, all additional analyses conducted should be patients.’’ [143]
reported, not just those that were statistically significant. This
information will help avoid selective outcome reporting bias Explanation. Authors should give a brief and balanced
within the review as has been demonstrated in reports of summary of the nature and findings of the review. Sometimes,
randomized controlled trials [42,44,121,151,152]. Results from outcomes for which little or no data were found should be noted
exploratory subgroup or sensitivity analyses should be interpret- due to potential relevance for policy decisions and future research.
ed cautiously, bearing in mind the potential for multiple analyses Applicability of the review’s findings, to different patients, settings,
to mislead. or target audiences, for example, should be mentioned. Although
there is no standard way to assess applicability simultaneously to
DISCUSSION different audiences, some systems do exist [153]. Sometimes,
Item 24: SUMMARY OF EVIDENCE. Summarize the main authors formally rate or assess the overall body of evidence
findings, including the strength of evidence for each main addressed in the review and can present the strength of their
outcome; consider their relevance to key groups (e.g., health summary recommendations tied to their assessments of the quality
care providers, users, and policy makers). of evidence (e.g., the GRADE system) [10].
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