Title: Understanding the Difference Between a Meta-Analysis and a Systematic Literature Review

Welcome to our comprehensive guide on understanding the crucial disparities between a Meta-
Analysis and a Systematic Literature Review. Navigating the intricacies of academic research can be
daunting, particularly when distinguishing between these two commonly used methodologies. Let’s
delve into the nuances to clarify their unique purposes and methodologies.

Meta-Analysis: Unveiling Collective Insights

Meta-Analysis is a statistical technique used to integrate and analyze findings from multiple
independent studies on a particular topic. Its primary objective is to provide a comprehensive
overview by quantitatively synthesizing data across studies. Through rigorous statistical methods,
Meta-Analysis enables researchers to identify patterns, trends, and relationships that may not be
apparent in individual studies alone.

Systematic Literature Review: The Quest for Comprehensive Understanding

On the other hand, a Systematic Literature Review involves a meticulous and structured approach to
gather, evaluate, and synthesize existing literature relevant to a specific research question. Unlike
Meta-Analysis, the emphasis is not solely on statistical analysis but rather on providing a
comprehensive narrative summary of existing knowledge.

Key Differences: Meta-Analysis vs. Systematic Literature Review

1. Methodology: While both methodologies involve a systematic approach, Meta-Analysis

focuses on quantitative data synthesis, whereas a Systematic Literature Review emphasizes
qualitative synthesis and analysis.
2. Purpose: Meta-Analysis aims to quantitatively analyze and summarize findings from multiple
studies to draw overarching conclusions, whereas a Systematic Literature Review aims to
provide a comprehensive qualitative overview of existing literature.
3. Data Synthesis: In Meta-Analysis, statistical techniques are employed to pool data from
individual studies, allowing for the calculation of effect sizes and measures of significance.
In contrast, a Systematic Literature Review synthesizes findings qualitatively, often
organizing literature thematically or chronologically.

The Challenge of Crafting a Literature Review

Undoubtedly, crafting a literature review, whether it be for a Meta-Analysis or a Systematic

Literature Review, presents significant challenges. From meticulously searching databases to
critically evaluating sources and synthesizing findings, the process demands time, expertise, and
attention to detail. Moreover, ensuring methodological rigor and adhering to academic standards
adds another layer of complexity.

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In conclusion, understanding the distinctions between Meta-Analysis and Systematic Literature

Review is essential for conducting robust research and contributing to scholarly discourse. Whether
you opt for quantitative synthesis through Meta-Analysis or qualitative synthesis through a
Systematic Literature Review, both methodologies play crucial roles in advancing knowledge within
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Overlapping systematic reviews of anterior cruciate ligament reconstruction comparing hamstring
autograft with bone-patellar tendon-bone autograft: why are they different. Rachel Huelin. Director
and Research Scientist, Meta Research. Literature Review, Systematic Review and Meta-analysis
Literature reviews can be a good way to narrow down theoretical interests; refine a research
question; understand contemporary debates; and orientate a particular research project. Systematic
reviews present the ideal opportunity to undertake in-depth assessments of evidence relevant to your
practice and have the potential to influence national guidelines in your area. Hence, it can be said
that meta-analysis and systematic review overlap and when they do the former is always a subset of
the latter. Most systematic reviews preregister the research plan, meaning that the authors submit
their planned methods to a registry like PROSPERO prior to conducting the study. The Cochrane
CENTRAL register of controlled trials, which includes over 640,000 records, is the best single
source for identifying reports of controlled trials (both published and unpublished). On the other
hand, if you are going to conduct a meta-analysis, then you can use the higher as well as some lower
forms of conducting the analysis. If the CI includes 1, then the difference in the effect of
experimental and control. You’ll need to discuss the studies and assess their overall quality. The
documentation provides a clear overview of scoping reviews. My favourite thing to do at the
weekend is get up early and go for a swim in the sea. Abstracts or unpublished work with insuf?cient
information. Availability of data and materials The datasets used and analyzed during the current
study are available from the corresponding author on reasonable request. From haircuts, colours,
highlights and barbering, to a full salon treatment, we offer hairdressing to suit. Three reviewers
independently reviewed titles and available abstracts to retrieve potentially relevant studies; studies
needed to be identified by only one person to be retrieved. Work Sample of Research Proposal Work
Sample of Research Proposal An-empirical-examination-of-the-text-structure-of-original-research-
articles-. Do these two have different scope of work and methodology. The literature is composed of
colonizing countries that deals with colonization or colonized peoples. PubMed; Google Scholar This
figure is adapted from a recent systematic review and meta-analysis which. My background is in
academic publishing: I've worked as an editor both freelance and in-house for Wiley and Cambridge
University Press. It is possible at this stage that you need to go back to your protocol and reconsider
if the methods are still fit-for-purpose (Fig. 2). Reading and Critically Appraising Systematic
Reviews. Literature reviews, on the other hand, do not follow such rigid or explicit methods.
Follow-up should be complete, with as few participants as. The steps involved in a systematic review
are similar to any other research undertaking ( Figure 12.1 ). Figure 12.1 Steps in a systematic
review. In: Cochrane handbook for systematic reviews of interventions, version 5.1.0. The Cochrane
Collaboration; 2011. p. 9.2.3.2. Ranganathan P, Pramesh CS, Buyse M. Participants Aged older than
16 years Diseases with disease-speci?c immunode?ciencies (eg. Bias can be minimized during the
conduct of studies (e.g., through randomizing participants, allocation concealment, blinding patients,
researchers and healthcare personnel, withdrawals and drop-outs, reporting of outcomes, etc.), and
these are tangible things that can be assessed in a systematic review to form judgments about the risk
of bias, and how believable the results of the studies are. A systematic review that incorporates
quantitative pooling of similar studies to produce an overall. In a meta-analysis, the main objective is
to provide more precise estimates of the effects of a treatment or of a risk factor for a disease, than
any of the individual studies included in the pooled analysis.
The data are summarized, and, if the data are statistically combined group (for randomized trials7),
and the Meta-analysis Of Observa-. The rows represent each study included in the review, and the
columns indicate the review authors’ determination about potential bias in each study. For instance,
the intervention may work differently in different contexts, and the included studies were gathered
from all over the world. PRISMA 2020 Statement The PRISMA 2020 Statement was published in
2021. Are orthopaedic surgeons performing fewer arthroscopic partial meniscectomies in patients
greater than 50 years old. Systematic reviews typically answer their research question by
synthesizing all available evidence and evaluating the quality of the evidence. Synthesizing means
bringing together different information to tell a single, cohesive story. You may find that systematic
review software will help you to manage this stage (see Ref. 7 for further guidance on choosing
appropriate software). Seroprevalence of hepatitis B among a 1-69-year-old population in Nanjing
city in 2020. Where meta-analysis is not appropriate, the results may be presented using tables and
text. The name lagged behind, appearing first in 1996, apparently referring to the tree-line optics
typical of most forest plots. No nationwide studies were identified in this meta-analysis from 2018
to 2022, there is a need for more systematic estimates of nationwide HBV prevalence. It supports
reviewers with study selection, data extraction and quality assessment. We here describe the essential
features of these methods and discuss their strengths and weaknesses. Empirical evidence shows
that, in systematic reviews of randomised controlled trials, results presented as risk ratios or odds
ratios are more consistent than those expressed as risk differences. Further Reading: Moher D,
Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Meta-analysis is a specialised type of systematic
review which is quantitative and rigorous, often comparing data and results across multiple similar
studies. The retrieved studies are then screened for eligibility using the inclusion and exclusion
criteria (this is done by at least two people working independently). Thus, combining the results of
various studies will provide an estimate of this common value. They also allow the results of
different studies to be evaluated together when these are inconsistent. Ayeni Section Editor
information UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery,
University of Pittsburgh, Pittsburgh, PA, USA Volker Musahl MD Division of Orthopaedic Surgery,
McMaster University, Hamilton, ON, Canada Mohit Bhandari Mark R. Covidence helps researchers
complete systematic review quickly and easily. It may also be, however, that the inclusion criteria do
cover these but no relevant studies have yet been conducted. Most systematic reviews preregister the
research plan, meaning that the authors submit their planned methods to a registry like PROSPERO
prior to conducting the study. Hence for final analysis, only about 10% of the original selection of
articles made it through the entire screening process. Rather, the relevant methodological aspects
should be identified in the study protocol, and assessed individually. A systematic review is a piece
of work that asks a research question and then answers it by summarising the evidence that meets a
set of pre-specified criteria. Supplementary Information Additional file 1.. Search Term Additional
file 2: Table S1. But, whereas a systematic review can include several research studies to answer a
specific question, typically a meta analysis includes a comparison of different studies to suss out any
inconsistencies or discrepancies. Systematic Reviews Meta-analysis Research Methodology
Evidence-Based Orthopedics Evidence-Based Medicine This is a preview of subscription content,
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Data extraction forms should be piloted, and revised if necessary. In their report, Boyle and
colleagues concluded that probiotics cannot be recommended for reducing eczema symptoms or
improving quality of life in patients with eczema. J Bone Jt Surg. 2013;95(11):377. Stroup DF,
Berlin JA, Morton SC, Olkin I, Williamson D, Rennie D, et al. People aged ?18?years old showed a
higher HBV prevalence. It supports reviewers with study selection, data extraction and quality
assessment. In our meta-analysis, the age group with higher prevalence was people aged ?18?years
old, while the age group with lower prevalence was those aged Over the past 30?years, numerous
strategies addressing HBV have been implemented within China and the prevalence of HBV has
been declining during this period. If you are on the search for an expert writer for your business
plan, systematic review and meta analysis, then your search ends here. Information about
subscriptions and ASH membership may be found online at. Descriptive Research Design and Its
Myriad Uses Five Common Mistakes to Avoid When Writing a Biomedical Research Paper Making
Technical Writing in Environmental Engineering Accessible To Err is Not Human: The Dangers of
AI-assisted Academic Writing When Data Speak, Listen: Importance of Data Collection and
Analysis Methods Choosing the Right Research Methodology: A Guide for Researchers Why is data
validation important in research. The Cochrane CENTRAL register of controlled trials, which
includes over 640,000 records, is the best single source for identifying reports of controlled trials
(both published and unpublished). Individual studies are often not big and powerful enough to
provide reliable answers on their own. The risk of perinatal hepatitis B virus transmission: hepatitis B
e antigen (HBeAg) prevalence estimates for all world regions. Sitemap case study creative writing
presentation problem solving rewiew prompts websites tips. Like meta-analysis, subgroup analysis
and meta-regression are advisable only in certain circumstances. However, heterogeneity in the
subgroup analysis did not decrease substantially. Our editors are PhD or PhD candidates, who are
native-English speakers. Request a consultation with one of our team members and start
empowering your researchers: By using our site you consent to our use of cookies to measure and
improve our site’s performance. There are two fundamental categories of research: Primary research
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Attach Resume ( Optional ) Max. Cite this Scribbr article If you want to cite this source, you can
copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the
citation to our free Citation Generator. Turney, S. (2023, November 20). This can be done either
through conducting the review via an organization such as the Cochrane Collaboration, or Campbell
Collaboration, by registering the protocol in a dedicated database such as PROSPERO (see link
above), or through publishing with a journal. Subscribe to our newsletter You will receive our
monthly newsletter and free access to Trip Premium. We used random effects meta-analysis to
combine estimates of the association between differences in SBP between arms and each outcome.
This may indicate whether the effect of the corresponding risk factors (Glossary) is different in the
different subgroups. Examining the evidence in anesthesia literature: a critical appraisal of systematic
reviews. We only retained studies with sample sizes above 800 participants, as this was estimated by
the review team to be a reasonable sample size for population-level studies and to minimize bias from
smaller studies on the pooled HBV prevalence. It consists of a checklist and a flow diagram, and is
intended to be accompanied by the PRISMA 2020 Explanation and Elaboration document.
Cumulative Index to Nursing and Allied Health (CINAHL) Journals, books, conference proceedings,
pamphlets, and educational software of nursing literature. Given malignancies13 for detailed
examples of study inclusion and. Find your local Melbourne hair salon or book online today.
Pubrica A comprehensive study of clinical efficacy in cochlear implant surgery among. Combating
hepatitis B and C by 2030: achievements, gaps, and options for actions in China. Bias occurs if the
results of a study are distorted by flaws in its design or conduct (see Chapter 3), while applicability
may be limited by differences between included patients’ demographic or clinical features, or in
how the intervention was applied, compared to the patients or intervention that are specified in the
review question. But it is also used in clinical trials, social studies, etc. Download citation Received:
18 April 2023 Accepted: 05 February 2024 Published: 16 February 2024 DOI: Share this article
Anyone you share the following link with will be able to read this content: Sorry, a shareable link is
not currently available for this article. A systematic review summarizes available literature of a
specific research question, and meta-analysis applies statistical methods to combine results from two
or more studies. Most studies account for this within their results. Scoping Reviews, JBI Manual for
Evidence Synthesis The Joanna Briggs Institute provides extensive guidance for their authors in
producing both systematic and scoping reviews. Do these two have different scope of work and
methodology. The prevalence of HBV infection was similar between males and females (both 3%),
while rural areas had a higher prevalence than urban areas (3% vs 2%). The advent of evidence-based
medicine has increased the demand for systematic methods to analyze and synthesize clinical
evidence. The research question for the systematic reviews may be related to a major public health
problem or a controversial clinical situation which requires acceptable intervention as a possible
solution to the present healthcare need of the community. The data from the studies can then be
extracted, usually onto difference of ?1.3 days compared with patients not taking. In this presented
review, there were 6 studies on rural prevalence and 5 studies on urban prevalence. These review
articles, known as highlight areas in which research is needed. Questions Score detect a “real”
difference that exists between the 2 groups). One of. We only retained studies with sample sizes
above 800 participants, as this was estimated by the review team to be a reasonable sample size for
population-level studies and to minimize bias from smaller studies on the pooled HBV prevalence.
Sitemap case study creative writing presentation problem solving rewiew prompts websites tips.
Other organizations with similar objectives have emerged, including the Australian-based Joanna
Briggs Institute (covering best evidence for global health care information), The Campbell
Collaboration (a sister organization to The Cochrane Collaboration) which provides systematic
evidence for issues of broader public policy, and the EPPI centre database providing well-designed
evaluations of interventions in the fields of education and social welfare. Analysis on economic
efficacy regarding previous strategies and current recommendations for vaccination against hepatitis
B virus in China. One way to address this is to use individual-level data from a large population
across China. Ethics declarations Ethics approval and consent to participate. This is followed by an
extensive search of the literature and a critical analysis of the search results. Quantitative literature
review Synthesize the results of previous studies. Thus, after the analysis, if changing makes little or
no difference to the overall results, the reviewer's conclusions are robust. Eczema is a common skin
condition that causes red, itchy skin. A clear research question will: Allow you to more effectively
communicate your research to other researchers and practitioners Guide your decisions as you plan
and conduct your systematic review A good research question for a systematic review has four
components, which you can remember with the acronym PICO: Population(s) or problem(s)
Intervention(s) Comparison(s) You can rearrange these four components to write your research
question: What is the effectiveness of I versus C for O in P. Types of Literature Reviews Meta-
analysis: Technique that statistically combines the results of quantitative studies to provide a more
precise effect of the results: Aims for exhaustive, comprehensive searching.. Refers to any
combination of methods where one significant component is a literature review (usually systematic).
The development of an inclusive search be dif?cult to locate) are known as “gray literature.”11
Inclusion of. In this article, we will look at the definition of a systematic review, and understand how
it is different from a meta-analysis.
A well-conducted systematic review might (for a number of reasons) have only included studies on
participants very dissimilar to the patient(s) the clinician has in mind. Read the articles and decide
which articles meet the selection criteria. However, not all research areas have enough evidence to
allow a meta-analysis. How was the pooled effect estimate calculated?—The effect estimates of the
individual studies are combined by statistical procedures to give a common pooled effect estimate (
9 ) (Figure 1). They’re thorough: they summarize all available evidence. The risk of perinatal hepatitis
B virus transmission: hepatitis B e antigen (HBeAg) prevalence estimates for all world regions.
These preregistration plans include a specific search strategy using specific search terms for
individual scholarly databases so other researchers can recreate the search. The graphical output of
meta-analysis is a forest plot which provides information on individual studies and the pooled effect.
The largest study sample size included in this review included 21,177 participants and the smallest
included 836 participants. Veronica Tanco Tellechea Leave a reply cancel reply. By formally
assessing the conflicting study results, it is possible to eventually reach new hypotheses and explore
the reasons for controversy. Data exported from Covidence can be saved in Excel for reliable transfer
to your choice of data analysis software or, if you’re writing a Cochrane Review, to RevMan 5. A
27-item checklist, PRISMA focuses on randomized trials but can also be used as a basis for
reporting systematic reviews of other types of research, particularly evaluations of interventions.
Introduction Evidence-based healthcare is the integration of best research evidence with clinical
expertise and patient values. This may indicate whether the effect of the corresponding risk factors
(Glossary) is different in the different subgroups. PO Box 660 Camden 2570, NSW SBS
cibus.com.au. Meta-analysis. Literature search study quality assessment Selection criteria Statistical
analysis Heterogeneity. Chronic maternal hepatitis B virus infection and pregnancy outcome-a single
center study in Kunming. It answers a clearly formulated research question and explicitly states the
methods used to arrive at the answer. In addition, they are normally collated and appraised by an
independent panel of experts in the field. The completeness of the search strategy will determine the
comprehen- be published in journals but may be published in abstract form. If the individual studies
are too heterogenous, a pooled effect estimate should not be calculated. Should this be the case,
there may be reasons to suspect that the findings are not applicable to the patient(s) in question. We
don’t know if it prevents maternal deaths, as this would require very large studies to detect an effect.
Precisely, the RR of mortality showed no difference in the sotrovimab group compared to treatment
with other drugs (OR 0.38, 95% CI 0.10-1.49, p Interpretation: In conclusion, this meta-analysis
showed no significant difference between sotrovimab or other antivirals in reducing COVID-19
evolution in patients with a high risk of progression, considering both hospitalization and mortality. It
would be understandable to think that a systematic literature review is similar to a meta analysis. The
first step is to frame a question which can guide the review. The previous 2017 meta-analysis divided
the age groups into 9 groups but in our meta-analysis, we only had two age groups. Thus, random-
effects meta-analyses give relatively more weight to smaller studies. A detailed search strategy, using
synonyms for the type of patients and interventions of interest, and combined using logical AND and
OR operators should be used to help identify relevant studies. In general, specific and systematic
methods selected are intended to minimize bias.
Often, novice. This figure is adapted from a recent systematic review and meta-analysis which.
Typically, an expert in a topic will qualitatively summarize and evaluate previous work, without using
a formal, explicit method. Identify ways to implement summarizing in the classroom. This kind of
analysis is only possible in a pooled reanalysis, as the original data with precise information on all
parameters for each participant are then available. The data are then summarized through narrative
and tables and, where appropriate, statistical tests to combine included studies (meta-analyses) may
be undertaken to provide statistical summaries of the study results. MEDLINE Contents of 3900
health journals and conferences. It’s very important to keep a meticulous record of why you included
or excluded each article. This is an important step because having a plan allows you to work more
efficiently and reduces bias. The different types of review and meta-analysis are discussed with
examples from the literature on one particular topic. It is based on the understanding that all similar
studies contain a common truth between them to which all individual studies arrive with a degree of
error. Sometimes, you may want to include a fifth component, the type of study design. The
literature is composed of colonizing countries that deals with colonization or colonized peoples.
Publication and level of evidence trends in the American journal of sports medicine from 1996 to
2011. In a recent review of 300 systematic reviews, few authors reported assessing possible
publication bias even though there is overwhelming evidence both for its existence and its impact on
the results of systematic reviews. The aim of the present article is to describe and distinguish these
forms and to allow the reader to perform a critical analysis of the results of individual studies and
the quality of the systematic review or meta-analysis. Do these two have different scope of work and
methodology. It supports reviewers with study selection, data extraction and quality assessment.
Publication Recognition How to Make a PowerPoint Presentation of Your Research Paper
Manuscript Preparation What is and How to Write a Good Hypothesis in Research. Systematic
reviews are studies of studies that offer a systematic approach to reviewing and summarising
evidence. Systematic Review VS Meta-Analysis 51.6K views Table of Contents What is a
Systematic Review. In contrast, our meta-analysis included 99,816 individuals across 25 studies, all
of which were local or regional studies and none were conducted at the national level. Our most
comprehensive editing package, Language Editing Plus also includes any English-editing needs for
up to 180 days. The components of a systematic literature review are quite different from the
standard literature review research theses that most of us are used to (more on this below). Device-
assisted tensioning is associated with lower rates of graft failure when compared to manual
tensioning in ACL reconstruction. This helps to make the differences between the studies clear with
respect to the data examined. 6. Were the calculations of the effect estimates of the individual studies
and of the pooled effect estimate presented. Were sensitivity analyses performed?—Like subgroup
analyses, sensitivity analyses (Glossary) serve to test the stability of the pooled estimate. Screening
for a literature review is typically less intensive. Table of contents What is a systematic review,
systematic review vs. Data extraction length of stay and patients who had taken antibiotics had a
mean. Key characteristics of a systematic review include a set of objectives with pre-defined
inclusion criteria, explicit and reproducible methodology, comprehensive searches that aim to identify
all relevant studies, assessment of the quality of included studies, and a standardised presentation and
synthesis of the characteristics and findings of the included studies.
My supervisors had pushed me to explain what kind of realist review I intended to undertake, and I
found out there was a branch of critical realism which was briefly of interest. A detailed search
strategy, using synonyms for the type of patients and interventions of interest, and combined using
logical AND and OR operators should be used to help identify relevant studies. Databases searched
included four international databases (Medline, Web of Science, Cochrane Database of Systematic
Reviews, and Embase) and three national databases (China National Knowledge Infrastructure
(CNKI), Chinese Biomedical Database (CBM), and WanFang Data). The JBI Manual for Evidence
Synthesis should be used in conjunction with the support and tutorials offered at the JBI SUMARI
Knowledge Base. Studies that had duplicated data, including the same group of patients or for
whom there were updated results available, were excluded. Systematic reviews strive to be as
thorough and rigorous as possible to minimise the bias that would result from cherry-picking studies
in a non-systematic way. Also explains which tests were performed, looking for heterogeneity and.
International Journal of Environmental Research and Public Dealth, 18 (2), 704. Gianluigi Savarese,
MD, FESC, ACC FIT Department of Advanced Biomedical Sciences, Federico II University,
Naples, Italy Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
Characteristics of age groups of the studies included in the meta-analysis Additional file 4: Table S3.
Covidence helps researchers complete systematic review quickly and easily. PRISMA may also be
useful for critical appraisal of published systematic reviews, although it is not a quality assessment
instrument to gauge the quality of a systematic review. This is what makes systematic reviews the
most reliable form of evidence (see figure 2). Search strategy: Discuss your plan for finding studies.
If the CI includes 1, then the difference in the effect of experimental and control. Using the above
example, this systematic review might be included in a broader OoR which examines a range of
interventions to reduce neurological damage following coronary artery bypass surgery (Figure 1).
Chronic maternal hepatitis B virus infection and pregnancy outcome-a single center study in
Kunming. How you organize your research is incredibly important; whether you're preparing a report,
research review, thesis or an article to be published. Radeva-Petrova et al. ( 2014 ) wrap up on page
120. For instance, the systematic review will include: Eligibility criteria for included research A
description of the systematic research search strategy An assessment of the validity of reviewed
research Interpretations of the results of research included in the review As you can see, contrary to
the general overview or summary of a topic, the systematic literature review includes much more
detail and work to compile than a standard literature review. This is done by calculating a weighted
average of the effect estimates from the individual studies (for example, estimates of the effect of
the intervention from randomised clinical trials, or estimates of the magnitude of association from
epidemiological studies). Alim Pharm Ther 2007 Example Search Strategy Spiegel et al. Firstly, it has
not been clearly defined what is the maximum order of heterogeneity between the studies which is
negligible and which then allows a meaningful calculation of a pooled effect estimate ( 1, 19 ). Each
study’s point estimate of the relative risk is plotted around a line of “no effect.” A risk of 1 means
that there is no difference between the intervention and control groups. A systematic review with
meta-analysis on functional changes associated with neck pain in adolescents. Because of this, when
carried out well, they provide reliable estimates about the effects of interventions so that conclusions
are defensible. Is my research topic appropriate for systematic review methods. Gray literature: Gray
literature includes documents produced by governments, universities, and other institutions that
aren’t published by traditional publishers. Writing a good review article Input your search keywords
and press Enter. Apart from the searchable databases discussed earlier, there are recording for each
study not only reduces the risk of bias but also.