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Presenting at conferences.

Academic conferences are a useful way to present the results of a Cochrane review to people either through an oral presentation, a poster presentation, or a booth. Conferences also have the additional benefit of networking and an opportunity to promote both Cochrane and the results of your review to peers.

How to present at conferences  

Oral presentation.

Good oral presentations should be captivating, get the message across clearly, consider the language and context of the audience, and keep people engaged throughout. Not everyone can be an expert public speaker, and in many ways, it takes practice to become good at delivering engaging oral presentations. Our resources below can help.

The ‘Community Templates’ section on the brand resources page provides templates for PowerPoint presentations that can be used at conferences. There is a video on Creating a PowerPoint Presentation to explain how to use the template.

This video gives some tips for effective presentations at conferences such as:

• Choosing your content
• Using an appropriate structure
• Eliminating jargon
• Creating effective slides
• Finding your passion!

Poster presentation

Make your poster one that people want to stop and look at when you are at a conference. If you are preparing a poster presentation, these resources will help your work stand out in a sea of posters:

• The ‘Community Templates’ on the brand resources page provide pre-branded poster templates. They are very simple to use – you just need to download and add in the content.  
• Cochrane officially endorses the #betterposter design. These new templates offer posters with less text and a decluttered design with the main finding in plain English as the highlighted feature. Learn more about the design and watch a quick introduction.  
• This  information sheet contains useful questions for preparing a poster for a conference.

Conference booth

At some conferences, you may have the opportunity to showcase your work at a booth. If you have multiple dissemination products that you created, you can display them here. You might also want to bring screens or computers to make your booth more interactive. Like posters, you want to make sure your booth is one that people want to visit and interact with.

You can contact Cochrane to discuss your event , get clarification on Cochrane event policies, or help with event branding such as special banners, flyers or branded items to give away.

If you are hosting the symposium or conference, contact Cochrane to have it listed and promoted on our website.

Sharing your presentation

When you know you'll be presenting at a conference, share the details on social media. For more information on social media platforms and how to use them effectively, visit this page.   On social media, tell people where you are going, what you'll be presenting, and provide a link to sign up to attend (if possible).  

During your presentation, you might want to consider having a colleague or peer live-tweeting. This will give you content to re-tweet later, and give people in the room content to share as well. Others in the room might also be tweeting about your presentation, which you can re-tweet later. You might want to consider live streaming your presentation on YouTube, Facebook or Instagram so your followers who aren’t in attendance can watch you present in real time.  

If you don’t have your own social media accounts, we can share a picture of you at a conference on Cochrane’s social media. It is great to get a picture beside your poster, at your booth, or beside something with the conference name. If you are interested, please send the following to Muriah Umoquit at [email protected] : - Your name - Your Instagram/Twitter handle if you want it included - The related Review or Centre group - Title of your poster or presentation - Link to Cochrane Review if appropriate - Title of the conference - Official conference hashtag - A picture

After your presentation, you can distribute materials to your audience so that the information stays with them. This could be copies or recordings of the presentation, or another dissemination product related to what you presented. You can distribute in person at the conference, afterwards if you have the details of who attended your session, or through social media for anyone who may have followed you on a social media platform because of your presentation.

Evaluating the effect of your presentation

Many conferences will do their own evaluation of their conference programming, including oral presentations that were given. They may ask attendees questions about the topic that was presented, the effectiveness of the presenters, and the quality of the presentation. Ask your conference host whether they evaluate presentations. If they do, you can request feedback on your presentation that way.

You can also seek feedback on your own from your audience if you gave a presentation. You can do this through hard copy surveys at tables or chairs that you can collect, through email after your presentation, or you can do live evaluation surveys. These work by surveying people in real time through posing a question you can embed in your presentation, and have audience members provide input on their phones by visiting a link you give them. Sli.do and Menti are popular tools for this.

Examples of presenting at conferences by Cochrane groups

This is a great case study of how Cochrane UK used a booth at a conference – with great tips on what to do before, during, and after the conference.

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Systematic Reviews

• Conference Presentations
• BIOMED CENTRAL Proceedings What's included: meeting abstracts published in BioMed Central Journals, usually includes abstracts and conference name. How to search: Browse list of journals indexing conferences.
• BIOSIS Previews This link opens in a new window What's included: Includes citations to individual poster/paper abstracts – rarely with abstract. May include citations to conferences as a whole (without listing individual presentations). How to search: limit search by "Publication Type" to meeting, meeting abstract or meeting paper. more... less... BIOSIS Previews Help: Basic Search BIOSIS Previews Help

• NLM Meeting Abstracts What's included: collection of abstracts from HIV/AIDS, Health Services Research, and Space Life Sciences meetings. How to search: search, then follow the "Meeting Abstracts" link.
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How to present a review paper at a conference?

I sent an abstract of a review paper for oral presentation to a conference, and it was accepted. The presentation will be about the most important developments and contributions made in the last decade on my specific area of research. Now I am preparing the speech, but I am not sure how to give a 12-minutes speech about all the work that has been done (it's a lot). Can someone give some suggestions on how to do a nice presentation about a review paper?

• presentation
• literature-review

In 12 minutes, the best you can do for your audience is highlight four to six broad observations or conclusions about the state of research. Here are some questions you might address with your observations:

• Are the lines of research diverging and multiplying, or converging and consolidating?
• Has it divided into "factions" or "schools" that define problems, methods, and solutions differently? Or is all research operating under a single paradigm?
• What's the influence and interaction with other fields and disciplines?
• Where has research made progress addressing fundamental questions? Where has research made no meaningful progress?
• Where should researchers look for the most promising research directions and under-explored areas?

Don't try to make more than six observations in 12 minutes. By trying to say more, you are actually communicating less effectively. Any one who wants the full story can read your paper.

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Systematic reviews: Structure, form and content

This article aims to provide an overview of the structure, form and content of systematic reviews. It focuses in particular on the literature searching component, and covers systematic database searching techniques, searching for grey literature and the importance of librarian involvement in the search. It also covers systematic review reporting standards such as PRISMA-P and PRISMA, critical appraisal and tools and resources to support the review and ensure it is conducted efficiently and effectively. Finally, it summarizes the requirements when screening search results for inclusion in the review, and the statistical synthesis of included studies’ findings.

Provenance and Peer review: Solicited contribution; Peer reviewed; Accepted for publication 24 January 2021.

Introduction

A systematic review collects secondary data, and is a synthesis of all available, relevant evidence which brings together all existing primary studies for review ( Cochrane 2016 ). A systematic review differs from other types of literature review in several major ways. It requires a transparent, reproducible methodology which indicates how studies were identified and the criteria upon which they were included or excluded. As well as synthesis of these studies' findings, there should be an element of evaluation and quality assessment. The systematic review methodology originated in medical and healthcare research, but it has now been adopted by other disciplines, such as engineering, education, economics and business studies. The processes and requirements for conducting a systematic review can seem arduous or time consuming, but with the use of appropriate tools and resources, and with thorough planning undertaken before beginning the review, researchers will be able to conduct their systematic reviews efficiently and smoothly.

This article provides an overview of the structure, form and content of systematic reviews, with a particular focus on the literature searching component. It will also discuss tools and resources – including those relating to reporting standards and critical appraisal of the articles included in the review – which will be of use to researchers conducting a systematic review.

Topic selection and planning

In recent years, there has been an explosion in the number of systematic reviews conducted and published ( Chalmers & Fox 2016 , Fontelo & Liu 2018 , Page et al 2015 ) – although a systematic review may be an inappropriate or unnecessary research methodology for answering many research questions. Systematic reviews can be inadvisable for a variety of reasons. It may be that the topic is too new and there are not enough relevant published papers to synthesise and analyse for a systematic review, or, conversely, that many other researchers have already published systematic reviews on the topic. However, if a scoping search appears to yield sufficient relevant studies for evidence synthesis, and indicates that no previous systematic reviews have been published (or that those previously published require an update or have methodological flaws), systematic reviews are likely to be appropriate.

Most systematic reviews take between six and 18 months to complete, and require a minimum of three authors to independently screen search results. Although many university modules require students to complete systematic reviews, due to this time and authorship requirement, it would be better to describe such student reviews as ‘reviews with systematic literature searches,’ as it is not possible to fulfil all the methodological requirements of a systematic review in a piece of work with a single author. Researchers without the available time or number of potential co-authors may prefer to adopt a different approach, such as narrative, scoping, or umbrella reviews. The systematic, transparent searching techniques outlined in this article can be adopted and adapted for use in other forms of literature review ( Grant & Booth 2009 ), for example, while the critical appraisal tools highlighted are appropriate for use in other contexts in which the reliability and applicability of medical research require evaluation.

Once it has been determined that a systematic review is the appropriate methodology for the research, and that there is sufficient time and resources to conduct it, researchers should then spend some time developing their review topic. It is appropriate at this point to do some scoping searches in relevant subject databases, first to ensure that the proposed review is unique, and meets a research need, and second to obtain a broad overview of the literature that exists, and which is likely to be included in the eventual systematic review. Based on this scoping work, the review topic may need to be refined or adapted, possibly to broaden or narrow it in focus. Once reviewers are satisfied with their chosen topic, the next step is to prepare a protocol which states transparently the methodology they intend to follow when conducting their review.

Creating a protocol

A protocol is a description of the proposed systematic review, including methods, the rationale for the review, and steps which will be taken to eliminate bias while conducting the review. Registering the protocol stakes a claim on the research, and it also means that researchers have done a significant portion of the work required before they formally begin the review, as they will have written the Methods section in draft form and planned what will be necessary to document and report by the time the protocol is finished.

Most protocols are registered with PROSPERO (2020), although it is also possible to upload your protocol on an institutional or subject repository, or publish the protocol in a journal. Guidance for creating a protocol can be found at PRISMA-P (The PRISMA Group et al 2015), or by working through the online training on protocols available at the Cochrane Library ( Cochrane Interactive Learning 2019 ).

Reporting standards and structure

PRISMA (the Preferred Reporting Items for Systematic Reviews and Meta-analyses) is 'an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses' ( Moher et al 2009 ). The PRISMA checklist is a useful guideline of content that should be reported and included in the final published version of the systematic review, and will help when in the planning stages as well. Most systematic reviews will be written up using the PRISMA checklist as their underlying structure, so familiarity with this checklist and the content required when reporting the findings of the systematic review should be established at the earliest planning stages of the research.

PRISMA-P (The PRISMA Group et al 2015) is the reporting guidelines for protocols. The EQUATOR Network lists reporting standards for multiple different types of study design ( EQUATOR Network 2020 ). Researchers can search for the right guideline for their type of study. Those undertaking a Cochrane review should select the correct Cochrane Handbook ( Cochrane Training 2020 ) for their review type.

Search strategy

The search strategy for systematic reviews is the main method of collecting the data which will underpin the review's findings. This means that the search must be sufficiently robust – both sensitive and specific – to capture all relevant articles. Ideally, multiple databases and other sources of information should be searched, using a consistent, predetermined search string. Generally, this will involve multiple synonyms for each theme of the review's topic, and a multifield search including freetext terms in (at minimum) the title and abstract, and the controlled vocabulary in the database thesaurus. These words are then combined with the Boolean operators AND, OR and NOT so that search results are both sensitive and specific.

Grey literature

It is likely that systematic reviews will need to include a search of grey literature as well as the peer-reviewed journal articles found through database searching. Grey literature includes unpublished theses, conference proceedings, government reports, unpublished trial data and more. Leaving grey literature out can run the risk of biasing the reviews results ( Goldacre 2011 ).

Searching grey literature can be challenging. Most sources of grey literature cannot be searched with complex Boolean operators and myriad synonymous keywords in the manner of a database. Likewise, the websites and other sources used to search for grey literature are unlikely to have a controlled vocabulary thesaurus. The Canadian Agency for Drugs and Technologies in Health (CADTH) tool is designed to help adapt complex systematic database search strategies for use when searching for grey literature ( CADTH 2009 ).

Snowballing, hand-searching and reference lists

Sometimes it may be appropriate to 'snowball' a search. This involves screening all the articles that cite included papers (the articles which meet the inclusion criteria after screening). Search for the titles of each included article in Web of Science or Scopus (or both), and any listed citing article which meets your inclusion criteria should also be included in the review.

Hand searching involves looking back through the tables of contents of key journals, conference proceedings, or lists of conference presentations relevant to the systematic review topic. Once key journals have been identified, reviewers should plan how many years back they will look – this will need to be done consistently across all journals that are hand-searched.

After reviewers have screened all the papers identified by the database and grey literature searches, and agreed on which will be included in the review, they should check through these articles' reference lists. Any articles in their reference lists which meet all inclusion criteria should also be included in the review.

Librarian co-authorship

There is some evidence that having a librarian co-author on a systematic review can improve the review's quality. A number of recent studies have indicated that librarian involvement improves the reproducibility of the literature searching ( Hameed et al 2020 , Koffel 2015 , Rethlefsen et al 2015 ). Reviews without librarian involvement often have problems with their search strategies – for example Boolean operators used incorrectly, inappropriate search syntax, or a lack of sufficient synonyms for each search term, meaning that relevant studies might be missed ( Golder et al 2008 , Li et al 2014 ). Unfortunately, in some instances, systematic reviews without librarian co-authors will still be published, even if their search strategies have significant methodological flaws ( Brasher & Giustini 2020 ). Librarian involvement will help ensure that the search strategy is robust, and that it is described accurately in the methodology to ensure that the systematic review is reproducible. Generally, if a librarian is developing the search terms, running the searches in databases and writing the search methods, they should be a co-author of the systematic review, whereas if the librarian supports researchers who then conduct the searches themselves, co-authorship is not necessary. This also aligns with the Vancouver recommendations on co-authorship ( International Committee of Medical Journal Editors 2019 ).

After database and grey literature searches are completed, and researchers have identified other papers through hand-searching, they will need to screen the titles and abstracts to determine if they meet the criteria for inclusion. These criteria should be pre-defined (ie: stated in the protocol before searches have begun). Inclusion criteria might relate to the following:

Date range of publication. Study design type. Whether a study focuses on the review's specific disease, condition, or patient population. Whether a study focuses mainly on the review's specific intervention. Whether a study focused on a certain country, region, or healthcare context (for example primary care, outpatient department, critical care unit, or similar).

This list is not exhaustive, and there are many other inclusion criteria to apply, depending on the scope of the topic of the systematic review. It is important that these criteria are stated clearly in the Methods section of both the protocol and systematic review, and that all co-authors understand them.

Generally, articles are screened against these criteria independently by at least two authors. Initially they should screen the titles and abstracts, and then move on to screening the full text for any articles which could not be judged as fulfilling (or not fulfilling) all inclusion criteria on the basis of the information in their titles and abstracts.

Referencing software such as Endnote, EndnoteWeb, Mendeley or Zotero can be used for screening, or reviewers may prefer to use systematic review screening software such as Covidence or Rayyan.

Critical appraisal tools

There are a number of tools and checklists available to help assess the quality of studies to be included in a review. Studies included in a systematic review should be assessed for their quality and reliability. While poor quality studies should not be excluded if they fulfil predefined inclusion criteria, the systematic review should make clear that all included studies have been assessed according to consistent principles of critical appraisal, and the results of that appraisal should be included in the review.

Most critical appraisal tools consist of different checklists to apply to different types of study design. If a systematic review includes multiple types of study design, it is advisable that researchers are consistent about which tools they use – it is preferable to use different checklists from a single source, rather than picking and choosing from a variety of sources.

If the systematic review is only including peer-reviewed, published journal articles, the checklists from either CASP (Critical Appraisal Skills Programme), Centre for Evidence-Based Medicine, SIGN (Scottish Intercollegiate Guidelines Network), or Joanna Briggs Institute will be appropriate ( Brice 2020 , Centre for Evidence-Based Medicine 2020 , Joanna Briggs Institute 2020 , SIGN 2020 ). Reviews which include grey literature should use a grey literature appraisal tool, such as AACODS ( Tyndall 2008 ). There are also risk of bias assessment tools, such as RoBiS for evaluating systematic reviews, and RoB 2 for evaluating randomized controlled trials ( Bristol Medical School 2020 , Sterne et al 2019 ).

One of the main advantages of systematic reviews is that they combine the analysis of the data from a number of primary studies. Most commonly, this is done through meta-analysis – the statistical combination of results from two or more studies. As outlined in the Cochrane Handbook, in interventional studies, a systematic review meta-analysis will seek to answer these three main questions:

What is the direction of effect? What is the size of effect? Is the effect consistent across [all included] studies? ( Higgins et al 2019 )

The researchers will then make a judgement as to the strength of evidence for the effect. If the systematic review is assessing the effectiveness of a variety of different interventions, it may not be possible to combine all studies for meta-analysis as the studies may be sufficiently different to make meta-analysis inappropriate. Researchers should ensure that when interpreting the results they consider the limitations and potential biases of included studies. When reporting the findings it is also usually necessary to consider applicability, and make recommendations – such as for a change in practice.

Systematic reviews – when an appropriate approach to the topic being researched – are a way to synthesize and evaluate the range of evidence available in multiple primary studies. Their methodology is complex, but if the correct reporting guidelines are followed, and researchers make use of tools, resources and the support of librarians and other information specialists, the process will be more straightforward. Planning is key: researchers should have a clear picture of what is involved, and what will need to be documented and reported in any resulting publications, and put measures in place to ensure that they capture all of this essential information.

No competing interests declared .

ORCID iD: Veronica Phillips https://orcid.org/0000-0002-4383-9434

How Do You Present a Literature Review in a Conference?

Presenting a literature review at a conference is an art that balances information delivery with engaging storytelling. In the context of “How do you present a literature review in a conference?” it’s essential to transform your extensive review into a concise, impactful presentation.

The presentation involves highlighting key findings, elaborating on methodologies, and illustrating their significance in relation to the conference’s theme. To captivate your audience, incorporate visuals and accurately cite your sources, ensuring your presentation is both informative and visually appealing.

Moreover, an engaging delivery style can substantially impact audience reception. Be prepared to handle questions and encourage discussions, turning your presentation into an interactive learning experience. For more insights and detailed guidance, continue reading our comprehensive article.

What Is the Literature Review?

A literature review is a scholarly endeavor that synthesizes existing research on a specific topic. It’s not merely a summary; it critically analyzes and links various studies. This comprehensive overview helps identify patterns, gaps, and the current state of knowledge.

In undertaking a literature review, the researcher examines relevant publications to establish an understanding of the subject. This process involves evaluating sources’ relevance, credibility, and contributions to the field. The outcome is a cohesive narrative contextualizing the research within its academic landscape, providing a foundation for new inquiries.

Can You Present a Literature Review at A Conference?

Yes, presenting a literature review at a conference is a valuable contribution. It offers insights into existing research and highlights emerging trends in a specific field. This presentation can spark discussions and foster academic collaborations.

When presenting a literature review at an event with multinational participants , the key is to distill complex information into accessible insights. This involves selecting key studies, weaving them into a narrative, and emphasizing their collective significance. Such a presentation can illuminate research gaps, setting the stage for future work.

In doing so, the presenter navigates through various studies, offering a critical analysis and synthesis. This approach educates and engages the audience, inviting them to explore the subject deeper. The literature review thus catalyzes knowledge exchange and scholarly debate at the conference.

Why Should You Present Your Literature Review at A Conference?

Presenting a literature review at a conference is a strategic move for any researcher or academic. It is a platform to share findings, gain feedback, and engage with peers. This opportunity can significantly impact one’s academic journey and research direction.

• Showcasing Expertise : Presenting a review establishes you as a knowledgeable professional. It highlights your ability to analyze and synthesize complex information.
• Networking Opportunities : Conferences attract like-minded professionals, offering a space to build valuable connections. Sharing your review can lead to collaborations and future research opportunities.
• Receiving Constructive Feedback : Peer conference feedback can refine your understanding and approach. This interaction often leads to improvements in your research methodology and perspective.
• Identifying Research Gaps : Discussing your review exposes you to different viewpoints, revealing gaps in current research. This insight can guide your future research endeavors.

Presenting a literature review at a conference is not just about sharing knowledge; it’s a gateway to professional growth, collaboration, and refining your research. It’s an invaluable experience for anyone looking to make a mark in their academic field.

How Do You Present a Literature Review in A Conference?

The process of presenting a literature review at a conference requires careful preparation and strategic execution. It involves a deep understanding of the subject matter and the ability to succinctly and engagingly convey complex ideas. This guide offers a structured approach to ensure your presentation is impactful and memorable.

Step 1: Understand Your Audience

Before you begin, assess who will be attending your session. Tailor your presentation to their knowledge level, interests, and the conference theme.

Step 2: Condense Your Content

Select key findings and essential studies from your review. Focus on presenting these elements clearly and concisely to maintain audience engagement.

Step 3: Create a Compelling Narrative

Weave your selected studies into a story that highlights their relevance and interconnections. This narrative approach makes your presentation more relatable and easier to follow.

Step 4: Utilize Visual Aids

Incorporate visuals like graphs, charts, and infographics to illustrate complex points. These aids can make your presentation more dynamic and understandable.

Step 5: Practice Your Delivery

Rehearse your presentation multiple times. Focus on clarity, pacing, and maintaining a conversational tone to keep your audience engaged.

Step 6: Prepare for Questions

Anticipate potential questions and prepare thoughtful responses. Engaging with your audience in this way can deepen their understanding and interest.

A literature review at a conference offers an ideal platform for showcasing your work and engaging with the academic community. Your presentation will be both informative and engaging if you follow these steps.

Considerations While Presenting Your Paper at A Conference

Presenting a paper at a conference is a crucial moment for any researcher or academic. It’s an opportunity to share your work with peers and experts in your field, receive feedback, and build your professional network. However, several considerations should be taken into account to ensure the presentation is effective and well-received.

• Understand Your Audience : Tailor your presentation to the audience’s expertise and interests. This ensures that your content is relevant and engaging to them.
• Clarity and Conciseness : Be clear and to the point in your delivery. Avoid overloading your presentation with excessive detail or jargon.
• Effective Use of Visuals : Use visuals like charts and slides to complement your speech. Ensure they are clear, relevant, and aid in understanding your points.
• Engaging Delivery : Practice your speech to maintain a natural, confident tone. Avoid monotonous delivery to keep the audience interested.
• Time Management : Adhere strictly to your allotted time slot. Plan your presentation to cover all points without rushing or overextending.
• Prepare for Questions : Anticipate questions and prepare concise, informative answers. This interaction can enhance the audience’s understanding of your work.

A successful conference presentation starts by understanding your audience’s needs and interests. Clear and engaging communication ensures your message resonates, while effective visuals enhance comprehension and retention.

Good time management keeps the presentation focused and allows for interactive discussions or Q&A sessions, fostering deeper engagement with your audience. By considering these factors, you can ensure that your presentation not only conveys your research effectively but also leaves a positive impression on your audience.

Tips to Select the Right Conference for Presenting Your Literature Review

Selecting the right conference to present your research is a critical decision that can significantly impact your academic and professional journey. It’s about finding a platform where your work will be appreciated and can contribute meaningfully to the field. This guide provides strategic tips to help you make an informed choice.

Relevance to Your Field

Choose a conference that aligns closely with your research area. This ensures your work is relevant to the attendees. Look for events where current trends and developments in your field are discussed. A conference with a specific focus can provide a more engaged audience for your topic.

Conference Reputation

Research the conference’s standing in the academic community. Established conferences often attract high-quality research and renowned speakers. Check past conference proceedings to gauge the quality of presentations. A reputable conference can add significant value to your CV and professional profile.

Type of Audience

Consider the typical audience of the conference. Whether it’s more academic or industry-focused can affect the reception of your work. A diverse audience can provide varied perspectives, enriching the discussion around your research. Tailor your presentation to suit the audience for maximum impact.

Networking Opportunities

Evaluate the networking potential of the conference. Conferences are excellent for meeting peers, mentors, and leaders in your field. Look for events that facilitate networking, such as workshops or social gatherings. Networking can open doors to collaborations and future research opportunities.

Publication Opportunities

Some conferences offer publication opportunities in journals or conference proceedings. Choose conferences where your work has the potential to be published. This can provide broader exposure and enhance your research’s credibility. Ensure the publication aligns with reputable and relevant academic journals.

Location and Accessibility

Consider the conference’s location and your ability to attend. The benefits of attending top-notch international conferences are appealing; however, local or regional conferences can also be beneficial. Factor in travel costs, visa requirements, and the conference’s accessibility. Sometimes, a nearby conference can offer more engagement and less logistical stress.

Selecting the right conference requires careful consideration of factors like relevance, reputation, audience type, networking opportunities, publication potential, and location. Making an informed choice can enhance your presentation’s impact, contribute to your professional development, and broaden your academic horizons.

Closing Remarks

In summarizing the key aspects of presenting a literature review at a conference, it’s clear that meticulous preparation and strategic considerations are paramount. From understanding your audience to selecting the right conference, each step is crucial for a successful presentation. “How do you present a literature review in a conference?” becomes a question of not just content, but context and delivery.

Accurate application of these principles ensures that your literature review is not only well-received but also stands out as a significant contribution to your field. Missteps in any of these areas, whether in presentation style or conference selection, can lead to missed opportunities and diminished impact.

Thus, the importance of precision and thoroughness in every aspect of conference presentation cannot be overstated. This holistic approach shapes not only how your work is perceived but also your professional trajectory in the academic community.

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Publications after conference presentations: A systematic review of published studies

Affiliations.

• 1 Professor, Department of Psychiatry, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160 012 INDIA.
• 2 Senior Resident, Department of Psychiatry, Post Graduate Institute of Medical Education and Research(PGIMER), Chandigarh, 160 012, INDIA.
• 3 Assistant Professor, Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110 029 INDIA.
• PMID: 34080994
• DOI: 10.20529/IJME.2020.106

Background and aims: Conferences provide an opportunity to present findings to an audience of experts in the field and get feedback for putting the research in context. Since conference proceedings provide limited space for presenting the findings, research publications are able to provide a better platform for the wider reach, scrupulous peer evaluation, and temporal consolidation of the medical scientific material. This review attempts to collate the studies which have evaluated the abstract publication ratio of the conference presentations.

Methods: The systematic review and meta-analysis included peer reviewed publications which quantitatively reported the publication rate of conference presentations.

Results: A total of 28 studies were included, with sample sizes ranging from 82 to 1897 abstracts (total 17,172 abstracts). The publication rate ranged from 3.8% to 78.0%, with weighted mean publication rate of 41.8% (95% confidence interval of 34.1% to 49.5%). Oral presentations had a greater chance of being published as compared to poster presentations (odds ratio of 2.693, 95% confidence intervals of 1.285 to 5.646). There was high degree of heterogeneity in the findings.

Conclusions: A small proportion of the conference presentations ispublished. Efforts should be made to improve the abstract publication ratio to improve the wider dissemination of the available research.

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• Systematic Review
• Open access
• Published: 14 September 2024

Crystal-induced arthritis in prosthetic joints: a systematic review of clinical features, diagnosis, management, and outcomes

• Haruki Sawada 1 ,
• Jared Dang 2 ,
• Bibek Saha 3 ,
• Luke Taylor 4 ,
• Yoshito Nishimura 5 , 7 ,
• Melissa Kahili-Heede 4 ,
• Cass Nakasone 6 &
• Sian Yik Lim 4 , 6 , 8  

BMC Rheumatology volume  8 , Article number:  43 ( 2024 ) Cite this article

Metrics details

To summarize clinical presentations, baseline characteristics, diagnosis, treatment, and treatment outcomes through a systematic review of cases of crystal-induced arthritis in prosthetic joints in the literature.

A systematic review of case reports and case series was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search was performed through PubMed/MEDLINE, Google Scholar, Embase, Cumulative Index to Nursing & Allied Health, and Web of Science. We identified case reports/case series in English of adult patients presenting with crystal-induced arthritis (gout, calcium pyrophosphate deposition disease) in prosthetic joints. Articles that met the inclusion criteria were utilized for qualitative data synthesis.

We found 44 cases of crystal-induced arthritis in prosthetic joints from 1984 to 2021. Crystal-induced arthritis in periprosthetic joints most frequently affects patients who had knee arthroplasty and most often presents as monoarticular arthritis that is usually acute in onset. However, several cases in the literature involved patients who had bilateral knee replacements and presented with a concurrent flare of gout or calcium pyrophosphate deposition disease in bilateral knees. Patients with crystal-induced arthritis in prosthetic joints show elevated white blood cell counts with neutrophil predominance and respond favorably to anti-inflammatory treatments, usually within one week. In many cases, crystal-induced arthritis was challenging to differentiate from prosthetic joint infection, with approximately one-third of patients undergoing surgical intervention and 35% receiving antibiotic treatment.

Crystal-induced arthritis in prosthetic joints can mimic prosthetic joint infections and should always be considered in the differential diagnoses of joint pain in prosthetic joints. We present the first systematic review of crystal-induced arthritis in prosthetic joints to increase awareness of the diagnosis and proper management.

Peer Review reports

Introduction

Crystal-induced arthritis is characterized by joint inflammation due to crystal deposition. The primary etiologies of crystal-induced arthritis include gout and calcium pyrophosphate deposition disease, which involve monosodium urate (MSU) and calcium pyrophosphate dihydrate (CPPD) crystal deposition, respectively. Crystal-induced arthritis is common, with gout affecting approximately 1–4% of adults worldwide and calcium pyrophosphate deposition disease having an estimated prevalence of 4–7% among adults in the United States and Europe [ 1 ]. In contrast, crystal-induced arthritis in prosthetic joints is poorly characterized, with only a few case reports in the orthopedic literature [ 2 ].

Total arthroplasty, especially total hip and knee arthroplasty, is increasingly used in treating arthritis. The number of total hip and knee arthroplasties is anticipated to increase significantly over the next few decades as populations in advanced countries age. More patients are undergoing joint arthroplasty at a younger age. With the number of arthroplasties increasing and more adults undergoing arthroplasty, research into one of the common causes of arthroplasty failure-periprosthetic joint infection (PJI) [ 2 ] and conditions that may mimic PJI is critical to improving the quality of care [ 3 , 4 , 5 ].

Infection control is crucial in managing PJI and therefore involves surgical intervention and antibiotic therapy in most cases. In contrast, most reported cases of crystal-induced arthritis in prosthetic joints have been managed medically with agents like colchicine and nonsteroidal anti-inflammatory drugs [ 6 ]. Consequently, unnecessary surgery could result from crystal-induced arthritis presumed to be PJI. Therefore, this study aimed to systematically review the literature to characterize cases of crystal-induced arthritis in prosthetic joints.

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 7 , 8 ]. Before initiating the literature search, the study protocol was registered with The International Prospective Register of Systematic Reviews (PROSPERO), PROSPERO ID: CRD42022362899. Specifically, MKH, an information services and instruction librarian, was enlisted to conduct an extensive systematic search through PubMed/MEDLINE, Google Scholar, Embase, Cumulative Index to Nursing & Allied Health (CINAHL), and Web of Science. The language was limited to English. The search strategy ( Appendix A ) involved relevant keywords, including gout, calcium pyrophosphate deposition disease, crystal-induced arthritis, prosthetic joint, and patient population (adult patient). De-duplication and screening of articles were undertaken using Covidence, a web-based collaboration software platform that streamlines the production of systematic and other literature reviews [ 9 ]. Two authors (HS and JD) independently screened all titles and abstracts obtained from the literature search from 1984 to 2021. The remaining articles underwent a full-text assessment to determine eligibility based on the inclusion criteria, including the article must be written in English, it must be a case report or case series, but not a review, the patient must be 18 years old or more, and present with proven crystal-induced arthritis of a prosthetic joint without another diagnosis (infection ruled out). Any disagreements between the two reviewers were resolved with discussion or the involvement of a third reviewer (SYL). A standardized data collection form that followed the PRISMA and Cochrane Collaboration guidelines for systematic reviews was used to obtain information regarding the name of authors, year of publication, country of origin, study characteristics (symptoms. age, gender, comorbidities, the reason for prosthetic joints, locations of affected joints, number of affected joints, laboratory findings: serum WBC (white blood cell) count, CRP (c-reactive protein), ESR (erythrocyte sedimentation rate), serum urate, means of diagnosis, synovial fluid analysis (synovial fluid WBC, synovial fluid polymorphonuclear leukocytes (PMNs), type of crystals), treatments, time course (time from prosthetic surgery to onset of symptoms, time from onset to diagnosis, time from therapeutic initiation to symptomatic resolution), and limitations. We calculated descriptive statistics to summarize the clinical characteristics of the included cases. We conducted analyses using JMP statistical software, version 15.1 (SAS Institute Inc., Cary, NC).

Figure  1 shows a PRISMA flow diagram summarizing the identification, screening, eligibility, and inclusion and exclusion processes of the studies involved. The initial MEDLINE, Embase, Web of Science, CINAHL, and Google Scholar databases review yielded 405, 879, 381, 64, and three articles, respectively. We removed three hundred thirty-nine duplicate studies. A total of 1393 articles were screened based on their relevance and type, whereas 1341 were either review articles, editorials, or focused on matters irrelevant to the research question and were excluded from the study. We evaluated 55 articles for full-text review. Review articles or articles that did not meet our inclusion criteria were excluded. As a result, 36 articles, including 44 cases from case reports and series, were included in the review) ( Appendix B ) [ 2 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ].

PRISMA flow diagram

Table  1 presents the baseline demographics, diagnostic findings, chief clinical symptoms, indications for prosthetic joints, and affected joints from the individual cases ( n  = 44). The median age of the included cases was 71.0 years (interquartile range [IQR] 61.8–77.0) without skewed deviation in terms of sex. History of gout and CPPD was found in 44.8% (13/29) and 5.0% (1/20), respectively. The median time from onset to diagnosis was three days (range 1–28 days) The most common symptoms included joint pain (97.6%), joint swelling (100%), and warmth (100%) of the affected joint. 47.5% of patients had a fever. The most common indication for prosthetic joints was osteoarthritis (59.1%, 26/44). Approximately 90% of cases involved prosthetic knees, followed by the hips and metatarsophalangeal joints. In terms of initial presentation, 80% of patients were monoarticular. Approximately 15.9% of cases involved two prosthetic joints, most commonly the contralateral joint. Of the cases involving two joints where the contralateral joints were affected, 6 cases occurred in prosthetic knees (the patient had bilateral knee replacement), and 1 case occurred in contralateral prosthetic metatarsophalangeal joints (the patient had bilateral silicone interposition arthroplasty). In contrast, two cases occurred in the contralateral native joint.

Table  2 presents laboratory data and diagnostic findings. According to the available data, the median serum urate level was 8.9 mg/dl (IQR 8.1–10.4). Of 16 cases that reported serum urate level only 2 cases had a uric acid measurement of less than 6.0 mg/dl. Synovial fluid analysis was remarkable for a median WBC count of 22.0 × 10 3 /µL (IQR 9.5–40.1). The median synovial fluid polymorphonuclear neutrophil percentage was 90% (IQR 81.5–95.0). There was no skewed deviation regarding monosodium urate and CPPD crystals, 56.8% and 45.5% respectively. 68% of cases were diagnosed with arthrocentesis. 7.3% were diagnosed directly with synovial biopsy/synovectomy. 19.5% of patients were diagnosed based on arthrocentesis, followed by synovial biopsy or synovectomy. The median time from prosthetic surgery to the onset of symptoms was 7.0 years (IQR 0.19-10.0).

Table  3 presents treatments and outcomes. Colchicine, Non-steroidal anti-inflammatory drugs (NSAIDs), and oral/intraarticular steroids were most frequently used. Approximately 35% of patients received antibiotics, and 29.5% underwent surgical intervention. It took a median of 4.0 days (IQR 2.3-7.0) until the resolution of symptoms from the initiation of treatment.

In the present study, we thoroughly reviewed case reports of crystal-induced arthritis in prosthetic joints. This is the first systematic review of crystal-induced arthritis in prosthetic joints to increase awareness of the diagnosis and proper management and to clarify detailed clinical presentations, treatments, and time course of symptoms. Crystal-induced arthritis in periprosthetic joints is acute in onset, most frequently affects the knee, and usually presents as monoarticular arthritis. However, there were several cases in the literature where the patient had bilateral knee replacements and presented with a flare of gout or calcium pyrophosphate deposition disease in bilateral knees. Patients with crystal-induced arthritis in prosthetic joints show elevated WBC count with neutrophil predominance in synovial fluid and respond favorably to anti-inflammatory treatments, including systemic glucocorticoids, colchicine, and NSAIDs, usually within one week. It appears that crystal-induced arthritis in prosthetic joints shows almost similar synovial fluid findings and treatment responses as native joint crystal-induced arthritis. These findings make it challenging to differentiate periprosthetic joint infection from crystal-induced arthritis in prosthetic joints, especially on initial presentation. Our study summarizes the clinical characteristics of crystal-induced arthritis in periprosthetic joints, providing insight for the multidisciplinary team of internists, rheumatologists, orthopedists, and infectious disease physicians involved in patient care.

We found a total of 44 cases of crystal-induced arthritis in prosthetic joints since 1984, when the first case of gout following joint arthroplasty was reported [ 26 ]. In contrast, CPPD following a major joint arthroplasty was not reported until 2007 [ 44 ]. Crystal-induced arthritis in prosthetic joints is an uncommon diagnosis, but it may be under-reported [ 35 ]. Routine testing for crystals may not be routinely performed at many centers when synovial fluid is aspirated from prosthetic joints, and there is the possibility that an inflammatory response from gout or CPPD crystals may cause cases reported as culture-negative prosthetic joint infection. Because of this, there is a paucity of studies and research on crystal-induced arthritis in prosthetic joints. Almost all patients presented with joint pain, swelling, and warmth in the affected joints, while most also had erythema and decreased range of motion. Only about half of patients had a fever. The onset of symptoms to diagnosis was variable (1–28 days) with a median of 3 days, compared to gout and acute CPP crystal arthritis flares, which are typically acute in onset (maximum pain noted within 24 h) [ 45 , 46 ]. Over half of the patients had elevated serum WBC count, ESR, and CRP. Synovial WBC count was elevated with median polymorphonuclear neutrophils of 90%. About one-third of the patients underwent treatment for presumed PJI with surgery and antibiotics. This result is consistent with literature describing the difficulty distinguishing between crystal-induced arthropathy and PJI presentations in prosthetic joints [ 2 , 12 ].

Prosthetic joint infection is a common and severe postoperative complication that may be challenging to differentiate from aseptic causes of inflammation, like crystal-induced arthritis, as both may present similarly with symptoms like acute joint pain, swelling, and erythema [ 2 , 45 , 46 ].

The challenge in clinical practice is that no single test provides a definitive diagnosis of prosthetic joint infection. There is a significant overlap between findings found in prosthetic joint infection and crystal-induced arthritis in prosthetic joints [ 5 ]. In 2018, the Musculoskeletal Infection Society and the Infectious Diseases Society published criteria to standardize the diagnosis of prosthetic joint infection [ 47 ]. While the 2018 criteria have a 97.7% sensitivity and 99.5% specificity, many preoperative minor criteria overlap with crystal-induced arthritis, including elevated inflammatory markers, synovial PMNs, and synovial white blood cell count. Besides specific signs such as sinus tract evidence of joint communication, many criteria were based on an intraoperative diagnosis. Alpha-defensin testing was a minor criterion in the 2018 International Consensus Meeting criteria for PJI. Alpha-defensin is an antimicrobial peptide produced by the innate immune system, and a positive alpha-defensin test has been shown to have a sensitivity of 69–100% and specificity of 94–98% for PJI [ 35 , 48 ]. While promising, further research is necessary to assess the validity of alpha-defensin testing in periprosthetic crystal-induced arthropathy.

Prompt arthrocentesis and identification and verification of synovial fluid are critical for diagnosis. Ideally, for suspected PJI, arthrocentesis is performed in a sterile environment in an operating theatre (by orthopedics) or interventional radiology suite to prevent sample contamination [ 49 ]. However, clinical decision-making is even more complicated, considering that both conditions may present concurrently in the same joint [ 3 , 4 ], and a missed PJI can have devastating consequences. Further efforts are needed to help develop methods or systems to reliably differentiate PJI and crystal-induced arthritis, especially preoperatively, because treatment, prognosis, and healthcare utilization differ significantly for both conditions. Increased awareness is essential, with consideration given to testing for crystals in synovial fluid samples obtained from prosthetic joints as recommended per guidelines where septic prosthetic arthritis is suspected. Only monosodium urate crystals and calcium pyrophosphate crystals can be identified on light microscopy, while wet preparation with alizarin red stain is needed to identify the presence of calcium hydroxyapatite crystals [ 50 ].

A high clinical suspicion is needed to make an accurate diagnosis. Crystalline arthritis flares can occur during the treatment of trauma, as well as before and after surgery [ 51 ]. In certain cases, crystalline arthritis flares can be triggered by surgical procedures [ 52 ]. We found that 44.8% of patients had a history of gout, while just 5% reported a history of CPPD. As half of the patients had no history of gout or CPPD, crystal-induced arthritis in prosthetic joints should be suspected, even in patients not reporting a prior history of gout or calcium pyrophosphate deposition disease. Viriyavejkul et al. reported that CPPD crystals were present in 52.9% of patients who underwent knee arthroplasty in a case series of 102 patients [ 53 ]. However, almost all patients were unaware of the presence of calcium crystals. Identifying chondrocalcinosis on prior radiographs, while not diagnostic, may be helpful in the diagnosis. Further, we found a wide range of time to presentation, from a few days after surgery to decades after surgery, suggesting crystal-induced arthritis should always be suspected in cases with prosthetic joint pain regardless of the surgery date. Close coordination of care with a multidisciplinary team, including rheumatologists, infectious disease experts, and orthopedic surgeons closely coordinating care, may be optimal in management. Critical aspects of the appropriate management include promptly verifying synovial fluid for the presence of crystals and assessing the probability of infection. Confirmation of a favorable response to anti-inflammatory treatments (NSAIDs, colchicine, and prednisone) is essential. In our review, most cases were resolved within seven days of treatment. Ultimately, the patient may undergo surgical intervention due to difficulty distinguishing PJI and crystal-induced arthritis. In general, intraarticular corticosteroid injections into prosthetic joints are not recommended due to the increased risk of prosthetic joint infections [ 54 ].

While the mechanism of crystal-induced arthritis in prosthetic joints is not wholly understood, several authors have provided several suggestions [ 6 , 55 ]. Calcium pyrophosphate deposition disease crystals are manifestations of metabolic derangement that originate from the cartilage. CPPD crystals deposit in the cartilage leading to joint damage [ 6 , 56 , 57 ]. Implantation of prosthetic joints does not remove all of the cartilage in the joint; therefore, CPPD crystals can still be formed from the persistence of native cartilage (i.e., in the patella with certain types of knee replacement procedures). Furthermore, cartilage can also be formed after joint replacement surgery by cartilaginous metaplasia around the prosthetic joint [ 6 , 55 ]. Similarly, the pathophysiology of a gout flare requires the presence of synovial tissue. Synovial remnants may persist in the prosthetic joint. Neosynovial tissue also may develop around the prosthesis post-surgery [ 55 ]. When monosodium urate crystals are deposited within the synovial tissue, this leads to a gout flare.

Although both time from symptom onset to diagnosis and symptom resolution following appropriate therapy was relatively quick, this delay in diagnosis and treatment adds unnecessary days of hospitalization and, thus, unnecessary costs to both the patient and the hospital. While research into effectively identifying crystal-induced arthritis is needed, consideration should be given to optimizing the situation for patients who undergo arthroplasty. Data from the United States National Inpatient Sample 1998–2014 found that gout was independently associated with an 18% increased risk of discharge to a non-home setting. Gout was also found to increase the length of stay by 8% [ 58 ]. Further research is needed to determine if better gout management can reduce the increased healthcare utilization of gout in patients undergoing arthroplasty. Notably, in our study, only very few patients with gout had urate lowering therapy. Optimizing urate control may be beneficial in reducing the risk of gout after arthroplasty; however future research is needed. Of interest, Harato and Yoshida reported the use of prophylactic NSAIDs in a patient with a high risk of flare [ 25 ]. Further studies are needed to clarify the utility of prophylactic treatment and determine patients at increased risk of developing crystal-induced arthropathy in prosthetic joints. Some authors have noted the possibility of a more aggressive synovectomy during joint replacement for high-risk patients [ 59 ]. However, this remains to be investigated further because synovectomy does not produce improved pain or range of motion outcomes and is associated with increased blood loss and operative time [ 59 ].

Strengths of this study include a comprehensive systematic review of all cases reported in the literature of crystal-induced cases in prosthetic joints, involving an experienced librarian, and a multidisplinary team of board certified rheumatologists and orthopedics surgeons following PRISMA guidelines. It provides insight into an understudied area where further research is needed because of the increasing number of joint arthroplasties used to treat arthritis as the population ages from a rheumatology perspective, where the literature has been mainly reported in the orthopedic literature. Several limitations of this study should also be discussed. There were no laboratory results or joint x-rays before prosthetic joint replacement in certain articles, and we could not contact authors to obtain data not mentioned in the literature. Secondly, we did not include review articles, conference abstracts, or preprints, leading to uncertainty in the evidence level discussed.

In conclusion, crystal-induced arthritis in prosthetic joints is a rare condition that presents similarly to PJI. This uncertain clinical picture often leads to unnecessary treatment such as antibiotics and surgery, exposing the patient to the risks involved with those treatments without any benefits. Thus, we present the first systematic review of crystal-induced arthritis in prosthetic joints to increase awareness of the diagnosis and proper management. Crystal-induced arthritis should always be considered in the differential diagnosis of joint pain in prosthetic joints. Prompt diagnosis and treatment with typical crystal-induced arthritis medications should result in rapid resolution of symptoms and, thus, prevent unnecessary treatment and increased length of hospital stay.

Data availability

The data presented in this study are available on request from the corresponding author.

Abbreviations

Monosodium urate

Calcium pyrophosphate

Calcium pyrophosphate dihydrate

Periprosthetic joint infection

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Cumulative Index to Nursing & Allied Health

White Blood Cell

C-reactive protein

Erythrocyte sedimentation rate

Polymorphonuclear leukocytes

Interquartile range

Non-steroidal anti-inflammatory drugs

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Department of Medicine, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI, USA

Haruki Sawada

Department of Medicine, Scripps Mercy Hospital San Diego, San Diego, CA, USA

Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA

John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI, USA

Luke Taylor, Melissa Kahili-Heede & Sian Yik Lim

Department of General Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan

Yoshito Nishimura

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Cass Nakasone & Sian Yik Lim

Division of Hematology and Oncology, Mayo Clinic, Rochester, MN, USA

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HS- study design, data collection, interpretation of data, drafting, and revising the manuscript. JD - data collection, interpretation of data, drafting, and revising the manuscript. BS - study design, data collection, interpretation of data, drafting, and revising the manuscript. LT - data collection, interpretation of data, drafting, and revising the manuscript. YN - interpretation of data, drafting, and revising the manuscript. MK - study design, data collection. CN - study design, data collection, interpretation of data, drafting, and revising the manuscript. SYL - study design, data collection, interpretation of data, drafting, and revising the manuscript. All authors read and approved the final manuscript.

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Sawada, H., Dang, J., Saha, B. et al. Crystal-induced arthritis in prosthetic joints: a systematic review of clinical features, diagnosis, management, and outcomes. BMC Rheumatol 8 , 43 (2024). https://doi.org/10.1186/s41927-024-00411-9

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The impact of chiropractic care on prescription opioid use for non-cancer spine pain: protocol for a systematic review and meta-analysis

• Peter C. Emary 1 , 2 , 3 ,
• Kelsey L. Corcoran 4 , 5 ,
• Brian C. Coleman 5 , 6 , 7 ,
• Amy L. Brown 3 ,
• Carla Ciraco 8 ,
• Jenna DiDonato 9 ,
• Li Wang 10 , 11 , 12 ,
• Rachel J. Couban 10 ,
• Abhimanyu Sud 13 , 14 &
• Jason W. Busse 10 , 11 , 12 , 15  

Systematic Reviews volume  13 , Article number:  232 ( 2024 ) Cite this article

Metrics details

In recent studies, receipt of chiropractic care has been associated with lower odds of receiving prescription opioids and, among those already prescribed, reduced doses of opioids among patients with non-cancer spine pain. These findings suggest that access to chiropractic services may reduce reliance on opioids for musculoskeletal pain.

To assess the impact of chiropractic care on initiation, or continued use, of prescription opioids among patients with non-cancer spine pain.

We will search for eligible randomized controlled trials (RCTs) and observational studies indexed in MEDLINE, Embase, AMED, CINAHL, Web of Science, and the Index to Chiropractic Literature from database inception to June 2024. Article screening, data extraction, and risk-of-bias assessment will be conducted independently by pairs of reviewers. We will conduct separate analyses for RCTs and observational studies and pool binary outcomes (e.g. prescribed opioid receipt, long-term opioid use, and higher versus lower opioid dose) as odds ratios (ORs) with associated 95% confidence intervals (CIs). When studies provide hazard ratios (HRs) or relative risks (RRs) for time-to-event data (e.g. time-to-first opioid prescription) or incidence rates (number of opioid prescriptions over time), we will first convert them to an OR before pooling. Continuous outcomes such as pain intensity, sleep quality, or morphine equivalent dose will be pooled as weighted mean differences with associated 95% CIs. We will conduct meta-analyses using random-effects models and explore sources of heterogeneity using subgroup analyses and meta-regression. We will evaluate the certainty of evidence of all outcomes using the GRADE approach and the credibility of all subgroup effects with ICEMAN criteria. Our systematic review will follow the PRISMA statement and MOOSE guidelines.

Our review will establish the current evidence informing the impact of chiropractic care on new or continued prescription opioid use for non-cancer spine pain. We will disseminate our results through peer-reviewed publication and conference presentations. The findings of our review will be of interest to patients, health care providers, and policy-makers.

Trial registration

Systematic review registration: PROSPERO CRD42023432277.

Peer Review reports

Low back pain remains the leading cause of years lived with disability (YLD) worldwide [ 1 ]. In 2017, low back pain was responsible for around 64.9 million YLD, an increase of 47.5% since 1990; YLD due to neck pain also increased by 65.8% during the same period [ 1 ]. In North America, opioids are commonly prescribed to relieve low back and neck pain [ 2 ]; however, opioids provide only modest improvements in pain intensity, physical function, and sleep quality [ 3 , 4 ]. Moreover, opioids are associated with rare but catastrophic risks, including nonfatal and fatal unintentional overdose, and 1 in 20 patients prescribed opioids for chronic pain will develop an opioid use disorder [ 5 , 6 , 7 ]. Accordingly, current clinical practice guidelines recommend optimization of non-opioid pharmacotherapy and non-pharmacologic treatments (e.g. education, exercise, cognitive behavioural therapy, soft-tissue massage, spinal manipulation) rather than prescription opioids as first-line therapy for acute or chronic non-cancer musculoskeletal pain [ 6 , 8 , 9 ].

In several recent studies, receipt of chiropractic care has been associated with lower chances of receiving prescription opioids [ 10 , 11 , 12 , 13 , 14 , 15 , 16 ] and, among those already prescribed, reduced opioid dose [ 17 , 18 , 19 ] among patients with non-cancer spine pain. A 2022 observational study of 40,929 opioid-naive persons with new-onset low back pain found that those who received chiropractic treatment early in their complaint had 12% lower odds of incident opioid use (adjusted odds ratio [OR] = 0.88; 95% confidence interval [CI], 0.80 to 0.97) and 44% lower odds of long-term opioid use (adjusted OR  = 0.56; 95% CI , 0.40 to 0.77) [ 13 ]. A 2022 mixed-methods analysis of 210 opioid-using community health centre patients with chronic back or neck pain [ 19 ] found that the rate of prescription opioid fills over 12-month follow-up was 34% lower (adjusted incidence rate ratio (IRR) = 0.66; 95% CI , 0.52 to 0.83), and refills were 73% lower (adjusted IRR  = 0.27; 95% CI , 0.17 to 0.42), among those who initiated chiropractic care ( n  = 49) versus non-recipients ( n  = 161). Recipients were also between 78 and 86% less likely to be prescribed a higher (i.e. \(\ge\)  50-mg morphine equivalents daily [MED]) opioid dose [ 19 ]. These findings, combined with those of other reports [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ], suggest that access to chiropractic services may reduce reliance on opioids for acute or chronic musculoskeletal pain.

A prior systematic review and meta-analysis of six uncontrolled observational studies [ 20 ] found an inverse association between attending a chiropractor and opioid receipt among patients with spinal pain (pooled OR  = 0.36; 95% CI , 0.30 to 0.43). However, the literature search informing this systematic review was conducted up to April 18, 2018, the certainty of evidence was not examined, and assessments of risk of bias and heterogeneity were suboptimal [ 20 ]. Moreover, at least 10 additional studies investigating the effect of chiropractic care on new and existing opioid use have since been published [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. As such, an updated systematic review and meta-analysis on chiropractic use and opioid receipt among patients with spinal pain is warranted.

The purpose of our systematic review is to assess the impact of chiropractic care on (1) initiation, or continued use, of prescription opioids and (2) patient-important outcomes, including pain intensity, physical and emotional functioning, sleep quality, patient satisfaction, and adverse events, among adult patients with non-cancer spine pain. Our focus is on non-cancer spine pain because cancer-related spine pain is a contraindication to high-velocity, low-amplitude spinal manipulation [ 21 ]. We will explore whether our results are influenced by factors such as the year the study was conducted, methodological quality, whether pain is acute or chronic, type of opioid prescriber(s), earlier versus later chiropractic exposure, or frequency of chiropractic treatment visits.

We have reported our systematic review protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement [ 22 ] (Additional file 1). Our protocol is also registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42023432277.

Eligibility criteria

Our eligibility criteria are summarized below using the PICOS (i.e. Population, Intervention, Comparison intervention, Outcome measures, Study designs) framework [ 23 ].

Participants/population

We will include adult patients ( \(\ge\) 18 years of age) with non-cancer back or neck pain (with or without radicular symptoms) of any duration.

We will exclude patients with spinal neoplasms or other contraindications to chiropractic treatment (i.e. ‘red flag’ diagnoses such as fractures, infections, inflammatory arthritis, or cauda equina syndrome) [ 21 ].

Intervention/exposure

Our exposure of interest will be receipt of chiropractic care, which is defined as care provided by a chiropractor, including, but not limited to spinal manipulation, soft-tissue therapy, education, reassurance, and self-care advice (e.g. icing, stretching, and strengthening exercises) [ 24 ].

Comparator/control

The comparison will be nonreceipt of chiropractic care (e.g. usual medical care, physiotherapy).

Primary outcomes

Our primary outcomes will be as follows: (1) prescription opioid receipt and (2) continued prescription opioid use (measured as the number and/or dose of opioid prescriptions).

Secondary outcomes

We will extract data on all other patient-important outcomes [ 25 ] that are reported, including the following: (1) pain intensity, (2) physical functioning, (3) emotional functioning, (4) sleep quality, (5) patient satisfaction, and (6) adverse events [ 26 , 27 ]. We will consider outcomes for physical and emotional functioning that are reported over a minimum 4-week follow-up period.

Study designs

We will include both randomized and non-randomized (quasi-experimental) controlled trials and observational studies (including cohort and case–control studies) that reported an adjusted analysis exploring the association between receipt of chiropractic care and opioid use.

We will exclude case reports, case series, cross-sectional studies, protocols, letters, editorials, commentaries, books and book chapters, dissertations, conference abstracts, and secondary sources of evidence, including clinical practice guidelines and systematic, scoping, or narrative reviews.

We will not exclude studies based on geographic location, language, or date of publication. Studies that either were published before, or were included in, the 2020 systematic review by Corcoran et al. [ 20 ] will be re-examined to ensure a comprehensive literature search and to validate eligibility.

Information sources

We will search MEDLINE, Embase, AMED, CINAHL, Web of Science, and the Index to Chiropractic Literature without geographic or language restrictions from the inception of each database to June 2024. Our database-specific search strategies have been developed by an academic librarian (RJC) and were reviewed by a second librarian using the peer review of electronic search strategies (PRESS) checklist [ 28 ] (Additional files 2 and 3). We will also hand-search reference lists of eligible articles and related systematic reviews and contact content experts to identify additional eligible studies. We will re-run our database searches prior to our final analyses and retrieve any additional eligible studies for inclusion.

Study selection

After duplicate records have been removed (see Fig.  1 ), pairs of reviewers will independently screen titles, abstracts, and full-text studies for eligibility using online systematic review software (DistillerSR, Evidence Partners, Ottawa, Canada; https://www.distillersr.com/ ). Calibration exercises will be conducted prior to title/abstract and full-text screening to improve consistency between reviewers throughout the study selection process. Disagreements on eligibility will be resolved through discussion to achieve consensus or, when not possible, adjudication by a third reviewer. We will calculate inter-rater agreement on title/abstract and full-text screening using an adjusted kappa ( \(\kappa\) ) statistic [ 29 ] and interpret the strength of agreement at each stage as follows: poor ( \(\kappa\) \(\le\) 0.2), fair (0.21 \(\le\) \(\kappa\) \(\le\) 0.4), moderate (0.41 \(\le\) \(\kappa\) \(\le\) 0.6), substantial (0.61 \(\le\) \(\kappa\) \(\le\) 0.8), or almost perfect ( \(\kappa\) > 0.8). We will adapt our screening processes (e.g. re-train or substitute raters) if \(\kappa\) agreement on title/abstract or full-text screening is < 0.6 [ 30 ]. A PRISMA flow diagram [ 31 ] of our study selection process is provided in Fig.  1 .

PRISMA flow diagram

Data collection process

Using standardized, pre-piloted data extraction forms, pairs of reviewers will independently extract data from included studies. We will conduct calibration exercises prior to our formal data extraction and quality assessment procedures to ensure consistency between reviewers. Extracted information will include the following: (1) the last name of first author, (2) year of publication; (3) country where the study was conducted; (4) study design; (5) number of participants; (6) participant demographics (i.e. age, sex, primary pain complaint); (7) chiropractic care and control group information (e.g. proportion of patients receiving chiropractic or usual medical care; type of usual medical care provided, such as primary or specialist care; number of days between the index visit date and initiation of chiropractic care; number of chiropractic treatment sessions attended over follow-up); (8) duration of follow-up; (9) details on opioid use (i.e. proportion of sample prescribed opioids and, when available, total number and dose of opioid prescriptions); and (10) all patient-important outcomes including pain intensity, physical and emotional functioning, sleep quality, patient satisfaction, and adverse events. Discrepancies between reviewers will be resolved as previously described. We will also contact study authors when necessary to request unpublished or missing data or for clarification regarding eligibility.

Risk of bias in individual studies

Two reviewers will independently assess risk of bias of eligible randomized controlled trials (RCTs) and quasi-experimental studies using a risk-of-bias tool developed by the CLARITY group ( https://www.distillersr.com/resources ), according to the following domains: sequence generation; allocation concealment; blinding of patients, health care providers, data collectors, outcome assessors, and data analysts; infrequent missing data (> 20% will be considered high risk of bias); and selective outcome reporting. For this final item, we will search clinical trial registries (e.g. clinicaltrials.gov) to compare studies’ pre-specified outcomes with their published results. When protocols are not available, we will compare the methods and results in each trial publication. Response options for each item will be categorized as ‘definitely or probably yes’ (assigned as low risk of bias) and ‘definitely or probably no’ (assigned as high risk of bias). We will also use criteria suggested by the CLARITY group to assess the risk of bias of observational (i.e. cohort and case control) studies, including the following: selection bias, assessment of exposure, validity of outcome assessment(s), control of confounding variables (with adjustment for age, sex, and severity or duration of non-cancer spine pain, at a minimum, considered as an adequately adjusted model), and loss to follow-up. Disagreements between reviewers will be resolved by consensus or adjudication by a third reviewer.

Data synthesis

We will pool all binary outcomes that are reported by more than one study (e.g. prescribed opioid receipt, long-term opioid use, higher versus lower opioid dose) using ORs and associated 95% CIs. We will use a threshold of 50-mg MED to define higher versus lower opioid dose [ 6 ]. When studies provide hazard ratios (HRs) and relative risks (RRs) for time-to-event data (e.g. time-to-first opioid prescription) or incidence rates (number of opioid prescriptions over time), we will convert the HR or RR to an OR using a baseline risk (i.e. proportion of patients in the non-chiropractic care control group who had the events) before pooling [ 32 ]. Continuous outcomes such as pain intensity, physical and emotional functioning, sleep quality, or morphine equivalent dose will be pooled as weighted mean differences (WMDs) with associated 95% CIs after converting different instruments that report on the same domain (e.g. pain) into the most commonly reported scale among studies eligible for review [ 33 , 34 ]. For all outcomes, we will conduct separate analyses for RCT/quasi-experimental and observational studies and prioritize adjusted over unadjusted effect estimates from observational studies if both sets of data are available.

We will conduct all meta-analyses using random-effects models [ 35 ] and the DerSimonian-Laird method [ 36 ]. We will also explore the consistency of association between our pooled results and studies reporting the same outcome domains that were unable to be pooled.

To avoid overestimating the magnitude of effect or association when restricting statistical pooling to estimates that appear in adjusted regression models, we will impute an OR of ‘1’ or WMD of ‘0’ for effects (from RCTs) and associations (from observational studies) that were tested in bivariable analyses but because of non-significance were excluded from adjusted analyses or were included in multivariable analyses with the only information provided being that they were ‘not significant’. We will impute an associated variance for all such estimates using the hot deck approach [ 37 ].

If there are ≥ 10 studies available for meta-analysis [ 35 ], publication bias will be assessed for each outcome by visual assessment of funnel plots for asymmetry and calculation of Egger’s test [ 38 ] for continuous outcomes and Harbord’s test [ 39 ] for binary outcomes. We will evaluate the certainty of evidence for all pooled measures of association using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach [ 40 , 41 , 42 ] (Tables 1 and 2 ). All analyses will be performed using Stata V.18 (StataCorp, College Station, TX, USA), and comparisons will be two-tailed using a statistical significance threshold ( \(\alpha\) ) of 5%.

Subgroup, meta-regression, and sensitivity analyses

Heterogeneity will be examined through tau-squared and visual inspection of forest plots [ 42 , 43 ]. When there are at least two studies in each subgroup, we will explore sources of heterogeneity with six prespecified subgroup hypotheses, assuming larger effects or associations with the following: (1) studies conducted in earlier versus later calendar years — a proxy for increased pressure on physicians to reduce opioid prescribing [ 6 , 8 ]; (2) higher versus lower risk of bias, evaluated on a criterion-by-criterion basis; (3) acute versus chronic pain; (4) general practitioner versus specialist (e.g. physiatrist/pain physician) or emergency department opioid prescriber(s) [ 11 , 13 ]; (5) early versus later chiropractic exposure; and (6) lower versus higher frequency of chiropractic treatment visits [ 14 , 19 , 44 ]. In line with previous literature [ 12 , 13 , 14 , 16 ], we will define ‘early’ chiropractic exposure as receipt of chiropractic services within the first 30 days after an index visit for acute or chronic non-cancer spine pain.

When there are at least 10 studies available [ 35 , 45 ], we will use meta-regression to explore the relationship between time period or chiropractic visit frequency and the association of chiropractic care on opioid use. If we find a significant slope, we will use the distribution of the scatter plot to determine an appropriate cut-off value for our subgroup analyses involving studies conducted in earlier versus later calendar years and lower versus higher frequency of chiropractic treatment visits. Tests for interaction will be performed to establish whether subgroups differ significantly from one another, and we will assess the credibility of significant subgroup effects (test for interaction p  < 0.05) using the Instrument for Assessing the Credibility of Effect Modification Analyses (ICEMAN) criteria [ 46 ].

We will conduct sensitivity analyses to examine the impact of converting ORs from HRs or RRs, and to examine the effect of imputing data for nonsignificant effects or associations.

Patient and public involvement

We did not engage patients or the public as direct contributors to the current protocol. However, we prefaced our review with two mixed-methods studies, including interviews of people with lived and living experience of spine pain, opioid use, and chiropractic care [ 14 , 19 ] that helped inform the current project. Further, we relied on the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials [ 25 , 47 ], which was informed by patient focus groups and surveys [ 48 ], to select patient important outcomes.

Ethical considerations

This is a systematic literature review of previously published studies and does not require ethics approval.

Opioid-related morbidity and mortality have risen in several countries over the past 25 years but particularly in Canada and the United States (US) [ 49 ]. In Canada, there were 44,592 opioid-related deaths and 42,711 opioid-related hospitalizations between January 2016 and December 2023 [ 50 ]. In the USA, there were more than 70,000 opioid-related deaths in 2020 alone [ 49 ]. Young- to middle-aged adult men have been most affected by the opioid crisis [ 49 , 50 , 51 ], which has arisen partly among individuals who were initially prescribed opioids for back pain or some other musculoskeletal condition [ 49 , 51 , 52 , 53 ]. The US Centers for Disease Control and Prevention estimated the annual cost of the opioid crisis at over US $1 trillion in 2017, equivalent to 5% of US gross domestic product [ 49 , 54 ]. Recent reports from Canada and the USA also indicate that rates of opioid-related deaths and hospitalizations have worsened since before the COVID-19 pandemic [ 49 , 50 , 55 ].

The ongoing opioid crisis in North America has generated interest in exploring treatment options that may reduce reliance on opioids for patients with spine-related or other musculoskeletal pain. Findings from a 2020 systematic review [ 20 ] and some subsequent primary studies suggest that utilization of chiropractic services may be effective in reducing opioid prescribing [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 20 ] and long-term opioid use [ 17 , 18 , 19 ]; however, the overall magnitude and certainty of these effects are unknown. The aim of our systematic review will be to assess the impact of chiropractic care on initiation, or continued use, of prescription opioids for adult patients with non-cancer spine pain. The results of our systematic review will be of interest to patients, health care providers, and policy-makers.

Strengths and limitations

Our review has several strengths. First, we will use explicit eligibility criteria and conduct a comprehensive search without date, geographic, or language restrictions to identify RCTs and observational studies exploring the impact of chiropractic care for spine pain and opioid receipt [ 20 ]. Second, we will assess the risk of bias among individual studies and evaluate the certainty of evidence using the GRADE approach. Third, we will use pre-defined subgroup analyses to explore sources of heterogeneity, and we will assess the credibility of all potential subgroup effects. Fourth, we will conduct sensitivity analyses to confirm the robustness of our meta-analyses. A limitation of our review is that we anticipate most eligible studies will be observational, which may limit the strength of inferences from our results.

Knowledge translation

The results of our review will be disseminated via a peer-reviewed publication and conference presentations.

Availability of data and materials

The datasets to be used and/or analyzed for the current study will be available from the corresponding author on reasonable request.

Abbreviations

Allied and Alternative Medicine Database

Confidence interval

Cumulative Index to Nursing and Allied Health Literature

Clinical advances through research and information translation

Excerpta Medica Database

Grading of Recommendations Assessment, Development, and Evaluation

Hazard ratio

Instrument for assessing the Credibility of Effect Modification Analyses

Morphine equivalents daily

Medical Literature Analysis and Retrieval System Online

Meta-analysis Of Observational Studies in Epidemiology

Peer review of electronic search strategies

Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols

International Prospective Register of Systematic Reviews

Randomized controlled trial

Relative risk

Short form 36 health survey questionnaire

United States

United States of America

Visual analogue scale

Years lived with disability

Weighted mean difference

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Acknowledgements

The authors thank Sadaf Ulla for their recommendations and peer review of our electronic database search strategies.

This project is supported by a research grant from D’Youville University and a post-doctoral award from the Michael G. DeGroote Institute for Pain Research and Care at McMaster University. The funders had no role in the development of the protocol, approval of the protocol manuscript, or decision to submit the protocol manuscript for publication.

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Concept development, PCE and KLC; design, PCE and JWB; supervision, JWB; methods/statistical consultation, LW and JWB; literature search, RJC; writing of the protocol manuscript, PCE; critical review of the protocol manuscript for intellectual content, PCE and KLC, BCC, ALB, CC, JD, LW, RJC, AS, and JWB. All authors read and approved the final manuscript. PCE is the guarantor of the review.

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PCE is supported by a postdoctoral fellowship from the Michael G. DeGroote Institute for Pain Research and Care (IPRC) at McMaster University. PCE is also supported by grants from the Canadian Institutes of Health Research (CIHR), the Michael G. DeGroote IPRC, and the Canadian Chiropractic Research Foundation for postdoctoral research outside of the submitted work. JWB is supported, in part, by a CIHR Canada Research Chair in the prevention and management of chronic pain. The other authors declare that they have no competing interests.

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Emary, P.C., Corcoran, K.L., Coleman, B.C. et al. The impact of chiropractic care on prescription opioid use for non-cancer spine pain: protocol for a systematic review and meta-analysis. Syst Rev 13 , 232 (2024). https://doi.org/10.1186/s13643-024-02654-6

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DOI : https://doi.org/10.1186/s13643-024-02654-6

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JSmol Viewer

Carbon farming of main staple crops: a systematic review of carbon sequestration potential.

1. Introduction

• S O C i = soil organic carbon stock (in Mg C h a − 1 ) of the depth increment i.
• O C i = organic carbon content (mg C g s o i l − 1 ) of the fine soil fraction (<2 mm) in the depth increment i.
• BD f i n e i = the mass of the fine earth per volume of fine earth of the depth increment i, (g fine earth c m − 3 fine earth = dry soil mass [g] − coarse mineral fragment mass [g])/(soil sample volume [ c m − 3 ] − coarse mineral fragment volume [ c m − 3 ]).
• v G i = the volumetric coarse fragment content of the depth increment i.
• t i = thickness (depth, in cm) of the depth increment i.
• 0.1 = conversion factor for Mg C c m − 2 to Mg C h a − 1 .

2. Materials and Methods

3.1. carbon sequestration rate analysis, 3.2. research trends in the field of carbon sequestration through vosviewer, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

Click here to enlarge figure

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Share and Cite

Arellano Vazquez, D.A.; Gagliano, E.; Del Borghi, A.; Tacchino, V.; Spotorno, S.; Gallo, M. Carbon Farming of Main Staple Crops: A Systematic Review of Carbon Sequestration Potential. Sustainability 2024 , 16 , 7907. https://doi.org/10.3390/su16187907

Arellano Vazquez DA, Gagliano E, Del Borghi A, Tacchino V, Spotorno S, Gallo M. Carbon Farming of Main Staple Crops: A Systematic Review of Carbon Sequestration Potential. Sustainability . 2024; 16(18):7907. https://doi.org/10.3390/su16187907

Arellano Vazquez, Diego Armando, Erica Gagliano, Adriana Del Borghi, Valeria Tacchino, Stefano Spotorno, and Michela Gallo. 2024. "Carbon Farming of Main Staple Crops: A Systematic Review of Carbon Sequestration Potential" Sustainability 16, no. 18: 7907. https://doi.org/10.3390/su16187907

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