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Literature Review: Traditional or narrative literature reviews

Traditional or narrative literature reviews.

A narrative or traditional literature review is a comprehensive, critical and objective analysis of the current knowledge on a topic. They are an essential part of the research process and help to establish a theoretical framework and focus or context for your research. A literature review will help you to identify patterns and trends in the literature so that you can identify gaps or inconsistencies in a body of knowledge. This should lead you to a sufficiently focused research question that justifies your research.

Onwuegbuzie and Frels (pp 24-25, 2016) define four common types of narrative reviews:

References and additional resources

Baker, J. D. (2016) The purpose, process and methods of writing a literature review: Editorial . Association of Operating Room Nurses. AORN Journal, 103 (3), 265-269. doi:10.1016/j.aorn.2016.01.016

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Acknowledgement of Country

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How to Conduct a Literature Review: A Guide for Graduate Students

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Where to Get Help

The ISU Library has a great staff of librarians (complete with superpowers!) who can answer questions about any aspect of your research that involves searching for information. Each of our liaison librarians is responsible for one or more subject areas and has subject expertise you can tap as you're doing your research.

They can help with advice about research methodologies , database suggestions, data management plans - anything related to how to find use, and evaluate resources. Getting to know your liaison librarian will make your life as a graduate student easier.

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    Find Your Librarian

“Google can bring you back 100,000 answers. A librarian can bring you back the right one.” - Neil Gaiman

The literature review is an important part of your thesis or dissertation. It is a survey of existing literature that provides context for your research contribution, and demonstrates your subject knowledge. It is also the way to tell the story of how your research extends knowledge in your field.

The first step to writing a successful literature review is knowing how to find and evaluate literature in your field. This guide is designed to introduce you to tools and give you skills you can use to effectively find the resources needed for your literature review.

Before getting started, familiarize yourself with some essential resources provided by the Graduate College:

Below are some questions that you can discuss with your advisor as you begin your research:

Questions to ask as you think about your literature review:

What is my research question.

Choosing a valid research question is something you will need to discuss with your academic advisor and/or POS committee. Ideas for your topic may come from your coursework, lab rotations, or work as a research assistant. Having a specific research topic allows you to focus your research on a project that is manageable. Beginning work on your literature review can help narrow your topic.

What kind of literature review is appropriate for my research question?

Depending on your area of research, the type of literature review you do for your thesis will vary. Consult with your advisor about the requirements for your discipline. You can view theses and dissertations from your field in the library's Digital Repository can give you ideas about how your literature review should be structured.

What kind of literature should I use?

The kind of literature you use for your thesis will depend on your discipline. The Library has developed a list of Guides by Subject with discipline-specific resources. For a given subject area, look for the guide titles "[Discipline] Research Guide." You may also consult our liaison librarians for information about the literature available your research area.

How will I make sure that I find all the appropriate information that informs my research?

Consulting multiple sources of information is the best way to insure that you have done a comprehensive search of the literature in your area. The What Literature to Search tab has information about the types of resources you may need to search. You may also consult our liaison librarians for assistance with identifying resources..

How will I evaluate the literature to include trustworthy information and eliminate unnecessary or untrustworthy information?

While you are searching for relevant information about your topic you will need to think about the accuracy of the information, whether the information is from a reputable source, whether it is objective and current. Our guides about Evaluating Scholarly Books and Articles and Evaluating Websites will give you criteria to use when evaluating resources.

How should I organize my literature? What citation management program is best for me?

Citation management software can help you organize your references in folders and/or with tags. You can also annotate and highlight the PDFs within the software and usually the notes are searchable. To choose a good citation management software, you need to consider which one can be streamlined with your literature search and writing process. Here is a guide page comparing EndNote, Mendeley & Zotero. The Library also has guides for three of the major citation management tools:

What steps should I take to ensure academic integrity?

The best way to ensure academic integrity is to familiarize yourself with different types of intentional and unintentional plagiarism and learn about the University's standards for academic integrity. Start with this guide . The Library also has a guide about your rights and responsibilities regarding copyrighted images and figures that you include in your thesis.

Where can I find writing and editing help?

Writing and editing help is available at the Graduate College's Center for Communication Excellence . The CCE offers individual consultations, peer writing groups, workshops and seminars to help you improve your writing.

Where can I find I find formatting standards? Technical support?

The Graduate College has a Dissertation/ Thesis website with extensive examples and videos about formatting theses and dissertations. The site also has templates and formatting instructions for Word and LaTex .

What citation style should I use?

The Graduate College thesis guidelines require that you "use a consistent, current academic style for your discipline." The Library has a Citation Style Guides resource you can use for guidance on specific citation styles. If you are not sure, please consult your advisor or liaison librarians for help.

Adapted from The Literature Review: For Dissertations, by the University of Michigan Library. Available:

Center for Communication Excellence/ Library Workshop Slides

Slides from the CCE/ Library Workshop "A Citation Here...A Citation There...Pretty Soon You'll Have a Lit Review" held on April 11, 2022 are below:

narrative literature review guide

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Planning For Your Literature Review in the Health Professions

Narrative literature reviews.

Further Reading

Narrative or traditional literature reviews can take many shapes and forms. They do not need to follow any specific guideline or standard. A narrative literature view may be assigned as part of your coursework or capstone.

A narrative literature review can be a first step to building on other research in the field. After all, if it's a topic that you're interested in, you need to know what's already been done, right?

Your Narrative Literature Review Should Have...

A common structure for narrative literature reviews is IMRaD, or:

While the structure above may be sufficient for your topic, you may also consider using the similar but more robust structure IAMRDC, or:

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Writing narrative literature reviews for peer-reviewed journals: secrets of the trade

Bart n. green.

a Associate Editor, National University of Health Sciences

Claire D. Johnson

b Editor, National University of Health Sciences

c Vice President of Academic Affairs and Program Development, Texas Chiropractic College

This document may be redistributed and reused, subject to certain conditions .

To describe and discuss the process used to write a narrative review of the literature for publication in a peer-reviewed journal. Publication of narrative overviews of the literature should be standardized to increase their objectivity.

In the past decade numerous changes in research methodology pertaining to reviews of the literature have occurred. These changes necessitate authors of review articles to be familiar with current standards in the publication process.

Narrative overview of the literature synthesizing the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative texts.

An overview of the use of three types of reviews of the literature is presented. Step by step instructions for how to conduct and write a narrative overview utilizing a ‘best-evidence synthesis’ approach are discussed, starting with appropriate preparatory work and ending with how to create proper illustrations. Several resources for creating reviews of the literature are presented and a narrative overview critical appraisal worksheet is included. A bibliography of other useful reading is presented in an appendix.

Narrative overviews can be a valuable contribution to the literature if prepared properly. New and experienced authors wishing to write a narrative overview should find this article useful in constructing such a paper and carrying out the research process. It is hoped that this article will stimulate scholarly dialog amongst colleagues about this research design and other complex literature review methods.

Sources of support: This article is reprinted with permission. Its original citation is: Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Sports Chiropr Rehabil 2001;15:5–19.

Please note that Internet Explorer version 8.x is not supported as of January 1, 2016. Please refer to this page for more information.

Narrative Review

Narrative reviews fail to content-code the studies either for theoretically important aspects or for aspects that gauge methodological quality, with the result that the accuracy of the review’s claims about the characteristics of the studies and the quality of their methods is difficult to judge.

From: Handbook of Child and Adolescent Sexuality , 2013

Related terms:

Defining and Analyzing the Problem

George Demiris , ... Karla T. Washington , in Behavioral Intervention Research in Hospice and Palliative Care , 2019

3.2.1 Narrative Review

A narrative review is the type first-year college students often learn as a general approach. Its purpose is to identify a few studies that describe a problem of interest. Narrative reviews have no predetermined research question or specified search strategy, only a topic of interest. They are not systematic and follow no specified protocol. No standards or protocols guide the review. Although the reviewers will learn about the problem, they will not arrive at a comprehensive understanding of the state of the science related to the problem. Fins and colleagues provide an example of a narrative review in hospice and palliative care. 6 Box 3.3 outlines steps for conducting a narrative review.

Steps for Conducting a Narrative Literature Review

The published scientific literature is indexed in a variety of databases. Search these databases for studies. It is important to search numerous databases to ensure that the majority of relevant studies have been identified. Neglecting a database in the search strategy will result in studies going unidentified. Common databases for hospice and palliative care studies include PubMed, PsycINFO, and CINAHL.

Authors call out several keywords when publishing their research so others can identify the work during database searches. Once you find a relevant article, use its keywords and similar ones in your search. To find individual studies on similar topics, you must use the keywords that were used when they were indexed. You may try numerous keywords before finding a paper that is pertinent to your review question.

After the search is complete and all duplicates are thrown out, it is time to review the abstracts of the remaining articles to ensure that they address your review question. With narrative reviews, it is not necessary to include every article on a topic.

Summarize and synthesize the findings from the articles you have found, and integrate them into your writing as appropriate. You do not need to document your literature search. Reference the articles as you use information from the studies.

Volunteering and health in later life*

Jeffrey A. Burr , ... Sae Hwang Han , in Handbook of Aging and the Social Sciences (Ninth Edition) , 2021

Mortality risk

Narrative reviews and meta-analyses conclude that the association between volunteering and risk of mortality is substantial, with the earliest evidence found in the seminal work of Berkman and Syme (1979) . A meta-analysis study by Okun et al. (2013) reports that volunteering is associated with an average adjusted effect of 24% decreased risk of death (95% CI=16%–31%). Similarly, the Jenkinson et al. (2013) meta-analysis finds an average adjusted effect of 22% (95% CI=10%–34%). Based on their evaluation, Okun et al. (2013 , 576) conclude that

…it is no longer a question of whether volunteering is predictive of reduced mortality risk; rather, our results suggest that the volunteering-mortality association is reliable, and that the magnitude of the relationship is sizable.

Further, prospective research design studies demonstrating an association between volunteering and mortality include Ayalon (2008) , using Israeli data, Luoh and Herzog (2002) , using the Assets and Health Dynamics (AHEAD) data, and Musick, Herzog, and House (1999) , using data from the American’s Changing Lives study, adding to substantial empirical literature that evaluates the benefits of helping others and being socially engaged.

Some research indicates that the benefit of volunteering for human longevity may be strongest for certain kinds of people and under certain conditions. For example, Konrath, Fuhrel-Forbis, Lou, and Brown (2012) , examining 4-year follow-up data from the Wisconsin Longitudinal Study, discovered that the survival benefits accrue only to those who volunteer for “other-oriented” reasons (i.e., in alignment with social connections or altruistic values). Lee, Steinman, and Tan (2011) demonstrated with Health and Retirement Study data that volunteering is only beneficial in reducing mortality risk among those who are nondrivers, and they propose that volunteering may benefit those who are otherwise at risk of social isolation.

Okun et al. (2010) , using 6-year follow-up data from the Later Life Study of Social Exchanges, argue that volunteering serves as a buffer between functional limitations and mortality, with one result being that people with functional limitations may benefit from volunteering in terms of expanded longevity. In comparison, Rogers et al. (2016) , using the English Longitudinal Study on Aging in an 11-year follow-up research design, reveal that the benefit of volunteering for reducing risk of mortality occurs only among those who report no disabilities.

Case Conceptualization and Treatment: Adults

Alan Carr , in Comprehensive Clinical Psychology (Second Edition) , 2022 Adults

Narrative reviews and meta-analyses support the effectiveness of FBPIs as an adjunct to medical care for adults with chronic pain, heart disease, cancer, diabetes, HIV, and caring for aging relatives with dementia ( Campbell, 2003 ; Han et al., 2019 ; Hartmann et al., 2010 ; Nguyen et al., 2019 ; Vintilă et al., 2019 ). For example, in a meta-analysis of 52 randomized controlled trials involving a range of conditions in adults including cardiovascular disease, stroke, cancer, and chronic pain conditions such as arthritis, Hartmann et al. (2010) found that FBPIs led to significantly better physical health in patients and better physical and mental health in both patients and other family members compared with routine care. Effect sizes were small, ranging from 0.28 to 0.35 indicating that the average case treated with systemic therapy fared better than 61%–64% of cases who received routine care. Effects were stable over long follow-up periods. FBPIs included psychoeducational and cognitive behavioral couple and family therapy as well as multifamily support groups, and carer support groups. These interventions had some or all of the following elements ( McDaniel et al., 2013 ; Rolland, 1994 ). They provided psychoeducation about the affected family member's medical condition and its management. They promoted adherence to medical regimes, an increase in adaptive “well behavior”, and a reduction of “illness behavior”. They offered a context within which to enhance support for the person with the chronic illness, and other family members. They provided a forum for exploring ways of coping with the condition, and its impact on family relationships.

Other Sources of Evidence

Susan M. Wilczynski , in A Practical Guide to Finding Treatments That Work for People with Autism , 2017

Narrative Reviews

Narrative reviews include consensus and critical reviews. When a group of scholars create a consensus review (also known as a best practice panel), they draw from their expertise and evaluation of the scientific literature. These experts have been asked to lend their expertise to the review because they are very familiar with the evidence and have been regular contributors to the literature. The greatest weakness of a consensus review results from the potential for bias entering into the final conclusions. Bias may result from the selection process that initiates a review. That is, there is little transparency about how editors or funding agencies select the experts to complete reviews. Editors (of a book, journal, or other document) or funders may include experts who confirm their biases and exclude experts who offer disconfirmatory perspectives ( Slocum et al., 2012 ). The expert may also introduce bias by placing inordinate weight on a single research article or completely ignore another. This form of bias is typically unintentional; however, human beings inadvertently allow bias to influence their conclusions. Group-based bias can also influence the reported outcomes of consensus reviews. For example, when a highly prestigious member of an expert panel states his or her opinion, others may agree without applying due diligence. This source of bias is less likely to occur when experts hold diverse views about the literature. Unfortunately, it is also more difficult to achieve consensus when a larger, more diverse group of experts write a review ( Wilczynski, 2012 ).

A critical review is similar to a consensus review, but it is completed by a single researcher or a group of researchers who have not been invited to discuss their views based on their expertise. These reviews are prone to the same sources of bias as consensus reviews. Despite these limitations, consensus and critical reviews were the primary source of evidence that could guide practitioners until recently. They may still prove very useful, particularly when a systematic review closely matching the characteristics of a given case is not available. Evidence-based practitioners should recognize that a consensus or critical review of the literature may reflect a better fit with the specifics of a given case. For example, a critical review could match the setting, diagnosis for participant, target behavior, etc., in every way—and better than the parameters used to conduct the only available systematic review.

Sensorimotor Rehabilitation

Hamza Farooq , ... David W. Cadotte , in Progress in Brain Research , 2015

This narrative review captures a subset of recent advances in imaging of the central nervous system. First, we focus on improvements in the spatial and temporal profile afforded by optical coherence tomography, fluorescence-guided surgery, and Coherent Anti-Stokes Raman Scattering Microscopy. Next, we highlight advances in the generation and uses of imaging-based atlases and discuss how this will be applied to specific clinical situations. To conclude, we discuss how these and other imaging tools will be combined with neuronavigation techniques to guide surgeons in the operating room. Collectively, this work aims to highlight emerging biomedical imaging strategies that hold potential to be a valuable tool for both clinicians and researchers in the years to come.

Behavioral Couples Therapy in the Treatment of Alcohol Problems

Adrian B. Kelly , in Evidence-Based Addiction Treatment , 2009

How Well does ABCT Work?

Recent narrative reviews (e.g., O’Farrell & Fals-Stewart, 2003 ) and meta-analytic reviews (e.g., Powers, Vedel, & Emmelkamp, 2008 ) conclude that ABCT has better outcomes than individual-based treatment for alcoholism, and indeed other drug use problems. Based on 12 randomized controlled trials of BCT (8 relating to alcohol and 4 relating to other substance abuse), Powers et al. (2008) found that ABCT outperformed controlled conditions when all follow-up time points were combined. When results were assessed for specific post-therapy time points, results were somewhat different. Specifically, ABCT produced improvements in relationship satisfaction at post-treatment, but did not result in improvements in the frequency or consequences of alcohol/substance use relative to control conditions. At follow-up, ABCT retained its superiority in terms of elevated relationship satisfaction, but also showed better outcomes on alcohol/substance use measures at later follow-ups. As noted earlier, ABCT programs contain some variability in therapeutic factors that may differentially account for positive findings. For example, three studies reviewed by Powers et al. (2008) included naltrexone or disulfiram in the couple conditions and not others. However, Powers and colleagues found that the effect sizes for BCT with and without these medication regimes were comparable. These authors conclude that the improvements in relationship satisfaction evident at the end of therapy may provide a context for improved substance-related gains in the longer term.

In general, ABCT has been used with couples in which only one partner (typically the male) is the identified drinker and the alcohol problems are moderate to severe. It is less clear how well ABCT works for couples where both partners have substance abuse problems and how well ABCT works for problem drinkers (as opposed to alcohol-dependent people). O’Farrell and Fals-Stewart (2006) recommend that a couples approach is contraindicated when both partners have substance abuse problems. Preliminary research suggests that ABCT may not be any more efficacious than alcohol-focused spouse involvement for people with mild to moderate alcohol problems. Walitzer and Dermen (2004) compared BCT (group format) to alcohol-focused spouse involvement and treatment for problem drinkers only. For those whose partners participated, identified drinkers reported fewer heavy drinking days and more abstinence/light drinking days in the year following treatment relative to treatment for problem drinkers only. However, the combination of alcohol-focused spouse involvement and BCT yielded no better outcomes than alcohol-focused spouse involvement alone. More research is needed on the utility of ABCT for problem drinkers. It is possible that couples with less severe alcohol problems may also have less severe couple relationship problems, so ABCT-related improvements may not be as marked. It is also possible that these couples may have more circumscribed problems than those with severe alcohol problems and that a tailored ABCT program to meet circumscribed relationship issues might yet prove effective. It would be surprising if such couples approaches were not helpful to couples with less severe alcohol problems, but this remains an empirical question yet to be tested.

Personality and Type 2 Diabetes

Mika Kivimäki , ... Markus Jokela , in Personality and Disease , 2018

Conclusions and Practical Implications

In this narrative review , we have described evidence for an association between personality and diabetes. Individuals with high conscientiousness seem to experience a reduced risk of developing, and dying from, diabetes, indicating that this personality trait may affect both the etiology and prognosis of type 2 diabetes. One of the mechanisms underlying the protective effect of high conscientiousness was the ability to maintain a healthy body weight. Other evidence suggests bidirectionality whereby having multiple chronic conditions, including diabetes, was related to reductions in conscientiousness over time.

In general, the contribution of personality to diabetes risk and prognosis seemed relatively modest compared with conventional diabetes risk factors, such as obesity and physical inactivity. In light of this small effect size and the overall difficulty to modify psychological characteristics, personality is unlikely to be considered as an important risk factor in diabetes prevention strategies. In relation to targeted strategies, however, personality might have a role. Better understanding of the role of personality in diabetes etiology and progression could help in developing more personalized prevention and treatment strategies for people with high risk of diabetes and those who already have type 2 diabetes.

Environmental protection through societal change

Sebastian Bamberg , ... Maxie Schulte , in Psychology and Climate Change , 2018

8.4.1 Positive and negative outcomes of being an activist

In an extensive narrative review , Vestergren, Drury, and Chiriac (2016) summarized the outcomes for participants after they had taken part in protest and activism. The authors categorized the changes they found in published research articles into two domains, the behavioral or objective and the psychological or subjective changes. As already suggested, these effects point to both negative and positive personal outcomes for individuals engaging in protest and activism. On the one hand, activists reported negative objective changes, such as a higher rate of divorces, fewer children, and tension affecting personal relationships, which were not part of their activism. These effects might be related, for example, to participants’ changes in attitudes toward life or a lack of time caused by the engagement in collective actions. However, on the other hand, activists also described the formation of new and strong social relationships during the collective action. They emphasized positive subjective changes of, e.g., feeling empowered by the participation, increased self-esteem and self-confidence, taking up a new job in the educational, social or creative area, gaining new organizational skills and knowledge.

Participating in collective action in general and in the context of environmental activism more specifically can be a frustrating enterprise. Especially when actions do not succeed as planned, such failures can evoke feelings of frustration and helplessness. Activists need strategies for dealing with frustration to ensure their continued participation, given that fundamental societal change usually needs a long time to unfold and that the process of change is often characterized by setbacks. One obvious psychosocial resource for coping with these negative experiences is the group itself: As part of groups, individuals experience that collective action helps them deal with what might seem like an unsolvable, overwhelming problem at first. To elaborate on this idea of the group as a psychological resource, we briefly review evidence from the London road protests including the mass occupation of a green area ( Drury & Reicher, 2005 ). This campaign in northeast London was part of an active UK-wide antiroads movement. People living in the area were involved and hundreds of people motivated by ecological principles joined the protests. The activists mobilized for a rally at a green area, which should be removed within the construction of the road. On the day of the rally, contractors had erected a fence around the green and it was guarded by security. The rally first took place in front of the fence. After the rally had finished, participants started to climb over the fence, started to push it down, and the crowd entered the site.

The Human Hypothalamus: Neuropsychiatric Disorders

Michael Nair-Collins , Ari R. Joffe , in Handbook of Clinical Neurology , 2021

Management of the patient diagnosed as “brain dead”

There are many narrative reviews on the management of patients diagnosed as brain dead ( Gupta and Dhanani, 2016 ; Maciel and Greer, 2016 ; Chamorro-Jambrina et al., 2017 ; Meyfroidt et al., 2019 ; Opdam, 2019 ). There are also systematic reviews ( D’Aragon et al., 2017 ; Buchanan and Mehta, 2018 ) and guidelines on this management ( Kotloff et al., 2015 ; Canadian Blood Services, 2019 ). These publications give guidance on all acute clinical management of patients with brain death, with an emphasis on maintaining organ functions to optimize organ donation rates. It is beyond the scope of this chapter to discuss all of this management, and here we focus on what has been called Hormonal Replacement Therapy (HRT) aimed to replace hypothalamic–pituitary axis hormonal deficiencies.

When hypothalamic–posterior pituitary function is lost, indicated by central diabetes insipidus (see previously for manifestations of this), treatment with antidiuretic hormone replacement is indicated to prevent dehydration, hypovolemia, hemodynamic instability, and hypernatremia from the hypoosmotic polyuria. This can be done using desmopressin (1-deamino-8- d -arginine vasopressin or DDAVP), a vasopressin analogue with a much greater affinity for V2 renal receptors than for V1 vascular smooth muscle receptors. Usually, a dose of 1–4   mcg IV is used initially, typically followed by 1–2   mcg IV q6h titrated to maintain urine output <   34   mL/kg/h ( Kotloff et al., 2015 ). In pediatrics, the dose for DDAVP is 0.25–1   mcg IV q6h for the same target urine output ( Gupta and Dhanani, 2016 ). If the dosing is adequate, intravenous fluids can be administered as insensible losses (20% maintenance fluids as dextrose 5% in 0.9% sodium chloride) plus urine output (as normal saline (NS)); if the serum sodium is dropping at a rate more than 10   mmol/L/day, and urine sodium is measured to be much lower than that of NS (i.e., ≪   154   mmol/L), urine replacement fluid may need to be changed to 0.45% sodium chloride with a close following of serum sodium measured every 4–6   h initially.

Another option to replace antidiuretic hormone is to use vasopressin, which has affinity for all three receptors, and thus can treat diabetes insipidus and also improve vasodilatory shock from vasopressin deficiency at the vascular smooth muscle V1 receptor ( Gupta and Dhanani, 2016 ; Maciel and Greer, 2016 ; Chamorro-Jambrina et al., 2017 ; Meyfroidt et al., 2019 ; Opdam, 2019 ). In the presence of hypotension from vasodilatory shock, vasopressin is considered as a first-line vasoactive agent and given by intravenous infusion ( Kotloff et al., 2015 ; Canadian Blood Services, 2019 ). The dosing of vasopressin suggested in the literature can be confusing, given variously in units/min, units/h, milliunits/h, milliunits/kg/min (mU/kg/min), etc., and clinicians need to pay close attention to these details when prescribing vasopressin to avoid dosing errors. We suggest that the dose used is best given as 0.3–0.7   mU/kg/min, with the maximum being an absolute dose of 40   mU/min (which is 2.4   U/h) IV, titrated to effect on blood pressure and urine output of ~   100   mL/h in adults and 2–3   mL/kg/h in children. Oral DDAVP is used in the setting of chronic vasopressin deficiency from loss of hypothalamic–posterior pituitary function; however, this is not a reliable treatment in the acute setting and will not be discussed more here.

More controversial is whether to treat for hypothalamic–anterior pituitary loss of function. As reviewed previously, central thyroid deficiency may occur in 16%–22% of patients with brain death and central adrenal deficiency in at least 27%–29% of patients with brain death. Studies and reviews focus on whether replacing thyroid and adrenal hormones improves the outcomes of the number of organs donated and post-organ-transplant organ function, and not on efficacy for long-term maintenance. Most narrative reviews suggest replacement of thyroid and corticosteroid hormones based on retrospective observational studies and expert opinion; however, the evidence from randomized controlled trials is not supportive of this practice ( Meyfroidt et al., 2019 ; Opdam, 2019 ). There are no studies of the efficacy of HRT in pediatric patients.

Thyroid hormone replacement has had no effect on the number of organs donated (based on findings from five of six observational studies), on heart donation rates (based on four of six observational studies and four of four randomized controlled trials), or on heart function (based on three of three randomized controlled trials; Buchanan and Mehta, 2018 ; Canadian Blood Services, 2019 ). Nevertheless, the Society of Critical Care Medicine guideline still suggests that thyroid replacement be “considered” for hemodynamically unstable donors or for potential heart donors with “left ventricular ejection fraction less than 45%” ( Kotloff et al., 2015 ). If used, T4 can be given as 20   mcg IV bolus followed by 10   mcg/h IV, or, if available, T3 can be given as 4   mcg IV bolus followed by 3   mcg/h IV infusion ( Kotloff et al., 2015 ). In pediatrics, the dosing of T4 is an initial bolus of 1–5   mcg/kg IV followed by 0.8–1.4   mcg/kg/h IV infusion. These ranges are based on age: for age ranges of 0–6   months, 6–12   months, 1–5   years, 6–12   years, 13–16   years, and   greater than 16   years, the loading dose is 5, 4, 3, 2.5, 1.5, and 0.8   mcg/kg IV, respectively, followed by the infusion dose of 1.4, 1.3, 1.2, 1.0, 0.8, and 0.8   mcg/kg/h IV, respectively. T3 dosing in pediatrics is 0.05–0.2   mcg/kg/h IV infusion, with the higher dose used in younger patients ( Kotloff et al., 2015 ; Gupta and Dhanani, 2016 ). Again, for chronic thyroid deficiency, oral dosing is used, and this is beyond the scope of this review.

Replacement of corticosteroids has had a possible benefit on treating hypotension (based on two of four observational studies reporting increased donor blood pressure; however, this was not confirmed in meta-analysis of three randomized controlled trials), no clear benefit on the number of organs donated (based on five observational studies and two randomized controlled trials), and no effect on post-organ-transplant organ function in recipients (based on nine randomized controlled trials) ( D’Aragon et al., 2017 ; Canadian Blood Services, 2019 ). In spite of these findings, for unclear reasons, the guideline from the Society of Critical Care Medicine states that administration of corticosteroids “reduces the potential deleterious effects of the inflammatory cascade on donor organ function” and therefore recommends using methylprednisolone 15   mg/kg (up to 1   g) IV daily or 250   mg IV bolus followed by 100   mg/h infusion ( Kotloff et al., 2015 ). In pediatrics, the dose is 20–30   mg/kg IV daily (up to a maximum of 1   g IV daily) ( Kotloff et al., 2015 ; Gupta and Dhanani, 2016 ). Some reviews suggest an alternative is to use hydrocortisone 1   mg/kg/dose q6h, up to 50   mg IV q6h ( Canadian Blood Services, 2019 ; Opdam, 2019 ). In the setting of chronic adrenal insufficiency oral corticosteroids are used, and the dosing is beyond the scope of this review.

It is important to emphasize that these reviews and guidelines only address the acute short-term (i.e., at most days) management of the hypothalamic–pituitary axis in brain-dead patients. No study we are aware of addresses whether treatment of thyroid and/or adrenal failure can change the results of apnea testing. No study we are aware of addresses cases of “chronic-brain-death” where testing for, and treatment of central thyroid and/or adrenal failure may be used to support homeostasis. The testing and treatment of these deficiencies in the chronic setting are beyond the scope of this chapter.

Health Psychology

Chris J. Main , Michael K. Nicholas , in Comprehensive Clinical Psychology (Second Edition) , 2022 The Yellow Flags Framework

In 1997, following a narrative review , a system for the identification and management of (primarily) psychological risk factors (or yellow flags) for the development of chronic low back disability were developed. The clinical yellow flags were further differentiated from psychiatric factors ( orange flags) and socio-occupational factors. The latter comprised blue flags potentially modifiable worker and workplace centered risk factors (such as perceptions of work as harmful or the possibility or work accommodations); and black flags or system factors such as conditions of employment, and benefit entitlement that are outside the immediate control of the employee and/or the team trying to facilitate the return to work. They are more fully described elsewhere ( Main et al., 2008 ; Nicholas et al., 2011 ; Shaw et al., 2009 ).

There is specific evidence for both yellow flags and blue flags as risk factors for long-term work disability. There also is evidence for the influence of pain severity and level of depressive symptoms on the transition to chronicity. The influence of these factors is variable across studies, and there is dispute among authors as to their relative importance, but the weight of current evidence supports the yellow flag hypothesis, with maladaptive pain coping behaviors, anxiety, and depressive features being especially salient factors. ( Chou and Shekelle, 2010 ). However, the Flags classification is offered however as a framework rather than a model and has been developed as a way of thinking about interventions in the context of obstacles to recovery. In that sense it aligns both with the sociological framework distinguishing macro-, meso- and micro-levels of focus, but draws attention to fact that the prevention of chronic pain or disability may involve different sorts of solution. The framework has three important features. It offers a “systems perspective” and assumes that an adequate understanding of the problem requires consideration of both the injured worker and the individual's social and occupational context. It contains both clinical and occupational elements. Finally, it makes an important distinction between the individual's perception of the situation and the objective features. However, it is important to understand yellow flags in context and to appreciate that they do not operate in isolation from other factors.


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    for creating reviews of the literature are presented and a narrative overview critical appraisal ... a manuscript using these guidelines is essential to.

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    designing studies or developing practice guidelines. The two standard types of reviews are (a) systematic and (b) non-systematic or narrative review. Unlike.

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