Technical refinements of the scapular tip-free flap for mandibular reconstruction.

BACKGROUND: The use of scapular tip chimeric free flaps (STFFs) for reconstructing mandibular defects has recently become popular, but its utility relative to other bone-containing free flaps remains debatable. The aim of the report is to describe how technical modification of STFF impacted in its use for mandibular reconstruction also commenting results obtained in a unicentric series of patients. PATIENTS AND METHODS: Patients undergoing mandibular reconstruction using an STFF from January 1, 2014 to June 1, 2022 were retrospectively enrolled in this report. We collected data on chimeric flap type, bone management, vascular pedicles, and the final outcomes. In total, 31 patients (13 men and 18 women) with a mean age of 68 years were enrolled. According to the classification system of Urken, 15 patients had body defects, while 7 had ramus defects, another 7 had symphysis defects, and 2 had both ramus and bodily defects. STFF was always harvested working in two equips simultaneously, in supine position. Dissection included preparation of chimeric components of the flap as latissimus dorsi, serratus and scapular tip. After pedicle dissection scapular bone was cut basing on reconstructive needing with a rectangular (stick) shape including the border of the scapula. In cases of longer bone harvesting, circumflex pedicle was also included to perfuse the upper portion of the scapular border. In five cases, the STFF was harvested with only the scapular angle component, and was thus a composite osteomuscular flap; for the remaining 26 cases, a chimeric STFF was used. Circumflex pedicle was included for eight patients. Six of the seven patients with symphyseal defects underwent a single osteotomy. RESULTS: The average length of the harvested was 69.92 mm (maximum length = 104 mm). The average height of transplanted bone was 26.78 mm (maximum height = 44.2 mm). Mouth-opening was normal in 25 patients, limited in 6 patients, and severely impaired in no patients. The cosmetic results were rated as excellent by 20 patients, good by 8 patients, and poor by 3 patients. CONCLUSION: The STFF is an excellent option for mandibular reconstruction when other flaps are not available and for patients in poor general condition. Technical innovations here presented made possible to harvest long bone segments with accurate shape thanks to osteotomies if needed and with adequate soft tissues components of the chimeric flap, ensuring satisfactory functional and cosmetic results.

Submental Flap Versus Radial Forearm Free Flap for the Reconstruction of Medium Size Soft Tissue Defect in the Oral Cavity.

The aim of this work is to compare the functional and esthetic outcome of the submental flap and radial forearm free flap for the reconstruction of medium-sized soft tissue defect in the oral cavity. Patients diagnosed with squamous cell carcinoma of the oral cavity and reconstructed with a submental flap or radial forearm free flap between 2015 and 2020 were reviewed and analyzed. Tumor site, complication at the donor site, complication at the recipient site, duration of the hospital stay, local or cervical recurrence, and esthetic results were also analyzed to compare the difference in outcomes between the two groups. Submental flap represents a safe and useful reconstructive recourse for head and neck reconstructive surgeons when it is correctly indicated. Lower rate of complication at the donor site, better esthetic result, and a shorter hospital stay represent the strengths of this flap when it is not necessary to perform compartment surgery. However, more studies are needed with a larger number of patients.

The ability of the eighth edition of the TNM staging system plus minor invasion criteria to predict the biological behaviour of oral cavity carcinomas.

BACKGROUND: Oral squamous cell carcinoma (OSCC) treatment is based largely on the TNM stage. The eighth edition includes important new prognostic parameters (extranodal extension and depth of invasion), while it does not consider tumour molecular characteristics or minor invasion criteria (perineural and lymphovascular invasion, grading and resection margins). This study evaluated how well the TNM eighth edition predicts the biological behaviour of OSCC, considering survival and risk of locoregional recurrence. MATERIALS AND METHODS: Data from 217 patients treated for OSCC were analysed, including epidemiologic characteristics, histological features and treatment. RESULTS: No significant correlations with overall survival or tumour recurrence were found for pT stages and the type of treatment, while different pN stages had significant differences in recurrence, but not in overall survival. We found significant correlations between overall survival and tumour grade and lymphovascular and perineural invasion and a significant correlation between tumour resection margins and the risk of recurrence. CONCLUSIONS: The current TNM staging system is a necessary but not sufficient tool for predicting the overall survival and risk of recurrence of OSCC. It could be improved by considering other factors, such as minor invasion criteria and biological markers.

A Modified Technique for Harvesting Scapular Tip Flap and to Allow 2 Teams to Work at the Same Time.

AIM: The main aim of the present report is to describe a modified technique of tip scapular flap harvesting to allow 2 surgical teams to work at the same time and to shorten surgical times. MATERIALS AND METHODS: The medical records of 25 patients that had undergone maxillary or mandibular reconstruction by using a free scapular tip flap were retrospectively reviewed to identify the possible advantages and disadvantages of this type of flap. RESULTS: Thirteen patients analyzed in this series underwent maxillary reconstruction with tip scapular flap, while the other 12 patients underwent mandibular reconstruction. No failures, partial failures, or infections were evidenced in this series. Scapular tip flap allowed for acceptable esthetic and functional outcomes. In all cases, the patient was placed supine. No major complications were observed at the donor site during follow-up. CONCLUSION: Scapular tip flap might be extremely useful for head and neck reconstruction. Pedicle length, versatility, and reliability represent the major advantages of this reconstructive recourse. Moreover, the resistance of the scapular vascular system to atherosclerosis could be helpful in patients showing contraindications to free fibula flaps.

Double Arterialized Scapular Tip Free Flap for Mandibular Reconstruction.

INTRODUCTION: Scapular tip free flap (STFF) has become today one of the workhorse flaps for maxillary reconstruction; recently, the possibility of extending the vascular supply by adding to the angular branch of the circumflex pedicle up to its periosteal entrance in the lateral border of the scapula has been proposed as a reliable technique to improve the length of perfused bone when STFF is used for mandibular reconstruction. The purpose of this study was to evaluate the patients who had received microvascular reconstruction of the mandible with STFF vascularized by both the circumflex scapular artery via the periosteal branch and the thoracodorsal artery via the angular artery. METHODS: A retrospective chart review was conducted for all patients who underwent reconstruction with an STFF for mandibular defect between January 2016 and December 2020 at the University Hospital of Parma. The outcome was evaluated by assessing dietary intake (unrestricted, soft, liquid, and tube feed) and speech (normal, intelligible, partially intelligible, and unintelligible). RESULTS: The final study sample included 9 patients (5 men and 4 women). The average patient age was 68.9 years (range, 59.9-74.8 y) at the time of surgery. There was no flap loss. A 1-year postoperative computed tomography scan revealed full osteointegration of the flap. CONCLUSIONS: Our results show that the STFF is a valuable reconstructive option, especially in patients with complex head and neck defects requiring soft and hard tissues.

Efficacy and characteristics of physiotherapy interventions in patients with lumbar spinal stenosis: a systematic review.

PURPOSE: To determine the efficacy of physiotherapy approaches used in the treatment of LSS and compare their delivery characteristics. METHODS: A systematic search was conducted using MEDLINE/PubMed, EMBASE, Scopus, PEDro, CINAHL and Web of Science databases, from inception until March 2021. Inclusion criteria were clinical diagnosis of LSS confirmed through imaging techniques, RCTs written in English comparing physiotherapy interventions among them or versus placebo or usual care without restrictions on treatment and follow-up duration, outcomes related to pain, physical function, disability and quality of life. Two independent reviewers assessed records for eligibility and methodological quality (PEDro scale) and extracted participants' characteristics, interventions details and outcome measures at each timepoint. Pooled or un-pooled findings were reported as mean difference with 95% confidence interval, depending on heterogeneity. Evidence quality was rated using the GRADE approach. RESULTS: Twelve studies (944 patients, mean PEDro score 7.6, range 5-9) were included. Three weeks of weight-supported walking improved pain and disability, while 8 weeks of aquatic exercises improved pain and walking tolerance (very low evidence). Six weeks of cycling reduced disability compared to weight-supported walking (low evidence). Six weeks of manual therapy plus exercise was not superior to supervised exercises (low evidence), but improved pain, walking tolerance, disability and quality of life compared to home/group exercises (moderate to very low evidence). Very low evidence supported 2 weeks of electromagnetic fields, whereas TENS (low evidence) and ultrasounds (very low evidence) revealed no effects. CONCLUSIONS: These findings may assist clinicians in delivering effective physiotherapy interventions in LSS patients.

Maxillary reconstruction with scapular tip chimeric free flap.

PURPOSE: Purpose of the article is to discuss the use of the scapular tip free flap (STFF) for the reconstruction of maxillary defects. METHODS: A retrospective evaluation of patients who underwent maxillary reconstruction with STFF is presented. Patients were evaluated with respect to complications, function, and cosmesis. RESULTS: Study population consisted of 53 patients. All flaps survived and partial bone resorption only occurred in a young patient. Minor complications included two instances of partial muscular necrosis. The donor site was primarily closed in all patients. Mouth opening was assessed as good (>3 cm) in 41 patients, partially limited (2-3 cm) in 9 patients, and limited (<2 cm) in 3 patients. Dental rehabilitation was achieved in 35 patients; esthetic results were assessed by patient as excellent in 19 patients, good in 28 patients, and poor in 6 patients. CONCLUSIONS: The scapular tip chimeric free flap represents an indispensable tool for reconstructive head and neck microsurgery. The main advantages of this technique are very low donor site morbidity and a long pedicle, as well as the potential for harvesting multiple flaps in a chimeric design; STFF represents the first choice for treatment of small postero-lateral defects of the maxilla, and of wide and complex through-and-through defects involving all components of the midface.

Intraoperative cytological examination of bone medullary. A useful technique to predict the extension of bone invasion in segmental mandibulectomy.

AIM: The main of the present report is to evaluate the utility of intraoperative cytological analysis of medullary bone to predict the extension of bone infiltration in segmental mandibulectomy. MATERIALS AND METHOD: Between the years 2016 and 2018, a total of 17 previously untreated patients with squamous cell carcinoma of the oral cavity underwent a segmental mandibular resection and intraoperative cytological analysis of the bone medullary at Virgen de las Nieves University Hospital (HUVN). The results of the intraoperative cytological analysis were compared with the result of the postoperative histopathological examination and sensitivity, specificity, positive predictive value, and negative predictive value of the test were calculated. RESULTS: Cytological analysis was positive in three patients and the bone resection was consequently extended. All the extensions of these bone margins were clean following the postoperative histological examination. However, two other patients previously classified as clean with intraoperative cytological analysis of bone medullary presented infiltration of bone margins postoperatively. The protocol demonstrated a high negative predictive value (85,7%). The positive predictive value, sensitivity, and specificity were 33,3%, 33,3%, and 85,7% respectively. CONCLUSION: Intraoperative cytological analysis of bone medullary could represent an easy, fast, reliable and inexpensive method to reduce the rate of r1 surgeries attributable to the infiltration of the bone margin. This may have a positive impact on overall survival without increasing the duration and the iatrogenicity of surgery.

Sexual disability in patients with chronic non-specific low back pain-a multicenter retrospective analysis.

[Purpose] Oswestry Disability Index includes an item (Oswestry Disability Index-8) aiming to assess sexual disability associated to low back pain. The aim of this study is to investigate the percentage of participants who answered the Oswestry Disability Index-8, and the relevance and characteristics of sexual disability due to low back pain in Italian patients. [Participants and Methods] Design: multicenter retrospective analysis. Population: six hundred and ninety-seven outpatients with non-specific low back pain. Variables: pain characteristics (amount, localization, and duration of perceived pain), disability, and psychological variables (anxiety, depression, catastrophizing, kinesiophobia, pain acceptance, and pain vigilance and awareness). [Results] Seventy-seven participants (11.05%) did not answer the Oswestry Disability Index-8. The odds of being not responding to the Oswestry Disability Index-8 item appeared related to age (odds=7.50 for over 60), gender (odds=2.65 for females), and marital status (odds=2.33 for not married). Concerning the psychological variables, Activity Avoidance (coefficient=0.071), Depression (coefficient=0.068), and Rumination (coefficient=0.031) showed a positive impact on sexual disability. [Conclusion] In Italian patients, the percentage of not-responding to Oswestry Disability Index-8 was relatively low. In addition, sexual disability was related to depression, activity avoidance, and rumination.

Molecular dynamics simulations of inverse patchy colloids.

Inverse patchy colloids are patchy particles with differently charged surface regions. In this paper we focus on inverse patchy colloids with two different polar patches and an oppositely charged equatorial belt, and we describe a model and a reliable and efficient numerical algorithm that can be applied to investigate the properties of these particles in molecular dynamics simulations.

Perioperative pain management after fibular free flap harvesting for head-and-neck reconstruction using mini-catheters to inject local anesthetic: A pilot study.

BACKGROUND: Fibular donor site pain management in the early postoperative period can help minimize complications, patient discomfort, and agitation. Traditional management of postoperative pain consists of systemic administration of opioids and NSAIDS. The use of local anesthetics in addition to systemic analgesics has the potential to improve pain control. Purpose of the study is to evaluate the efficacy of mini-catheters used to inject local anesthetic into the fibular donor site after flap harvesting for reconstruction of the head-and-neck area. METHODS: Prospective study on 31 patients (mean age 52 years) treated for head and neck reconstruction with fibula free flap using minicatheter for local anesthetic injection in the early postoperative time. A bolus of chirochaine (0.125% w/v; 20 mL) was injected through the catheter before the patient regained consciousness. Postoperatively, three consecutive injections (20 mL each) were administered 8, 16, and 24 h after surgery. Pain evaluation before and after local anesthetic injection is used to assess efficacy and overall pain control. RESULTS: No major or minor complication occurred. Mean pain value was 1.69. At 8 h, the pain scores before injection ranged from 0 to 10 (mean 4.13 ± 3.06). After injection, the pain scores ranged from 0 to 5 (mean 1 ± 1.34). Similarly, at 16 h, the pain scores ranged from 0 to 8 (mean 2.77 ± 2.42) before injection and from 0 to 6 (mean 0.42 ± 1.2) thereafter. At 24 h, the initial pain score ranged from 0 to 6 (mean 1.71 ± 1.74) and from 0 to 1 (mean 0.1 ± 0.3) after drug administration. Pre and postinjection pain scores differences were statistically significant after all three injections (P < .001). CONCLUSIONS: Minicatheter seems to be easy, safe, and efficient when used to control pain after fibular free-flap harvesting.

Bilateral Harvesting of a Fibula Free Flap: Assessment of Morbidity.

PURPOSE: To investigate morbidity related to harversting of bilateral fibula free flap for head and neck reconstruction using subjective and functional tests. METHODS: Patients were retrospectively evaluated using point evaluation system (PES) and balance evaluation systems test (BESTest) questionnaires to assess morbidity related to surgery. RESULTS: Five patients were enrolled in the study. Mean PES scores was 22.2 over 24. Mean overall function assessed with BESTest was 77.6%, and the results were poorest for section I. Sections V and VI had scores of 88% and 83%, respectively, indicating that the sensory balance and gait stability of the patients were compromised only minimally. CONCLUSION: Bilateral harvesting of the fibula free flap is not associated with an increase in long-term morbidity and does not lead to significant functional impairments. Therefore, this procedure should be considered safe, and can be performed without concern regarding morbidity, when bone reconstruction with a fibula free flap is indicated.

Responsiveness and minimum important change of the Oswestry Disability Index in Italian subjects with symptomatic lumbar spondylolisthesis.

BACKGROUND: This study aims to investigate the responsiveness and the minimum important change of the Italian version of the Oswestry Disability Index (ODI-I) in subjects with symptomatic specific low back pain associated with lumbar spondylolisthesis (SPL). MATERIALS AND METHODS: One hundred and fifty-one patients with symptomatic SPL completed the ODI-I, a 0-100 numerical rating scale (NRS), and performed the prone and supine bridge tests. The global perception of effectiveness was measured with a 7-point Likert scale. Responsiveness was assessed by distribution methods (minimum detectable change [MDC], effect size [ES], standardized response mean [SRM]) and anchor-based methods (ROC curves). RESULTS: The MDC was 4.23, the ES was 0.95 and the SRM was 1.25. ROC analysis revealed an area under the curve of 0.76 indicating moderate discriminating capacity. The best cut-off point for the dichotomous outcome was 7.5 (sensitivity 90.3%, specificity 56.7%). . CONCLUSIONS: The ODI-I proved to be responsive in detecting changes after conservative treatment in subjects with lumbar SPL. LEVEL OF EVIDENCE: II.

The Relationship Between Clinical Instability and Endurance Tests, Pain, and Disability in Nonspecific Low Back Pain.

OBJECTIVE: The aims of this study were (1) to investigate the relationship between clinical tests detecting spinal instability and the perceived pain and disability in nonspecific low back pain and (2) to investigate the relationship between endurance and instability tests. METHODS: Four instability tests (aberrant movements, active straight leg raising, prone instability test, and passive lumbar extension test) and 2 endurance tests (prone bridge test [PBT] and supine bridge test [SBT]) were performed on 101 participants. Their results were compared with the Numerical Rating Scale and the Oswestry Disability Index evaluating pain and disability, respectively. RESULTS: A low to moderate significant relationship between pain, disability, and all tests with the exception of PBT was observed. A low to moderate significant relationship between endurance tests and instability tests was also shown. The results of PBT and SBT were significantly related to the duration of symptoms (P = .0014 and P = .0203, respectively). CONCLUSION: The results of endurance and instability tests appear to be related to the amount of pain and the disability in nonspecific low back pain. The persistence of pain significantly reduces anterior and posterior core muscle endurance.

Pain Self-Efficacy and Fear of Movement are Similarly Associated with Pain Intensity and Disability in Italian Patients with Chronic Low Back Pain.

The purpose of this study was to investigate cross-sectional associations of pain self-efficacy and fear of movement with pain intensity and disability in Italian patients with chronic low back pain (CLBP). One hundred and three adult outpatients with nonspecific CLBP were included in the study. Socio-demographic and clinical characteristics were assessed, together with Italian versions of self-reported questionnaires to measure the four constructs of interest. Multiple linear regression models were built with psychosocial constructs as main determinants, and pain intensity and disability as outcomes. Potential confounding of socio-demographic and clinical characteristics was assessed. Pain self-efficacy and fear of movement displayed moderate correlations with pain intensity (r = -0.41 and 0.42, respectively) and disability (-0.55 and 0.54). Association models adjusted for pain intensity showed that both pain self-efficacy (ß = -0.35, 95% CI = -0.5; -0.2, R2  = 41%) and fear of movement (ß = 0.65, 95% CI = 0.36; 0.93, R2  = 40%) are significantly and strongly associated with disability. Pain self-efficacy was no longer significantly associated with pain intensity when disability was added as a confounder to the model, whereas fear of movement retained its significant association (ß = 0.06, 95% CI = 0.00;0.11, R2  = 30%). No other variables acted as confounders in these associations. Pain self-efficacy and fear of movement are very similarly associated with main outcomes in this sample of Italian patients with CLBP. The results of this study suggest that both psychosocial constructs should be considered in clinical management. Future studies should investigate whether these findings can be replicated in other samples, in longitudinal designs and if other variables not measured in this study confound the associations.

Theoretical and numerical investigations of inverse patchy colloids in the fluid phase.

We investigate the structural and thermodynamic properties of a new class of patchy colloids, referred to as inverse patchy colloids (IPCs) in their fluid phase via both theoretical methods and simulations. IPCs are nano- or micro- meter sized particles with differently charged surface regions. We extend conventional integral equation schemes to this particular class of systems: our approach is based on the so-called multi-density Ornstein-Zernike equation, supplemented with the associative Percus-Yevick approximation (APY). To validate the accuracy of our framework, we compare the obtained results with data extracted from NpT and NVT Monte Carlo simulations. In addition, other theoretical approaches are used to calculate the properties of the system: the reference hypernetted-chain (RHNC) method and the Barker-Henderson thermodynamic perturbation theory. Both APY and RHNC frameworks provide accurate predictions for the pair distribution functions: APY results are in slightly better agreement with MC data, in particular at lower temperatures where the RHNC solution does not converge.

Head and neck reconstruction using the superiorly based reversed-flow facial artery myomucosal flap.

PURPOSE: The use of myomucosal buccinator flaps in the reconstruction of oral cavity defects is well established in the international literature; however, their use for the reconstruction of defects not in the oral cavity has been largely underestimated. The purpose of this report was to describe and review the applications of the superiorly based facial artery myomucosal (FAMM) flap in head and neck reconstruction. MATERIALS AND METHODS: This study was a retrospective evaluation of 12 patients who underwent reconstruction of the palate, lip, nasal septum, and conjunctiva with reversed-flow FAMM flaps. Mouth opening, speech, reconstruction effectiveness, and esthetic outcomes were analyzed. RESULTS: The patient cohort consisted of 7 men and 5 women 33 to 80 years old (mean, 56.2 yr old). No major complication occurred. Cosmetic results were excellent in most patients. Functionally, the best reconstruction results were obtained in the palate, lip, and conjunctiva. Nasal reconstruction led to mild airway obstruction in 2 cases and severe obstruction in 1 case. CONCLUSION: The superiorly based FAMM flap plays an important role in the reconstruction of particular defects involving the oral cavity and other distant sites of the head and neck area. The reliability, low morbidity, and optimal results that can be achieved using this technique make this flap a good option for such reconstructions.

Donor site morbidity after scapular tip free flaps in head-and-neck reconstruction.

BACKGROUND: Recently, the scapular tip free flap has been popularized as a valuable option for bone reconstruction of the head and neck area. Analyses of perioperative and long-time morbidity are crucial to enable complete comprehension of this technique and will be presented in this paper. METHODS: Perioperative and long-term morbidity of scapular tip flaps harvesting were analyzed in a cohort of 19 patients. Local complications and ambulation-time were used to assess perioperative results, while Constant-Murley and DASH scores were used to evaluate long-term morbidity on shoulder functions. RESULTS: Local perioperative complications were minimal (three cases of seroma and two wound dehiscence). Ambulation time ranged between 2 and 4 days (mean 2.7 days). Constant-Murley scores ranged between 66 and 100 (mean 92.2). The DASH score ranged between 39 and 85 (mean 48.6). CONCLUSION: Harvesting a scapular tip free flap resulted in very low shoulder morbidity, without interfering the patient's daily activities. © 2015 Wiley Periodicals, Inc. Microsurgery 35:447-450, 2015.

Reconstruction of mandibular defects using the scapular tip free flap.

PURPOSE: Purpose of the article is to present the use of the scapular tip free flap (STFF) for the reconstruction of oromandibular defects. PATIENTS: Eleven patients who underwent oromandibular reconstruction with STFF were retrospectively evaluated with regards to form and function assessing mouth opening, dietary intake, and cosmetic outcome. Donor site morbidity was evaluated using the Constant-Murley test for the shoulder unit. RESULTS: Follow-up ranged from 6 to 35 months (mean 20.6 months). Good or excellent results in mouth opening and cosmesis were achieved in eight patients, speech was assessed as intelligible or normal in all but one patient and mean ambulation time after surgery was 2.5 days. Results of Constant score ranged from 45 to 70 (mean 60.6), and the main limitation encountered was elevation of the arm above the head, which was seen in all but one patient confirming the low impact of the technique on the shoulder system. CONCLUSION: Low morbidity, early ambulation time, possibility of simultaneous harvesting with the tumor resection, large musculocutaneous paddles in the chimeric version of the flap are advantages of the STFF and makes it a good choice in elderly patients, when other bone containing free flaps are not indicated because of the related morbidity, when other flaps are not available or when wide composite defects are approached.

Using PubMed search strings for efficient retrieval of manual therapy research literature.

OBJECTIVE: The aim of this study was to construct PubMed search strings that could efficiently retrieve studies on manual therapy (MT), especially for time-constrained clinicians. METHODS: Our experts chose 11 Medical Subject Heading terms describing MT along with 84 additional potential terms. For each term that was able to retrieve more than 100 abstracts, we systematically extracted a sample of abstracts from which we estimated the proportion of studies potentially relevant to MT. We then constructed 2 search strings: 1 narrow (threshold of pertinent articles ≥40%) and 1 expanded (including all terms for which a proportion had been calculated). We tested these search strings against articles on 2 conditions relevant to MT (thoracic and temporomandibular pain). We calculated the number of abstracts needed to read (NNR) to identify 1 potentially pertinent article in the context of these conditions. Finally, we evaluated the efficiency of the proposed PubMed search strings to identify relevant articles included in a systematic review on spinal manipulative therapy for chronic low back pain. RESULTS: Fifty-five search terms were able to extract more than 100 citations. The NNR to find 1 potentially pertinent article using the narrow string was 1.2 for thoracic pain and 1.3 for temporomandibular pain, and the NNR for the expanded string was 1.9 and 1.6, respectively. The narrow search strategy retrieved all the randomized controlled trials included in the systematic review selected for comparison. CONCLUSION: The proposed PubMed search strings may help health care professionals locate potentially pertinent articles and review a large number of MT studies efficiently to better implement evidence-based practice.