Orthopaedic and trauma surgeons' prioritisation of app quality principles based on their demographic background.

BACKGROUND: Although apps are becoming increasingly relevant in healthcare, there is limited knowledge about how healthcare professionals perceive "quality" in this context and how quality principles that can aid them in assessing health-related apps may be prioritised. The objective was to investigate physicians' views of predefined (general) quality principles for health apps and to determine whether a ranking algorithm applied to the acquired data can provide stable results against various demographic influences and may thus be appropriate for prioritisation. METHODS: Participants of an online survey of members of two German professional orthopaedics associations conducted between 02/12/2019 and 02/01/2020 were asked about their perception of a set of quality principles for health apps (i.e., "practicality," "risk adequacy," "ethical soundness," "legal conformity," "content validity," "technical adequacy," "usability," "resource efficiency," and "transparency"). Structured as a Kano survey, for each principle, there were questions about its perceived relevance and opinions regarding the presence or absence of corresponding characteristics. The available data were evaluated descriptively, and a newly developed method for prioritisation of the principles was applied overall and to different demographic strata (for validation). RESULTS: Three hundred eighty-two datasets from 9503 participants were evaluated. Legal conformity, content validity, and risk adequacy filled ranks one to three, followed by practicability, ethical soundness, and usability (ranks 4 to 6). Technical adequacy, transparency, and resource efficiency ranked last (ranks 7 to 9). The ranking based on the proposed method was relatively stable, irrespective of demographic factors. The principles were seen as essential, with one exception ("resource efficiency"). Only those with little to no interest in digitisation (22/382, 5.8%) rated the nine principles indifferently. CONCLUSIONS: The specified quality principles and their prioritisation can lay a foundation for future assessments of apps in the medical field. Professional societies build upon this to highlight opportunities for digital transformations in medicine and encourage their members to participate.

[Mobile health for detection of atrial fibrillation-Status quo and perspectives]. / Mobile Health zur Detektion von Vorhofflimmern ­ Status quo und Perspektiven.

Mobile health (mHealth) for the detection of atrial fibrillation is an innovative domestic monitoring of the heart rhythm. The use of mHealth in the context of atrial fibrillation increases the availability of diagnostic technologies and facilitates the integration into telemedical treatment concepts as well as the active participation of patients in the treatment process. The detection of atrial fibrillation with mHealth applications is usually based on electrocardiography (ECG) or by detection of the pulse wave using photoplethysmography (PPG). Some applications require additional sensors, others make use of sensors integrated into smartphones or smartwatches. A high diagnostic accuracy for the detection of atrial fibrillation has been shown for most mHealth applications regardless of the underlying technology (analytical validation); however, the evidence on positive care effects and improvement of medical endpoints (clinical validation) is so far scarce. Screening of symptomatic or asymptomatic patients and the follow-up care after antiarrhythmic measures are possibilities for the integration into the reality of care. The preventive detection of atrial fibrillation is an attractive field of application for mHealth with great potential for the future. Nevertheless, at present mHealth is only integrated to a limited extent into the reality of patient care. Adequate reimbursement and medical remuneration as well as opportunities to derive information and qualification are prerequisites in order to be able to guarantee a comprehensive implementation in the future. The Digital Health Care Act passed in 2019, regulates the reimbursement of digital healthcare applications but issues of primary preventive applications have not yet been included.

Potentials of Digitalization in Sports Medicine: A Narrative Review.

Digital transformation is becoming increasingly common in modern life and sports medicine, like many other medical disciplines, it is strongly influenced and impacted by this rapidly changing field. This review aims to give a brief overview of the potential that digital technologies can have for health care providers and patients in the clinical practice of sports medicine. We will focus on mobile applications, wearables, smart devices, intelligent machines, telemedicine, artificial intelligence, big data, system interoperability, virtual reality, augmented reality, exergaming, or social networks. While some technologies are already used in current medical practice, others still have undiscovered potential. Due to the diversity and ever changing nature of this field, we will briefly review multiple areas in an attempt to give readers some general exposure to the landscape instead of a thorough, deep review of one topic. Further research will be necessary to show how digitalization applications could best be used for patient treatments.

Medical Apps in Oto-Rhino-Laryngology. / Medizinische Apps in der HNO-Heilkunde.

The implementation of mobile information and communication technology in the field of health services, e. g. in the form of apps, is becoming increasingly important. Unfortunately, the necessary quality criteria are often mising. Thus, it seems important, that in addition to an app controlling authority highly qualified health care professionals participate in the development of these applications. For reasons of liability, however, the physician must exercise great caution in the selection and recommendation of medical apps, especially considering, that only a few apps are certified as medical devices. There are a large number of medical apps on the market, with only a small proportion being assigned to the field of otorhinolaryngology. The areas of audiology, sleep medicine and allergology are most frequently represented. Althouhgh there is increasing scientific work on this topic in the field of otorhinolaryngology, there is a lack of scientific evidence of contents and results, as is generally the case of medical apps. However, there are other possibilities for users to rate medical apps regarding defined qualitiy criteria such as functionality, scientific integrity, but also data privacy. None of the apps assessed by such a evaluation tool met all the required quality criteria, but the applied instrument helped to better assess the application. However, it was possible to consider the quality criteria in the developmental process of an medical app for the field of otorhinolaryngoglogy. In summary, the present work provide a comprehensive insight into the topic "Apps in Otorhinolaryngology" with the aim to use these modern aids in a beneficial way.

[Assessing the benefits of digital health solutions in the societal reimbursement context]. / Nutzenbewertung von digitalen Gesundheitsprodukten (Digital Health) im gesellschaftlichen Erstattungskontext.

For a number of reasons, achieving reimbursability for digital health products has so far proven difficult. Demonstrating the benefits of the technology is the main hurdle in this context. The generally accepted evaluation processes, especially parallel group comparisons in randomized controlled trials (RCTs) for (clinical) benefit assessment, are primarily intended to deal with questions of (added) medical benefit. In contrast to drugs or classical medical devices, users of digital health solutions often profit from gaining autonomy, increased awareness and mindfulness, better transparency in the provision of care, and improved comfort, although there are also digital solutions with an interventional character targeting clinical outcomes (e. g. for indications such as anorexia, depression). Commonly accepted methods for evaluating (clinical) benefits primarily rely on medical outcomes, such as morbidity and mortality, but do not adequately consider additional benefits unique to digital health. The challenge is therefore to develop evaluation designs that respect the particularities of digital health without reducing the validity of the evaluations (especially with respect to safety). There is an increasing need for concepts that include both continuous feedback loops for adapting and improving an application while at the same time generate sufficient evidence for complex benefit assessments. This approach may help improve risk benefit ratio assessments of digital health when it comes to implementing digital innovations in healthcare.

Google Glass for documentation of medical findings: evaluation in forensic medicine.

BACKGROUND: Google Glass is a promising premarket device that includes an optical head-mounted display. Several proof of concept reports exist, but there is little scientific evidence regarding its use in a medical setting. OBJECTIVE: The objective of this study was to empirically determine the feasibility of deploying Glass in a forensics setting. METHODS: Glass was used in combination with a self-developed app that allowed for hands-free operation during autopsy and postmortem examinations of 4 decedents performed by 2 physicians. A digital single-lens reflex (DSLR) camera was used for image comparison. In addition, 6 forensic examiners (3 male, 3 female; age range 23-48 years, age mean 32.8 years, SD 9.6; mean work experience 6.2 years, SD 8.5) were asked to evaluate 159 images for image quality on a 5-point Likert scale, specifically color discrimination, brightness, sharpness, and their satisfaction with the acquired region of interest. Statistical evaluations were performed to determine how Glass compares with conventionally acquired digital images. RESULTS: All images received good (median 4) and very good ratings (median 5) for all 4 categories. Autopsy images taken by Glass (n=32) received significantly lower ratings than those acquired by DSLR camera (n=17) (region of interest: z=-5.154, P<.001; sharpness: z=-7.898, P<.001; color: z=-4.407, P<.001, brightness: z=-3.187, P=.001). For 110 images of postmortem examinations (Glass: n=54, DSLR camera: n=56), ratings for region of interest (z=-8.390, P<.001) and brightness (z=-540, P=.007) were significantly lower. For interrater reliability, intraclass correlation (ICC) values were good for autopsy (ICC=.723, 95% CI .667-.771, P<.001) and postmortem examination (ICC=.758, 95% CI .727-.787, P<.001). Postmortem examinations performed using Glass took 42.6 seconds longer than those done with the DSLR camera (z=-2.100, P=.04 using Wilcoxon signed rank test). The battery charge of Glass quickly decreased; an average 5.5% (SD 1.85) of its battery capacity was spent per postmortem examination (0.81% per minute or 0.79% per picture). CONCLUSIONS: Glass was efficient for acquiring images for documentation in forensic medicine, but the image quality was inferior compared to a DSLR camera. Images taken with Glass received significantly lower ratings for all 4 categories in an autopsy setting and for region of interest and brightness in postmortem examination. The effort necessary for achieving the objectives was higher when using the device compared to the DSLR camera thus extending the postmortem examination duration. Its relative high power consumption and low battery capacity is also a disadvantage. At the current stage of development, Glass may be an adequate tool for education. For deployment in clinical care, issues such as hygiene, data protection, and privacy need to be addressed and are currently limiting chances for professional use.

Conversion of hemi into reverse shoulder arthroplasty: implant design limitations.

PURPOSE: Cranial migration of shoulder hemiarthroplasties due to rotator cuff insufficiency typically requires conversion into a reverse total shoulder arthroplasty. This study was conducted to analyze differences between the height and offset of six implants designed to enable conversion of a hemiarthroplasty into a reverse system. METHODS: Anteroposterior radiographs of 40 shoulders were taken. An image analyzing software was used to simulate the implantation of the hemiprostheses. Then the implant was dissembled, leaving on the stem within the humeral shaft. Finally, the implantation of a reverse system was simulated using the stem in the same position. Values are reported as ∆-height and ∆-offset ± standard deviation. Significance was assumed for P < 0.05. RESULTS: The least decrease in height was determined for Implantcast with 11.6 ± 3.3 mm, followed by DePuy (16 ± 5.7 mm) and the greatest for Tornier with 33 ± 5.3 mm. No significant differences were found among Exactech, Mathys and Zimmer. The largest offset-deviation was calculated for DePuy (-21.7 ± 3.7 mm) and the smallest for Implantcast (-3.3 ± 2.8 mm) and Tornier (1.5 ± 5.7 mm). CONCLUSIONS: Due to the modular stem, the system of Implantcast can be converted in a reverse system with the least changes in height and offset. For the other manufacturers it does not seem possible to convert a hemiprosthesis to a reversed prosthesis without accepting additional tension of the deltoid muscle. Further experimental studies have to analyze the changes in deltoid abduction moments after conversion of a hemi- into a reversed prosthesis.

Automated Heart Rate Detection in Seismocardiograms Using Electrocardiogram-Based Algorithms-A Feasibility Study.

In recent decades, much work has been implemented in heart rate (HR) analysis using electrocardiographic (ECG) signals. We propose that algorithms developed to calculate HR based on detected R-peaks using ECG can be applied to seismocardiographic (SCG) signals, as they utilize common knowledge regarding heart rhythm and its underlying physiology. We implemented the experimental framework with methods developed for ECG signal processing and peak detection to be applied and evaluated on SCGs. Furthermore, we assessed and chose the best from all combinations of 15 peak detection and 6 preprocessing methods from the literature on the CEBS dataset available on Physionet. We then collected experimental data in the lab experiment to measure the applicability of the best-selected technique to the real-world data; the abovementioned method showed high precision for signals recorded during sitting rest (HR difference between SCG and ECG: 0.12 ± 0.35 bpm) and a moderate precision for signals recorded with interfering physical activity-reading out a book loud (HR difference between SCG and ECG: 6.45 ± 3.01 bpm) when compared to the results derived from the state-of-the-art photoplethysmographic (PPG) methods described in the literature. The study shows that computationally simple preprocessing and peak detection techniques initially developed for ECG could be utilized as the basis for HR detection on SCG, although they can be further improved.

Beyond technology acceptance-a focused ethnography on the implementation, acceptance and use of new nursing technology in a German hospital.

Introduction: Hospitalised patients could benefit from the emergence of novel technologies for nursing care. There are numerous technical products available, but these rarely find their way into practice. Further knowledge is required about the circumstances under which technology in nursing is accepted and used. In the research project "Centre for Implementing Nursing Care Innovations", technical innovations are implemented on a trauma surgery inpatient ward in Germany. After implementation, it was investigated: Which implemented technologies are accepted/rejected, and which factors influence the acceptance/rejection of technology for nurses? Material and methods: A focused ethnography was used, containing two approaches: First, participant observation was conducted to examine nurses' and patients' interaction with technologies. Observations were fixed in a field research diary and analysed using evaluative qualitative content analysis. Second, a questionnaire was used by nurses to provide information about the use frequency and technology suitability. The results of the study were consolidated and analysed using the UTAUT model. Results: Seven studied technologies can be summarised in four result categories: (1) A Mobilising mattress, a Special projector and a Sound pillow are accepted and used by nurses and patients, because they offer a way to provide high quality care with little additional effort. (2) A Fall prevention system is consistently used in patient care as a work obligation, but since nurses consider the system error-prone, acceptance is low. (3) An Interactive therapy ball is accepted but nurses cannot use it due to the high workload. (4) An App for nurse-patient communication and a work-equipment tracking system are not used or accepted because nurses do not see a practical benefit in the systems. Discussion: Acceptance or rejection of a product does not necessarily equate to use or non-use of the technology. Before implementation, technology acceptance among users occurs as prejudice-when users are given time to experiment with technology, intention-to-use can stabilize into sustained use. Accepted and used technologies can serve to mask problems (such as staff shortages) and encourage problematic developments, such as the reduction of contact time at the bedside. Therefore, technology acceptance should be qualified in asking to what accepted technology contributes.

Effects of mobile augmented reality learning compared to textbook learning on medical students: randomized controlled pilot study.

BACKGROUND: By adding new levels of experience, mobile Augmented Reality (mAR) can significantly increase the attractiveness of mobile learning applications in medical education. OBJECTIVE: To compare the impact of the heightened realism of a self-developed mAR blended learning environment (mARble) on learners to textbook material, especially for ethically sensitive subjects such as forensic medicine, while taking into account basic psychological aspects (usability and higher level of emotional involvement) as well as learning outcomes (increased learning efficiency). METHODS: A prestudy was conducted based on a convenience sample of 10 third-year medical students. The initial emotional status was captured using the "Profile of Mood States" questionnaire (POMS, German variation); previous knowledge about forensic medicine was determined using a 10-item single-choice (SC) test. During the 30-minute learning period, the students were randomized into two groups: the first group consisted of pairs of students, each equipped with one iPhone with a preinstalled copy of mARble, while the second group was provided with textbook material. Subsequently, both groups were asked to once again complete the POMS questionnaire and SC test to measure changes in emotional state and knowledge gain. Usability as well as pragmatic and hedonic qualities of the learning material was captured using AttrakDiff2 questionnaires. Data evaluation was conducted anonymously. Descriptive statistics for the score in total and the subgroups were calculated before and after the intervention. The scores of both groups were tested against each other using paired and unpaired signed-rank tests. An item analysis was performed for the SC test to objectify difficulty and selectivity. RESULTS: Statistically significant, the mARble group (6/10) showed greater knowledge gain than the control group (4/10) (Wilcoxon z=2.232, P=.03). The item analysis of the SC test showed a difficulty of P=0.768 (s=0.09) and a selectivity of RPB=0.2. For mARble, fatigue (z=2.214, P=.03) and numbness (z=2.07, P=.04) decreased with statistical significance when comparing pre- and post-tests. Vigor rose slightly, while irritability did not increase significantly. Changes in the control group were insignificant. Regarding hedonic quality (identification, stimulation, attractiveness), there were significant differences between mARble (mean 1.179, CI -0.440 to 0.440) and the book chapter (mean -0.982, CI -0.959 to 0.959); the pragmatic quality mean only differed slightly. CONCLUSIONS: The mARble group performed considerably better regarding learning efficiency; there are hints for activating components of the mAR concept that may serve to fascinate the participants and possibly boost interest in the topic for the remainder of the class. While the small sample size reduces our study's conclusiveness, its design seems appropriate for determining the effects of interactive eLearning material with respect to emotions, learning efficiency, and hedonic and pragmatic qualities using a larger group. TRIAL REGISTRATION: German Clinical Trial Register (DRKS), DRKS-ID: DRKS00004685; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004685.

Standardized, App-based disinfection of iPads in a clinical and nonclinical setting: comparative analysis.

BACKGROUND: With the use of highly mobile tools like tablet PCs in clinical settings, an effective disinfection method is a necessity. Since manufacturers do not allow cleaning methods that make use of anything but a dry fleece, other approaches have to be established to ensure patient safety and to minimize risks posed by microbiological contamination. OBJECTIVE: The ability of isopropanol wipes to decontaminate iPads was evaluated prospectively in a observer blinded, comparative analysis of devices used in a clinical and a nonclinical setting. METHODS: 10 new iPads were randomly deployed to members of the nursing staff of 10 clinical wards, to be used in a clinical setting over a period of 4 weeks. A pre-installed interactive disinfection application (deBac-app, PLRI MedAppLab, Germany) was used on a daily basis. Thereafter, the number and species of remaining microorganisms on the surface of the devices (13 locations; front and back) was evaluated using contact agar plates. Following this, the 10 iPads were disinfected and randomly deployed to medical informatics professionals who also used the devices for 4 weeks but were forbidden to use disinfecting agents. The quality of a single, standardized disinfection process was then determined by a final surface disinfection process of all devices in the infection control laboratory. No personal data were logged with the devices. The evaluation was performed observer blinded with respect to the clinical setting they were deployed in and personnel that used the devices. RESULTS: We discovered a 2.7-fold (Mann-Whitney U test, z=-3.402, P=.000670) lower bacterial load on the devices used in the clinical environment that underwent a standardized daily disinfection routine with isopropanol wipes following the instructions provided by "deBac-app". Under controlled conditions, an average reduction of the mainly Gram-positive normal skin microbiological load of 99.4% (Mann-Whitney U test, z=-3.1798, P=.001474) for the nonclinical group and 98.1% (Mann-Whitney U test, z=3.1808, P=.001469) for the clinical group was achieved using one complete disinfecting cycle. CONCLUSIONS: Normal use of tablet PCs leads to a remarkable amount of microbial surface contamination. Standardized surface disinfection with isopropanol wipes as guided by the application significantly reduces this microbial load. When performed regularly, the disinfection process helps with maintaining a low germ count during use. This should reduce the risk of subsequent nosocomial pathogen transmission. Unfortunately, applying a disinfection procedure such as the one we propose may lead to losing the manufacturer's warranty for the devices; this remains an unsolved issue.

Access to the hip joint from standard arthroscopic portals: a cadaveric study.

PURPOSE: Our purpose was to study and describe the areas of the hip joint that can be safely visualized and operated on using a variety of portals for the central and peripheral compartments. METHODS: Twelve hip joints in 6 human cadavers were examined through 9 different central and peripheral arthroscopic portals. Markings of the accessible areas within the joint were made through an arthroscope. Dissection of the cadavers was carried out for final evaluation of the visible areas and those accessible for instruments. During dissection, anatomic proximity of the portals to relevant neurovascular structures was measured. RESULTS: The central compartment was sufficiently accessible using the anterior, anterolateral, and posterolateral portals, with slight limitations in the posteromedial corner. A more medial portal did not offer substantial advantages regarding accessibility but decreased the safety distance to the femoral nerve. With regard to the peripheral compartment, the combination of the anterolateral and posterolateral portals allowed visualization of most of the joint. It was observed that the structure at highest risk of injury for the central anterior and the peripheral anterolateral portals was the lateral femoral cutaneous nerve. CONCLUSIONS: In hip arthroscopy, the use of the standard anterior, anterolateral, and posterolateral portals allows proper accessibility of the central compartment, with slight limitations in the posteromedial corner. A more medial portal is not recommended with regard to its risk-benefit ratio. The peripheral compartment of the hip joint is sufficiently visible using the anterolateral and posterolateral portals. For treatment of specific pathologic conditions, a variation of these portals improves surgical accessibility. The anatomic structure at highest risk of injury during hip arthroscopy is the lateral femoral cutaneous nerve. CLINICAL RELEVANCE: The general objectives of this study were to prepare surgeons to develop appropriate concepts of surgery and to facilitate preoperative planning.

[Secure app usage-Evaluation benchmarks for medical apps : Quality aspects for health apps based on 9 key criteria]. / "Secure app usage" ­ Bewertungsmaßstäbe für klinische Applikationen : Qualitätsaspekte für Gesundheits-Apps anhand von 9 Qualitätskriterien.

Smartphones and health apps are an integral part of everyday life. They are increasingly being used for medical purposes. However, there is no fundamental basis or consensus on the evidence on which decisions are made towards a unified digital strategy. Consequently, the understanding of the quality of health apps is only inconsistent and fuzzily defined. The 9 quality criteria presented by the Association of Medical Societies (AWMF)-transparency, appropriateness, risk appropriateness, ethical harmlessness, legal conformity, content validity, technical appropriateness, usability, resource efficiency-serve as a guide for individual and institutionalized quality assessment. The principles are based on a comprehensive compilation of existing (inter-) national standards and evaluation benchmarks. Analogously to usual medical practice, it is also obligatory to conduct one's own research for a suitable app and to weigh up the risks and benefits when using an app.

On-Site Visualization of Ballistocardiography Data.

We describe the background, features and functions of a custom application for the acquisition, live presentation, and convenient recording of ballistocardiography data acquired by external accelerometric sensors.

COVID-19 Mobile Apps Trends Derived from Long-Term Google Play Analysis.

In this paper, we describe the 5-year trends of COVID-related mobile apps in the Google Play platform obtained by retrospectively analyzing app descriptions. Out of 21764 and 48750 unique apps available free of charge in the "medical" and "health and fitness", there were 161 and 143 COVID-related apps, respectively. The prominentrise in apps' prevalence occurred in January 2021.

Conciliation and Approval of Quality Principles for the Self-Declaration of the Quality of Health Apps.

This poster describes the conciliation and approval process of the unified set of criteria for self-declaration of health app quality. The timeline underlines the necessity of transparency and open communication in regulations.

Expectations of new technologies in nursing care among hospital patients in Germany - an interview study.

Introduction: New technologies will be increasingly available for nursing care, including robots, patient mobilisation devices, digital event detection or prevention equipment. Technologies are expected to support nurses, increase patients' safety and reduce costs. Yet, although these technologies will significantly shape patients' experience, we need to learn more about patients' perspectives regarding new technology in care. This study aims to investigate attitudes, expectations, worries and anticipated implementation effects of new assistive technology in nursing care by patients. Methods: Qualitative, guided, semi-open interviews were conducted. The recruitment was carried out in a trauma surgery ward of a university hospital in Germany. Eight different technologies were presented via video clips and additional information to the patients, followed by in-depth discussions. The interviews were analysed using qualitative evaluative content analysis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist was used to ensure study quality. Results: Study participants anticipate different outcomes for the implementation of new nursing technology: (1) For patients, they consider the potential for improvement in health and well-being as well as for their hospital stay experience, but also fear possible health risks or social or emotional factors like loss of autonomy or loneliness. (2) For professional nurses, participants expect relief from physically stressful work routines; however, they might be replaced by machines and lose their employment (3) For the nursing process, safety and quality improvements for care delivery may encounter a negative quantification of human life and risks of constant surveillance. Conclusion: Patients identify opportunities, challenges and shortcomings of nursing technology implementation. They describe nuanced and mixed accounts of patients' perspectives that are structured in a 'continuum of anticipated effects' of implementing technology in our article. The results can inform future implementation strategies.

Do Health Apps Stigmatize People with Obesity?

Apps in the "Medicine" category of Apple's App Store were examined concerning the potential stigmatization of people with obesity through word and image language. Only 5/71 potentially stigmatizing apps related to obesity were identified. Stigmatization in this context can occur, for example, through the excessive promotion of very slim people in connection with weight loss-related apps.

Medical Apps for Android and iOS: Differences and Similarities.

Google Play and Apple's App Store dominate the mobile health app market. We analyzed the metadata and descriptive texts of apps in the medical category using semi-automated retrospective app store analysis (SARASA) and compared the store offerings in terms of their number, descriptive texts, user ratings, medical device status, diseases, and conditions (both keyword-based). Relatively speaking, the store listings for the selected items were comparable.

Evidence of Digital Health Applications from a State-Regulated Repository for Reimbursable Health Applications in Germany.

17 RCTs for 15 digital health applications (DiGA) permanently listed in the state-regulated register were analyzed descriptively for methodological study aspects relevant to evidence analysis. The analysis revealed that several underlying studies had limitations, at least worthy of discussion, in terms of their power concerning sample size, intervention and control group specifications, drop-out rates, and blinding.