scholarly journals Impact of obstetric unit closures, travel time and distance to obstetric services on maternal and neonatal outcomes in high-income countries: a systematic review

BMJ Open ◽  
2020 ◽  
Vol 10 (12) ◽  
pp. e036852
Author(s):  
Reem Saleem Malouf ◽  
Claire Tomlinson ◽  
Jane Henderson ◽  
Charles Opondo ◽  
Peter Brocklehurst ◽  
...  
Keyword(s):  
Systematic Review ◽  
Grey Literature ◽  
Risk Of Bias ◽  
High Income ◽  
Travel Distance ◽  
Neonatal Outcomes ◽  
Increased Risk ◽  
Maternal And Neonatal Outcomes ◽  
The Impact ◽  
Travel Distances

ObjectivesTo systematically review (1) The effect of obstetric unit (OU) closures on maternal and neonatal outcomes and (2) The association between travel distance/time to an OU and maternal and neonatal outcomes.DesignSystematic review of any quantitative studies with a comparison group.Data sourcesEmbase, MEDLINE, PsycINFO, Applied Social Science Index and Abstracts, Cumulative Index to Nursing and Allied Health and grey literature were searched.MethodsEligible studies explored the impact of closure of an OU or the effect of travel distance/time on prespecified maternal or neonatal outcomes. Only studies of women giving birth in high-income countries with universal health coverage of maternity services comparable to the UK were included. Identification of studies, extraction of data and risk of bias assessment were undertaken by at least two reviewers independently. The risk of bias checklist was based on the Cochrane Effective Practice and Organisation of Care criteria and the Newcastle-Ottawa scale. Heterogeneity across studies precluded meta-analysis and synthesis was narrative, with key findings tabulated.Results31 studies met the inclusion criteria. There was some evidence to suggest an increase in babies born before arrival following OU closures and/or associated with longer travel distances or time. This may be associated with an increased risk of perinatal or neonatal mortality, but this finding was not consistent across studies. Evidence on other maternal and neonatal outcomes was limited but did not suggest worse outcomes after closures or with longer travel times/distances. Interpretation of findings for some studies was hampered by concerns around how accurately exposures were measured, and/or a lack of adjustment for confounders or temporal changes.ConclusionIt is not possible to conclude from this review whether OU closure, increased travel distances or times are associated with worse outcomes for the mother or the baby.PROSPERO registration numberCRD42017078503.

scholarly journals P070: Mixed effectiveness of emergency department diversion strategies: a systematic review

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S102
Author(s):  
S.W. Kirkland ◽  
A. Soleimani ◽  
B.H. Rowe ◽  
A.S. Newton
Keyword(s):  
Systematic Review ◽  
Health Care ◽  
Emergency Department ◽  
Health Care Services ◽  
Grey Literature ◽  
Study Data ◽  
Care Utilization ◽  
Alternative Source ◽  
Increased Risk ◽  
The Impact

Introduction: Diverting patients away from the emergency department (ED) has been proposed as a solution for reducing ED overcrowding. The objective of this systematic review is to examine the effectiveness of diversion strategies designed to either direct patients seeking care at an ED to an alternative source of care. Methods: Seven electronic databases and grey literature were searched. Randomized/controlled clinical trials and cohort studies assessing the effectiveness of pre-hospital and ED-based diversion interventions with a comparator were eligible for inclusion. Two reviewers independently screened the studies for relevance, inclusion, and risk of bias. Intervention effects are reported as proportions (%) or relative risks (RR) with 95% confidence intervals (CI). Methodological and clinical heterogeneity prohibited pooling of study data. Results: From 7,306 citations, ten studies were included. Seven studies evaluated a pre-hospital diversion strategy and three studies evaluated an ED-based diversion strategy. The impact of diversion on subsequent health services was mixed. One study of paramedic practitioners reported increased ED attendance within 7 days (11.9% vs. 9.5%; p=0.049) but no differences in return visits for similar conditions (75.2% vs. 72.1%; p=0.64). The use of paramedic practitioners was associated with an increased risk of subsequent contact with health care services (RR=1.21, 95% CI 1.06, 1.38), while the use of deferred care was associated with no increase in risk of subsequently seeking physician care (RR=1.09, 95% CI 0.23, 5.26). While two studies reported that diverted patients were at significantly reduced risk for hospitalization, two other studies reported no significant differences between diverted or standard care patients. Conclusion: The evidence regarding the impact of pre-hospital and ED-based diversion on ED utilization and subsequent health care utilization is mixed. Additional high-quality comparative effectiveness studies of diversion strategies are required prior to widespread implementation.

PP39 What is the risk of major trauma following a fall down stairs? – A systematic review

2021 ◽  
Vol 38 (9) ◽  
pp. A16.2-A16
Author(s):  
Christopher Holt ◽  
Samuel Keating ◽  
Michael Tonkins ◽  
Daniel Bradbury ◽  
Gordon Fuller
Keyword(s):  
Systematic Review ◽  
Major Trauma ◽  
Alcohol Intoxication ◽  
Grey Literature ◽  
Developed Countries ◽  
Risk Of Bias ◽  
Qualitative Synthesis ◽  
Increased Risk ◽  
Study Heterogeneity ◽  
Serious Injury

BackgroundSpecific mechanisms of injury are stated in pre-hospital triage tools to identify suspected cases of major trauma. Falls down stairs are common presentations in UK emergency departments, yet are frequently overlooked as a causative mechanism of major trauma. No prior systematic review has examined this association.MethodsSeven internationally recognised literature databases and seven grey literature databases were screened utilising a common search strategy from inception until 31 December 2019. Abstracts were screened for relevance by a single reviewer. Full texts were screened and subsequently extracted by 3 separate reviewers against strict inclusion/exclusion criteria. A risk of bias assessment based on GRADE recommendations was performed. In the absence of study heterogeneity, a narrative synthesis was planned. The reporting of this systematic review followed PRISMA 2009 statement guidelines.Results5240 articles were identified from database searching, 89 articles had their full texts assessed for eligibility and 6 articles were included for qualitative synthesis. All studies were retrospective in nature and originated from more economically developed countries. 7431 patients who fell down stairs were analysed, of which, 707 (9.5%) met major trauma definitions. Falls down stairs resulted in a significantly increased risk of serious injury compared to other fall mechanisms (OR: 1.621, 95% CI: 1.381 – 1.902, p<0.0005). Analysis of confounding factors demonstrated age (OR: 2.59, 95% CI: 1.57 – 4.28, p<0.001) and alcohol intoxication (OR: 2.6, 95% CI: 1.4 – 4.7, p=0.001) to be significantly associated with major trauma. Risk of bias was moderate to high across all 6 studies.ConclusionThis systematic review highlighted the paucity of literature surrounding the incidence of major trauma following falls down stairs.A retrospective cohort study is currently being undertaken to analyse the risk of major trauma following falls down stairs. On completion, the results will be incorporated with the results of this systematic review.

scholarly journals Characteristics and Recovery Methods of Studies Falsely Excluded During Literature Screening –A Systematic Review

2021 ◽  
Author(s):  
Lisa Affengruber ◽  
Andreea Dobrescu ◽  
Emma Persad ◽  
Irma Klerings ◽  
Gernot Wagner ◽  
...  
Keyword(s):  
Systematic Review ◽  
Information Science ◽  
Citation Index ◽  
Grey Literature ◽  
Case Series ◽  
Rapid Review ◽  
Reference List ◽  
Search Methods ◽  
Increased Risk ◽  
The Impact

Abstract Background: Due to the growing need to provide evidence syntheses under time constraints, researchers have begun focusing on the exploration of rapid review methods, which often employ single-reviewer literature screening. However, single-reviewer screening misses, on average, 13% of relevant studies, compared to 3% with dual-reviewer screening. Little guidance exists regarding methods to recover studies falsely excluded during literature screening. Likewise, it is unclear whether specific study characteristics can predict an increased risk of false exclusion. This systematic review aimed to identify supplementary search methods that can be used to recover studies falsely excluded during literature screening. Moreover, it strove to identify study-level predictors that indicate an elevated risk of false exclusions of studies during literature screening. Methods: We performed literature searches for eligible studies in Medline, Science Citation Index Expanded, Social Sciences Citation Index, Current Contents Connect, Embase, Epistemonikos.org, and Information Science & Technology Abstracts from 1999 to June 23, 2020. We searched for grey literature, checked reference lists, and conducted hand searches in two relevant journals and similar articles searches current to January 28, 2021. Two investigators independently screened the literature; one investigator performed the data extraction, a second investigator checked for correctness and completeness. Two reviewers assessed the risk of bias of eligible studies. We synthesized the results narratively. Results: Three methods studies, two with a case study design and one with a case series design, met the inclusion criteria. One study reported that all falsely excluded publications (8%) could be recovered through reference list checking compared to other supplementary search methods. No included methods study analyzed the impact of recovered studies on conclusions or meta-analyses. Two studies reported that up to 8% of studies were falsely excluded due to uninformative titles and abstracts, and one study showed that 11% of non-English studies were falsely excluded. Conclusions: Due to the limited evidence based on two case studies and one case series, we can draw no firm conclusion about the most reliable and most valid method to recover studies falsely excluded during literature screening or about the characteristics that might predict a higher risk of false exclusion. Systematic review registration: https://osf.io/v2pjr/

scholarly journals The Impact of Histopathological Features on the Prognosis of Oral Squamous Cell Carcinoma: A Comprehensive Review and Meta-Analysis

2021 ◽  
Vol 11 ◽  
Author(s):  
Eder da Silva Dolens ◽  
Mauricio Rocha Dourado ◽  
Alhadi Almangush ◽  
Tuula A. Salo ◽  
Clarissa Araujo Gurgel Rocha ◽  
...  
Keyword(s):  
Systematic Review ◽  
Squamous Cell Carcinoma ◽  
Oral Squamous Cell Carcinoma ◽  
Cell Carcinoma ◽  
Squamous Cell ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Histopathological Features ◽  
Increased Risk ◽  
The Impact

ObjectiveOver many decades, studies on histopathological features have not only presented high-level evidence of contribution for treatment directions and prognosis of oral squamous cell carcinoma (OSCC) but also provided inconsistencies, making clinical application difficult. The 8th TNM staging system of OSCC has acknowledged the importance of some histopathological features, by incorporating depth of invasion (DOI) to T category and extranodal extension (ENE) to N category. The aim of this systematic review with meta-analysis is to determine the most clinically relevant histopathological features for risk assessment and treatment planning of OSCC and to elucidate gaps in the literature.MethodsA systematic review was conducted using PRISMA guidelines, and the eligibility criteria were based on population, exposure, comparison, outcome, and study type (PECOS). PubMed, Cochrane, Scopus, and Web of Science were searched for articles exploring the impact of histopathological features on OSCC outcomes with Cox multivariate analysis. Pooled data were subjected to an inverse variance method with random effects or fixed effect model, and the risk of bias was evaluated using quality in prognosis studies (QUIPS). Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.ResultsThe study included 172 articles published from 1999 to 2021. Meta-analyses confirmed the prognostic potential of DOI, ENE, perineural invasion, lymphovascular invasion, and involvement of the surgical margins and brought promising results for the association of bone invasion, tumor thickness, and pattern of invasion with increased risk for poor survival. Although with a small number of studies, the results also revealed a clinical significance of tumor budding and tumor-stroma ratio on predicted survival of patients with OSCC. Most of the studies were considered with low or moderate risk of bias, and the certainty in evidence varied from very low to high.ConclusionOur results confirm the potential prognostic usefulness of many histopathological features and highlight the promising results of others; however, further studies are advised to apply consistent designs, filling in the literature gaps to the pertinence of histopathological markers for OSCC prognosis.Systematic Review RegistrationInternational Prospective Register of Systematic Reviews (PROSPERO), identifier CRD42020219630.

scholarly journals Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus

BMJ Open ◽  
2018 ◽  
Vol 8 (8) ◽  
pp. e022262 ◽  
Author(s):  
Caroline Perrin ◽  
Lothaire Hounga ◽  
Antoine Geissbuhler
Keyword(s):  
Systematic Review ◽  
Low Income ◽  
Delphi Study ◽  
Risk Of Bias ◽  
Neonatal Outcomes ◽  
Local Context ◽  
Neonatal Health ◽  
Middle Income ◽  
Proxy Indicators ◽  
The Impact

ObjectiveTo identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes.DesignSystematic review and Delphi study.MethodsWe searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists.ResultsWe included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators.ConclusionsThe proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable.PROSPERO registration numberCRD42015027351.

Pregnancy outcomes among women with peptic ulcer disease

2020 ◽  
Vol 48 (3) ◽  
pp. 209-216
Author(s):  
Charlotte Rosen ◽  
Nicholas Czuzoj-Shulman ◽  
Daniel S. Mishkin ◽  
Haim Arie Abenhaim
Keyword(s):  
Peptic Ulcer ◽  
Peptic Ulcer Disease ◽  
The United States ◽  
Neonatal Outcomes ◽  
Intrauterine Fetal Death ◽  
Ulcer Disease ◽  
Increased Risk ◽  
Maternal And Neonatal Outcomes ◽  
The Impact ◽  
In Pregnancy

AbstractBackgroundLittle is known about the impact of peptic ulcer disease (PUD) on pregnancy. Our objective was to evaluate the effect of PUD on pregnancy and newborn outcomes.MethodsA retrospective cohort study was carried out using the Healthcare Cost and Utilization Project (HCUP)-National Inpatient Sample (NIS) from the United States. The cohort consisted of all births that took place from 1999 to 2015. PUD was classified on the basis of the International Classification of Diseases-Ninth Revision (ICD-9) coding. Multivariate logistic regression was used to evaluate the adjusted effect of PUD on maternal and neonatal outcomes.ResultsOf the 13,792,544 births in this cohort, 1005 were to women with PUD (7/100,000 births). Between 1999 and 2015, prevalence of PUD in pregnancy increased from 4/100,000 to 11/100,000, respectively. Women with PUD were more commonly older and more likely to have comorbid illnesses. Women with PUD were at greater risk of preeclampsia [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.67–2.66], preterm premature rupture of membranes (PPROM; OR 2.16, 95% CI 1.30–3.59), cesarean delivery (OR 1.60, 95% CI 1.40–1.82), venous thromboembolism (OR 3.77, 95% CI 2.08–6.85) and maternal death (OR 24.50, 95% CI 10.12–59.32). Births to women with PUD were at increased risk of intrauterine growth restriction (IUGR; OR 1.54, 95% CI 1.11–2.14), preterm birth (OR 1.84, 95% CI 1.54–2.21), intrauterine fetal death (OR 2.18, 95% CI 1.35–3.52) and congenital anomalies (OR 2.69, 95% CI 1.59–4.56).ConclusionThe prevalence of PUD in pregnancy has risen over the last several years. PUD in pregnancy should be considered a high-risk condition associated with important adverse maternal and neonatal outcomes.

scholarly journals Electronic Health Records, Interoperability and Patient Safety in Health Systems of High-income Countries: A Systematic Review Protocol

BMJ Open ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. e044941
Author(s):  
Edmond Li ◽  
Jonathan Clarke ◽  
Ana Luisa Neves ◽  
Hutan Ashrafian ◽  
Ara Darzi
Keyword(s):  
Systematic Review ◽  
Patient Safety ◽  
Electronic Health Records ◽  
Health Systems ◽  
Risk Of Bias ◽  
High Income ◽  
The Body ◽  
Health Records ◽  
Electronic Health ◽  
The Impact

IntroductionThe availability and routine use of electronic health records (EHRs) have become commonplace in healthcare systems of many high-income countries. While there is an ever-growing body of literature pertaining to their use, evidence surrounding the importance of EHR interoperability and its impact on patient safety remains less clear. There is, therefore, a need and opportunity to evaluate the evidence available regarding this relationship so as to better inform health informatics development and policies in the years to come. This systematic review aims to evaluate the impact of EHR interoperability on patient safety in health systems of high-income countries.Methods and analysisA systematic literature review will be conducted via a computerised search through four databases: PubMed, Embase, Health Management Information Consortium and PsycInfo for relevant articles published between 2010 and 2020. Outcomes of interest will include impact on patient safety and the broader effects on health systems. Quality of the randomised quantitative studies will be assessed using Cochrane Risk of Bias Tool. Non-randomised papers will be evaluated with the Risk of Bias In Non-Randomised Studies—of Interventions tool. Drummond’s Checklist will be used for publications pertaining to economic evaluation. The National Institute for Health and Care Excellence quality appraisal checklist will be used to assess qualitative studies. A narrative synthesis will be conducted for included studies, and the body of evidence will be summarised in a summary of findings table.Ethics and disseminationThis review will summarise published studies with non-identifiable data and, thus, does not require ethical approval. Findings will be disseminated through preprints, open access peer-reviewed publications, and conference presentations.PROSPERO registration numberCRD42020209285.

scholarly journals Assessing the Risk of Respiratory-Related Healthcare Visits Associated with Wildfire Smoke Exposure in Children 0–18 Years Old: A Systematic Review

2021 ◽  
Vol 18 (16) ◽  
pp. 8799
Author(s):  
Shelby Henry ◽  
Maria B. Ospina ◽  
Liz Dennett ◽  
Anne Hicks
Keyword(s):  
Systematic Review ◽  
Respiratory Symptoms ◽  
Grey Literature ◽  
Health Assessment ◽  
Smoke Exposure ◽  
Risk Of Bias ◽  
Emergency Department Visits ◽  
Cross Sectional ◽  
Wildfire Smoke ◽  
Increased Risk

Wildfires are increasing in frequency, size, and intensity, and increasingly affect highly populated areas. Wildfire smoke impacts cardiorespiratory health; children are at increased risk due to smaller airways, a higher metabolic rate and ongoing development. The objective of this systematic review was to describe the risk of pediatric respiratory symptoms and healthcare visits following exposure to wildfire smoke. Medical and scientific databases and the grey literature were searched from inception until December 2020. Included studies evaluated pediatric respiratory-related healthcare visits or symptoms associated with wildfire smoke exposure. Prescribed burns, non-respiratory symptoms and non-pediatric studies were excluded. Risk of bias was evaluated using the National Toxicology Program’s Office of Health Assessment and Translation Risk of Bias Rating Tool. Data are presented narratively due to study heterogeneity. Of 2138 results, 1167 titles and abstracts were screened after duplicate removal; 65 full text screens identified 5 pre-post and 11 cross-sectional studies of rural, urban and mixed sites from the USA, Australia, Canada and Spain. There is a significant increase in respiratory emergency department visits and asthma hospitalizations within the first 3 days of exposure to wildfire smoke, particularly in children < 5 years old.

scholarly journals Timing of Pubertal Milestones in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 11 (4) ◽  
pp. 951-959 ◽  
Author(s):  
Jenna L Moodie ◽  
Susan C Campisi ◽  
Kristen Salena ◽  
Megan Wheatley ◽  
Ashley Vandermorris ◽  
...  
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Grey Literature ◽  
Tanner Stage ◽  
High Income ◽  
Age At Menarche ◽  
Middle Income ◽  
Middle Income Countries ◽  
The Impact ◽  
Low And Middle Income

ABSTRACT Despite increasing global attention to adolescent health in low- and middle-income countries (LMICs), limited literature exists on the timing of pubertal development in these settings. This study aimed to determine the age at menarche (AAM) and age of puberty onset [female Tanner Stage Breast 2 (B2) and male Tanner Stage Genital 2 (G2)] among healthy adolescents living in LMICs. It also aimed to explore the impact of nutritional status on pubertal timing in this population. MEDLINE, Embase, Cochrane CENTRAL, Web of Science, Scopus, and grey literature databases were searched. Observational studies and control arms of randomized controlled trials (RCTs) with healthy participants from LMICs born in or after 1998 were included. Pooled estimates with 95% CIs were calculated by random-effects meta-analyses using the DerSimonian and Laird inverse variance method for each pubertal milestone and by BMI category subgroups. Twenty-seven studies were included in the meta-analysis, representing 90,188 adolescents (78.3% female). Pooled mean estimates for AAM for normal, thin, and overweight BMI groupings were 12.3 y (95% CI: 12.1, 12.5), 12.4 y (95% CI: 12.2, 12.6), and 12.1 y (95% CI: 11.7, 12.5), respectively. For Tanner Stage B2, pooled mean age estimates for normal, thin, and overweight BMI groupings were 10.4 y (95% CI: 9.2, 11.6), 10.2 y (95% CI: 9.3, 11.4), and 8.4 y (95% CI: 6.8, 10.0), respectively. Finally, for Tanner Stage G2, pooled mean estimates for normal, thin, and overweight BMI groupings were 11.0 y (95% CI: 10.3, 11.7), 11.3 y (95% CI: 9.8, 12.9), and 10.3 y (95% CI: 10.0, 10.6), respectively. Data on the timing of pubertal milestones has traditionally come from high-income settings. In this systematic review of contemporary data from adolescents in LMICs, AAM, as well as age at pubertal onset, were similar to those reported from high-income settings.

scholarly journals A systematic review of discomfort due to toe or ear clipping in laboratory rodents

2017 ◽  
Vol 51 (6) ◽  
pp. 583-600 ◽  
Author(s):  
Kimberley E. Wever ◽  
Florentine J. Geessink ◽  
Michelle A. E. Brouwer ◽  
Alice Tillema ◽  
Merel Ritskes-Hoitinga
Keyword(s):  
Systematic Review ◽  
Animal Welfare ◽  
Outcome Measures ◽  
Grey Literature ◽  
Sample Size Calculation ◽  
Risk Of Bias ◽  
Individual Identification ◽  
Laboratory Rodents ◽  
Study Results ◽  
The Impact

Toe clipping and ear clipping (also ear notching or ear punching) are frequently used methods for individual identification of laboratory rodents. These procedures potentially cause severe discomfort, which can reduce animal welfare and distort experimental results. However, no systematic summary of the evidence on this topic currently exists. We conducted a systematic review of the evidence for discomfort due to toe or ear clipping in rodents. The review methodology was pre-specified in a registered review protocol. The population, intervention, control, outcome (PICO) question was: In rodents, what is the effect of toe clipping or ear clipping, compared with no clipping or sham clipping, on welfare-related outcomes? Through a systematic search in PubMed, Embase, Web of Science and grey literature, we identified seven studies on the effect of ear clipping on animal welfare, and five such studies on toe clipping. Studies were included in the review if they contained original data from an in vivo experiment in rodents, assessing the effect of toe clipping or ear clipping on a welfare-related outcome. Case studies and studies applying unsuitable co-interventions were excluded. Study quality was appraised using an extended version of SYstematic Review Centre for Laboratory animal Experimentation (SYRCLE)’s risk of bias tool for animal studies. Study characteristics and outcome measures were highly heterogeneous, and there was an unclear or high risk of bias in all studies. We therefore present a narrative synthesis of the evidence identified. None of the studies reported a sample size calculation. Out of over 60 different outcomes, we found evidence of discomfort due to ear clipping in the form of increased respiratory volume, vocalization and blood pressure. For toe clipping, increased vocalization and decreased motor activity in pups were found, as well as long-term effects in the form of reduced grip strength and swimming ability in adults. In conclusion, there is too little evidence to reliably assess discomfort due to toe or ear clipping, and the quality of the available evidence is uncertain. Adequately powered, high-quality studies reporting reliable, relevant outcome measures are needed to accurately assess the impact of these identification techniques. Until more reliable evidence is available, any effect of toe clipping or ear clipping on animal welfare and study results cannot be confirmed or excluded.

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