systematic narrative literature review

About Systematic Reviews

The Difference Between Narrative Review and Systematic Review

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Reviews in scientific research are tools that help synthesize literature on a topic of interest and describe its current state. Different types of reviews are conducted depending on the research question and the scope of the review. A systematic review is one such review that is robust, reproducible, and transparent. It involves collating evidence by using all of the eligible and critically appraised literature available on a certain topic. To know more about how to do a systematic review , you can check out our article at the link. The primary aim of a systematic review is to recommend best practices and inform policy development. Hence, there is a need for high-quality, focused, and precise methods and reporting. For more exploratory research questions, methods such as a scoping review are employed. Be sure you understand the difference between a systematic review and a scoping review , if you don’t, check out the link to learn more.

When the word “review” alone is used to describe a research paper, the first thing that should come to mind is that it is a literature review. Almost every researcher starts off their career with literature reviews. To know the difference between a systematic review and a literature review , read on here.  Traditional literature reviews are also sometimes referred to as narrative reviews since they use narrative analysis to synthesize data. In this article, we will explore the differences between a systematic review and a narrative review, in further detail.

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Narrative Review vs Systematic Review

Both systematic and narrative reviews are classified as secondary research studies since they both use existing primary research studies e.g. case studies. Despite this similarity, there are key differences in their methodology and scope. The major differences between them lie in their objectives, methodology, and application areas.

Differences In Objective

The main objective of a systematic review is to formulate a well-defined research question and use qualitative and quantitative methods to analyze all the available evidence attempting to answer the question. In contrast, narrative reviews can address one or more questions with a much broader scope. The efficacy of narrative reviews is irreplaceable in tracking the development of a scientific principle, or a clinical concept. This ability to conduct a wider exploration could be lost in the restrictive framework of a systematic review.

Differences in Methodology

For systematic reviews, there are guidelines provided by the Cochrane Handbook, ROSES, and the PRISMA statement that can help determine the protocol, and methodology to be used. However, for narrative reviews, such standard guidelines do not exist. Although, there are recommendations available.

Systematic reviews comprise an explicit, transparent, and pre-specified methodology. The methodology followed in a systematic review is as follows,

• Formulating the clinical research question to answer (PICO approach)
• Developing a protocol (with strict inclusion and exclusion criteria for the selection of primary studies)
• Performing a detailed and broad literature search
• Critical appraisal of the selected studies
• Data extraction from the primary studies included in the review
• Data synthesis and analysis using qualitative or quantitative methods [3].
• Reporting and discussing results of data synthesis.
• Developing conclusions based on the findings.

A narrative review on the other hand does not have a strict protocol to be followed. The design of the review depends on its author and the objectives of the review. As yet, there is no consensus on the standard structure of a narrative review. The preferred approach is the IMRAD (Introduction, Methods, Results, and Discussion) [2]. Apart from the author’s preferences, a narrative review structure must respect the journal style and conventions followed in the respective field.

Differences in Application areas

Narrative reviews are aimed at identifying and summarizing what has previously been published. Their general applications include exploring existing debates, the appraisal of previous studies conducted on a certain topic, identifying knowledge gaps, and speculating on the latest interventions available. They are also used to track and report on changes that have occurred in an existing field of research. The main purpose is to deepen the understanding in a certain research area. The results of a systematic review provide the most valid evidence to guide clinical decision-making and inform policy development [1]. They have now become the gold standard in evidence-based medicine [1].

Although both types of reviews come with their own benefits and limitations, researchers should carefully consider the differences between them before making a decision on which review type to use.

• Aromataris E, Pearson A. The systematic review: an overview. AJN. Am J Nurs. 2014;114(3):53–8.
• Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Chiropratic Medicine 2006;5:101–117.
• Linares-Espinós E, Hernández V, Domínguez-Escrig JL, Fernández-Pello S, Hevia V, Mayor J, et al. Metodología de una revisión sistemática. Actas Urol Esp. 2018;42:499–506.

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Annual Review of Psychology

Volume 70, 2019, review article, how to do a systematic review: a best practice guide for conducting and reporting narrative reviews, meta-analyses, and meta-syntheses.

• Andy P. Siddaway 1 , Alex M. Wood 2 , and Larry V. Hedges 3
• View Affiliations Hide Affiliations Affiliations: 1 Behavioural Science Centre, Stirling Management School, University of Stirling, Stirling FK9 4LA, United Kingdom; email: [email protected] 2 Department of Psychological and Behavioural Science, London School of Economics and Political Science, London WC2A 2AE, United Kingdom 3 Department of Statistics, Northwestern University, Evanston, Illinois 60208, USA; email: [email protected]
• Vol. 70:747-770 (Volume publication date January 2019) https://doi.org/10.1146/annurev-psych-010418-102803
• First published as a Review in Advance on August 08, 2018
• Copyright © 2019 by Annual Reviews. All rights reserved

Systematic reviews are characterized by a methodical and replicable methodology and presentation. They involve a comprehensive search to locate all relevant published and unpublished work on a subject; a systematic integration of search results; and a critique of the extent, nature, and quality of evidence in relation to a particular research question. The best reviews synthesize studies to draw broad theoretical conclusions about what a literature means, linking theory to evidence and evidence to theory. This guide describes how to plan, conduct, organize, and present a systematic review of quantitative (meta-analysis) or qualitative (narrative review, meta-synthesis) information. We outline core standards and principles and describe commonly encountered problems. Although this guide targets psychological scientists, its high level of abstraction makes it potentially relevant to any subject area or discipline. We argue that systematic reviews are a key methodology for clarifying whether and how research findings replicate and for explaining possible inconsistencies, and we call for researchers to conduct systematic reviews to help elucidate whether there is a replication crisis.

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• Systematic Review | Definition, Example, & Guide

Systematic Review | Definition, Example & Guide

Published on June 15, 2022 by Shaun Turney . Revised on November 20, 2023.

A systematic review is a type of review that uses repeatable methods to find, select, and synthesize all available evidence. It answers a clearly formulated research question and explicitly states the methods used to arrive at the answer.

They answered the question “What is the effectiveness of probiotics in reducing eczema symptoms and improving quality of life in patients with eczema?”

In this context, a probiotic is a health product that contains live microorganisms and is taken by mouth. Eczema is a common skin condition that causes red, itchy skin.

Table of contents

What is a systematic review, systematic review vs. meta-analysis, systematic review vs. literature review, systematic review vs. scoping review, when to conduct a systematic review, pros and cons of systematic reviews, step-by-step example of a systematic review, other interesting articles, frequently asked questions about systematic reviews.

A review is an overview of the research that’s already been completed on a topic.

What makes a systematic review different from other types of reviews is that the research methods are designed to reduce bias . The methods are repeatable, and the approach is formal and systematic:

• Formulate a research question
• Develop a protocol
• Search for all relevant studies
• Apply the selection criteria
• Extract the data
• Synthesize the data
• Write and publish a report

Although multiple sets of guidelines exist, the Cochrane Handbook for Systematic Reviews is among the most widely used. It provides detailed guidelines on how to complete each step of the systematic review process.

Systematic reviews are most commonly used in medical and public health research, but they can also be found in other disciplines.

Systematic reviews typically answer their research question by synthesizing all available evidence and evaluating the quality of the evidence. Synthesizing means bringing together different information to tell a single, cohesive story. The synthesis can be narrative ( qualitative ), quantitative , or both.

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Systematic reviews often quantitatively synthesize the evidence using a meta-analysis . A meta-analysis is a statistical analysis, not a type of review.

A meta-analysis is a technique to synthesize results from multiple studies. It’s a statistical analysis that combines the results of two or more studies, usually to estimate an effect size .

A literature review is a type of review that uses a less systematic and formal approach than a systematic review. Typically, an expert in a topic will qualitatively summarize and evaluate previous work, without using a formal, explicit method.

Although literature reviews are often less time-consuming and can be insightful or helpful, they have a higher risk of bias and are less transparent than systematic reviews.

Similar to a systematic review, a scoping review is a type of review that tries to minimize bias by using transparent and repeatable methods.

However, a scoping review isn’t a type of systematic review. The most important difference is the goal: rather than answering a specific question, a scoping review explores a topic. The researcher tries to identify the main concepts, theories, and evidence, as well as gaps in the current research.

Sometimes scoping reviews are an exploratory preparation step for a systematic review, and sometimes they are a standalone project.

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A systematic review is a good choice of review if you want to answer a question about the effectiveness of an intervention , such as a medical treatment.

To conduct a systematic review, you’ll need the following:

• A precise question , usually about the effectiveness of an intervention. The question needs to be about a topic that’s previously been studied by multiple researchers. If there’s no previous research, there’s nothing to review.
• If you’re doing a systematic review on your own (e.g., for a research paper or thesis ), you should take appropriate measures to ensure the validity and reliability of your research.
• Access to databases and journal archives. Often, your educational institution provides you with access.
• Time. A professional systematic review is a time-consuming process: it will take the lead author about six months of full-time work. If you’re a student, you should narrow the scope of your systematic review and stick to a tight schedule.
• Bibliographic, word-processing, spreadsheet, and statistical software . For example, you could use EndNote, Microsoft Word, Excel, and SPSS.

A systematic review has many pros .

• They minimize research bias by considering all available evidence and evaluating each study for bias.
• Their methods are transparent , so they can be scrutinized by others.
• They’re thorough : they summarize all available evidence.
• They can be replicated and updated by others.

Systematic reviews also have a few cons .

• They’re time-consuming .
• They’re narrow in scope : they only answer the precise research question.

The 7 steps for conducting a systematic review are explained with an example.

Step 1: Formulate a research question

Formulating the research question is probably the most important step of a systematic review. A clear research question will:

• Allow you to more effectively communicate your research to other researchers and practitioners
• Guide your decisions as you plan and conduct your systematic review

A good research question for a systematic review has four components, which you can remember with the acronym PICO :

• Population(s) or problem(s)
• Intervention(s)
• Comparison(s)

You can rearrange these four components to write your research question:

• What is the effectiveness of I versus C for O in P ?

Sometimes, you may want to include a fifth component, the type of study design . In this case, the acronym is PICOT .

• Type of study design(s)
• The population of patients with eczema
• The intervention of probiotics
• In comparison to no treatment, placebo , or non-probiotic treatment
• The outcome of changes in participant-, parent-, and doctor-rated symptoms of eczema and quality of life
• Randomized control trials, a type of study design

Their research question was:

• What is the effectiveness of probiotics versus no treatment, a placebo, or a non-probiotic treatment for reducing eczema symptoms and improving quality of life in patients with eczema?

Step 2: Develop a protocol

A protocol is a document that contains your research plan for the systematic review. This is an important step because having a plan allows you to work more efficiently and reduces bias.

Your protocol should include the following components:

• Background information : Provide the context of the research question, including why it’s important.
• Research objective (s) : Rephrase your research question as an objective.
• Selection criteria: State how you’ll decide which studies to include or exclude from your review.
• Search strategy: Discuss your plan for finding studies.
• Analysis: Explain what information you’ll collect from the studies and how you’ll synthesize the data.

If you’re a professional seeking to publish your review, it’s a good idea to bring together an advisory committee . This is a group of about six people who have experience in the topic you’re researching. They can help you make decisions about your protocol.

It’s highly recommended to register your protocol. Registering your protocol means submitting it to a database such as PROSPERO or ClinicalTrials.gov .

Step 3: Search for all relevant studies

Searching for relevant studies is the most time-consuming step of a systematic review.

To reduce bias, it’s important to search for relevant studies very thoroughly. Your strategy will depend on your field and your research question, but sources generally fall into these four categories:

• Databases: Search multiple databases of peer-reviewed literature, such as PubMed or Scopus . Think carefully about how to phrase your search terms and include multiple synonyms of each word. Use Boolean operators if relevant.
• Handsearching: In addition to searching the primary sources using databases, you’ll also need to search manually. One strategy is to scan relevant journals or conference proceedings. Another strategy is to scan the reference lists of relevant studies.
• Gray literature: Gray literature includes documents produced by governments, universities, and other institutions that aren’t published by traditional publishers. Graduate student theses are an important type of gray literature, which you can search using the Networked Digital Library of Theses and Dissertations (NDLTD) . In medicine, clinical trial registries are another important type of gray literature.
• Experts: Contact experts in the field to ask if they have unpublished studies that should be included in your review.

At this stage of your review, you won’t read the articles yet. Simply save any potentially relevant citations using bibliographic software, such as Scribbr’s APA or MLA Generator .

• Databases: EMBASE, PsycINFO, AMED, LILACS, and ISI Web of Science
• Handsearch: Conference proceedings and reference lists of articles
• Gray literature: The Cochrane Library, the metaRegister of Controlled Trials, and the Ongoing Skin Trials Register
• Experts: Authors of unpublished registered trials, pharmaceutical companies, and manufacturers of probiotics

Step 4: Apply the selection criteria

Applying the selection criteria is a three-person job. Two of you will independently read the studies and decide which to include in your review based on the selection criteria you established in your protocol . The third person’s job is to break any ties.

To increase inter-rater reliability , ensure that everyone thoroughly understands the selection criteria before you begin.

If you’re writing a systematic review as a student for an assignment, you might not have a team. In this case, you’ll have to apply the selection criteria on your own; you can mention this as a limitation in your paper’s discussion.

You should apply the selection criteria in two phases:

• Based on the titles and abstracts : Decide whether each article potentially meets the selection criteria based on the information provided in the abstracts.
• Based on the full texts: Download the articles that weren’t excluded during the first phase. If an article isn’t available online or through your library, you may need to contact the authors to ask for a copy. Read the articles and decide which articles meet the selection criteria.

It’s very important to keep a meticulous record of why you included or excluded each article. When the selection process is complete, you can summarize what you did using a PRISMA flow diagram .

Next, Boyle and colleagues found the full texts for each of the remaining studies. Boyle and Tang read through the articles to decide if any more studies needed to be excluded based on the selection criteria.

When Boyle and Tang disagreed about whether a study should be excluded, they discussed it with Varigos until the three researchers came to an agreement.

Step 5: Extract the data

Extracting the data means collecting information from the selected studies in a systematic way. There are two types of information you need to collect from each study:

• Information about the study’s methods and results . The exact information will depend on your research question, but it might include the year, study design , sample size, context, research findings , and conclusions. If any data are missing, you’ll need to contact the study’s authors.
• Your judgment of the quality of the evidence, including risk of bias .

You should collect this information using forms. You can find sample forms in The Registry of Methods and Tools for Evidence-Informed Decision Making and the Grading of Recommendations, Assessment, Development and Evaluations Working Group .

Extracting the data is also a three-person job. Two people should do this step independently, and the third person will resolve any disagreements.

They also collected data about possible sources of bias, such as how the study participants were randomized into the control and treatment groups.

Step 6: Synthesize the data

Synthesizing the data means bringing together the information you collected into a single, cohesive story. There are two main approaches to synthesizing the data:

• Narrative ( qualitative ): Summarize the information in words. You’ll need to discuss the studies and assess their overall quality.
• Quantitative : Use statistical methods to summarize and compare data from different studies. The most common quantitative approach is a meta-analysis , which allows you to combine results from multiple studies into a summary result.

Generally, you should use both approaches together whenever possible. If you don’t have enough data, or the data from different studies aren’t comparable, then you can take just a narrative approach. However, you should justify why a quantitative approach wasn’t possible.

Boyle and colleagues also divided the studies into subgroups, such as studies about babies, children, and adults, and analyzed the effect sizes within each group.

Step 7: Write and publish a report

The purpose of writing a systematic review article is to share the answer to your research question and explain how you arrived at this answer.

Your article should include the following sections:

• Abstract : A summary of the review
• Introduction : Including the rationale and objectives
• Methods : Including the selection criteria, search method, data extraction method, and synthesis method
• Results : Including results of the search and selection process, study characteristics, risk of bias in the studies, and synthesis results
• Discussion : Including interpretation of the results and limitations of the review
• Conclusion : The answer to your research question and implications for practice, policy, or research

To verify that your report includes everything it needs, you can use the PRISMA checklist .

Once your report is written, you can publish it in a systematic review database, such as the Cochrane Database of Systematic Reviews , and/or in a peer-reviewed journal.

In their report, Boyle and colleagues concluded that probiotics cannot be recommended for reducing eczema symptoms or improving quality of life in patients with eczema. Note Generative AI tools like ChatGPT can be useful at various stages of the writing and research process and can help you to write your systematic review. However, we strongly advise against trying to pass AI-generated text off as your own work.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Student’s  t -distribution
• Normal distribution
• Null and Alternative Hypotheses
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Data cleansing
• Reproducibility vs Replicability
• Peer review
• Prospective cohort study

Research bias

• Implicit bias
• Cognitive bias
• Placebo effect
• Hawthorne effect
• Hindsight bias
• Affect heuristic
• Social desirability bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

A systematic review is secondary research because it uses existing research. You don’t collect new data yourself.

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Systematic Reviews

• Types of Literature Reviews

What Makes a Systematic Review Different from Other Types of Reviews?

• Planning Your Systematic Review
• Database Searching
• Creating the Search
• Search Filters and Hedges
• Grey Literature
• Managing and Appraising Results
• Further Resources

Reproduced from Grant, M. J. and Booth, A. (2009), A typology of reviews: an analysis of 14 review types and associated methodologies. Health Information & Libraries Journal, 26: 91–108. doi:10.1111/j.1471-1842.2009.00848.x

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What is a Narrative Literature Review

Narrative review process.

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A narrative literature review is an integrated analysis of the existing literature used to summarize a body of literature, draw conclusions about a topic, and identify research gaps.  By understanding the current state of the literature, you can show how new research fits into the larger research landscape.  

A narrative literature review is NOT:  

• Just a summary of sources
• A review of  everything  written on a particular topic
• A research paper arguing for a specific viewpoint - a lit review should avoid bias and highlight areas of disagreements
• A systematic review

Purposes of a narrative literature review:

• Explain the background of research on a topic
• Demonstrate the importance of a topic
• Suggest new areas of research
• Identify major themes, concepts, and researchers in a topic
• Identify critical gaps, points of disagreement, or flawed approaches for a research topic

1. Choose a topic & create a research question

• Use a narrow research question for more focused search results
• Use a question framework such as PICO to develop your research question
• Breakdown your research question into searchable concepts and keywords
• Research skills tutorials : How to choose a topic
• Ask a librarian for assistance

2. Select the sources for searching & develop a search strategy

• Identify databases to search for articles relevant to your topic
• Ask a librarian for recommended databases
• Develop a comprehensive search strategy using keywords, controlled vocabularies and Boolean operators
• Research skills tutorials: How to develop a search strategy

3. Conduct the search

• Use a consistent search strategy between databases
• Document the strategies employed to keep track of which are more successful
• Use a citation manager to organize your search results
• Ask a librarian for help or refer to the Research skills tutorials

4. Review the references

• Review the search results for relevant articles that answer your research question
• Review the bibliography of all relevant articles for additional sources
• Consider developing subfolders in the citation manager to organize sources by topic
• Use interlibrary loan for any articles without full text access

5. Summarize findings

• Synthesize the findings from the articles into a final paper
• The final paper should cover the themes identified in the research, explain any conflicts or disagreements, identify research gaps and potential future research areas, explain how this narrative review fits within the existing research and answer the research question . 

For additional information : 

Hempel. (2020). Conducting your literature review. American Psychological Association .

• Buchholz, & Dickins, K. A. (2023). Literature review and synthesis : a guide for nurses and other healthcare professionals . Springer Publishing Company, LLC.
• Coughlan, Michael, and Patricia Cronin.  Doing a Literature Review in Nursing, Health and Social Care . 2nd edition., SAGE, 2017.
• Nundy, S., Kakar, A., Bhutta, Z.A. (2022). How to Do a Review of the Literature? . In: How to Practice Academic Medicine and Publish from Developing Countries?. Springer, Singapore.  https://doi.org/10.1007/978-981-16-5248-6_18
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How to Conduct a Systematic Review: A Narrative Literature Review

Affiliations.

• 1 Psychiatry, Mount Sinai Chicago.
• 2 Psychiatry, KVC Prairie Ridge Hospital.
• 3 Department of Psychiatry, Bronx Lebanon Hospital Icahn School of Medicine at Mount Sinai, Bronx, NY.
• 4 Psychiatry, Suny Upstate Medical University, Syracuse, NY.
• PMID: 27924252
• PMCID: PMC5137994
• DOI: 10.7759/cureus.864

Systematic reviews are ranked very high in research and are considered the most valid form of medical evidence. They provide a complete summary of the current literature relevant to a research question and can be of immense use to medical professionals. Our goal with this paper is to conduct a narrative review of the literature about systematic reviews and outline the essential elements of a systematic review along with the limitations of such a review.

Keywords: meta-analysis; narrative literature review; prisma checklist; systematic reviews.

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Conflict of interest statement

The authors have declared that no competing interests exist.

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The Literature Review

• Narrative Review
• Systematic Review
• Scoping Review

Writing your Literature Review

Once you have developed a body of literature to draw from, you can begin writing your literature review. There is no set format for a narrative literature review, and it can vary across fields. However, you will typically see the following elements:

• Sections you might see in a typical research paper including Introduction, background, (possibly) methods, Main/Body, and Conclusion
• Some logical structure of sections (i.e. by time period, by areas of the field, by approach of article etc.)
• Analysis of the relative value of contributions across different sources
• section on areas for further development or further research suggestions

Need writing help? Head to the Graduate Writing Center for help with your literature review!

What is a narrative literature review.

Narrative Literature Reviews are works in which the author reviews a body of literature on a topic and synthesizes the information into a clear narrative that demonstrates the general context of the field . They can also be called a Traditional Literature Review. Compared to Systematic and Scoping reviews, Narrative literature reviews do not use an established method or protocol, but rather take a broad, unspecified approach to what sources are selected to represent the field. Typically narrative literature reviews use peer-reviewed journal articles as their source of scholarship to review, but this might vary based on the individual assignment or review you are conducting. Below are some key elements of a Narrative Lit Review:

• Places the topic within an existing context
• Describes relationships between and around sources cited
• Typically includes critical analysis
• Organizes ideas by theme and/or relevance
• Demonstrates author's knowledge

Staying Organized

Use a reference management software.

Reference Managers are tools that can help you keep track of the scholarly articles you are collecting and reading for your literature review. They can also help you generate citations and bibliographies within your writing. Use the Reference Management Software Guide linked below to learn more about how to get started with one.

Reference Management Research Guide

Keep your search terms in a document or spreadsheet.

Although in Narrative Lit Reviews you are not required to keep detailed reports on your search strategy, it is still important to keep track of the terms you are searching and include information about them to be sure you are casting the widest net possible. Organize your search terms in a way that makes sense to you. As an example, you could keep tabs on:

• Broader terms
• Narrower terms
• Filters that work / filters that don't
• Search strings you can copy and paste directly into search engines and databases

The Research Process

Start with an exploratory/preliminary search.

Use a couple key terms about your topic to try searching without keeping track to see whats out there. This is also a good time to search for already existing reviews on your topic and see if something similar has already been completed. After doing a preliminary search in your general topic, you can begin thinking about your specific research question.

Drafting a Research Question

To start drafting your research question, it may be helpful to consider how your topic fits within a couple of different broad overlapping fields of research. For example, the research question illustrated below asks about identity perspectives from Asian American students in high schools. Each individual topic in this question is its own circle, and the intersection of these circles is the main focus of the literature review. There could be more circles added for each new dimension I would like to add to my research question whether it be a location (i.e. New York City), a clarifying detail (i.e. generational identity), or other form of context.

As you are searching, use the different dimensions of your research question to find individual areas of research, For example, I may want to look at the literature around just the identity of Asian American students, or maybe just look at identity formation in High School. Then, in my literature review, I can synthesize these various fields to explain the different backgrounds and how they all converge around my central topic, the middle of the diagram.

Image from Tips and Strategies for Writing a Dissertation Proposal on Ashe Grads blog.

Conducting your Search

Once you have your research question and key terms from that research question, you can start your formal searching process. In narrative literature reviews it is less important to be comprehensive in checking every possibly relevant result, but more focused on making sure the results you are getting are representative of the fields you are analyzing.

Books in the Libraries to Help with you Narrative Lit Review

Literature Review and Research Design: A Guide to Effective Research Practice

They Say / I Say: The Moves That Matter in Academic Writing, with Readings

The Literature Review: Six Steps to Success

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Why Systematic Review rather than Narrative Review?

1 Department of Psychiatry, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea.

2 Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.

Sir: Recently review articles including systematic and narrative reviews have been significantly increasing in most psychiatric journals in the world alongside "Psychiatry Investigation (PI)". Since the launch of the "PI" at March 2004, there have been a number of review articles; indeed 54 papers were published as format of regular review papers or special articles in the "PI" from 2004 to 2014. However, of the 54 papers, only one review paper partially met the contemporary criteria of systematic review, otherwise were written as a format of narrative review for diverse topics such as epidemiological findings, concept and hypothesis of certain psychiatric disease, current understandings on certain disease, psychopharmacology, and treatment guidelines. This is unsatisfactory when reflecting the fact that systematic reviews have been rapidly and increasingly replacing traditional narrative (explicit) reviews as a standard platform of providing and updating currently available research findings as confident evidence. Most journals have started to change their policy in acceptance of review papers, they have been giving a priority to systematic review only as a regular review article and excluding narrative reviews, to provide the best evidence for all basic and clinical questions and further hypotheses. Of course, there should be Pros and Cons between systematic and narrative reviews; for instance, the major advantage of systematic reviews is that they are based on the findings of comprehensive and systematic literature searches in all available resources, with minimization of selection bias avoiding subjective selection bias, while narrative reviews, if they can be written experts in certain research area, can provide experts' intuitive, experiential and explicit perspectives in focused topics. 1

The absence of objective and systematic selection criteria in review method substantially results in a number of methodological shortcomings leading to clear bias of the author's interpretation and conclusions. Such differences are quite clear when referring to the review paper of Drs. Cipriani and Geddess, 2 where 7 narrative and 2 systematic reviews were compared and found that narrative reviews including same studies reached different conclusions against each other, indicating the difficulties of appraising and using narrative reviews to have conclusion on specific topic. Hence, narrative reviews may be evidence-based, but they are not truly useful as scientific evidence.

Even in reported as systematic review, it is also frequent that those papers are not true systematic review or they have certain bias in data search method and conclusions. For instance, due to lack of satisfactory pharmacotherapy for post-traumatic stress disorder (PTSD) and its frequent comorbid psychotic symptoms, a possible role of atypical antipsychotics (AAs) for PTSD has been consistently proposed. 3 In fact various AAs have demonstrated positive antidepressant and ant-anxiety effects in a number of small-scale, open-label studies (OLSs) or randomised, controlled clinical trials (RCTs). 4 In this context, a recent systematic review (4 olanzapine, 7 risperidone and 1 ziprasidone trials) by Wang et al. 5 has also suggested the positive prospect on the role of AAs for the treatment of PTSD; however, the review has a number of faulty and wrong selection of clinical trials data and interpretation of studies included in their review. The authors neglected wide range of clinical information such as patient characteristics (particularly, initial severity of disease), comorbidity issues, trial duration issues, trial design characteristics, primary endpoint difference, study sponsoring; that is, heterogeneity of clinical trials would substantially influence the quality and clinical implications of the study results. The basic problem of non-systematic search of data is that beneath the shining surface, it seems that the authors utilizing it often misunderstand the true value, underpinning meanings and correct nature of the data, or their true limitations and strengths, and they often go too far or short with the interpretation. 6 Indeed, the main conclusion of a narrative review may often be based on evidence, but such reviews themselves are not rigorous evidence since such reviews are too selective and thus little good quality information could be included. 2 In addition, I found one olanzapine trial was OLS but they included the study in the result (this is a mixture of data yielding a huge heterogeneity). 7 This clearly indicates they were not consistent in collection of the study for their review. Olanzapine has a lot of OLSs beyond the study, likewise other AAs also have a plenty of OLSs. Regarding an inclusion of OLSs for systematic reviews, an interesting metaanalyses are available on the role of olanzapine for adolescent bipolar disorder 8 and aripiprazole augmentation therapy 9 for depression. According to Pae et al. 9 the treatment effects were not significantly different between OLSs and RCTs in efficacy of aripiprazole augmentation for treating depression; the pooled effect size was statistically significant in both study design and also in a meta-analysis regression, study design was not a significant predictor of mean change in the primary endpoint, clearly indicating that OLSs are useful predictors of the potential safety and efficacy of a given compound. This finding was also supported by another meta-analysis. 8 Hence, the value of OLSs should be carefully re-evaluated for practical information source, development of new drugs or acquisition for new indications, and should not be neglected for data research, especially for narrative reviews. Furthermore, Dr. Wang et al. 5 did not include one important RCT; quetiapine has a RCT for PTSD, 10 which was presented in the thematic meeting of the CINP 2009. A 12-week RCT was conducted for 80 PTSD patients. Finally, Wang et al. 5 surprisingly did not present any effect size (ES) for studies, although such calculations are conventionally included in the review papers. Another critical example is Hickie and Rogers's review, 11 according to their article, agomelatine was efficacious antidepressant; however, subsequent researchers who avoided selection bias have clearly demonstrated its weak efficacy as an antidepressant. 12 Therefore, reflecting two review papers, 5 , 11 we can realize that inappropriate aggregation of studies may definitely bias conclusion. Hence, entire published and unpublished dataset should be considered in systematic review, especially, when clinical data is not sufficient and the medication has no officially approved indication by the regulatory agency.

To summarize, systematic review should include followings respecting recommendation from currently available systematic review guidelines (e.g., The Cochrane Library www.cochrane.org ); clear basic and clinical hypothesis, predefined protocol, designation of search resources, through data search (regardless of publication), transparent selection criteria, qualification of studies selected, synthesis of study data and information, relevant summary and conclusion. Table 1 compares systematic and narrative reviews ( Table 1 ). Since the evidence-based medicine is the current trend and also mandatory for establishment of heath policy, the PI should also turn to encourage submission of systematic reviews rather than narrative reviews.

Acknowledgments

This work was supported by a grant of the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (HI12C0003).

Something old, new, and borrowed . Rise of the systematic reviews

• Published: 24 August 2024

Cite this article

• Gheorghe-Gavrilă Hognogi 1 &
• Ana-Maria Pop   ORCID: orcid.org/0000-0001-9958-1391 1  

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Systematic reviews and other types of literature reviews are more prevalent in clinical medicine than in other fields. The recurring need for improvement and updates in these disciplines has led to the Living Systematic Review (LSR) concept to enhance the effectiveness of scientific synthesis efforts. While LSR was introduced in 2014, its adoption outside clinical medicine has been limited, with one exception. However, it is anticipated that this will change in the future, prompting a detailed exploration of four key dimensions for LSR development, regardless of the scientific domain. These dimensions include (a) compliance with FAIR principles, (b) interactivity to facilitate easier access to scientific knowledge, (c) public participation for a more comprehensive review, and (d) extending the scope beyond mere updates to living systematic reviews. Each field needs to establish clear guidelines for drafting literature reviews as independent studies, with discussions centring around the central theme of the Living Systematic Review.

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Aguilar Gómez, F., & Bernal, I. (2023). FAIR EVA: Bringing institutional multidisciplinary repositories into the FAIR picture. Scientific Data . https://doi.org/10.1038/s41597-023-02652-8

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Occupational, environmental, and toxicological health risks of mining metals for lithium-ion batteries: a narrative review of the Pubmed database

• Connor W. Brown 1 , 2 ,
• Charlotte E. Goldfine 1 , 2 ,
• Lao-Tzu Allan-Blitz 3 &
• Timothy B. Erickson 1 , 2 , 4 , 5  

Journal of Occupational Medicine and Toxicology volume  19 , Article number:  35 ( 2024 ) Cite this article

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Metrics details

The global market for lithium-ion batteries (LIBs) is growing exponentially, resulting in an increase in mining activities for the metals needed for manufacturing LIBs. Cobalt, lithium, manganese, and nickel are four of the metals most used in the construction of LIBs, and each has known toxicological risks associated with exposure. Mining for these metals poses potential human health risks via occupational and environmental exposures; however, there is a paucity of data surrounding the risks of increasing mining activity. The objective of this review was to characterize these risks.

We conducted a review of the literature via a systematic search of the PubMed database on the health effects of mining for cobalt, lithium, manganese, and nickel. We included articles that (1) reported original research, (2) reported outcomes directly related to human health, (3) assessed exposure to mining for cobalt, lithium, manganese, or nickel, and (4) had an available English translation. We excluded all other articles. Our search identified 183 relevant articles.

Toxicological hazards were reported in 110 studies. Exposure to cobalt and nickel mining were most associated with respiratory toxicity, while exposure to manganese mining was most associated with neurologic toxicity. Notably, no articles were identified that assessed lithium toxicity associated with mining exposure. Traumatic hazards were reported in six studies. Three articles reported infectious disease hazards, while six studies reported effects on mental health. Several studies reported increased health risks in children compared to adults.

Conclusions

The results of this review suggest that occupational and environmental exposure to mining metals used in LIBs presents significant risks to human health that result in both acute and chronic toxicities. Further research is needed to better characterize these risks, particularly regarding lithium mining.

Introduction

In recent years, the global market for lithium-ion batteries (LIBs) has grown exponentially in response to increasing economic and political interests in energy alternatives to fossil fuels [ 1 ]. LIBs are rechargeable batteries that are used in a multitude of products including electric motor vehicles, smartphones, laptops, power tools, and energy storage systems. Rapid economic growth is projected to continue, with the global LIB market currently valued around $54 billion and anticipated to increase by 20–30% annually until 2030 [ 2 , 3 ]. Consequently, there has been a dramatic increase in efforts to mine the metals used to manufacture LIBs [ 4 ].

In addition to the titular lithium, LIBs contain transition metals that are typically used to construct the cathode of the battery system [ 5 ]. The anode is generally constructed of graphite. Cobalt, manganese, nickel, and lithium are four of the most heavily mined metals for LIB production [ 5 ]. Large quantities of these metals are often required for manufacturing. A single car battery, for example, can contain up to 20 kg of cobalt [ 6 ]. Significant expansion of mining activities for these metals is occurring on a global scale and poses potential health risks to mine workers and neighboring communities via occupational and environmental exposures [ 7 ]. Despite this, there is a paucity of data surrounding the risks of such increased mining activity.

Each of the metals in this study has well-documented toxicity. The respiratory effects of cobalt have been described for centuries, since German miners discovered that toxic gases were released during the smelting process [ 8 ]. The miners believed the metal was bewitched by devilish spirits and nicknamed the metal “kobold” or “goblin of the mines”. Cobalt inhalation can cause direct respiratory toxicity, including hard metal lung disease, while systemic cobalt toxicity can cause cardiomyopathy, thyroid dysfunction, neurologic dysfunction, and aseptic lymphocyte-dominated vasculitis-associated lesions [ 9 ]. The neurotoxicity of manganese has been extensively documented and was described as early as the nineteenth century. Occupational and environmental exposures have been associated with numerous neurologic and psychiatric manifestations including Parkinsonism, motor deficits, cognitive impairment, and psychosis [ 10 ]. Nickel is a known genotoxin and carcinogen [ 11 ]. Occupational exposure primarily occurs through inhalation; however, toxicity can also develop via ingestion or skin absorption [ 12 ]. Lithium is nephrotoxic and thyrotoxic, can cause neuropsychiatric symptoms, and is a teratogen [ 13 , 14 ].

In this study, we conducted a narrative review of the occupational, environmental, and toxicological hazards associated with mining exposure to cobalt, lithium, manganese, and nickel to better characterize the risks associated with growing demand for LIBs.

We systematically searched the PubMed database using the pre-defined search term “((cobalt) OR (lithium) OR (manganese) OR (nickel)) AND ((health) OR (disease) OR (injury)) AND ((mine) OR (mining))” on January 24, 2024. We analyzed the results of the search in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 15 ]. We did not apply any other restrictions to the initial search. We imported all studies resulting from this search into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) for review. A minimum of two authors independently screened titles and abstracts for inclusion, with discrepancies resolved by a third author. We then reviewed full texts for all articles included in the screening.

We included studies if they (1) reported original research, (2) reported outcomes directly related to human health, (3) assessed exposure to mining for cobalt, lithium, manganese, or nickel, and (4) had an English translation that could be obtained electronically either via internet search or inter-library loan. We excluded studies that did not meet all inclusion criteria. Following review, we extracted the following variables from the articles meeting inclusion criteria, as applicable: date of publication, country or countries in which the study was conducted, study design, which of the four previously chosen metals (cobalt, lithium, manganese, or nickel) were included, report of human health or toxicological hazards, report of traumatic hazards, report of non-traumatic occupational hazards, and calculated health risk based on environmental data.

The initial search term yielded 649 unique articles, of which 183 met inclusion criteria (Fig. 1 ). The final set of included articles contained 22 cohort studies, 3 case–control studies, 91 cross-sectional studies, and 4 case reports or series, in addition to 2 in vitro studies and 61 articles that calculated human health risk based on environmental sampling without including human participants. Included articles were published between 1955 and 2023 and came from 47 countries (Fig. 2 ). The countries that appeared most frequently were China (30 articles), the Democratic Republic of the Congo (12), Mexico (11), and South Africa (11). Manganese appeared in the most articles, while lithium appeared in the least. Many articles discussed more than one of the study metals.

PRISMA analysis of articles

Country locations of included studies

Toxicological hazards: cobalt mining

Toxicity associated with exposure to cobalt mining was assessed in 28 articles [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. Respiratory disease was the most common category of toxicological hazard reported in papers discussing cobalt exposure. Respiratory health problems described in populations exposed to cobalt mining included upper and lower respiratory infections, lung cancer, hard metal lung disease, pneumoconiosis, chronic bronchitis, and chronic mountain or altitude sickness [ 24 , 25 , 29 , 39 , 40 , 42 ]. A case report discussed a patient in whom hard metal lung disease re-occurred even after a lung transplant [ 42 ]. Three studies conducted in areas of the Democratic Republic of the Congo known for cobalt mining described birth defects in children whose parents held mining-related jobs [ 26 , 27 , 43 ]. Several studies reported increased in vivo levels of heavy metals in populations exposed to mining compared to reference values or control groups [ 17 , 18 , 20 , 22 , 32 , 36 , 37 ]. Levels as much as 40 times greater than reference values were reported [ 17 ]. One such study also found that exposed children had higher urine levels of DNA oxidative damage markers, a difference that was not observed in adult participants [ 18 ]. In pregnant women exposed to cobalt mining, elevated maternal blood levels were associated with fetal levels, suggesting cross-placental transfer [ 28 ]. Cobalt mining work was also reported to be associated with male sexual dysfunction and decreased testosterone [ 33 , 34 ].

Toxicological hazards: manganese mining

Toxicity associated with exposure to manganese mining was assessed in 73 papers, more than any other metal in this study [ 16 , 17 , 18 , 19 , 20 , 21 , 23 , 31 , 32 , 35 , 37 , 38 , 41 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 ]. Neurologic toxicity was the most cited category of disease, with studies reporting cognitive impairment, muscle weakness, gait instability, tremors, impaired motor control, hearing loss, memory problems, and Parkinsonism [ 46 , 58 , 61 , 66 , 68 , 71 , 89 , 90 , 91 , 92 ]. Psychiatric symptoms were described in multiple studies including higher scores on psychiatric distress assessments, emotional instability, disorganization, manic symptoms, and hallucinations [ 44 , 89 , 92 ]. Increased iron deficiency among manganese miners was reported in one study and rates of iron deficiency improved after reconstitution of drinking water [ 48 ]. Manganese mining exposure was also associated with prostate cancer, prolactin levels, and sexual dysfunction [ 81 , 89 , 92 , 96 , 99 ]. Respiratory disease was less commonly reported in papers discussing manganese mining than for cobalt or nickel, although studies did report associations between exposure to mining activities involving manganese and worse respiratory function metrics, pneumoconiosis, respiratory infections, and development of restrictive lung disease [ 47 , 70 , 89 , 94 ]. Cytotoxic and immunotoxic effects in mining-exposed populations were described in multiple studies, including T-cell receptor mutations, and lower levels of CD3 + and CD4 + lymphocytes [ 55 , 56 ]. In one in vitro study, exposure to manganese oxides obtained from mine dust was associated with DNA damage [ 45 ]. Multiple studies assessed risks in children. Studies reported that the concentration of manganese in the hair of children living near mines was elevated compared to controls and associated with worse performance on visuospatial and verbal learning and memory testing [ 63 , 66 ]. Manganese in umbilical cord blood was reported to be associated with birth defects in a case–control study while cognitive and motor function in children was negatively associated with maternal levels of manganese [ 43 , 54 ]. A study comparing children living in a manganese mining area to a control group found decreased performance on IQ testing [ 88 ]. Children exposed to manganese mining were also reported to have higher incidence of skeletal deformities [ 62 ]. Increased in vivo levels of manganese associated with mining exposure were also described in several studies [ 16 , 20 , 35 , 38 , 47 , 48 , 65 , 66 , 69 , 84 , 88 , 93 ].

Toxicological hazards: nickel mining

Toxicity associated with exposure to nickel mining was assessed in 56 papers [ 17 , 20 , 21 , 23 , 31 , 32 , 35 , 37 , 38 , 39 , 41 , 45 , 55 , 56 , 60 , 67 , 77 , 83 , 87 , 97 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 ]. Like cobalt, respiratory toxicity was the most common type of pathology reported. Respiratory manifestations associated with nickel mining included lung cancer, chronic bronchitis, respiratory infections, and nasal obstruction/rhinitis [ 39 , 109 , 110 , 111 , 118 , 119 , 123 , 128 , 133 ]. Increased mortality due to other types of cancer and cardiovascular disease was also reported in populations exposed to nickel mining and refining. 120,125  One study found that 75% of participants living in a nickel mining region who used dug wells as a water source had elevated urinary creatinine [ 131 ]. Mine workers exposed to nickel were found to have higher urinary nickel and cystatin C levels than steel plant workers [ 135 ]. A large cross-sectional study found increased diabetes in nickel miners compared to office workers [ 136 ]. Constitutional growth delay was reported at several times greater prevalence in a population exposed to manganese and nickel pollution relative to a control population [ 102 ]. Studies also reported elevated markers of DNA damage, inflammatory markers, and auto-antibodies among populations exposed to nickel mining [ 105 , 108 , 112 , 122 ]. DNA damage was also shown to be induced by in vitro exposure to mine evaporite [ 124 ]. Populations exposed to mining were found to have elevated nickel levels in blood, urine, hair, and breast milk compared to reference values or control groups [ 20 , 21 , 22 , 31 , 32 , 37 , 41 , 60 , 77 , 97 ]. Elevated physiologic levels were observed multiple decades after the cessation of mining activity, indicating the longevity of environmental contamination [ 107 ].

Toxicological hazards: lithium mining

No studies identified in this review described toxicological effects associated with lithium exposure due to mining.

Infectious disease hazards

Infectious disease hazards were described in three articles. Two studies reported outcomes from a Histoplasmosis outbreak among manganese mine workers in Guyana in 2019 [ 98 , 100 ]. The third study was a survey conducted in a South African mining community, in which miners expressed concerns regarding high rates of communicable diseases, including tuberculosis and HIV. The miners cited residential overcrowding, inadequate toilet facilities, and prostitution as contributing factors [ 86 ].

Traumatic/physical hazards

Six articles were found that reported traumatic injuries or fatalities associated with mine work. Studies reported a variety of traumatic hazards, including falls, cave-ins, explosions, and mine fires [ 95 , 117 , 138 ] These hazards were reported to be associated with the quality of working conditions and factors such as poor visibility, extreme noise, and inadequate ventilation. Injuries related to machinery were cited in multiple studies and attributed to both inadequate training and malfunctioning or outdated equipment. Interviews with manganese miners reported insufficient personal protective equipment as a hazard and described a culture in which reluctance to work in unsafe conditions is penalized by supervisors, potentially resulting in job loss [ 86 ]. Two large retrospective studies of mortality among Canadian nickel workers found significantly increased mortality due to injury or violence compared to expected values [ 104 , 127 ]. Although these studies did not differentiate between fatal injuries that occurred in occupational versus non-occupational settings, injury mortality was particularly increased among underground miners.

Psychiatric/mental health hazards

Psychiatric illness and effects on mental health were reported in six papers. Chronic stress was described in multiple papers and occupational stress was associated with worse perceived quality of life [ 86 , 121 ]. Higher scores on a standardized survey of psychological distress were recorded among participants residing in areas with increased levels of metal contamination [ 44 ]. An early study of mine workers with manganese poisoning described multiple psychiatric symptoms including mood instability and psychosis [ 92 ]. A survey of over 1000 nickel miners in China reported symptoms of burnout in more than 80% of participants [ 130 ]. Increased mortality due to suicide was also reported among miners [ 104 ].

Environmental sampling

A total of 61 studies measured levels of metals in environmental samples from areas contaminated by mining activity and calculated health risk via pre-determined acceptable values [ 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167 , 168 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 , 184 , 185 , 186 , 187 , 188 , 189 , 190 , 191 , 192 , 193 , 194 , 195 , 196 , 197 , 198 , 199 ]. These studies did not directly involve human participants. A variety of substrates were sampled including soil, water, air, plants, and animal tissue. Non-carcinogenic health risks were reported in many studies and determined from the Total Hazard Quotient or Hazard Index. A smaller subset of studies also reported carcinogenic risks, which were calculated based on standardized cancer slope factors and compared to acceptable levels determined by the International Agency for Research on Cancer. Of the studies, 43 reported a Hazard Index > 1 or lifetime cancer risk > 1 × 10 –4 for one or multiple metals in at least one assay, indicating unacceptable levels of risk. In 14 of these studies, reported risks were increased for children compared to adults.

The results of this literature review demonstrate the breadth of adverse outcomes on health and wellbeing associated with occupational and environmental exposure via mining to the four metals historically most used in the construction of LIBs. Our results are largely consistent with known pathologic mechanisms; cobalt and nickel mining were more commonly discussed in articles describing respiratory disease, while all studies reporting neurologic pathology involved manganese exposure. Given the exponential growth of mining for these metals in recent years, it is likely that effects on human health will increase without mitigation efforts.

The lack of studies examining the health effects of lithium mining is noteworthy given the recent exponential increase in the global market for this metal, which has been termed “white gold”. Pathologic manifestations of both acute and chronic lithium toxicity have long been recognized medically given its common use as a treatment for psychiatric illness and its narrow therapeutic index. Less is known about the effects of environmental lithium, although studies have reported associations between naturally occurring lithium concentrations in ground water and psychiatric illness, thyroid dysfunction, and adverse birth outcomes [ 200 , 201 , 202 ]. Lithium mining has also been shown to increase the concentration of other heavy metals, such as arsenic, in surrounding surface water [ 203 ]. In traditional lithium mining, salt-rich brine is pumped from deep in the earth to the surface, forming man-made lakes that are then allowed to evaporate [ 204 ]. Lithium can also be mined from hard rock ores. Given the methods used in lithium mining, it is reasonable to hypothesize that there is a significant risk of environmental contamination, which might lead to toxicity from lithium and other metals. Additional chemicals are often added to the brine to facilitate the precipitation of unwanted compounds. Multiple instances of lithium mining affecting nearby communities have attracted media attention, such as the 2016 contamination of the Liqi River in Tibet resulting in the destruction of the local water supply and the death of livestock and fish used as a food source [ 205 ]. Despite these high-profile incidents, no studies could be found examining the health effects of exposure to lithium mining.

Our review revealed other concerning gaps in the literature, specifically a paucity of studies describing infectious and traumatic hazards. Mine workers often reside in overcrowded conditions with poor sanitation, infrastructure, and inadequate access to medical care. These conditions promote the transmission of communicable diseases such as malaria and tuberculosis [ 206 ]. In addition, the construction of mining facilities often encroaches on the natural habitats of wild animals that may expose workers to zoonotic pathogens [ 207 ]. Sexually transmitted diseases including HIV are also prevalent in many mining communities, which can be sites of prostitution and sex trafficking [ 32 , 208 , 209 ] Similarly, few articles discussed traumatic and violent injuries, even though it is well known that many miners work in unsafe conditions and are subjected to falls, cave-ins, injuries from machinery, and other hazards [ 210 ]. Traumatic hazards arise from the essentially dangerous nature of mining work and are often compounded by a lack of safety regulations and cultural and economic systems that incentivize workers to perform unsafe tasks.

There are multiple likely explanations for this lack of data. The populations most affected by mining activities are inherently vulnerable. They are often poor, and many are migrants. In some countries, they are subject to human rights violations [ 209 ]. People depend on the mines as a source of income and may therefore be less likely to engage with researchers or report accidents for fear of retribution or loss of employment. This can be compounded by the fact that small-scale mining practices are often carried out in violation of local laws. Additionally, access to healthcare is inadequate in many areas, and health systems that do exist may lack the ability to track and report outcomes. Further research and illumination of the plight of miners may also represent a conflict of interest with mining companies that benefit from a source of cheap, exploitable labor. The logistics of carrying out studies are therefore more difficult.

In response to these issues, some mining areas have implemented environmental management programs (EMP) aimed at mitigating the exposure to these metals in mining communities [ 48 , 57 , 58 ]. The strategies utilized by these EMPs are aimed at decreasing dust emissions to decrease the particulate matter in the air. This includes improving clean water availability; updating to equipment that decreases emissions; paving roads and frequently travelled routes; and reforesting the areas. Studies have shown EMPs in manganese mining communities decreased the air concentration of manganese; however there have been variable results regarding the effect on health outcomes [ 57 , 58 ]. Nevertheless, EMPs are an important step in decreasing the health risks. Other potential interventions to help mitigate health risks include increasing the use and availability of personal protection equipment as well as implementing a medical surveillance program to monitor exposures [ 48 ].

An interesting subset of studies in this review collected qualitative information via interviews that present the perspectives of people who work in and live near mining sites [ 32 , 49 , 50 , 51 , 52 , 86 , 109 , 110 , 111 , 117 ]. Overall, there is evidence that affected populations are aware that mining poses significant health risks; however, there is economic and social pressure to tolerate health hazards to make a living. Participants reported that engaging in protests or voicing opposition to mining development placed them at risk of violent suppression from police or military forces or ostracization from other members of the community. In interviews, people living near the mines reported a perceived connection between the growth of mining activities and various health problems including acute and chronic symptoms (e.g., respiratory illnesses, chest pain, chronic headaches), impaired cognitive development in children, pollution of air and water, and destruction of farmland. Displacement of local populations by expansion of mining sites was also reported. These studies highlight the complex effects, both positive and negative, of mining presence in a community.

The results of this review are consistent with well-documented prior data suggesting that children are at disproportionately increased risk from metal toxicity compared to adults [ 211 , 212 , 213 ]. Children are at increased risk for toxicity due to heavy metal exposure for multiple reasons including their smaller body size, tendency to ingest non-food materials, hand-to-mouth behaviors, and the increased risks of exposure during physiologic and cognitive developmental periods. Multiple studies in our review reported increased adverse health outcomes in children relative to adults in the same populations [ 17 , 18 , 32 , 40 , 41 , 76 ]. Child labor is also unfortunately common in many mining industries. An estimated 40,000 children work in cobalt mines in the Democratic Republic of Congo [ 7 ]. In addition to the physical hazards associated with mine work, they also face the consequences of lost years of education and mental health trauma.

A significant number of studies in this review focused on measuring levels of metals in environmental substrates such as soil, water, plant, and animal specimens to calculate estimated carcinogenic or non-carcinogenic health risks. While there was significant heterogeneity in the type of environmental substrate studied, collection method, and study design, the totality of results suggests significant environmental contamination across a variety of media poses a significant risk. Most studies reported calculated health risks above standard acceptable levels in at least one assay. While these studies do not measure health outcomes in human participants, environmental sampling can be used as a viable method of identifying populations that may be at risk of health effects from mining and should guide the development of future studies measuring direct health outcomes.

Limitations

Our study had several important limitations. First, our results are limited by the quality of studies included in our review; all data were observational, thus limiting the certainty of our findings. Types of bias likely introduced by this limitation include selection bias as well as reporting bias, with many consequences of mining going unreported. Second, our review was limited to articles available in English. Given the locations where mining typically occurs are low- and middle-income countries, there are likely many reports that were not captured in our search. Third, our review was limited to the PubMed database. Finally, while our search criteria were systematic in nature, the aim of this manuscript was not to conduct a systematic review of the literature. Our review was not prospectively registered and study quality and bias were not assessed. Therefore, for all of the above reasons, our results should be viewed as supportive of further research into this important field. The above limitations additionally reflect the current landscape of research into the hazards faced by miners. In that context, additional, comprehensive evaluation of the consequences inherent in such mining practices should be undertaken, and should aim to characterize additional key topics, such as the health effects of mining-related lithium toxicity and traumatic and infectious hazards associated with mining.

The information gathered in this narrative review strongly suggests that the global demand for LIBs and exponential growth of mining for cobalt, lithium, manganese, and nickel presents a significant risk to human health via occupational and environmental exposures that result in both acute and chronic toxicities. This is compounded by the facts that human rights violations are common in the mining industry and that the people most affected are often members of vulnerable populations, including children. Further research, particularly regarding the health and environmental effects of mining for lithium, is crucial to understanding and addressing the risks of the world’s growing reliance on LIBs.

Availability of data and materials

No datasets were generated or analyzed during the current study.

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Brown, C.W., Goldfine, C.E., Allan-Blitz, LT. et al. Occupational, environmental, and toxicological health risks of mining metals for lithium-ion batteries: a narrative review of the Pubmed database. J Occup Med Toxicol 19 , 35 (2024). https://doi.org/10.1186/s12995-024-00433-6

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Vascular complications in extracorporeal membrane oxygenation—a narrative review.

1. Introduction

3. pathophysiology, 3.1. bio-injury in ecmo, 3.2. acute arterial thrombosis, 3.3. acute arterial embolism, 3.4. compartment syndrome, 3.5. acute venous thrombosis, 3.6. acute venous thromboembolism, 3.7. iatrogenic injuries, 4. vascular complications, 4.1. predisposing factors, 4.2. access, 4.3. arterial events, 4.4. venous events, 5. treatment strategies, 5.1. ischemia secondary to arterial obstruction, 5.2. ischemia secondary to arterial embolism, 5.3. ischemia secondary to arterial thrombosis, 5.4. venous hypertension due to venous obstruction, 5.5. ischemia due to venous thrombosis, 5.6. compartment syndrome, 5.7. major amputation, 6. mitigation strategies, 6.1. access site assessment, 6.2. ultrasound-guided access, 6.3. cannula size, 6.4. distal perfusion catheter, 6.5. thrombus prevention, 6.6. improving venous drainage, 6.7. monitoring, 6.8. re-positioning or revision of the cannula site, 7. outcomes, 8. conclusions, author contributions, institutional review board statement, data availability statement, conflicts of interest.

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Hart, J.P.; Davies, M.G. Vascular Complications in Extracorporeal Membrane Oxygenation—A Narrative Review. J. Clin. Med. 2024 , 13 , 5170. https://doi.org/10.3390/jcm13175170

Hart JP, Davies MG. Vascular Complications in Extracorporeal Membrane Oxygenation—A Narrative Review. Journal of Clinical Medicine . 2024; 13(17):5170. https://doi.org/10.3390/jcm13175170

Hart, Joseph P., and Mark G. Davies. 2024. "Vascular Complications in Extracorporeal Membrane Oxygenation—A Narrative Review" Journal of Clinical Medicine 13, no. 17: 5170. https://doi.org/10.3390/jcm13175170

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