a literature review may not be

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Writing a Literature Review

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.

Introduction:

• An introductory paragraph that explains what your working topic and thesis is
• A forecast of key topics or texts that will appear in the review
• Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
• Summarize and synthesize: Give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: Don’t just paraphrase other researchers – add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically Evaluate: Mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: Use transition words and topic sentence to draw connections, comparisons, and contrasts.

Conclusion:

• Summarize the key findings you have taken from the literature and emphasize their significance
• Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

• Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
• Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
• Qualitative versus quantitative research
• Empirical versus theoretical scholarship
• Divide the research by sociological, historical, or cultural sources
• Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

• It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
• Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
• Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
• Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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See an example

Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

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

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit 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.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

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 .  

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Literature Reviews

What this handout is about.

This handout will explain what literature reviews are and offer insights into the form and construction of literature reviews in the humanities, social sciences, and sciences.

Introduction

OK. You’ve got to write a literature review. You dust off a novel and a book of poetry, settle down in your chair, and get ready to issue a “thumbs up” or “thumbs down” as you leaf through the pages. “Literature review” done. Right?

Wrong! The “literature” of a literature review refers to any collection of materials on a topic, not necessarily the great literary texts of the world. “Literature” could be anything from a set of government pamphlets on British colonial methods in Africa to scholarly articles on the treatment of a torn ACL. And a review does not necessarily mean that your reader wants you to give your personal opinion on whether or not you liked these sources.

What is a literature review, then?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper is likely to contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper’s investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Who writes these things, anyway?

Literature reviews are written occasionally in the humanities, but mostly in the sciences and social sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a literature review is written as a paper in itself.

Let’s get to it! What should I do before writing the literature review?

If your assignment is not very specific, seek clarification from your instructor:

• Roughly how many sources should you include?
• What types of sources (books, journal articles, websites)?
• Should you summarize, synthesize, or critique your sources by discussing a common theme or issue?
• Should you evaluate your sources?
• Should you provide subheadings and other background information, such as definitions and/or a history?

Find models

Look for other literature reviews in your area of interest or in the discipline and read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. You can simply put the word “review” in your search engine along with your other topic terms to find articles of this type on the Internet or in an electronic database. The bibliography or reference section of sources you’ve already read are also excellent entry points into your own research.

Narrow your topic

There are hundreds or even thousands of articles and books on most areas of study. The narrower your topic, the easier it will be to limit the number of sources you need to read in order to get a good survey of the material. Your instructor will probably not expect you to read everything that’s out there on the topic, but you’ll make your job easier if you first limit your scope.

Keep in mind that UNC Libraries have research guides and to databases relevant to many fields of study. You can reach out to the subject librarian for a consultation: https://library.unc.edu/support/consultations/ .

And don’t forget to tap into your professor’s (or other professors’) knowledge in the field. Ask your professor questions such as: “If you had to read only one book from the 90’s on topic X, what would it be?” Questions such as this help you to find and determine quickly the most seminal pieces in the field.

Consider whether your sources are current

Some disciplines require that you use information that is as current as possible. In the sciences, for instance, treatments for medical problems are constantly changing according to the latest studies. Information even two years old could be obsolete. However, if you are writing a review in the humanities, history, or social sciences, a survey of the history of the literature may be what is needed, because what is important is how perspectives have changed through the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is currently of interest to scholars in this field and what is not.

Strategies for writing the literature review

Find a focus.

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Convey it to your reader

A literature review may not have a traditional thesis statement (one that makes an argument), but you do need to tell readers what to expect. Try writing a simple statement that lets the reader know what is your main organizing principle. Here are a couple of examples:

The current trend in treatment for congestive heart failure combines surgery and medicine. More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You’ve got a focus, and you’ve stated it clearly and directly. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories

Just like most academic papers, literature reviews also must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. The following provides a brief description of the content of each:

• Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern.
• Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each).
• Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed?

Organizing the body

Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further.

To help you come up with an overall organizational framework for your review, consider the following scenario:

You’ve decided to focus your literature review on materials dealing with sperm whales. This is because you’ve just finished reading Moby Dick, and you wonder if that whale’s portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980’s. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick, so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel.

Now consider some typical ways of organizing the sources into a review:

• Chronological: If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus.
• By publication: Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies.
• By trend: A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.
• Thematic: Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a “chronological” and a “thematic” approach is what is emphasized the most: the development of the harpoon or the harpoon technology.But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as “evil” in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.
• Methodological: A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the “methods” of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed. Once you’ve decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

• Current Situation: Information necessary to understand the topic or focus of the literature review.
• History: The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Methods and/or Standards: The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research: What questions about the field has the review sparked? How will you further your research as a result of the review?

Begin composing

Once you’ve settled on a general pattern of organization, you’re ready to write each section. There are a few guidelines you should follow during the writing stage as well. Here is a sample paragraph from a literature review about sexism and language to illuminate the following discussion:

However, other studies have shown that even gender-neutral antecedents are more likely to produce masculine images than feminine ones (Gastil, 1990). Hamilton (1988) asked students to complete sentences that required them to fill in pronouns that agreed with gender-neutral antecedents such as “writer,” “pedestrian,” and “persons.” The students were asked to describe any image they had when writing the sentence. Hamilton found that people imagined 3.3 men to each woman in the masculine “generic” condition and 1.5 men per woman in the unbiased condition. Thus, while ambient sexism accounted for some of the masculine bias, sexist language amplified the effect. (Source: Erika Falk and Jordan Mills, “Why Sexist Language Affects Persuasion: The Role of Homophily, Intended Audience, and Offense,” Women and Language19:2).

Use evidence

In the example above, the writers refer to several other sources when making their point. A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be selective

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the review’s focus, whether it is thematic, methodological, or chronological.

Use quotes sparingly

Falk and Mills do not use any direct quotes. That is because the survey nature of the literature review does not allow for in-depth discussion or detailed quotes from the text. Some short quotes here and there are okay, though, if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Notice that Falk and Mills do quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. But if you find yourself wanting to put in more quotes, check with your instructor.

Summarize and synthesize

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. The authors here recapitulate important features of Hamilton’s study, but then synthesize it by rephrasing the study’s significance and relating it to their own work.

Keep your own voice

While the literature review presents others’ ideas, your voice (the writer’s) should remain front and center. Notice that Falk and Mills weave references to other sources into their own text, but they still maintain their own voice by starting and ending the paragraph with their own ideas and their own words. The sources support what Falk and Mills are saying.

Use caution when paraphrasing

When paraphrasing a source that is not your own, be sure to represent the author’s information or opinions accurately and in your own words. In the preceding example, Falk and Mills either directly refer in the text to the author of their source, such as Hamilton, or they provide ample notation in the text when the ideas they are mentioning are not their own, for example, Gastil’s. For more information, please see our handout on plagiarism .

Revise, revise, revise

Draft in hand? Now you’re ready to revise. Spending a lot of time revising is a wise idea, because your main objective is to present the material, not the argument. So check over your review again to make sure it follows the assignment and/or your outline. Then, just as you would for most other academic forms of writing, rewrite or rework the language of your review so that you’ve presented your information in the most concise manner possible. Be sure to use terminology familiar to your audience; get rid of unnecessary jargon or slang. Finally, double check that you’ve documented your sources and formatted the review appropriately for your discipline. For tips on the revising and editing process, see our handout on revising drafts .

Works consulted

We consulted these works while writing this handout. This is not a comprehensive list of resources on the handout’s topic, and we encourage you to do your own research to find additional publications. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. For guidance on formatting citations, please see the UNC Libraries citation tutorial . We revise these tips periodically and welcome feedback.

Anson, Chris M., and Robert A. Schwegler. 2010. The Longman Handbook for Writers and Readers , 6th ed. New York: Longman.

Jones, Robert, Patrick Bizzaro, and Cynthia Selfe. 1997. The Harcourt Brace Guide to Writing in the Disciplines . New York: Harcourt Brace.

Lamb, Sandra E. 1998. How to Write It: A Complete Guide to Everything You’ll Ever Write . Berkeley: Ten Speed Press.

Rosen, Leonard J., and Laurence Behrens. 2003. The Allyn & Bacon Handbook , 5th ed. New York: Longman.

Troyka, Lynn Quittman, and Doug Hesse. 2016. Simon and Schuster Handbook for Writers , 11th ed. London: Pearson.

You may reproduce it for non-commercial use if you use the entire handout and attribute the source: The Writing Center, University of North Carolina at Chapel Hill

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What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• Give a new interpretation of old material or combine new with old interpretations,
• Trace the intellectual progression of the field, including major debates,
• Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
• Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

Given this, the purpose of a literature review is to:

• Place each work in the context of its contribution to understanding the research problem being studied.
• Describe the relationship of each work to the others under consideration.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.
• Resolve conflicts amongst seemingly contradictory previous studies.
• Identify areas of prior scholarship to prevent duplication of effort.
• Point the way in fulfilling a need for additional research.
• Locate your own research within the context of existing literature [very important].

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply embedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to make summary claims of the sort found in systematic reviews [see below].

Integrative Review Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review A review does not always focus on what someone said [findings], but how they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection, and data analysis. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own study.

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

NOTE: Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

• An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
• Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most convincing or least convincing?
• Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Basic Stages of Writing 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources would be appropriate to include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

• Current Situation : Information necessary to understand the current topic or focus of the literature review.
• Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
• History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
• Standards : Description of the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

• Sources in your literature review do not clearly relate to the research problem;
• You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
• Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
• Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• Does not describe the search procedures that were used in identifying the literature to review;
• Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
• Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

• How are they organizing their ideas?
• What methods have they used to study the problem?
• What theories have been used to explain, predict, or understand their research problem?
• What sources have they cited to support their conclusions?
• How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

• Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
• Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
• Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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Conducting a literature review: why do a literature review, why do a literature review.

• How To Find "The Literature"
• Found it -- Now What?

Besides the obvious reason for students -- because it is assigned! -- a literature review helps you explore the research that has come before you, to see how your research question has (or has not) already been addressed.

You identify:

• core research in the field
• experts in the subject area
• methodology you may want to use (or avoid)
• gaps in knowledge -- or where your research would fit in

It Also Helps You:

• Publish and share your findings
• Justify requests for grants and other funding
• Identify best practices to inform practice
• Set wider context for a program evaluation
• Compile information to support community organizing

Great brief overview, from NCSU

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Neal Haddaway

October 19th, 2020, 8 common problems with literature reviews and how to fix them.

3 comments | 320 shares

Estimated reading time: 5 minutes

Literature reviews are an integral part of the process and communication of scientific research. Whilst systematic reviews have become regarded as the highest standard of evidence synthesis, many literature reviews fall short of these standards and may end up presenting biased or incorrect conclusions. In this post, Neal Haddaway highlights 8 common problems with literature review methods, provides examples for each and provides practical solutions for ways to mitigate them.

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Researchers regularly review the literature – it’s an integral part of day-to-day research: finding relevant research, reading and digesting the main findings, summarising across papers, and making conclusions about the evidence base as a whole. However, there is a fundamental difference between brief, narrative approaches to summarising a selection of studies and attempting to reliably and comprehensively summarise an evidence base to support decision-making in policy and practice.

So-called ‘evidence-informed decision-making’ (EIDM) relies on rigorous systematic approaches to synthesising the evidence. Systematic review has become the highest standard of evidence synthesis and is well established in the pipeline from research to practice in the field of health . Systematic reviews must include a suite of specifically designed methods for the conduct and reporting of all synthesis activities (planning, searching, screening, appraising, extracting data, qualitative/quantitative/mixed methods synthesis, writing; e.g. see the Cochrane Handbook ). The method has been widely adapted into other fields, including environment (the Collaboration for Environmental Evidence ) and social policy (the Campbell Collaboration ).

Despite the growing interest in systematic reviews, traditional approaches to reviewing the literature continue to persist in contemporary publications across disciplines. These reviews, some of which are incorrectly referred to as ‘systematic’ reviews, may be susceptible to bias and as a result, may end up providing incorrect conclusions. This is of particular concern when reviews address key policy- and practice- relevant questions, such as the ongoing COVID-19 pandemic or climate change.

These limitations with traditional literature review approaches could be improved relatively easily with a few key procedures; some of them not prohibitively costly in terms of skill, time or resources.

In our recent paper in Nature Ecology and Evolution , we highlight 8 common problems with traditional literature review methods, provide examples for each from the field of environmental management and ecology, and provide practical solutions for ways to mitigate them.

There is a lack of awareness and appreciation of the methods needed to ensure systematic reviews are as free from bias and as reliable as possible: demonstrated by recent, flawed, high-profile reviews. We call on review authors to conduct more rigorous reviews, on editors and peer-reviewers to gate-keep more strictly, and the community of methodologists to better support the broader research community. Only by working together can we build and maintain a strong system of rigorous, evidence-informed decision-making in conservation and environmental management.

Note: This article gives the views of the authors, and not the position of the LSE Impact Blog, nor of the London School of Economics. Please review our  comments policy  if you have any concerns on posting a comment below

Image credit:  Jaeyoung Geoffrey Kang  via unsplash

About the author

Neal Haddaway is a Senior Research Fellow at the Stockholm Environment Institute, a Humboldt Research Fellow at the Mercator Research Institute on Global Commons and Climate Change, and a Research Associate at the Africa Centre for Evidence. He researches evidence synthesis methodology and conducts systematic reviews and maps in the field of sustainability and environmental science. His main research interests focus on improving the transparency, efficiency and reliability of evidence synthesis as a methodology and supporting evidence synthesis in resource constrained contexts. He co-founded and coordinates the Evidence Synthesis Hackathon (www.eshackathon.org) and is the leader of the Collaboration for Environmental Evidence centre at SEI. @nealhaddaway

Why is mission creep a problem and not a legitimate response to an unexpected finding in the literature? Surely the crucial points are that the review’s scope is stated clearly and implemented rigorously, not when the scope was finalised.

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#9. Most of them are terribly boring. Which is why I teach students how to make them engaging…and useful.

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Libraries | Research Guides

Literature reviews, what is a literature review, learning more about how to do a literature review.

• Planning the Review
• The Research Question
• Choosing Where to Search
• Organizing the Review
• Writing the Review

A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

• Sage Research Methods Core This link opens in a new window SAGE Research Methods supports research at all levels by providing material to guide users through every step of the research process. SAGE Research Methods is the ultimate methods library with more than 1000 books, reference works, journal articles, and instructional videos by world-leading academics from across the social sciences, including the largest collection of qualitative methods books available online from any scholarly publisher. – Publisher

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Introduction to Literature Reviews

Introduction.

• Step One: Define
• Step Two: Research
• Step Three: Write
• Suggested Readings

A literature review is a written work that :

• Compiles significant research published on a topic by accredited scholars and researchers;
• Surveys scholarly articles, books, dissertations, conference proceedings, and other sources;
• Examines contrasting perspectives, theoretical approaches, methodologies, findings, results, conclusions.
• Reviews critically, analyzes, and synthesizes existing research on a topic; and,
• Performs a thorough “re” view, “overview”, or “look again” of past and current works on a subject, issue, or theory.

From these analyses, the writer then offers an overview of the current status of a particular area of knowledge from both a practical and theoretical perspective.

Literature reviews are important because they are usually a  required  step in a thesis proposal (Master's or PhD). The proposal will not be well-supported without a literature review. Also, literature reviews are important because they help you learn important authors and ideas in your field. This is useful for your coursework and your writing. Knowing key authors also helps you become acquainted with other researchers in your field.

Look at this diagram and imagine that your research is the "something new." This shows how your research should relate to major works and other sources.

Olivia Whitfield | Graduate Reference Assistant | 2012-2015

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• Last Updated: Aug 29, 2024 1:55 PM
• URL: https://libraryguides.missouri.edu/literaturereview

Writing A Literature Review  

7 common (and costly) mistakes to avoid ☠️.

By: David Phair (PhD) | Reviewed By: Dr Eunice Rautenbach | June 2021

Crafting a high-quality literature review is critical to earning marks and developing a strong dissertation, thesis or research project. But, it’s no simple task. Here at Grad Coach, we’ve reviewed thousands of literature reviews and seen a recurring set of mistakes and issues that drag students down.

In this post, we’ll unpack 7 common literature review mistakes , so that you can avoid these pitfalls and submit a literature review that impresses.

Overview: 7 Literature Review Killers

• Over-reliance on low-quality sources
• A lack of landmark/seminal literature
• A lack of current literature
• Description instead of integration and synthesis
• Irrelevant or unfocused content
• Poor chapter structure and layout
• Plagiarism and poor referencing

Mistake #1: Over-reliance on low-quality sources

One of the most common issues we see in literature reviews is an over-reliance on low-quality sources . This includes a broad collection of non-academic sources like blog posts, opinion pieces, publications by advocacy groups and daily news articles.

Of course, just because a piece of content takes the form of a blog post doesn’t automatically mean it is low-quality . However, it’s (generally) unlikely to be as academically sound (i.e., well-researched, objective and scientific) as a journal article, so you need to be a lot more sceptical when considering this content and make sure that it has a strong, well-reasoned foundation. As a rule of thumb, your literature review shouldn’t rely heavily on these types of content – they should be used sparingly.

Ideally, your literature review should be built on a strong base of journal articles , ideally from well-recognised, peer-reviewed journals with a high H index . You can also draw on books written by well-established subject matter experts. When considering books, try to focus on those that are published by academic publishers , for example, Cambridge University Press, Oxford University Press and Routledge. You can also draw on government websites, provided they have a strong reputation for objectivity and data quality. As with any other source, be wary of any government website that seems to be pushing an agenda.

Source: UCCS

As I mentioned, this doesn’t mean that your literature review can’t include the occasional blog post or news article. These types of content have their place , especially when setting the context for your study. For example, you may want to cite a collection of newspaper articles to demonstrate the emergence of a recent trend. However, your core arguments and theoretical foundations shouldn’t rely on these. Build your foundation on credible academic literature to ensure that your study stands on the proverbial shoulders of giants.

Mistake #2: A lack of landmark/seminal literature

Another issue we see in weaker literature reviews is an absence of landmark literature for the research topic . Landmark literature (sometimes also referred to as seminal or pivotal work) refers to the articles that initially presented an idea of great importance or influence within a particular discipline. In other words, the articles that put the specific area of research “on the map”, so to speak.

The reason for the absence of landmark literature in poor literature reviews is most commonly that either the student isn’t aware of the literature (because they haven’t sufficiently immersed themselves in the existing research), or that they feel that they should only present the most up to date studies. Whatever the cause, it’s a problem, as a good literature review should always acknowledge the seminal writing in the field.

But, how do you find landmark literature?

Well, you can usually spot these by searching for the topic in Google Scholar and identifying the handful of articles with high citation counts. They’ll also be the studies most commonly cited in textbooks and, of course, Wikipedia (but please don’t use Wikipedia as a source!).

So, when you’re piecing your literature review together, remember to pay homage to the classics , even if only briefly. Seminal works are the theoretical foundation of a strong literature review.

Mistake #3: A lack of current literature

As I mentioned, it’s incredibly important to acknowledge the landmark studies and research in your literature review. However, a strong literature review should also incorporate the current literature . It should, ideally, compare and contrast the “classics” with the more up to date research, and briefly comment on the evolution.

Of course, you don’t want to burn precious word count providing an in-depth history lesson regarding the evolution of the topic (unless that’s one of your research aims, of course), but you should at least acknowledge any key differences between the old and the new.

But, how do you find current literature?

To find current literature in your research area, you can once again use Google Scholar by simply selecting the “Since…” link on the left-hand side. Depending on your area of study, recent may mean the last year or two, or a fair deal longer.

So, as you develop your catalogue of literature, remember to incorporate both the classics and the more up to date research. By doing this, you’ll achieve a comprehensive literature base that is both well-rooted in tried and tested theory and current.

Mistake #4: Description instead of integration and synthesis

This one is a big one. And, unfortunately, it’s a very common one. In fact, it’s probably the most common issue we encounter in literature reviews.

All too often, students think that a literature review is simply a summary of what each researcher has said. A lengthy, detailed “he said, she said”. This is incorrect . A good literature review needs to go beyond just describing all the relevant literature. It needs to integrate the existing research to show how it all fits together.

A good literature review should also highlight what areas don’t fit together , and which pieces are missing . In other words, what do researchers disagree on and why might that be. It’s seldom the case that everyone agrees on everything because the “truth” is typically very nuanced and intricate in reality. A strong literature review is a balanced one , with a mix of different perspectives and findings that give the reader a clear view of the current state of knowledge.

A good analogy is that of a jigsaw puzzle. The various findings and arguments from each piece of literature form the individual puzzle pieces, and you then put these together to develop a picture of the current state of knowledge . Importantly, that puzzle will in all likelihood have pieces that don’t fit well together, and pieces that are missing. It’s seldom a pretty puzzle!

By the end of this process of critical review and synthesis of the existing literature , it should be clear what’s missing – in other words, the gaps that exist in the current research . These gaps then form the foundation for your proposed study. In other words, your study will attempt to contribute a missing puzzle piece (or get two pieces to fit together).

So, when you’re crafting your literature review chapter, remember that this chapter needs to go well beyond a basic description of the existing research – it needs to synthesise it (bring it all together) and form the foundation for your study.

Mistake #5: Irrelevant or unfocused content

Another common mistake we see in literature review chapters is quite simply the inclusion of irrelevant content . Some chapters can waffle on for pages and pages and leave the reader thinking, “so what?”

So, how do you decide what’s relevant?

Well, to ensure you stay on-topic and focus, you need to revisit your research aims, objectives and research questions . Remember, the purpose of the literature review is to build the theoretical foundation that will help you achieve your research aims and objectives, and answer your research questions . Therefore, relevant content is the relatively narrow body of content that relates directly to those three components .

Let’s look at an example.

If your research aims to identify factors that cultivate employee loyalty and commitment, your literature review needs to focus on existing research that identifies such factors. Simple enough, right? Well, during your review process, you will invariably come across plenty of research relating to employee loyalty and commitment, including things like:

• The benefits of high employee commitment
• The different types of commitment
• The impact of commitment on corporate culture
• The links between commitment and productivity

While all of these relate to employee commitment, they’re not focused on the research aims , objectives and questions, as they’re not identifying factors that foster employee commitment. Of course, they may still be useful in helping you justify your topic, so they’ll likely have a place somewhere in your dissertation or thesis. However, for your literature review, you need to keep things focused.

So, as you work through your literature review, always circle back to your research aims, objective and research questions and use them as a litmus test for article relevance.

Need a helping hand?

Mistake #6: Poor chapter structure and layout

Even the best content can fail to earn marks when the literature review chapter is poorly structured . Unfortunately, this is a fairly common issue, resulting in disjointed, poorly-flowing arguments that are difficult for the reader (the marker…) to follow.

The most common reason that students land up with a poor structure is that they start writing their literature review chapter without a plan or structure . Of course, as we’ve discussed before, writing is a form of thinking , so you don’t need to plan out every detail before you start writing. However, you should at least have an outline structure penned down before you hit the keyboard.

So, how should you structure your literature review?

We’ve covered literature review structure in detail previously , so I won’t go into it here. However, as a quick overview, your literature review should consist of three core sections :

• The introduction section – where you outline your topic, introduce any definitions and jargon and define the scope of your literature review.
• The body section – where you sink your teeth into the existing research. This can be arranged in various ways (e.g. thematically, chronologically or methodologically).
• The conclusion section – where you present the key takeaways and highlight the research gap (or gaps), which lays the foundation for your study.

Another reason that students land up with a poor structure is that they start writing their literature chapter prematurely . In other words, they start writing before they’ve finished digesting the literature. This is a costly mistake, as it always results in extensive rewriting , which takes a lot longer than just doing it one step at a time. Again, it’s completely natural to do a little extra reading as thoughts crop up during the writing process, but you should complete your core reading before you start writing.

Long story short – don’t start writing your literature review without some sort of structural plan. This structure can (and likely will) evolve as you write, but you need some sort of outline as a starting point. Pro tip – check out our free literature review template to fast-track your structural outline.

Mistake #7: Plagiarism and poor referencing

This one is by far the most unforgivable literature review mistake, as it carries one of the heaviest penalties , while it is so easily avoidable .

All too often, we encounter literature reviews that, at first glance, look pretty good. However, a quick run through a plagiarism checker and it quickly becomes apparent that the student has failed to fully digest the literature they’ve reviewed and put it into their own words.

“But, the original author said it perfectly…”

I get it – sometimes the way an author phrased something is “just perfect” and you can’t find a better way to say it. In those (pretty rare) cases, you can use direct quotes (and a citation, of course). However, for the vast majority of your literature review, you need to put things into your own words .

The good news is that if you focus on integrating and synthesising the literature (as I mentioned in point 3), you shouldn’t run into this issue too often, as you’ll naturally be writing about the relationships between studies , not just about the studies themselves. Remember, if you can’t explain something simply (in your own words), you don’t really understand it.

A related issue that we see quite often is plain old-fashioned poor referencing . This can include citation and reference formatting issues (for example, Harvard or APA style errors), or just a straight out lack of references . In academic writing, if you fail to reference a source, you are effectively claiming the work as your own, which equates to plagiarism. This might seem harmless, but plagiarism is a serious form of academic misconduct and could cost you a lot more than just a few marks.

So, when you’re writing up your literature review, remember that you need to digest the content and put everything into your own words. You also need to reference the sources of any and all ideas, theories, frameworks and models you draw on.

Recap: 7 Literature Review Mistakes

We’ve covered a lot of ground in this post. Let’s quickly recap on the 7 most common literature review mistakes.

Now that you’re aware of these common mistakes, be sure to also check out our literature review walkthrough video , where to dissect an actual literature review chapter . This will give you a clear picture of what a high-quality literature review looks like and hopefully provide some inspiration for your own.

If you have any questions about these literature review mistakes, leave a comment below and we’ll do our best to answer. If you’re interested in private coaching, book an initial consultation with a friendly coach to discuss how we can move you forward.

Psst… there’s more!

This post is an extract from our bestselling short course, Literature Review Bootcamp . If you want to work smart, you don't want to miss this .

10 Comments

Dear GradCoach,

Thank you for making our uni student lives better. Could you kindly do a video on how to use your literature review excel template? I am sure a lot of students would appreciate that.

Thank you so much for this inlightment concerning the mistakes that should be avoided while writing a literature review chapter. It is concise and precise. You have mentioned that this chapter include three main parts; introduction, body, and conclusion. Is the theoritical frameworke considered a part of the literature review chapter, or it should be written in a seperate chapter? If it is included in the literature review, should it take place at the beginning, the middle or at the end of the chapter? Thank you one again for “unpacking” things for us.

Hi I would enjoy the video on lit review. You mentioned cataloging references, I would like the template for excel. Would you please sent me this template.

on the plagiarism and referencing what is the correct way to cite the words said by the author . What are the different methods you can use

its clear, precise and understandable many thanks affectionately yours’ Godfrey

Thanks for this wonderful resource! I am final year student and will be commencing my dissertation work soon. This course has significantly improved my understanding of dissertation and has greater value in terms of its practical applicability compared to other literature works and articles out there on the internet. I will advice my colleague students more especially first time thesis writers to make good use of this course. It’s explained in simple, plain grammar and you will greatly appreciate it.

Thanks. A lot. This was excellent. I really enjoyed it. Again thank you.

The information in this article is very useful for students and very interesting I really like your article thanks for sharing this post!

Thank you for putting more knowledge in us. Thank you for using simple you’re bless.

This article is really useful. Thanks a lot for sharing this knowledge. Please continue the journey of sharing and facilitating the young researchers.

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Write a literature review.

• Examples and Further Information

1. Introduction

Not to be confused with a book review, a literature review surveys scholarly articles, books and other sources (e.g. dissertations, conference proceedings) relevant to a particular issue, area of research, or theory, providing a description, summary, and critical evaluation of each work. The purpose is to offer an overview of significant literature published on a topic.

2. Components

Similar to primary research, development of the literature review requires four stages:

• Problem formulation—which topic or field is being examined and what are its component issues?
• Literature search—finding materials relevant to the subject being explored
• Data evaluation—determining which literature makes a significant contribution to the understanding of the topic
• Analysis and interpretation—discussing the findings and conclusions of pertinent literature

Literature reviews should comprise the following elements:

• An overview of the subject, issue or theory under consideration, along with the objectives of the literature review
• Division of works under review into categories (e.g. those in support of a particular position, those against, and those offering alternative theses entirely)
• Explanation of how each work is similar to and how it varies from the others
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research

In assessing each piece, consideration should be given to:

• Provenance—What are the author's credentials? Are the author's arguments supported by evidence (e.g. primary historical material, case studies, narratives, statistics, recent scientific findings)?
• Objectivity—Is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness—Which of the author's theses are most/least convincing?
• Value—Are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

3. Definition and Use/Purpose

A literature review may constitute an essential chapter of a thesis or dissertation, or may be a self-contained review of writings on a subject. In either case, its purpose is to:

• Place each work in the context of its contribution to the understanding of the subject under review
• Describe the relationship of each work to the others under consideration
• Identify new ways to interpret, and shed light on any gaps in, previous research
• Resolve conflicts amongst seemingly contradictory previous studies
• Identify areas of prior scholarship to prevent duplication of effort
• Point the way forward for further research
• Place one's original work (in the case of theses or dissertations) in the context of existing literature

The literature review itself, however, does not present new primary scholarship.

• Next: Examples and Further Information >>

Creative Commons Attribution 3.0 License except where otherwise noted.

Land Acknowledgement

The land on which we gather is the unceded territory of the Awaswas-speaking Uypi Tribe. The Amah Mutsun Tribal Band, comprised of the descendants of indigenous people taken to missions Santa Cruz and San Juan Bautista during Spanish colonization of the Central Coast, is today working hard to restore traditional stewardship practices on these lands and heal from historical trauma.

The land acknowledgement used at UC Santa Cruz was developed in partnership with the Amah Mutsun Tribal Band Chairman and the Amah Mutsun Relearning Program at the UCSC Arboretum .

What is a Literature Review? How to Write It (with Examples)

A literature review is a critical analysis and synthesis of existing research on a particular topic. It provides an overview of the current state of knowledge, identifies gaps, and highlights key findings in the literature. 1 The purpose of a literature review is to situate your own research within the context of existing scholarship, demonstrating your understanding of the topic and showing how your work contributes to the ongoing conversation in the field. Learning how to write a literature review is a critical tool for successful research. Your ability to summarize and synthesize prior research pertaining to a certain topic demonstrates your grasp on the topic of study, and assists in the learning process. 

Table of Contents

What is the purpose of literature review , a. habitat loss and species extinction: , b. range shifts and phenological changes: , c. ocean acidification and coral reefs: , d. adaptive strategies and conservation efforts: .

• Choose a Topic and Define the Research Question: 
• Decide on the Scope of Your Review: 
• Select Databases for Searches: 
• Conduct Searches and Keep Track: 
• Review the Literature: 
• Organize and Write Your Literature Review: 
• How to write a literature review faster with Paperpal? 

Frequently asked questions 

What is a literature review .

A well-conducted literature review demonstrates the researcher’s familiarity with the existing literature, establishes the context for their own research, and contributes to scholarly conversations on the topic. One of the purposes of a literature review is also to help researchers avoid duplicating previous work and ensure that their research is informed by and builds upon the existing body of knowledge.

A literature review serves several important purposes within academic and research contexts. Here are some key objectives and functions of a literature review: 2  

1. Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge. 

2. Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field.

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3. Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research. 

4. Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered. 

5. Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research. 

6. Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature. 

Literature review example 

Let’s delve deeper with a literature review example: Let’s say your literature review is about the impact of climate change on biodiversity. You might format your literature review into sections such as the effects of climate change on habitat loss and species extinction, phenological changes, and marine biodiversity. Each section would then summarize and analyze relevant studies in those areas, highlighting key findings and identifying gaps in the research. The review would conclude by emphasizing the need for further research on specific aspects of the relationship between climate change and biodiversity. The following literature review template provides a glimpse into the recommended literature review structure and content, demonstrating how research findings are organized around specific themes within a broader topic. 

Literature Review on Climate Change Impacts on Biodiversity:  

Climate change is a global phenomenon with far-reaching consequences, including significant impacts on biodiversity. This literature review synthesizes key findings from various studies: 

Climate change-induced alterations in temperature and precipitation patterns contribute to habitat loss, affecting numerous species (Thomas et al., 2004). The review discusses how these changes increase the risk of extinction, particularly for species with specific habitat requirements. 

Observations of range shifts and changes in the timing of biological events (phenology) are documented in response to changing climatic conditions (Parmesan & Yohe, 2003). These shifts affect ecosystems and may lead to mismatches between species and their resources. 

The review explores the impact of climate change on marine biodiversity, emphasizing ocean acidification’s threat to coral reefs (Hoegh-Guldberg et al., 2007). Changes in pH levels negatively affect coral calcification, disrupting the delicate balance of marine ecosystems. 

Recognizing the urgency of the situation, the literature review discusses various adaptive strategies adopted by species and conservation efforts aimed at mitigating the impacts of climate change on biodiversity (Hannah et al., 2007). It emphasizes the importance of interdisciplinary approaches for effective conservation planning. 

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How to write a good literature review 

Writing a literature review involves summarizing and synthesizing existing research on a particular topic. A good literature review format should include the following elements. 

Introduction: The introduction sets the stage for your literature review, providing context and introducing the main focus of your review. 

• Opening Statement: Begin with a general statement about the broader topic and its significance in the field. 
• Scope and Purpose: Clearly define the scope of your literature review. Explain the specific research question or objective you aim to address. 
• Organizational Framework: Briefly outline the structure of your literature review, indicating how you will categorize and discuss the existing research. 
• Significance of the Study: Highlight why your literature review is important and how it contributes to the understanding of the chosen topic. 
• Thesis Statement: Conclude the introduction with a concise thesis statement that outlines the main argument or perspective you will develop in the body of the literature review. 

Body: The body of the literature review is where you provide a comprehensive analysis of existing literature, grouping studies based on themes, methodologies, or other relevant criteria. 

• Organize by Theme or Concept: Group studies that share common themes, concepts, or methodologies. Discuss each theme or concept in detail, summarizing key findings and identifying gaps or areas of disagreement. 
• Critical Analysis: Evaluate the strengths and weaknesses of each study. Discuss the methodologies used, the quality of evidence, and the overall contribution of each work to the understanding of the topic. 
• Synthesis of Findings: Synthesize the information from different studies to highlight trends, patterns, or areas of consensus in the literature. 
• Identification of Gaps: Discuss any gaps or limitations in the existing research and explain how your review contributes to filling these gaps. 
• Transition between Sections: Provide smooth transitions between different themes or concepts to maintain the flow of your literature review. 

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Conclusion: The conclusion of your literature review should summarize the main findings, highlight the contributions of the review, and suggest avenues for future research. 

• Summary of Key Findings: Recap the main findings from the literature and restate how they contribute to your research question or objective. 
• Contributions to the Field: Discuss the overall contribution of your literature review to the existing knowledge in the field. 
• Implications and Applications: Explore the practical implications of the findings and suggest how they might impact future research or practice. 
• Recommendations for Future Research: Identify areas that require further investigation and propose potential directions for future research in the field. 
• Final Thoughts: Conclude with a final reflection on the importance of your literature review and its relevance to the broader academic community. 

Conducting a literature review 

Conducting a literature review is an essential step in research that involves reviewing and analyzing existing literature on a specific topic. It’s important to know how to do a literature review effectively, so here are the steps to follow: 1  

Choose a Topic and Define the Research Question:  

• Select a topic that is relevant to your field of study. 
• Clearly define your research question or objective. Determine what specific aspect of the topic do you want to explore? 

Decide on the Scope of Your Review:  

• Determine the timeframe for your literature review. Are you focusing on recent developments, or do you want a historical overview? 
• Consider the geographical scope. Is your review global, or are you focusing on a specific region? 
• Define the inclusion and exclusion criteria. What types of sources will you include? Are there specific types of studies or publications you will exclude? 

Select Databases for Searches:  

• Identify relevant databases for your field. Examples include PubMed, IEEE Xplore, Scopus, Web of Science, and Google Scholar. 
• Consider searching in library catalogs, institutional repositories, and specialized databases related to your topic. 

Conduct Searches and Keep Track:  

• Develop a systematic search strategy using keywords, Boolean operators (AND, OR, NOT), and other search techniques. 
• Record and document your search strategy for transparency and replicability. 
• Keep track of the articles, including publication details, abstracts, and links. Use citation management tools like EndNote, Zotero, or Mendeley to organize your references. 

Review the Literature:  

• Evaluate the relevance and quality of each source. Consider the methodology, sample size, and results of studies. 
• Organize the literature by themes or key concepts. Identify patterns, trends, and gaps in the existing research. 
• Summarize key findings and arguments from each source. Compare and contrast different perspectives. 
• Identify areas where there is a consensus in the literature and where there are conflicting opinions. 
• Provide critical analysis and synthesis of the literature. What are the strengths and weaknesses of existing research? 

Organize and Write Your Literature Review:  

• Literature review outline should be based on themes, chronological order, or methodological approaches. 
• Write a clear and coherent narrative that synthesizes the information gathered. 
• Use proper citations for each source and ensure consistency in your citation style (APA, MLA, Chicago, etc.). 
• Conclude your literature review by summarizing key findings, identifying gaps, and suggesting areas for future research. 

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A literature review is a critical and comprehensive analysis of existing literature (published and unpublished works) on a specific topic or research question and provides a synthesis of the current state of knowledge in a particular field. A well-conducted literature review is crucial for researchers to build upon existing knowledge, avoid duplication of efforts, and contribute to the advancement of their field. It also helps researchers situate their work within a broader context and facilitates the development of a sound theoretical and conceptual framework for their studies.

Literature review is a crucial component of research writing, providing a solid background for a research paper’s investigation. The aim is to keep professionals up to date by providing an understanding of ongoing developments within a specific field, including research methods, and experimental techniques used in that field, and present that knowledge in the form of a written report. Also, the depth and breadth of the literature review emphasizes the credibility of the scholar in his or her field.  

Before writing a literature review, it’s essential to undertake several preparatory steps to ensure that your review is well-researched, organized, and focused. This includes choosing a topic of general interest to you and doing exploratory research on that topic, writing an annotated bibliography, and noting major points, especially those that relate to the position you have taken on the topic. 

Literature reviews and academic research papers are essential components of scholarly work but serve different purposes within the academic realm. 3 A literature review aims to provide a foundation for understanding the current state of research on a particular topic, identify gaps or controversies, and lay the groundwork for future research. Therefore, it draws heavily from existing academic sources, including books, journal articles, and other scholarly publications. In contrast, an academic research paper aims to present new knowledge, contribute to the academic discourse, and advance the understanding of a specific research question. Therefore, it involves a mix of existing literature (in the introduction and literature review sections) and original data or findings obtained through research methods. 

Literature reviews are essential components of academic and research papers, and various strategies can be employed to conduct them effectively. If you want to know how to write a literature review for a research paper, here are four common approaches that are often used by researchers.  Chronological Review: This strategy involves organizing the literature based on the chronological order of publication. It helps to trace the development of a topic over time, showing how ideas, theories, and research have evolved.  Thematic Review: Thematic reviews focus on identifying and analyzing themes or topics that cut across different studies. Instead of organizing the literature chronologically, it is grouped by key themes or concepts, allowing for a comprehensive exploration of various aspects of the topic.  Methodological Review: This strategy involves organizing the literature based on the research methods employed in different studies. It helps to highlight the strengths and weaknesses of various methodologies and allows the reader to evaluate the reliability and validity of the research findings.  Theoretical Review: A theoretical review examines the literature based on the theoretical frameworks used in different studies. This approach helps to identify the key theories that have been applied to the topic and assess their contributions to the understanding of the subject.  It’s important to note that these strategies are not mutually exclusive, and a literature review may combine elements of more than one approach. The choice of strategy depends on the research question, the nature of the literature available, and the goals of the review. Additionally, other strategies, such as integrative reviews or systematic reviews, may be employed depending on the specific requirements of the research.

The literature review format can vary depending on the specific publication guidelines. However, there are some common elements and structures that are often followed. Here is a general guideline for the format of a literature review:  Introduction:   Provide an overview of the topic.  Define the scope and purpose of the literature review.  State the research question or objective.  Body:   Organize the literature by themes, concepts, or chronology.  Critically analyze and evaluate each source.  Discuss the strengths and weaknesses of the studies.  Highlight any methodological limitations or biases.  Identify patterns, connections, or contradictions in the existing research.  Conclusion:   Summarize the key points discussed in the literature review.  Highlight the research gap.  Address the research question or objective stated in the introduction.  Highlight the contributions of the review and suggest directions for future research.

Both annotated bibliographies and literature reviews involve the examination of scholarly sources. While annotated bibliographies focus on individual sources with brief annotations, literature reviews provide a more in-depth, integrated, and comprehensive analysis of existing literature on a specific topic. The key differences are as follows: 

References 

• Denney, A. S., & Tewksbury, R. (2013). How to write a literature review.  Journal of criminal justice education ,  24 (2), 218-234. 
• Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Taylor & Francis. 
• Cantero, C. (2019). How to write a literature review.  San José State University Writing Center . 

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Eight problems with literature reviews and how to fix them

Affiliations.

• 1 Mercator Research Institute on Climate Change and Global Commons, Berlin, Germany. [email protected].
• 2 Stockholm Environment Institute, Stockholm, Sweden. [email protected].
• 3 Africa Centre for Evidence, University of Johannesburg, Johannesburg, South Africa. [email protected].
• 4 College of Medicine and Health, Exeter University, Exeter, UK.
• 5 Department of Zoology, University of Cambridge, Cambridge, UK.
• 6 School of Biological Sciences, University of East Anglia, Norwich, UK.
• 7 Department of Biological Sciences, Royal Holloway University of London, Egham, UK.
• 8 Stockholm Environment Institute, Stockholm, Sweden.
• 9 Department of Zoology, University of Oxford, Oxford, UK.
• 10 Collaboration for Environmental Evidence, UK Centre, School of Natural Sciences, Bangor University, Bangor, UK.
• 11 Liljus ltd, London, UK.
• 12 Department of Forest Sciences, University of Helsinki, Helsinki, Finland.
• 13 Evidence Synthesis Lab, School of Natural and Environmental Sciences, University of Newcastle, Newcastle-upon-Tyne, UK.
• PMID: 33046871
• DOI: 10.1038/s41559-020-01295-x
• Author Correction: Eight problems with literature reviews and how to fix them. Haddaway NR, Bethel A, Dicks LV, Koricheva J, Macura B, Petrokofsky G, Pullin AS, Savilaakso S, Stewart GB. Haddaway NR, et al. Nat Ecol Evol. 2020 Dec;4(12):1725. doi: 10.1038/s41559-020-01346-3. Nat Ecol Evol. 2020. PMID: 33077931

Traditional approaches to reviewing literature may be susceptible to bias and result in incorrect decisions. This is of particular concern when reviews address policy- and practice-relevant questions. Systematic reviews have been introduced as a more rigorous approach to synthesizing evidence across studies; they rely on a suite of evidence-based methods aimed at maximizing rigour and minimizing susceptibility to bias. Despite the increasing popularity of systematic reviews in the environmental field, evidence synthesis methods continue to be poorly applied in practice, resulting in the publication of syntheses that are highly susceptible to bias. Recognizing the constraints that researchers can sometimes feel when attempting to plan, conduct and publish rigorous and comprehensive evidence syntheses, we aim here to identify major pitfalls in the conduct and reporting of systematic reviews, making use of recent examples from across the field. Adopting a 'critical friend' role in supporting would-be systematic reviews and avoiding individual responses to police use of the 'systematic review' label, we go on to identify methodological solutions to mitigate these pitfalls. We then highlight existing support available to avoid these issues and call on the entire community, including systematic review specialists, to work towards better evidence syntheses for better evidence and better decisions.

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• Monolingual searches can limit and bias results in global literature reviews. Nuñez MA, Amano T. Nuñez MA, et al. Nat Ecol Evol. 2021 Mar;5(3):264. doi: 10.1038/s41559-020-01369-w. Nat Ecol Evol. 2021. PMID: 33398107 No abstract available.

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• Scoping reviews: reinforcing and advancing the methodology and application. Peters MDJ, Marnie C, Colquhoun H, Garritty CM, Hempel S, Horsley T, Langlois EV, Lillie E, O'Brien KK, Tunçalp Ӧ, Wilson MG, Zarin W, Tricco AC. Peters MDJ, et al. Syst Rev. 2021 Oct 8;10(1):263. doi: 10.1186/s13643-021-01821-3. Syst Rev. 2021. PMID: 34625095 Free PMC article.
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• Haddaway, N. R. & Macura, B. The role of reporting standards in producing robust literature reviews. Nat. Clim. Change 8, 444–447 (2018).
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• Lesson 1: What is a Literature Review

Literature Reviews in the Sciences

• Introduction
• Lesson 2: Fundamental Research Skills
• Lesson 3: Fundamental Writing Skills
• Lesson 4: Resources

What is a literature review? As stated earlier, a literature review is not a well-defined genre. Broadly speaking, a literature review is a single publication, or an element of a long publication, where a topic or research question is explored by examining a large body of prior publications relevant to that topic or research question. Literature review publications tend to self-identify as literature reviews by using those words in the title and in the abstract and body of the work. Literature review publications have extensive reference lists and a textual narrative that examines the content of the articles in that reference list. Article databases often allow you to limit results to literature reviews with the click of a button. Literature reviews are numerous and not difficult to locate.

Producing a literature review is a much different process than simply finding one to read. Literature reviews are diverse and dynamic because of the interrelationships among four major rhetorical features: type, form, purpose, and audience. Understanding these features can help you create an efficient research and writing plan, and ultimately craft a compelling final document. You may have observed these features and interrelationships among the review articles you’ve read.

Let’s delve into them.

Rhetorical Feature 1: Type

Literature reviews can be classified into many types based on characteristics like how the source material is found, the reason they are produced, and what they look like in their final form. New types continually evolve—a recent  piece of research identified 48 different literature review types !

Let’s look at three fundamental types of published literature reviews:

A narrative literature review is extremely common. You have probably read many literature reviews of this type. You may be tasked to produce a literature review of this type many times in your career. A narrative review uses past published research to tell a story about a topic. In the sciences, a narrative review can bring the reader up to date on an evolving research area, establish the scientific rationale for new research explorations, or provide a history of knowledge on a particular topic. They provide overviews or expert opinions grounded in prior published research on a topic. They are typically produced by a single author, or a small group of authors. A narrative literature review can be educational and informative for subject matter experts or non-experts.

What differentiates a narrative review from other review types is what is missing: a traditional narrative review typically does not follow a standardized method for locating the literature to be reviewed. Traditionally, the assumption is that the reader trusts the expertise of the author, and the review itself doesn’t necessarily follow a standard structure. The narrative review does not typically provide detailed information about how the prior research was located, or why some publications were chosen for inclusion over others. Narrative reviews can disclose their method for locating literature, and clarify the authors’ inclusion/exclusion criteria. This is generally helpful to the reader and adds credibility to the author’s words, but it is not a predominant element of the narrative review text. A traditional narrative review usually summarizes the take-home messages of the literature being reviewed, but doesn’t attempt to synthesize quantitative data from multiple studies into a single finding using statistical methods.

It is likely that most literature reviews you will write will be of the narrative review type.

A systematic review is a literature review that follows a highly specific protocol from start to finish. A systematic review of the literature intends to answer a specific research question. Instead of conducting laboratory or field research, a comprehensive search of all literature is conducted using a strict and reproducible search protocol that is designed ahead of time and made explicit in detail. The literature being searched can be published or unpublished.

Selection of articles to be included in the review also follows predetermined inclusion and exclusion criteria, and should involve multiple reviewers.  A systematic review is actually a research study that uses published literature as data.  Systematic reviews should never be undertaken alone, and like other forms of research, require team collaboration and significant time to conduct. The search and selection process for the literature to be reviewed is a significant portion of the systematic review text.

A narrative review can be conducted with methodological transparency, but that transparency alone does not transform it into a systematic review.

Meta-analysis

A meta-analysis is a sub-type of systematic reviews. A meta-analysis seeks to answer a specific research question using the literature as data. After the rigorous search and selection process is completed, the quantitative data in the individual studies selected for the review is extracted and synthesized (combined) statistically to achieve a result that has higher statistical power than the results of the individual studies. A meta-analysis is a literature review type as well as a research methodology.

The final activity of quantitative synthesis of data from multiple studies is the hallmark characteristic of a meta-analysis and is what transforms a systematic review into a meta-analysis. As a sub-type of systematic reviews, meta-analyses also require comprehensive review of the literature conducted with a specific protocol and adhering to methodological guidelines. Likewise, meta-analyses also investigate a specific research question. The search and selection process, as well as the data analysis, is a significant portion of the published meta-analysis. This type of literature review should also be conducted with a team, and will require significant time.

Questions to ask:

• What type of literature review do I need to write?
• Am I familiar with that type? What are its identifying characteristics?
• Are there guidelines for this type within my discipline that I can use to guide my workflow?

Rhetorical Feature 2: Form

As you might expect, the form that a literature review takes is closely related to its type. Literature reviews might be stand-alone publications that constitute a research study itself, part of a larger research project and publication, or part of a grant proposal.

Stand-alone review

Stand-alone reviews are frequently (but not always) themselves scholarly contributions to a field and published in a peer-reviewed journal. They may, either directly or indirectly, seek to move scholarly conversation and professional practice in a particular direction. Stand-alone reviews present the objective, methodology, and findings of their own internal research question.  Systematic reviews  and  meta-analyses  are most frequently published as stand-alone reviews.

Part of a larger research project

This may be the form that you are most familiar with. It tends to coincide with the  narrative review  type. Literature reviews are a requirement for theses and dissertations, as well as for most peer-reviewed articles (when the article is not itself a stand-alone review). In the case of theses and dissertations, the literature review frequently takes the form of a chapter with its own introduction, clearly defined sections, and conclusion. However, it can also take the form of a chapter section, typically as part of the introduction. In peer-reviewed articles, the literature review likewise takes the form of a section within the larger publication, typically as part of the introduction.

Annotated Article

Open Annotated Article in a new window

Part of a grant proposal

The literature review is a common feature in grant proposals as well, though it may not be as obvious as a dissertation chapter titled “Review of the Literature.” Frequently, a brief  narrative  literature review will be part of the (you guessed it!) “narrative” component of a grant proposal. (Check out  Lesson 4 of the Libraries’ micro-course on Grants & Funding  for more information about writing grant proposals.) In the case of research grants—like you might write for the NSF, NIH, USDA, or UW-Madison Graduate School—the literature review will most frequently occur within an “introduction” or “background” section of the project narrative.

• What form must my literature review take?
• Can I describe the general structure or organization typical of that form?
• What specific formal features have I noticed in examples from my field?

Rhetorical Feature 3: Purpose

Any single literature review often serves multiple purposes, so it will be important for you to understand what it is your literature review is meant to do on a few different levels. As you might guess, the purpose(s) of your literature review will strongly depend on its audience, type, and form.

There is one overriding purpose across nearly all literature reviews, however, which is to situate your research within relevant, ongoing conversations.

Situate your research within relevant, ongoing conversations

Imagine, for a moment, what it would feel like to read a scientific article without a narrative literature review incorporated into the text… You would probably have lots of questions! For instance, “What have other people researched in this area? What did they find? What were the implications, and how does this study support or complicate them? What were the limitations of past research, and how is this study’s approach different?”

The same questions could be asked of a dissertation or grant proposal without a literature review, and systematic reviews and meta-analyses simply wouldn’t exist! The most important thing your literature review needs to do is to summarize and synthesize existing research in a way that creates space for a new perspective—your perspective—to enter the conversation.

Depending on its type, form, and audience, your literature review might also seek to:

• Especially when a literature review is part of a thesis or dissertation project, one of its purposes may be to demonstrate your deep knowledge of the research area to an audience of specialists. The research project itself serves as a testament to your readiness to enter an industrial or scholarly profession, and the literature review specifically testifies to your knowledge of relevant research and your ability to synthesize that research into a coherent narrative.
• If your literature review is part of a grant proposal, it will likely need to communicate the broader impact of your research to an audience of non-specialists. Often, that impact will be framed within the context of real-world problems or challenges that your research aims to address. While your research project as a whole might propose changes in professional practice, public policy, or manufacturing products, the literature review can help you to establish the context for that change by providing an overview of what has and has not been done already.
• In the case of systematic reviews and meta-analyses, one major purpose must be to contribute new knowledge to the field through the review itself. Remember, these types of reviews are research studies themselves, whereas narrative literature reviews summarize and synthesize other research.
• What purpose(s) do I have in writing this literature review?
• What is my literature review supposed to accomplish?
• How is each purpose of my review related to the audience I’m writing for? To the type and form of the review?

Rhetorical Feature 4: Audience

Who will be engaging with your literature review? This element is closely tied to purpose and will impact choices you make while writing. Some audiences may be particularly interested in your literature review due to its type and form. The type and form of your review may also require particular writing conventions.

Specialists

What type of specialized knowledge or experience does your intended audience likely have? Is it likely that your intended audience has deep knowledge of your discipline and area of expertise? You may be able to avoid explanatory passages in your writing by assuming common knowledge or experiences. If your literature review is likely to challenge a status quo within a research area, you may need to devote more text to justifying the challenge. Also, readers who have specialized knowledge in your same area are likely to also know the literature well. Establishing and disclosing your inclusion/exclusion criteria, even in a narrative literature review, can help you respond to challenges.

For instance, suppose a senior faculty member, your advisor, or a peer-reviewer questions why you included certain publications in your review but did not include specified other articles. You may need to defend your choices, and having clearly defined inclusion/exclusion criteria already established will help you form your response to a challenge.

Non-specialists

We are defining a non-specialist as a person whose specialized knowledge is within a different scientific context than yours, or doesn’t run as deeply as yours. If you anticipate that your readership will include persons outside of your specific discipline, you may need to devote space to explaining the concepts and connections you are making so that their significance is readily apparent. For instance, if your literature review is a component of a grant application, the reviewers will likely have deep, specialized knowledge of their own, but not necessarily within your precise research area. It is important to not assume that they will automatically see how your literature review supports your funding need. A non-specialist may also not have a deep knowledge of the literature in your area and, as a critical reader, will want an understanding of your inclusion/exclusion criteria as well.

Questions to Ask:

• What audiences are likely to engage with my literature review?
• What audiences would I like to engage with my literature review?
• What are the concepts, nuances, methods, paradigms, intellectual history, or applications that I understand deeply when I engage with my specialty’s literature? Which of these is important to clarify so a non-specialist can engage purposefully with my literature review?

Rhetorical Features Review

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Literature Reviews

• What is a Literature Review?
• Steps for Creating a Literature Review
• Providing Evidence / Critical Analysis
• Challenges when writing a Literature Review
• Systematic Literature Reviews

Developing a Literature Review

1. Purpose and Scope

To help you develop a literature review, gather information on existing research, sub-topics, relevant research, and overlaps. Note initial thoughts on the topic - a mind map or list might be helpful - and avoid unfocused reading, collecting irrelevant content.  A literature review serves to place your research within the context of existing knowledge. It demonstrates your understanding of the field and identifies gaps that your research aims to fill. This helps in justifying the relevance and necessity of your study.

To avoid over-reading, set a target word count for each section and limit reading time. Plan backwards from the deadline and move on to other parts of the investigation. Read major texts and explore up-to-date research. Check reference lists and citation indexes for common standard texts. Be guided by research questions and refocus on your topic when needed. Stop reading if you find similar viewpoints or if you're going off topic.

You can use a "Synthesis Matrix" to keep track of your reading notes. This concept map helps you to provide a summary of the literature and its connections is produced as a result of this study. Utilizing referencing software like RefWorks to obtain citations, you can construct the framework for composing your literature evaluation.

2. Source Selection

Focus on searching for academically authoritative texts such as academic books, journals, research reports, and government publications. These sources are critical for ensuring the credibility and reliability of your review. 

• Academic Books: Provide comprehensive coverage of a topic.
• Journal Articles: Offer the most up-to-date research and are essential for a literature review.
• Research Reports: Detailed accounts of specific research projects.
• Government Publications: Official documents that provide reliable data and insights.

3. Thematic Analysis

Instead of merely summarizing sources, identify and discuss key themes that emerge from the literature. This involves interpreting and evaluating how different authors have tackled similar issues and how their findings relate to your research.

4. Critical Evaluation

Adopt a critical attitude towards the sources you review. Scrutinize, question, and dissect the material to ensure that your review is not just descriptive but analytical. This helps in highlighting the significance of various sources and their relevance to your research.

Each work's critical assessment should take into account:

Provenance:  What qualifications does the author have? Are the author's claims backed up by proof, such as first-hand accounts from history, case studies, stories, statistics, and current scientific discoveries? Methodology:  Were the strategies employed to locate, collect, and evaluate the data suitable for tackling the study question? Was the sample size suitable? Were the findings properly reported and interpreted? Objectivity : Is the author's viewpoint impartial or biased? Does the author's thesis get supported by evidence that refutes it, or does it ignore certain important facts? Persuasiveness:  Which of the author's arguments is the strongest or weakest in terms of persuasiveness? Value:  Are the author's claims and deductions believable? Does the study ultimately advance our understanding of the issue in any meaningful way?

5. Categorization

Organize your literature review by grouping sources into categories based on themes, relevance to research questions, theoretical paradigms, or chronology. This helps in presenting your findings in a structured manner.

6. Source Validity

Ensure that the sources you include are valid and reliable. Classic texts may retain their authority over time, but for fields that evolve rapidly, prioritize the most recent research. Always check the credibility of the authors and the impact of their work in the field.

7. Synthesis and Findings

Synthesize the information from various sources to draw conclusions about the current state of knowledge. Identify trends, controversies, and gaps in the literature. Relate your findings to your research questions and suggest future directions for research.

Practical Tips

• Use a variety of sources, including online databases, university libraries, and reference lists from relevant articles. This ensures a comprehensive coverage of the literature.
• Avoid listing sources without analysis. Use tables, bulk citations, and footnotes to manage references efficiently and make your review more readable.
• Writing a literature review is an ongoing process. Start writing early and revise as you read more. This iterative process helps in refining your arguments and identifying additional sources as needed.  

Brown University Library (2024) Organizing and Creating Information. Available at: https://libguides.brown.edu/organize/litreview (Accessed: 30 July 2024).

Pacheco-Vega, R. (2016) Synthesizing different bodies of work in your literature review: The Conceptual Synthesis Excel Dump (CSED) technique . Available at: http://www.raulpacheco.org/2016/06/synthesizing-different-bodies-of-work-in-your-literature-review-the-conceptual-synthesis-excel-dump-technique/ (Accessed: 30 July 2024).

Study Advice at the University of Reading (2024) Literature reviews . Available at: https://libguides.reading.ac.uk/literaturereview/developing (Accessed: 31 July 2024).

Further Reading

Frameworks for creating answerable (re)search questions  How to Guide

Literature Searching How to Guide

• << Previous: Steps for Creating a Literature Review
• Next: Providing Evidence / Critical Analysis >>
• Last Updated: Sep 4, 2024 11:43 AM
• URL: https://library.lsbu.ac.uk/literaturereviews

Reference management. Clean and simple.

What is a literature review? [with examples]

What is a literature review?

The purpose of a literature review, how to write a literature review, the format of a literature review, general formatting rules, the length of a literature review, literature review examples, frequently asked questions about literature reviews, related articles.

A literature review is an assessment of the sources in a chosen topic of research.

In a literature review, you’re expected to report on the existing scholarly conversation, without adding new contributions.

If you are currently writing one, you've come to the right place. In the following paragraphs, we will explain:

• the objective of a literature review
• how to write a literature review
• the basic format of a literature review

Tip: It’s not always mandatory to add a literature review in a paper. Theses and dissertations often include them, whereas research papers may not. Make sure to consult with your instructor for exact requirements.

The four main objectives of a literature review are:

• Studying the references of your research area
• Summarizing the main arguments
• Identifying current gaps, stances, and issues
• Presenting all of the above in a text

Ultimately, the main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

The format of a literature review is fairly standard. It includes an:

• introduction that briefly introduces the main topic
• body that includes the main discussion of the key arguments
• conclusion that highlights the gaps and issues of the literature

➡️ Take a look at our guide on how to write a literature review to learn more about how to structure a literature review.

First of all, a literature review should have its own labeled section. You should indicate clearly in the table of contents where the literature can be found, and you should label this section as “Literature Review.”

➡️ For more information on writing a thesis, visit our guide on how to structure a thesis .

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, it will be long. If your paper does not depend entirely on references, it will be short.

Take a look at these three theses featuring great literature reviews:

• School-Based Speech-Language Pathologist's Perceptions of Sensory Food Aversions in Children [ PDF , see page 20]
• Who's Writing What We Read: Authorship in Criminological Research [ PDF , see page 4]
• A Phenomenological Study of the Lived Experience of Online Instructors of Theological Reflection at Christian Institutions Accredited by the Association of Theological Schools [ PDF , see page 56]

Literature reviews are most commonly found in theses and dissertations. However, you find them in research papers as well.

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, then it will be long. If your paper does not depend entirely on references, then it will be short.

No. A literature review should have its own independent section. You should indicate clearly in the table of contents where the literature review can be found, and label this section as “Literature Review.”

The main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

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A systematic literature review of the clinical and socioeconomic burden of bronchiectasis

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Background The overall burden of bronchiectasis on patients and healthcare systems has not been comprehensively described. Here, we present the findings of a systematic literature review that assessed the clinical and socioeconomic burden of bronchiectasis with subanalyses by aetiology (PROSPERO registration: CRD42023404162).

Methods Embase, MEDLINE and the Cochrane Library were searched for publications relating to bronchiectasis disease burden (December 2017–December 2022). Journal articles and congress abstracts reporting on observational studies, randomised controlled trials and registry studies were included. Editorials, narrative reviews and systematic literature reviews were included to identify primary studies. PRISMA guidelines were followed.

Results 1585 unique publications were identified, of which 587 full texts were screened and 149 were included. A further 189 citations were included from reference lists of editorials and reviews, resulting in 338 total publications. Commonly reported symptoms and complications included dyspnoea, cough, wheezing, sputum production, haemoptysis and exacerbations. Disease severity across several indices and increased mortality compared with the general population was reported. Bronchiectasis impacted quality of life across several patient-reported outcomes, with patients experiencing fatigue, anxiety and depression. Healthcare resource utilisation was considerable and substantial medical costs related to hospitalisations, treatments and emergency department and outpatient visits were accrued. Indirect costs included sick pay and lost income.

Conclusions Bronchiectasis causes significant clinical and socioeconomic burden. Disease-modifying therapies that reduce symptoms, improve quality of life and reduce both healthcare resource utilisation and overall costs are needed. Further systematic analyses of specific aetiologies and paediatric disease may provide more insight into unmet therapeutic needs.

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Bronchiectasis imposes a significant clinical and socioeconomic burden on patients, their families and employers, and on healthcare systems. Therapies that reduce symptoms, improve quality of life and reduce resource use and overall costs are needed. https://bit.ly/4bPCHlp

• Introduction

Bronchiectasis is a heterogeneous chronic respiratory disease clinically characterised by chronic cough, excessive sputum production and recurrent pulmonary exacerbations [ 1 ], and radiologically characterised by the abnormal widening of the bronchi [ 2 ]. Bronchiectasis is associated with several genetic, autoimmune, airway and infectious disorders [ 3 ]. Regardless of the underlying cause, the defining features of bronchiectasis are chronic airway inflammation and infection, regionally impaired mucociliary clearance, mucus hypersecretion and mucus obstruction, as well as progressive structural lung damage [ 4 , 5 ]. These features perpetuate one another in a “vicious vortex” leading to a decline in lung function, pulmonary exacerbations and associated morbidity, mortality and worsened quality of life [ 4 , 5 ]. Bronchiectasis can be further categorised into several infective and inflammatory endotypes and is associated with multiple comorbidities and underlying aetiologies [ 6 ].

Bronchiectasis has been described as an emerging global epidemic [ 7 ], with prevalence and incidence rates increasing worldwide [ 8 – 12 ]. The prevalence of bronchiectasis, as well as of the individual aetiologies, varies widely across geographic regions [ 13 ]. In Europe, the reported prevalence ranges from 39.1 (females) and 33.3 (males) cases per 100 000 inhabitants in Spain and 68 (females) and 65 (males) cases per 100 000 inhabitants in Germany, to as high as 566 cases (females) and 486 cases (males) per 100 000 inhabitants in the UK [ 10 – 12 ]. In the US, the average overall prevalence was reported to be 139 cases per 100 000 [ 14 ], in Israel, the prevalence was reported to be 234 cases per 100 000 [ 15 ], and in China the prevalence was reported to be 174 per 100 000 [ 8 ]. Studies show that bronchiectasis prevalence increases with age [ 14 ]. This may increase the socioeconomic impact of bronchiectasis on countries with disproportionately higher number of older citizens. Large registry studies in patients with bronchiectasis have been published from the US (Bronchiectasis Research Registry) [ 16 ], Europe and Israel (European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC)); the largest and most comprehensive report available to date) [ 17 ], India (EMBARC-India) [ 18 , 19 ], Korea (Korean Multicentre Bronchiectasis Audit and Research Collaboration) [ 20 ] and Australia (Australian Bronchiectasis Registry) [ 21 ].

Although there are currently no approved disease-modifying therapies for bronchiectasis [ 4 ], comprehensive clinical care recommendations for the management of patients with bronchiectasis have been published [ 22 , 23 ]. However, the burden that bronchiectasis imposes on patients and their families, as well as on healthcare systems, payers and employers, remains poorly understood. No review to date has used a systematic method to evaluate the overall disease burden of bronchiectasis. This is the first systematic literature review aimed at investigating and synthesising the clinical and socioeconomic burden of bronchiectasis. A better understanding of the overarching burden of bronchiectasis, both overall and by individual aetiologies and associated diseases, will highlight the need for new therapies and assist healthcare systems in planning care and required resources.

The protocol of this systematic review was registered on PROSPERO (reference number: CRD42023404162).

Search strategy

This systematic literature review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines [ 24 ]. Embase, MEDLINE and the Cochrane Library were searched for studies related to the clinical and socioeconomic burden of bronchiectasis (noncystic fibrosis bronchiectasis (NCFBE) and cystic fibrosis bronchiectasis (CFBE)) using the search terms available in supplementary table S1 . Articles written in English and published over a 5-year period (December 2017–December 2022) were included.

Selection criteria

The following article types reporting on prospective and retrospective observational studies, registry studies and randomised controlled trials (only baseline data extracted) were included: journal articles, preprints, research letters, conference proceedings, conference papers, conference abstracts, meeting abstracts and meeting posters. Reviews, literature reviews, systematic reviews and meta-analyses, as well as editorials, commentaries, letters and letters to the editor, were included for the purpose of identifying primary studies. A manual search of references cited in selected articles was performed and references were only included if they were published within the 5 years prior to the primary article being published.

Screening and data extraction

A reviewer screened all titles and abstracts to identify publications for full-text review. These publications then underwent full-text screening by the same reviewer for potential inclusion. A second reviewer independently verified the results of both the title/abstract screen and the full-text screen. Any discrepancies were resolved by a third independent reviewer. Data relating to aetiology, symptoms, disease severity, exacerbations, lung function, infection, comorbidities, patient-reported outcomes (PROs), exercise capacity, mortality, impact on family and caregivers, healthcare resource utilisation (HCRU), treatment burden, medical costs, and indirect impacts and costs, as well as data relating to the patient population, study design, sample size and country/countries of origin, were extracted from the final set of publications into a standardised Excel spreadsheet by one reviewer. Studies were grouped based on the burden measure, and aggregate data (range of reported values) were summarised in table or figure format. For the economic burden section, costs extracted from studies reporting in currencies other than the euros were converted to euros based on the average exchange rate for the year in which the study was conducted.

Data from patients with specific bronchiectasis aetiologies and in children (age limits varied from study to study and included upper age limits of 15, 18, 19 and 20 years) were reported separately, where available. As literature relating to NCFBE and CFBE is generally distinct, any data related to CFBE are reported separately in the tables and text. We conducted subanalyses of key disease burden indicators, in which we extracted data from multicentre studies or those with a sample size >1000 subjects, to try to identify estimates from the most representative datasets. These data from larger and multicentre studies are reported in square brackets in tables 1 – 3 and supplementary tables S2–S7 , where available.

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Prevalence and severity of bronchiectasis symptoms overall, in children, during exacerbations and in individual bronchiectasis aetiologies

Patient-reported outcome scores in patients with bronchiectasis overall and in individual bronchiectasis aetiologies

Healthcare resource utilisation (HCRU) in patients with bronchiectasis overall and in individual bronchiectasis aetiologies

Given the nature of the data included in this systematic literature review (that is, a broad range of patient clinical and socioeconomic characteristics rather than the outcome(s) of an intervention), in addition to the broad range of study types included, meta-analyses to statistically combine data of similar studies were not deemed appropriate and therefore not performed.

Summary of included studies

A total of 1834 citations were retrieved from the Embase, MEDLINE and Cochrane Library databases, of which 1585 unique citations were identified. Abstract/title screening led to the inclusion of 587 citations for full-text screening. Following full-text screening, 149 primary citations and 110 literature reviews, systematic reviews and meta-analyses as well as editorials and letters to the editor remained. From the reference lists of these 110 citations, a further 189 primary citations were identified. These articles were only included if 1) the primary articles contained data relating to the burden of bronchiectasis and 2) the primary articles were published within the 5 years prior to the original article's publication date. In total, 338 publications were considered eligible and included in this review ( supplementary figure S1 ). This included 279 journal articles, 46 congress abstracts and 13 letters to the editor or scientific/research letters. The results are summarised in the sections below. For the results from individual studies, including a description of the patient population, study design, sample size and country/countries of origin, please see the supplemental Excel file .

The most frequently reported aetiologies included post-infectious, genetic (primary ciliary dyskinesia (PCD), alpha-1 antitrypsin deficiency (AATD) and cystic fibrosis (CF)), airway diseases (COPD and asthma), allergic bronchopulmonary aspergillosis (ABPA), aspiration and reflux-related, immunodeficiency and autoimmune aetiologies ( supplementary figure S2 ). However, in up to 80.7% of adult cases and 53.3% of paediatric cases, the aetiology was not determined (referred to as “idiopathic bronchiectasis”) ( supplementary figure S2 ). When limited to larger or multicentre studies, the frequency of idiopathic bronchiectasis ranged from 11.5 to 66.0% in adults and from 16.5 to 29.4% in children. Further details and additional aetiologies can be seen in the supplemental Excel file .

Clinical burden

Symptom burden and severity.

Commonly reported symptoms in patients with bronchiectasis included cough, sputum production, dyspnoea, wheezing and haemoptysis, with these symptoms more prevalent in adults compared with children ( table 1 ). Other reported symptoms included chest discomfort, pain or tightness (both generally and during an exacerbation), fever and weight loss in both adults and children, and fatigue, tiredness or asthenia, appetite loss, and sweating in adults. In children, respiratory distress, hypoxia during an exacerbation, sneezing, nasal and ear discharge, thriving poorly including poor growth and weight loss, exercise intolerance, malaise, night sweats, abdominal pain, recurrent vomiting, and diarrhoea were reported ( supplemental Excel file ). Classic bronchiectasis symptoms such as sputum production (range of patients reporting sputum production across all studies: 22.0–92.7%) and cough (range of patients reporting cough across all studies: 24.0–98.5%) were not universally reported ( table 1 ).

In a study comparing bronchiectasis (excluding CFBE) in different age groups (younger adults (18–65 years), older adults (66–75 years) and elderly adults (≥76 years) [ 63 ]), no significant differences across age groups were reported for the presence of cough (younger adults: 73.9%; older adults: 72.8%; elderly adults: 72.9%; p=0.90), sputum production (younger adults: 57.8%; older adults: 63.8%; elderly adults: 6.0%; p=0.16) or haemoptysis (younger adults: 16.5%; older adults: 19.3%; elderly adults: 16.3%; p=0.47).

Disease severity

Disease severity was reported according to several measures including the bronchiectasis severity index (BSI), the forced expiratory volume in 1 s (FEV 1 ), Age, Chronic Colonisation, Extension, Dyspnoea (FACED) score and the Exacerbations-FACED (E-FACED) score, all of which are known to be associated with future exacerbations, hospitalisations and mortality ( supplementary table S2 and the supplemental Excel file ). Up to 78.7, 41.8 and 40.8% of patients with bronchiectasis reported severe disease according to the BSI, FACED score and E-FACED score, respectively ( supplementary table S2 ). In most studies, severity scores were greater among people with bronchiectasis secondary to COPD or post-tuberculosis (TB) than idiopathic bronchiectasis ( supplementary table S2 ). No data relating to disease severity were reported for CFBE specifically.

Exacerbations

The number of exacerbations experienced by patients with bronchiectasis in the previous year, per year and during follow-up are presented in figure 1 . For further details, please see the supplemental Excel file . Two studies reported exacerbation length in patients with bronchiectasis; this ranged from 11 to 16 days (both small studies; sample sizes of 191 and 32, respectively) [ 25 , 64 ]. A study in children with NCFBE reported a median of one exacerbation in the previous year. Additionally, the same study reported that 31.1% of children with bronchiectasis experienced ≥3 exacerbations per year [ 65 ].

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Range of bronchiectasis exacerbations in the previous year, per year and in the first and second years of follow-up. # : Two studies reported significant differences in the number of exacerbations experienced in the previous year across individual aetiologies. Study 1 [ 90 ]: Patients with idiopathic bronchiectasis had significantly fewer exacerbations in the previous year compared with other aetiologies (primary ciliary dyskinesia (PCD), COPD and post-infectious) (p<0.021). Study 2 [ 33 ]: significant difference between post-tuberculosis (TB) bronchiectasis (mean: 2.8) and other aetiologies excluding idiopathic bronchiectasis (mean: 1.7) (p<0.05).

Lung function

Reduced lung function was reported across several different measures in adults and children with bronchiectasis overall, including FEV 1 (absolute values and % predicted), forced vital capacity (FVC; absolute values and % pred) and lung clearance index (adults only) ( supplementary table S3 and the supplemental Excel file ). In most studies, lung function was lowest among people with post-TB bronchiectasis and bronchiectasis secondary to COPD or PCD ( supplementary table S2 ). Additional measures of lung function are detailed in the supplemental Excel file . Lung clearance index, considered more sensitive than spirometry to early airway damage, was elevated in two studies in adults with bronchiectasis, with a range of 9.0–12.8 (normal: 6–7 or less) [ 66 , 67 ].

In a study comparing bronchiectasis (people with CFBE excluded) in different age groups, elderly adults (≥76 years) had significantly lower FEV 1 % pred (median: 67) compared with both younger (18–65 years; median: 78) and older adults (66–75 years; median: 75) (p<0.017 for both comparisons) [ 63 ]. FVC % pred was found to be significantly lower in elderly adults (mean: 65) compared with both younger adults (median: 78) and older adults (median: 75) (p<0.017 for both comparisons) [ 63 ].

Chronic infection with at least one pathogen was reported in 22.3–79.6% of patients with bronchiectasis, although each study defined chronic infection differently (number of studies: 20). When limited to larger or multicentre studies, chronic infection with at least one pathogen was reported in 10.7–54.5% of patients with bronchiectasis (number of studies: 12). In two studies in NCFBE, significant differences in the proportion of patients chronically infected with at least one pathogen were reported across aetiologies (p<0.001 for both studies) [ 68 , 69 ]. Patients with post-infectious (other than TB) bronchiectasis (34.9%) [ 68 ] and patients with PCD-related bronchiectasis (68.3%) [ 69 ] had the highest prevalence of chronic infection.

The most commonly reported bacterial and fungal pathogens are shown in supplementary table S4 . The two most common bacterial pathogens were Pseudomonas ( P .) aeruginosa and Haemophilus ( H. ) influenzae . In several studies, more patients with PCD, TB and COPD as the aetiology of their bronchiectasis reported infection with P. aeruginosa . Additionally, in one study, significantly more children with CFBE had P. aeruginosa infection compared with children with NCFBE [ 70 ]. Further details and additional pathogens are reported in the supplemental Excel file .

Diversity of the sputum microbiome was assessed in two studies. In the first study in people with bronchiectasis (people with CFBE excluded), reduced microbiome alpha diversity (defined as the relative abundance of microbial species within a sample), particularly associated with Pseudomonas or Proteobacteria dominance, was associated with greater disease severity, increased frequency and severity of exacerbations, and a higher risk of mortality [ 71 ]. In the second study (unknown whether people with CFBE were excluded), a lower Shannon–Wiener diversity index (a measure of species diversity, with lower scores indicating lower diversity) score was associated with multiple markers of disease severity, including a higher BSI score (p=0.0003) and more frequent exacerbations (p=0.008) [ 72 ].

In a study comparing bronchiectasis (people with CFBE excluded) in different age groups (younger adults: 18–65 years; older adults: 66–75 years; elderly adults: ≥76 years) [ 63 ], chronic infection with H. influenzae was reported in 18.3% of younger adults, 12.8% of older adults and 8.8% of elderly adults, and chronic infection with Streptococcus ( Str. ) pneumoniae was reported in 5.3% of younger adults, 2.8% of older adults and 1.3% of elderly adults. For both of the above, the prevalence was significantly higher in younger adults compared with elderly adults (p<0.017 for both comparisons). However, no significant differences across age groups were reported for P. aeruginosa , Moraxella catarrhalis or Staphylococcus ( Sta .) aureus chronic infection.

P. aeruginosa infection was significantly associated with reduced FEV 1 [ 73 ], more severe disease [ 74 ], more frequent exacerbations [ 35 , 49 , 75 , 76 ], increased hospital admissions, reduced quality of life based on St. George's Respiratory Questionnaire (SGRQ) and increased and 4-year mortality [ 49 , 76 ]. Additionally, in a study reporting healthcare use and costs in the US between 2007–2013, healthcare costs and hospitalisation costs were found to be increased in patients infected with P. aeruginosa ($56 499 and $41 972 more than patients not infected with P. aeruginosa , respectively) [ 77 ]. In the same study, HCRU was also higher in patients infected with P. aeruginosa (fivefold increase in the number of hospitalisations and 84% more emergency department (ED) visits compared with patients not infected with P. aeruginosa ) [ 77 ].

Comorbidities

The most frequently reported comorbidities included cardiovascular (including heart failure, cerebrovascular disease and hypertension), respiratory (including asthma, COPD and sinusitis), metabolic (including diabetes and dyslipidaemia), malignancy (including haematological and solid malignancies), bone and joint-related (including osteoporosis and rheumatological disease), neurological (including anxiety and depression), renal, hepatic, and gastrointestinal comorbidities ( supplementary table S5 ). No data relating to comorbidities were reported for CFBE specifically. For further details and additional comorbidities, please see the supplemental Excel file .

In a study comparing bronchiectasis (people with CFBE excluded) in different age groups (younger adults: 18–65 years; older adults: 66–75 years; elderly adults: ≥76 years), younger adults had a significantly lower prevalence of diabetes compared with older adults, a significantly lower prevalence of stroke compared with elderly adults and a significantly lower prevalence of heart failure, solid tumours and renal failure compared with both older and elderly adults (p<0.0017 for all comparisons). Additionally, the prevalence of COPD was significantly lower in both younger and older adults compared with elderly adults (p<0.017) [ 63 ]. In studies reporting in children with bronchiectasis, the prevalence of comorbid asthma ranged from 22.2 to 25.8% [ 65 , 78 ] and the prevalence of sinusitis was reported to be 12.7% in a single study [ 79 ].

Charlson comorbidity index (CCI)

CCI scores can range from 0 to 37, with higher scores indicating a decreased estimate of 10-year survival. In this review, CCI scores ranged from 0.7 to 6.6 in studies reporting means (number of studies: 7). In one study, adults with bronchiectasis (people with CFBE excluded) who experienced ≥2 exacerbations per year were found to have significantly higher CCI scores (3.3) compared with patients who experienced less than two exacerbations per year (2.2) (p=0.001) [ 35 ]. In another study in adults with bronchiectasis (people with CFBE excluded), CCI scores increased significantly with increasing disease severity, with patients with mild (FACED score of 0–2), moderate (FACED score of 3–4) and severe (FACED score of 5–7) bronchiectasis reporting mean CCI scores of 3.9, 5.7 and 6.3, respectively [ 80 ]. No CCI scores were reported for CFBE specifically.

Prevalence of comorbidities in patients with bronchiectasis compared with control individuals

Several studies reported a higher prevalence of cardiovascular comorbidities. such as heart failure [ 81 ], stroke [ 82 , 83 ] and hypertension [ 82 – 84 ] in patients with bronchiectasis compared with a matched general population or healthy controls. Conversely, several additional studies reported no significant differences [ 81 , 85 , 86 ]. Two large studies reported an increased prevalence of diabetes in patients with bronchiectasis compared with nonbronchiectasis control groups [ 83 , 84 ]; however, three additional smaller studies reported no significant differences [ 81 , 82 , 86 ]. The prevalence of gastro–oesophageal reflux disease was found to be significantly higher in patients with bronchiectasis compared with matched nonbronchiectasis controls in one study [ 87 ], but no significant difference was reported in a second study [ 85 ]. Both anxiety and depression were found to be significantly more prevalent in patients with bronchiectasis compared with matched healthy controls in one study [ 55 ]. Lastly, two large studies reported an increased prevalence of asthma [ 84 , 87 ] and five studies reported a significantly higher prevalence of COPD [ 81 , 82 , 84 , 85 , 87 ] in patients with bronchiectasis compared with matched nonbronchiectasis controls or the general population. A smaller study reported conflicting evidence whereby no significant difference in the prevalence of asthma in patients with bronchiectasis compared with matched controls was reported [ 85 ].

Socioeconomic burden

Patient-reported outcomes.

Health-related quality of life (HRQoL), fatigue, anxiety and depression were reported across several PRO measures and domains. The most frequently reported PROs are discussed in further detail in the sections below ( table 2 ). Further details and additional PROs can be seen in the supplemental Excel file .

In a study comparing bronchiectasis (people with CFBE excluded) in different age groups (younger adults: 18–65 years; older adults: 66–75 years; elderly adults: ≥76 years), the median SGRQ total score was significantly higher in elderly adults (50.8) compared with younger adults (36.1), indicating a higher degree of limitation (p=0.017) [ 63 ].

In a study that reported Leicester Cough Questionnaire (LCQ) scores in men and women with bronchiectasis (people with CFBE excluded) separately, women had significantly lower LCQ total scores (14.9) when compared with men (17.5) (p=0.006), indicating worse quality of life [ 88 ]. Additionally, women had significantly lower scores across all three LCQ domains (p=0.014, p=0.005 and p=0.011 for physical, psychological and social domains, respectively) [ 88 ].

Exercise capacity

Exercise capacity in patients with bronchiectasis was reported using walking tests namely the 6-minute walk test (6MWT) and the incremental shuttle walk test (ISWT) ( supplementary table S6 ). The 6MWT data from patients with bronchiectasis generally fell within the normal range for healthy people; however, the ISWT data was below the normal range for healthy people ( supplementary table S6 ). Studies also reported on daily physical activity, daily sedentary time and number of steps per day in patients with bronchiectasis, and in children specifically ( supplementary table S6 ). No data relating to disease severity were reported for CFBE specifically. Further details can be seen in the supplemental Excel file .

Exercise capacity in patients with bronchiectasis compared with control individuals

In one study, the ISWT distance was reported to be significantly lower in patients with NCFBE compared with healthy controls (592.6 m versus 882.9 m; difference of ∼290 m; p<0.001) [ 89 ]. Additionally, patients with bronchiectasis spent significantly less time on activities of moderate and vigorous intensity compared with healthy controls (p=0.030 and 0.044, respectively) [ 89 ]. Lastly, a study reported that patients with NCFBE had a significantly lower step count per day compared with healthy controls (p<0.001) [ 89 ].

Mortality rate during study period

Mortality ranged from 0.24 to 67.6%; however, it should be noted that the study duration differed across studies. When limited to larger or multicentre studies, the mortality rate ranged from 0.24 to 28.1%. One study reported more deaths in patients with NCFBE (9.1%; 5.9-year mean follow-up period) compared with patients without bronchiectasis (0.8%; 5.4-year mean follow-up period) [ 84 ]. In one study, significantly more patients with COPD-related bronchiectasis died (37.5%) compared with other aetiologies (19.0%) (3.4-year mean follow-up period; p<0.001). After adjusting for several factors, multivariate analysis showed that the diagnosis of COPD as the primary cause of bronchiectasis increased the risk of death by 1.77 compared with the patients with other aetiologies [ 41 ]. Similarly, in another study, COPD-associated bronchiectasis was associated with higher mortality (55%) in multivariate analysis as compared with other aetiologies (rheumatic disease: 20%; post-infectious: 16%; idiopathic: 14%; ABPA: 13%; immunodeficiency: 11%) (hazard ratio 2.12, 95% CI 1.04–4.30; p=0.038; 5.2-year median follow-up period) [ 90 ].

Mortality rates by year

The 1-, 2-, 3-, 4- and 5-year mortality rates in patients with bronchiectasis (people with CFBE excluded, unless unspecified) ranged from 0.0 to 12.3%, 0.0 to 13.0%, 0.0 to 21.0%, 5.5 to 39.1% and 12.4 to 53.0%, respectively (number of studies: 9, 4, 7, 1 and 4, respectively). When limited to larger or multicentre studies, the 1-, 2-, 3- and 5-year mortality rates ranges were 0.4–7.9%, 3.9–13.0%, 3.7–21.0% and 12.4–53.0% (no 4-year mortality data from larger or multicentre studies). No data relating to mortality rates were reported for CFBE specifically.

Two studies reported mortality rate by bronchiectasis aetiology (people with CFBE excluded). In the first study, no significant difference in the 4-year mortality rate was reported across aetiologies (p=0.7; inflammatory bowel disease: 14.3%; post-TB: 13.4%; rheumatoid arthritis: 11.4%; idiopathic or post-infectious: 10.1%; ABPA: 6.1%; other aetiologies: 6.1%) [ 49 ]. In the second study, patients with post-TB bronchiectasis had a significantly higher 5-year mortality rate (30.0%) compared with patients with idiopathic bronchiectasis (18.0%) and other aetiologies (10.0%) (p<0.05 for both comparisons) [ 32 ].

In-hospital and intensive care unit mortality

In-hospital mortality ranged from 2.9 to 59.3% in patients with bronchiectasis (people with CFBE excluded, unless unspecified) hospitalised for an exacerbation or for other reasons (number of studies: 7). When limited to larger or multicentre studies, in-hospital mortality rate was reported in only one study (33.0%). One study reported mortality in bronchiectasis patients admitted to a tertiary care centre according to aetiology; in-hospital mortality was highest in patients with post-pneumonia bronchiectasis (15.8%), followed by patients with idiopathic (7.1%) and post-TB (2.6%) bronchiectasis. No deaths were reported in patients with COPD, ABPA or PCD aetiologies [ 42 ]. Intensive care unit mortality was reported in two studies and ranged from 24.6 to 36.1% [ 62 , 91 ]. No data relating to mortality rates were reported for CFBE specifically.

Impact on family and caregivers

Only two studies discussed the impact that having a child with bronchiectasis has on parents/caregivers. In the first study, parents of children with bronchiectasis (not specified whether children with CFBE were excluded) were more anxious and more depressed according to both the Hospital Anxiety and Depression Scale (HADS) and the Centre of Epidemiological Studies depression scale, compared with parents of children without any respiratory conditions (both p<0.001; sample size of 29 participants) [ 53 ]. In the second study, parents or carers of children with bronchiectasis (multicentre study with a sample size of 141 participants; children with CFBE excluded) were asked to vote for their top five greatest concerns or worries; the most common worries or concerns that were voted for by over 15% of parents were “impact on his/her adult life in the future, long-term effects, normal life” (29.8%), “ongoing declining health” (25.5%), “the cough” (24.8%), “impact on his/her life now as a child (play, development)” (24.1%), “lack of sleep/being tired” (24.1%), “concerns over aspects of antibiotic use” (22.7%), “missing school or daycare” (17.7%) and “breathing difficulties/shortness of breath” (16.3%) [ 92 ].

HCRU in terms of hospitalisations, ED visits, outpatient visits and length of stay overall and by bronchiectasis aetiology are reported in table 3 . No data relating to HCRU were reported for CFBE specifically.

In a study in children with bronchiectasis (children with CFBE excluded), 30.0% of children were hospitalised at least once in the previous year [ 65 ]. The median number of hospitalisations per year was 0 (interquartile range: 0–1) [ 65 ]. In another study, the mean length of hospital stay for children with bronchiectasis was 6.7 days (standard deviation: 4.8 days) [ 93 ]. In a study comparing bronchiectasis (people with CFBE excluded) in different age groups, significantly more elderly adults (≥76 years; 26.0%) were hospitalised at least once during the first year of follow-up compared with younger adults (18–65 years; 17.0%) and older adults (66–75 years; 17.0%) (p<0.017 for both comparisons) [ 63 ]. Additionally, length of stay was found to be significantly longer in male patients (mean: 17.6 days) compared with female patients (mean: 12.5 days) (p=0.03) [ 94 ].

HCRU in patients with bronchiectasis compared with control individuals

Length of stay was found to be 38% higher in patients with bronchiectasis (mean: 15.4 days; people with CFBE excluded) compared with patients with any other respiratory illness (mean: 9.6 days) (p<0.001) [ 94 ]. In a study reporting on HCRU in patients with bronchiectasis (people with CFBE excluded) over a 3-year period (Germany; 2012–2015) [ 85 ], a mean of 24.7 outpatient appointments per patient were reported; there was no significant difference in the number of outpatient appointments between patients with bronchiectasis and matched controls (patients without bronchiectasis matched by age, sex and distribution, and level of comorbidities) (mean: 23.4) (p=0.12). When assessing specific outpatient appointments over the 3-year period, patients with bronchiectasis attended a mean of 9.2 general practitioner appointments, 2.9 radiology appointments, 2.5 chest physician appointments and 0.8 cardiologist appointments. Patients with bronchiectasis had significantly fewer general practitioner appointments compared with matched controls (mean: 9.8) (p=0.002); however, they had significantly more radiology appointments (mean for matched controls: 2.3) and chest physician appointments (mean for matched controls: 1.4) compared with matched controls (p<0.001 for both comparisons).

Hospital admission rates

In England, Wales and Northern Ireland, the crude hospital admission rate in 2013 was 88.4 (95% CI 74.0–105.6) per 100 000 person-years [ 91 ]. In New Zealand (2008–2013), the crude and adjusted hospital admission rates were 25.7 and 20.4 per 100 000 population, respectively [ 95 ]. Lastly, in Australia and New Zealand (2004–2008) the hospital admission rate ranged from 0.7 to 2.9 per person-year [ 96 ]. In all of the abovementioned studies, people with CFBE were excluded.

Treatment burden

In two studies, the percentage of patients with bronchiectasis receiving any respiratory medication at baseline ranged from 60.8 to 85.7% [ 97 , 98 ]. Additionally, in a study comparing healthcare costs in patients with bronchiectasis before and after confirmation of P. aeruginosa infection, mean pharmacy visits in the year preceding diagnosis were reported to be 23.2; this increased significantly by 56.5% to 36.2 in the year post-diagnosis (p<0.0001) [ 99 ]. In another study, patients with bronchiectasis were prescribed a mean of 12 medications for bronchiectasis and other comorbidities [ 100 ]. In all of the abovementioned studies, people with CFBE were excluded. The most frequently reported respiratory treatments can be seen in supplementary table S7 . These included antibiotics (including macrolides), corticosteroids, bronchodilators, mucolytics and oxygen. No treatment data were reported for CFBE specifically. Other respiratory treatments included saline, anticholinergics and leukotriene receptor antagonists ( supplemental Excel file ).

In studies reporting in children with bronchiectasis, 23.9% of children were receiving any bronchodilator at baseline [ 101 ], 9.0–21.7% of children were receiving inhaled corticosteroids (ICS) at baseline [ 101 , 102 ], 4.3% of children were receiving oral corticosteroids at baseline [ 101 ] and 12.1% of children were receiving long-term oxygen therapy [ 103 ].

Medical and nonmedical indirect impacts and costs

Medical costs for bronchiectasis included overall costs, hospitalisation costs, ED visits and outpatient visit costs and costs of treatment; indirect impacts and costs included sick leave and sick pay, missed work and income loss for caregivers, and missed school or childcare for children ( table 4 and the supplemental Excel file ). People with CFBE were excluded from all of the studies in table 4 below. In studies reporting in currencies other than the €, costs were converted to € based on the average exchange rate for the year in which the study was conducted.

Bronchiectasis-related medical costs and indirect impacts and costs (individual studies)

No review to date has systematically evaluated the overall disease burden of bronchiectasis. Here, we present the first systematic literature review that comprehensively describes the clinical and socioeconomic burden of bronchiectasis overall and across individual aetiologies and associated diseases. A total of 338 publications were included in the final analysis. Together, the results indicate that the burden of clinically significant bronchiectasis on patients and their families, as well as on healthcare systems, is substantial, highlighting the urgent need for new disease-modifying therapies for bronchiectasis.

Bronchiectasis is associated with genetic, autoimmune, airway and infectious disorders. However, in many patients with bronchiectasis, an underlying aetiology cannot be identified (idiopathic bronchiectasis) [ 1 , 3 , 4 ]. This is supported by the results of this systematic literature review, in which up to 80.7% of patients were reported to have idiopathic bronchiectasis. The results are in line with those reported in a systematic literature review of bronchiectasis aetiology conducted by G ao et al. [ 13 ] (studies from Asia, Europe, North and South America, Africa and Oceania included) in which an idiopathic aetiology was reported in approximately 45% of patients with bronchiectasis, with a range of 5–82%. The maximum of 80.7% of patients with idiopathic bronchiectasis identified by this systematic literature review is much higher than in the recent report on the disease characteristics of the EMBARC where idiopathic bronchiectasis was the most common aetiology and reported in only ∼38% of patients with bronchiectasis [ 17 ]. This highlights the importance of sample size and geographic variation (80.7% reported from a single-country study with a small sample size versus ∼38% reported from a continent-wide study with a large sample size). Nevertheless, identifying the underlying aetiology is a recommendation of bronchiectasis guidelines as this can considerably alter the clinical management and prognosis [ 23 , 110 ]. Specific therapeutic interventions may be required for specific aetiologies, such as ICS for people with asthma-related bronchiectasis, antifungal treatment for those with ABPA-associated bronchiectasis and immunoglobulin replacement therapy for those with common variable immunodeficiency-related bronchiectasis [ 23 , 111 ]. Indeed, an observational study has shown that identification of the underlying aetiology affected management in 37% of people with bronchiectasis [ 112 ]. Future studies to determine the impact of identifying the underlying aetiology on management and prognosis are needed to fully understand its importance.

Patients with bronchiectasis experienced a significant symptom burden, with dyspnoea, cough, wheezing, sputum production and haemoptysis reported most commonly. These symptoms were also reported in children with bronchiectasis at slightly lower frequencies. Dealing with bronchiectasis symptoms are some of the greatest concerns from a patient's perspective. In a study assessing the aspects of bronchiectasis that patients found most difficult to deal with, sputum, dyspnoea and cough were the first, fifth and sixth most common answers, respectively [ 113 ]. Some aetiologies were reported to have a higher prevalence of certain symptoms. For example, in single studies, patients with PCD-related bronchiectasis were found to have a significantly higher prevalence of cough and wheezing [ 39 ], patients with COPD-related bronchiectasis were found to have a significantly higher prevalence of sputum production [ 41 ], and patients with post-TB bronchiectasis were found to have a higher prevalence of haemoptysis [ 30 ] compared with other aetiologies. Together, these results highlight the need for novel treatments that reduce the symptom burden of bronchiectasis. They also highlight the importance of teaching patients to perform and adhere to regular nonpharmacological interventions, such as airway clearance using physiotherapy techniques, which have been shown to improve cough-related health status and chronic sputum production [ 110 ]. Future studies assessing when airway clearance techniques should be started, and which ones are the most effective, are a research priority [ 113 ].

The burden of exacerbations in patients with bronchiectasis was high, with patients experiencing three or more exacerbations in the previous year (up to 73.6%), per year (up to 55.6%) or in the first year of follow-up (up to 32.4%). Few studies reported significant differences between aetiologies. Importantly, exacerbations are the second-most concerning aspect of bronchiectasis from the patient's perspective [ 113 ]. Patients with frequent exacerbations have more frequent hospitalisations and increased 5-year mortality [ 114 ] and exacerbations are also associated with poorer quality of life [ 114 , 115 ]. Therefore, prevention of exacerbations is of great importance in the management of bronchiectasis [ 116 ]. The exact cause of exacerbations in bronchiectasis (believed to be multifactorial) is not fully understood due a lack of mechanistic studies [ 116 ]. Future studies into the causes and risk factors for exacerbations [ 113 ] may lead to improvements in their prevention.

Many patients with bronchiectasis, including children, experienced chronic infections with bacterial pathogens such as P. aeruginosa , H. influenzae , Sta. aureus and Str. pneumoniae as well as non-tuberculous mycobacteria. Importantly, P. aeruginosa infection was significantly associated with more severe disease, reduced lung function and quality of life, and increased exacerbations, hospital admission, morality, HCRU and healthcare costs. Due to the clear and consistent association between P. aeruginosa and poor outcomes, patients with chronic P. aeruginosa colonisation should be considered to be at a higher risk of bronchiectasis-related complications [ 110 ]. Additionally, regular sputum microbiology screening should be performed in people with clinically significant bronchiectasis to detect new isolation of P. aeruginosa [ 110 ]; in which case, patients should be offered eradication antibiotic treatment [ 23 ]. Eradication of P. aeruginosa is not only of clinical importance, but also of economic importance due to the associated HCRU and healthcare costs. As such, a better understanding of the key factors leading to P. aeruginosa infection is a priority for future research [ 113 ].

Bronchiectasis markedly impacted HRQoL across several PROs including the SGRQ, Quality of Life–Bronchiectasis score, LCQ, COPD Assessment Test and Bronchiectasis Health Questionnaire. In children with bronchiectasis, significantly lower quality of life (according to the Paediatric Quality of Life Inventory score) compared with age-matched controls was reported [ 53 ]. The majority of studies reporting HRQoL in individual aetiologies and associated diseases either reported in a single aetiology, did not perform any statistical analyses to compare aetiologies, or reported no significant differences across aetiologies. Patients also experienced mild-to-moderate anxiety and depression according to the HADS-Anxiety, HADS-Depression and 9-question Patient Health Questionnaire scores, with very limited data reported in individual aetiologies. When compared with healthy controls, anxiety and depression were found to be significantly more prevalent in patients with bronchiectasis [ 55 ]. Additionally, exercise capacity was reduced, with patients with bronchiectasis reported to spend significantly less time on activities of moderate and vigorous intensity and have a significantly lower step count per day compared with healthy controls [ 89 ]. Improvements in anxiety, depression and exercise capacity are important priorities for people with bronchiectasis; in a study assessing the aspects of bronchiectasis that patients found most difficult to manage, “not feeling fit for daily activities”, anxiety and depression were the fourth, eighth and ninth most common answers, respectively [ 113 ].

The studies relating to HCRU and costs in this review were heterogeneous in terms of methodology, time period, country and currency, making them challenging to compare. Nevertheless, this study found that HCRU was substantial, with patients reporting a maximum of 1.3 hospitalisation, 1.3 ED and 21.0 outpatient visits per year. Length of stay was found to be significantly longer in patients with bronchiectasis compared with patients with any other respiratory illness in one study [ 91 ]. In another study, patients with bronchiectasis reported significantly more specialist appointments (radiologist appointments and chest physician appointments) compared with matched controls [ 85 ]. Patients with bronchiectasis also experienced a significant treatment burden, with up to 36.4, 58.0 and 83.0% of patients receiving long-term inhaled antibiotics, oral antibiotics and macrolides, respectively, up to 80.4% receiving long-term ICS and up to 61.7% and 81.4% receiving long-term long-acting muscarinic antagonists and long-acting beta agonists, respectively. Wide ranges of treatment use were reported in this study, which may reflect geographic variation in treatment patterns. Heterogeneous treatment patterns across Europe were observed in the EMBARC registry data with generally higher medication use in the UK and Northern/Western Europe and lower medication use in Eastern Europe (inhaled antibiotics: 1.8–8.9%; macrolides: 0.9–24.4%; ICS: 37.2–58.5%; long-acting beta agonists: 42.7–52.8%; long-acting muscarinic antagonists: 26.5–29.8%) [ 17 ]. Similarly, data from the Indian bronchiectasis registry indicate that the treatment of bronchiectasis in India is also diverse [ 19 ]. Furthermore, in a comparison of the European and Indian registry data, both long-term oral and inhaled antibiotics were more commonly used in Europe compared with India [ 19 ].

Cost varied widely across studies. However, patients, payers and healthcare systems generally accrued substantial medical costs due to hospitalisations, ED visits, outpatient visits, hospital-in-the-home and treatment-related costs. Other medical costs incurred included physiotherapy and outpatient remedies (including breathing or drainage techniques), outpatient medical aids (including nebulisers and respiration therapy equipment) and the cost of attending convalescence centres. Only one study compared the medical costs in patients with bronchiectasis and matched controls (age, sex and comorbidities) and found that patients with bronchiectasis had significantly higher total direct medical expenditure, hospitalisation costs, treatment costs for certain medications and costs associated with outpatient remedies and medical aids [ 85 ]. Bronchiectasis was also associated with indirect impacts and costs, including sick leave, sick pay and income lost due to absenteeism and missed work, and lost wages for caregivers of patients with bronchiectasis. Children with bronchiectasis also reported absenteeism from school or childcare.

Our findings regarding HRCU and costs in bronchiectasis are mirrored by a recent systematic literature review by R oberts et al . [ 117 ] estimating the annual economic burden of bronchiectasis in adults and children over the 2001–2022 time period. R oberts et al . [ 117 ] found that annual total healthcare costs per adult patient ranged from €3027 to €69 817 (costs were converted from USD to € based on the average exchange rate in 2021), predominantly driven by hospitalisation costs. Likewise, we report annual costs per patient ranging from €218 to €51 033, with annual hospital costs ranging from €1215 to €27 612 (adults and children included) ( table 4 ). Further, R oberts et al . [ 117 ] reports a mean annual hospitalisation rate ranging from 0.11 to 2.9, which is similar to our finding of 0.03–1.3 hospitalisations per year ( table 3 ). With regard to outpatient visits, R oberts et al . [ 117 ] reports a mean annual outpatient respiratory physician attendance ranging from 0.83 to 6.8 visits, whereas we report a maximum of 21 visits per year ( table 3 ). It should be noted, however, that our value is not restricted to visits to a respiratory physician. With regard to indirect annual costs per adult patient, R oberts et al . [ 117 ] reports a loss of income because of illness of €1109–€2451 (costs were converted from USD to € based on the average exchange rate in 2021), whereas we report a figure of ∼€1410 ( table 4 ). Finally, burden on children is similarly reported by us and R oberts et al . [ 117 ], with children missing 12 days of school per year per child ( table 4 ).

Limitations of this review and the existing literature

Due to the nature of this systematic literature review, no formal statistical analyses or formal risk of bias assessments were performed.

Several limitations within the existing literature were identified. Firstly, the vast majority of studies reported patients with NCFBE overall, with limited availability of literature reporting on individual aetiologies and associated disease. Furthermore, where this literature was available, it was limited to a handful of individual aetiologies and associated diseases, and in many of these studies, no statistical analyses to compare different aetiologies and associated disease were performed. Additionally, the methods used to determine aetiologies within individual studies may have differed. Literature on NCFBE and CFBE has traditionally been very distinct; as such, most of the studies included in this review have excluded people with CF. As the general term “CF lung disease” was not included in our search string in order to limit the number of hits, limited data on CFBE are included in this review. Bronchiectasis remains largely under-recognised and underdiagnosed, thus limiting the availability of literature. There is a particular knowledge gap with respect to paediatric NCFBE; however, initiatives such as the Children's Bronchiectasis Education Advocacy and Research Network (Child-BEAR-Net) ( www.improvebe.org ) are aiming to create multinational registries for paediatric bronchiectasis.

There were variations in the amount of literature available for the individual burdens. While there was more literature available on the clinical burden of bronchiectasis, economic data (related to both medical costs and indirect costs) and data on the impact of bronchiectasis on families and caregivers, were limited. Additionally, cost comparisons across studies and populations were difficult due to differences in cost definitions, currencies and healthcare systems.

Sample sizes of the studies included in this systematic literature review varied greatly, with the majority of studies reporting on a small number of participants. Furthermore, many of the studies were single-centre studies, thus limiting the ability to make generalisations about the larger bronchiectasis population, and cross-sectional, thus limiting the ability to assess the clinical and socioeconomic burden of bronchiectasis over a patient's lifetime. Furthermore, there may be potential sex/gender bias in reporting that has not been considered in this systematic literature review.

Finally, for many of the reported outcomes, data varied greatly across studies, with wide estimates for the frequency of different aetiologies and comorbidities as well as disease characteristics such as exacerbations and healthcare costs noted. This reflects the heterogeneity of both the study designs (including sample size and inclusion and exclusion criteria) and the study populations themselves. Additionally, the use of non-standardised terms across articles posed a limitation for data synthesis. Systematic collection of standardised data across multiple centres, with standardised inclusion and exclusion criteria such as that being applied in international registries, is likely to provide more accurate estimates than those derived from small single-centre studies.

• Conclusions

Collectively, the evidence identified and presented in this systematic literature review show that bronchiectasis imposes a significant clinical and socioeconomic burden on patients and their families and employers, as well as on healthcare systems. Disease-modifying therapies that reduce symptoms, improve quality of life, and reduce both HCRU and overall costs are urgently needed. Further systematic analyses of the disease burden of specific bronchiectasis aetiologies and associated disease (particularly PCD-, COPD- and post-TB-associated bronchiectasis, which appear to impose a greater burden in some aspects) and paediatric bronchiectasis (the majority of data included in this study were obtained from adults) may provide more insight into the unmet therapeutic needs for these specific patient populations.

Questions for future research

Further research into the clinical and socioeconomic burden of bronchiectasis for individual aetiologies and associated diseases is required.

• Supplementary material

Supplementary Material

Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

Supplementary figures and tables ERR-0049-2024.SUPPLEMENT

Supplementary Excel file ERR-0049-2024.SUPPLEMENT

• Acknowledgements

Laura Cottino, PhD, of Nucleus Global, provided writing, editorial support, and formatting assistance, which was contracted and funded by Boehringer Ingelheim.

Provenance: Submitted article, peer reviewed.

Conflict of interest: The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE). J.D. Chalmers has received research grants from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Gilead Sciences, Grifols, Novartis, Insmed and Trudell, and received consultancy or speaker fees from Antabio, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Insmed, Janssen, Novartis, Pfizer, Trudell and Zambon. M.A. Mall reports research grants paid to their institution from the German Research Foundation (DFG), German Ministry for Education and Research (BMBF), German Innovation Fund, Vertex Pharmaceuticals and Boehringer Ingelheim; consultancy fees from AbbVie, Antabio, Arrowhead, Boehringer Ingelheim, Enterprise Therapeutics, Kither Biotec, Prieris, Recode, Santhera, Splisense and Vertex Pharmaceuticals; speaker fees from Vertex Pharmaceuticals; and travel support from Boehringer Ingelheim and Vertex Pharmaceuticals. M.A. Mall also reports advisory board participation for AbbVie, Antabio, Arrowhead, Boehringer Ingelheim, Enterprise Therapeutics, Kither Biotec, Pari and Vertex Pharmaceuticals and is a fellow of ERS (unpaid). P.J. McShane is an advisory board member for Boehringer Ingelheim's Airleaf trial and Insmed's Aspen trial. P.J. McShane is also a principal investigator for clinical trials with the following pharmaceutical companies: Insmed: Aspen, 416; Boehringer Ingelheim: Airleaf; Paratek: oral omadacycline; AN2 Therapeutics: epetraborole; Renovian: ARINA-1; Redhill; Spero; and Armata. K.G. Nielsen reports advisory board membership for Boehringer Ingelheim. M. Shteinberg reports having received research grants from Novartis, Trudell Pharma and GlaxoSmithKline; travel grants from Novartis, Actelion, Boehringer Ingelheim, GlaxoSmithKline and Rafa; speaker fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Insmed, Teva, Novartis, Kamada and Sanofi; and advisory fees (including steering committee membership) from GlaxoSmithKline, Boehringer Ingelheim, Kamada, Syncrony Medical, Zambon and Vertex Pharmaceuticals. M. Shteinberg also reports data and safety monitoring board participation for Bonus Therapeutics, Israel and is an ERS Task Force member on bronchiectasis guideline development. S.D. Sullivan has participated in advisory boards for Boehringer Ingelheim and has research grants from Pfizer, Bayer and GlaxoSmithKline. S.H. Chotirmall is on advisory boards for CSL Behring, Boehringer Ingelheim and Pneumagen Ltd, served on a data and safety monitoring board for Inovio Pharmaceuticals Inc., and has received personal fees from AstraZeneca and Chiesi Farmaceutici.

Support statement: This systematic literature review was funded by Boehringer Ingelheim International GmbH. The authors did not receive payment related to the development of the manuscript. Boehringer Ingelheim was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations. Funding information for this article has been deposited with the Crossref Funder Registry .

• Received March 8, 2024.
• Accepted June 4, 2024.
• Copyright ©The authors 2024

This version is distributed under the terms of the Creative Commons Attribution Licence 4.0.

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“mimics” of injuries from child abuse: case series and review of the literature.

1. Introduction

2. materials and methods, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Focardi, M.; Gori, V.; Romanelli, M.; Santori, F.; Bianchi, I.; Rensi, R.; Defraia, B.; Grifoni, R.; Gualco, B.; Nanni, L.; et al. “Mimics” of Injuries from Child Abuse: Case Series and Review of the Literature. Children 2024 , 11 , 1103. https://doi.org/10.3390/children11091103

Focardi M, Gori V, Romanelli M, Santori F, Bianchi I, Rensi R, Defraia B, Grifoni R, Gualco B, Nanni L, et al. “Mimics” of Injuries from Child Abuse: Case Series and Review of the Literature. Children . 2024; 11(9):1103. https://doi.org/10.3390/children11091103

Focardi, Martina, Valentina Gori, Marta Romanelli, Francesco Santori, Ilenia Bianchi, Regina Rensi, Beatrice Defraia, Rossella Grifoni, Barbara Gualco, Laura Nanni, and et al. 2024. "“Mimics” of Injuries from Child Abuse: Case Series and Review of the Literature" Children 11, no. 9: 1103. https://doi.org/10.3390/children11091103

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Advances in the Diagnosis and Management of Cardiac Amyloidosis: A Literature Review

Jordan llerena-velastegui.

a Medical School, Pontifical Catholic University of Ecuador, Quito, Ecuador

b Research Center, Center for Health Research in Latin America (CISeAL), Quito, Ecuador. Email: moc.liamg@4991anerellnadroj

Kristina Zumbana-Podaneva

Associated data.

All data generated or analyzed during this study are included in this published article, and further inquiries should be directed to the corresponding author.

Cardiac amyloidosis, increasingly recognized for its significant impact on global heart health and patient survival, demands a thorough review to understand its complexity and the urgency of improved management strategies. As a cause of cardiomyopathy and heart failure, particularly in patients with aortic stenosis and atrial fibrillation, this condition also relates to higher incidences of dementia in the affected populations. The objective of this review was to integrate and discuss the latest advancements in diagnostics and therapeutics for cardiac amyloidosis, emphasizing the implications for patient prognosis. We evaluated the latest literature from major medical databases such as PubMed and Scopus, focusing on research from 2020 to 2024, to gather comprehensive insights into the current landscape of this condition. Insights from our review highlight the complex pathophysiology of cardiac amyloidosis and the diagnostic challenges it presents. We detail the effectiveness of emerging treatments, notably gene silencing therapies like patisiran and vutrisiran, which offer transformative potential by targeting the production of amyloidogenic proteins. Additionally, the stabilization therapy acoramidis shows promise in modifying disease progression and improving clinical outcomes. This review underscores the critical need for updated clinical guidelines and further research to expand access to groundbreaking therapies and enhance disease management. Advocating for continued research and policy support, we emphasize the importance of advancing diagnostic precision and treatment effectiveness, which are vital for improving patient outcomes and addressing this debilitating disease globally.

Introduction

Cardiac amyloidosis (CA), an increasingly recognized condition within the realm of cardiology, is characterized by the extracellular deposition of amyloid fibrils in the heart, leading to restrictive cardiomyopathy (RCM) and substantial global health implications [ 1 ]. This condition primarily manifests as transthyretin (amyloid transthyretin (ATTR)) or immunoglobulin light chain (AL) amyloidosis, each posing unique diagnostic challenges and necessitating distinct therapeutic approaches [ 2 ].

CA is classified into several types, each with unique cardiac and extracardiac manifestations [ 3 ]. The three primary forms are AL amyloidosis and transthyretin amyloidosis, which includes wild-type (wild-type transthyretin amyloidosis (wtATTR)) and hereditary variants (hereditary transthyretin amyloidosis (hATTR)) [ 4 ]. AL amyloidosis, associated with plasma cell dyscrasias, is characterized by rapid progression and severe cardiac involvement, leading to high morbidity and mortality [ 5 ]. Transthyretin amyloidosis, on the other hand, often presents in an older population, manifesting predominantly as heart failure with preserved ejection fraction (HFpEF) and significant aortic stenosis [ 6 ].

wtATTR is frequently associated with aortic stenosis in elderly patients. This association is primarily due to the age-related accumulation of transthyretin amyloid deposits in the myocardium and aortic valve. The accumulation of amyloid in the aortic valve can contribute to the restriction of valve opening, thereby exacerbating aortic stenosis. Studies have shown that wtATTR is prevalent among patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis, suggesting a pathological link rather than a mere coincidence [ 7 ]. The amyloid deposits increase the stiffness of the valve and myocardial tissue, leading to decreased compliance and worsening of diastolic function, which further complicates the clinical management of these patients [ 8 ]. Understanding this relationship is crucial for early diagnosis and appropriate management of wtATTR in patients with aortic stenosis. By clearly elucidating the connection between wtATTR and aortic stenosis, this review aims to provide a comprehensive understanding of the pathophysiology and clinical implications of CA, thereby enhancing the management strategies for affected patients.

AL amyloidosis requires specific attention due to its distinct pathophysiology and treatment strategies. The primary treatment for AL amyloidosis involves chemotherapy regimens that target the underlying plasma cell dyscrasia, such as bortezomib, lenalidomide, and dexamethasone [ 7 ]. Autologous stem cell transplantation is also a treatment option for eligible patients, offering potential remission and improved survival rates [ 8 ]. The management of cardiac involvement in AL amyloidosis includes the use of heart failure medications, though these must be carefully tailored due to the unique challenges posed by amyloid infiltration in the myocardium [ 9 ].

In contrast, the treatment of ATTR amyloidosis has seen the advent of novel therapies like tafamidis, patisiran, and vutrisiran, which target the production and stabilization of transthyretin to prevent amyloid fibril formation and deposition [ 10 ]. These therapies offer a different mechanism of action compared to those used for AL amyloidosis, highlighting the need for distinct treatment pathways based on the type of amyloidosis diagnosed.

Recent clinical experiences highlight the complexity of diagnosing and treating CA. For instance, patients often present with nonspecific symptoms such as fatigue and edema, which can lead to misdiagnosis or delayed diagnosis. Advanced imaging techniques, such as echocardiography with strain imaging and cardiac magnetic resonance imaging (CMR), are pivotal in early detection and assessment of the extent of cardiac involvement [ 7 ]. Additionally, novel diagnostic tools like bone scintigraphy using 99mTc-pyrophosphate (99mTc-PYP) have shown high sensitivity and specificity for detecting transthyretin amyloidosis, further aiding in differentiating it from AL amyloidosis [ 8 ].

From a therapeutic perspective, the management of CA has evolved significantly. Therapies such as tafamidis, patisiran, and vutrisiran have shown promising results in clinical trials, offering hope for improved patient outcomes. However, these treatments come with challenges, including high costs and limited availability, which can impact their accessibility and overall effectiveness in real-world settings [ 9 ]. Clinicians must navigate these challenges while considering each patient’s unique clinical presentation and disease progression to optimize treatment strategies.

Through this review, we aim to provide a comprehensive and clinically relevant discussion on the pathophysiology, diagnosis, and management of CA. Our goal is to offer insights that can guide healthcare professionals in making informed decisions, ultimately improving patient care and outcomes in this challenging field.

The pathogenesis of CA involves the misfolding of protein precursors, leading to fibril formation and deposition in cardiac tissues [ 7 ]. This deposition disrupts myocardial structure and function, culminating in heart failure and arrhythmic complications [ 8 ]. Recent epidemiological data highlight a notable underdiagnosis of this condition, particularly among older adults presenting with HFpEF, where systematic screenings have revealed a prevalence as high as 16% in certain cohorts [ 9 ].

Despite the severity of the condition, recent years have witnessed significant advancements in the therapeutic landscape of CA [ 10 ]. Gene silencing therapies, such as patisiran and vutrisiran, target the RNA transcripts of amyloidogenic proteins, reducing their production and potentially altering the course of the disease [ 11 ]. Additionally, stabilizing agents like tafamidis have shown promise in managing TTR variants by preventing protein misfolding and deposition [ 12 ].

The increasing recognition of CA has not only improved our understanding of its clinical presentation but also highlighted the variability in outcomes and discrepancies in the availability of treatment options across different regions and populations [ 13 ]. This review seeks to consolidate current knowledge on the diagnosis, management, and outcomes of CA, with an emphasis on elucidating the pathophysiological mechanisms, optimizing therapeutic strategies, and addressing gaps in current research paradigms.

Thus, the objectives of this review are twofold: to provide a comprehensive overview of the contemporary diagnostic and management approaches in CA and to set a direction for future research that could potentially lead to groundbreaking advancements in the care of patients suffering from this debilitating condition. Through this exploration, we aim to foster a deeper understanding of CA, from its molecular underpinnings to its clinical implications, thereby improving patient outcomes and contributing to the global efforts in combating this intricate disease.

Epidemiology

CA, a form of cardiomyopathy primarily driven by the accumulation of amyloid proteins within the heart, manifests predominantly through transthyretin or immunoglobulin light chains [ 3 ]. The three major forms of CA identified are wtATTR, hATTR, and AL amyloidosis [ 4 ].

Recent epidemiological data suggest a notable underdiagnosis of wtATTR, particularly among older adults presenting with HFpEF and severe aortic stenosis [ 14 ]. Systematic screenings in such cohorts reveal a prevalence of approximately 6% in individuals over 60 years of age with HFpEF, compared to a mere 1% detected without dedicated screening [ 15 ]. Similar studies conducted in hospital settings on patients with HFpEF indicate a prevalence of 13%, and among those undergoing transcatheter aortic valve implantation for aortic stenosis, the detection rate of wtATTR amyloidosis climbs to 16% [ 16 ].

The epidemiology of hATTR (or ATTR variant (ATTRv)) remains less clear due to its association with over 120 pathogenic gene variants, each exhibiting varying geographical and ethnic prevalence [ 17 ]. Common mutations such as Val122Ile and Val30Met suggest a distinct genetic predisposition linked to specific populations, influencing the regional distribution of this amyloidosis type [ 18 ].

AL amyloidosis, although rare with an incidence of approximately one per 100,000 annually in the United States, is associated with plasma cell dyscrasias [ 19 ]. This form presents a critical need for enhanced diagnostic awareness due to its severe prognostic implications if left unidentified [ 20 ].

Demographically, recent insights indicate an increase in the prevalence and incidence of CA globally, with particular emphasis on the elderly and male populations [ 21 ]. This is corroborated by findings from autopsies and clinical screenings which suggest that CA, particularly transthyretin amyloid cardiomyopathy (ATTR-CM), may be significantly more prevalent than previously recognized in the aging population [ 22 ]. Ethnic and racial disparities also emerge in the manifestation and progression of the disease, with non-Hispanic Blacks and Hispanics exhibiting more aggressive disease phenotypes and higher hospitalization rates compared to Whites [ 23 ].

Understanding these epidemiological trends is essential for framing public health strategies and clinical approaches, aiming to enhance screening and early diagnosis, especially in high-risk groups. This is critical not only for improving outcomes through timely interventions but also for addressing disparities in the detection and management of CA across different demographic groups.

Pathophysiology

CA is characterized by the extracellular deposition of misfolded proteins in the myocardium, which results in RCM and progressive heart failure [ 24 ]. The pathophysiology of this disease involves complex molecular and biochemical mechanisms centered around the misfolding and aggregation of specific proteins, primarily transthyretin in ATTR and immunoglobulin light chains in AL [ 25 ].

In ATTR, genetic mutations such as Val122Ile, Thr60Ala, and Glu89Gln destabilize TTR tetramers, facilitating their dissociation into monomeric forms that are prone to misfold [ 26 ]. These misfolded proteins then aggregate into amyloid fibrils, which deposit in the cardiac extracellular matrix [ 27 ]. Similarly, in AL amyloidosis, abnormal immunoglobulin light chains produced by clonal plasma cells fold improperly and form amyloid fibrils [ 28 ].

Once deposited, these amyloid fibrils disrupt the structural integrity and functional capacity of the heart [ 29 ]. They interfere with the alignment and organization of cardiac muscle fibers, increase myocardial stiffness, and reduce elasticity [ 30 ]. This mechanical disruption leads to diastolic dysfunction as the heart becomes less compliant and unable to fill effectively during diastole [ 31 ]. Additionally, amyloid fibrils bind to cellular components such as receptors and enzymes, impairing intracellular signaling and metabolic processes, and disrupting ionic homeostasis [ 7 ]. The presence of amyloid also triggers an inflammatory response in the heart, marked by activation of cardiac fibroblasts and infiltration of inflammatory cells, contributing to further myocardial damage and fibrosis [ 32 ].

These pathophysiological changes culminate in progressive heart failure with symptoms such as dyspnea, fatigue, and edema [ 13 ]. Moreover, amyloid infiltration into the cardiac conduction system can lead to various arrhythmias, including atrial fibrillation (AF) and conduction blocks, further reducing cardiac output and increasing the risk of thromboembolic events [ 33 ].

Understanding these pathophysiological processes is crucial for the clinical management of CA and guides the development of therapeutic strategies [ 7 ]. One such strategy includes gene silencing therapies like patisiran, which target the production of amyloidogenic proteins at the transcriptional level [ 34 ]. By reducing the amount of mutant and wild-type TTR, these therapies aim to lessen the substrate available for amyloid formation [ 35 ]. The pathophysiological insights into how amyloid fibrils affect cardiac function support the use of such therapies, which, although they do not remove existing deposits, can prevent the formation of new amyloid accumulations and potentially ameliorate symptoms and disease progression [ 7 ].

Thus, the molecular and cellular mechanisms underlying the deposition of amyloid fibrils and their impact on cardiac tissues are fundamental to diagnosing and developing interventions for CA [ 36 ]. Further research into these mechanisms is essential for creating therapies that not only alleviate symptoms but also modify the underlying disease dynamics.

Clinical Manifestations

CA manifests through a spectrum of symptoms that vary depending on the type of amyloid protein involved and the extent of cardiac infiltration [ 37 ]. This condition, characterized by the deposition of amyloid proteins in the heart, leads to significant clinical challenges due to its diverse presentations and the progressive nature of the disease [ 38 ].

Patients with ATTR amyloidosis, whether hereditary or wild type, typically present in the later decades of life, with symptoms emerging predominantly after the age of 60 [ 39 ]. The clinical phenotype includes features of RCM such as dyspnea on exertion, fatigue, and lower extremity edema, reflecting the underlying heart failure caused by impaired ventricular filling and reduced diastolic function of the heart [ 13 ]. These symptoms are often more pronounced in patients with wild-type ATTR amyloidosis and certain hereditary variants, where cardiac involvement is the dominant clinical feature [ 5 ].

In contrast, AL amyloidosis affects patients usually beginning at age 40, with a wider range of organ involvement [ 40 ]. In addition to cardiac symptoms, patients may exhibit manifestations related to renal, neurological, and gastrointestinal involvement [ 3 ]. Cardiac-specific symptoms in AL amyloidosis tend to be severe due to the toxic effects of amyloidogenic light chains on myocardial cells, which can exacerbate cardiac dysfunction [ 13 ].

Common cardiac manifestations in all forms of amyloidosis include increased jugular venous pressure, hepatic congestion, and ascites associated with right ventricular failure [ 14 ]. Advanced disease stages are characterized by features of low cardiac output such as diminished pulse pressure and delayed capillary refill, indicating severe cardiac compromise [ 41 ].

Arrhythmias are a prevalent complication, with patients frequently presenting with syncope or presyncope [ 42 ]. These episodes are typically caused by bradyarrhythmias or advanced atrioventricular block, though ventricular arrhythmias can also occur [ 43 ]. The need for pacemaker implantation is common, especially in patients with ATTR amyloidosis due to progressive conduction system disease [ 44 ].

Electrocardiographic findings in CA often reveal a low voltage in the limb leads and a pseudoinfarct pattern in the precordial leads, despite echocardiographic evidence of increased left ventricular wall thickness [ 45 ]. This discordance is a notable diagnostic clue but varies in sensitivity depending on the amyloid type [ 20 ]. Echocardiography typically shows increased wall thickness, biatrial enlargement, and signs of diastolic dysfunction [ 46 ]. These imaging findings are crucial for assessing the severity and extent of myocardial involvement [ 47 ].

AF is another common finding, especially in patients with wtATTR amyloidosis, and is associated with an increased risk of thromboembolic events [ 33 ]. The deposition of amyloid proteins not only in the ventricles but also in the atrial walls can lead to atrial electromechanical dissociation during sinus rhythm, which further complicates the clinical picture [ 44 ].

In summary, the clinical manifestations of CA are complex and varied, often involving a combination of heart failure symptoms, arrhythmias, and conduction system abnormalities. The diagnosis is challenging due to the nonspecific nature of early symptoms and the multifaceted presentations that depend heavily on the type and extent of amyloid deposition within the heart. Early recognition and detailed cardiovascular evaluation are critical to managing this intricate and progressively debilitating disease.

Complications

CA presents significant challenges in clinical management due to its diverse array of complications, which predominantly affect the heart’s electrical system and mechanical function [ 48 ]. This disease process leads to substantial morbidity and mortality, primarily from AF, conduction system disease, heart failure, and sudden cardiac death (SCD) [ 49 ].

AF is notably prevalent in patients with ATTR-CA, occurring in up to 73% of cases. This high incidence is linked with older age, advanced disease stage, and increased left atrial volume index. The management of AF in this group is complicated by the high risk of thromboembolic events and the poor tolerance of rate control medications, often necessitating early adoption of rhythm control strategies [ 50 ]. Although anticoagulation therapy is crucial for preventing strokes in these patients, recent studies indicate that novel oral anticoagulants (NOACs) are associated with a lower risk of major bleeding compared to warfarin, while both options effectively reduce the incidence of thromboembolic events [ 50 ]. Furthermore, AF ablation appears to reduce mortality and hospitalization for heart failure when performed early, emphasizing the need for prompt and tailored treatment interventions [ 51 ].

Conduction system disease also emerges as a frequent complication due to amyloid fibril deposition within the myocardium. This deposition can lead to bundle branch blocks, atrioventricular block, or sick sinus syndrome. Management often requires the implantation of pacemakers, especially in patients exhibiting advanced conduction disorders [ 52 ]. However, the timing for such interventions is critical and demands careful clinical judgment to balance the benefits against potential risks. Moreover, standard arrhythmic drugs like beta-blockers and calcium-channel blockers are typically poorly tolerated in this patient population, complicating traditional therapeutic approaches [ 25 ].

Heart failure in CA is predominantly driven by RCM due to amyloid infiltration in the myocardial extracellular space. This condition leads to both diastolic and, eventually, systolic dysfunction as the disease progresses [ 24 ]. The management of heart failure in these patients is intricate, requiring a combination of standard heart failure therapies and novel disease-modifying treatments that aim to slow or halt the progression of amyloid deposition. Challenges include the systemic nature of the disease and the need for a multidisciplinary approach to address the complex clinical presentation [ 53 ].

SCD is a grave risk for patients with CA, with ventricular arrhythmias and electromechanical dissociation being primary contributors. While implantable cardioverter-defibrillators (ICDs) have been used for the prevention of SCD, their effectiveness in improving overall survival in this group remains uncertain [ 54 ]. This uncertainty is partly due to the high mortality rate observed despite ICD therapy and the complex interplay of risk factors including ventricular tachyarrhythmias, which may not be adequately managed by ICDs alone. Noninvasive measures of myocardial energy metabolism have been explored as potential tools for predicting SCD risk, suggesting that metabolic imaging could play a role in risk stratification [ 55 ].

In conclusion, the complications associated with CA necessitate a nuanced understanding of its pathophysiological impact on cardiac function and a comprehensive approach to management that integrates both symptomatic treatment and strategies aimed at modifying the underlying disease process. The intricate interplay of electrical and mechanical dysfunction requires targeted interventions to mitigate the high risk of morbidity and mortality in this patient population.

Diagnostic Criteria and Challenges

CA is a complex condition characterized by the deposition of amyloid proteins in the myocardium, leading to varied and often nonspecific clinical presentations that can challenge timely and accurate diagnosis. This section outlines the diagnostic criteria and challenges associated with identifying CA, emphasizing the systematic approaches required to confirm this condition [ 24 ].

The suspicion of CA should be raised in several clinical settings, particularly in patients presenting with unexplained left ventricular hypertrophy (LVH), whether they exhibit heart failure symptoms or not. Such cases necessitate a detailed clinical evaluation including a thorough history to note any presence of bilateral carpal tunnel syndrome before the onset of heart failure, which is suggestive of ATTR amyloidosis [ 56 ]. Other scenarios warranting suspicion include instances of low-flow, low-gradient aortic stenosis coupled with echocardiographic signs of impaired longitudinal strain and conditions like systemic AL amyloidosis or ATTR-related peripheral neuropathy, where cardiac involvement may often be secondary [ 57 ].

Once clinical suspicion is established, a structured diagnostic approach is vital. The initial evaluation should integrate a comprehensive clinical examination, detailed family and medical history, routine laboratory tests, and an electrocardiogram to identify cardiac and extracardiac symptoms and signs indicative of amyloidosis [ 58 ]. Subsequently, echocardiography serves as the principal noninvasive imaging modality, offering crucial insights such as the presence of a granular “sparkling” texture of the myocardium, biatrial enlargement, and thickening of the valves and interatrial septum. Notably, the echocardiographic finding of relative apical sparing of longitudinal strain is highly suggestive of CA and can aid in differentiating it from other causes of LVH [ 59 ].

Apical sparing refers to the preservation of myocardial strain in the apical segments of the heart while the basal and mid segments show reduced strain. This pattern is thought to result from the predilection of amyloid deposits to affect the basal and mid segments more extensively than the apex. The exact mechanisms are not fully understood, but it is hypothesized that variations in myocardial blood flow, amyloid deposition patterns, and differences in myocardial fiber orientation contribute to this phenomenon [ 60 ]. By highlighting these echocardiographic features and explaining their underlying mechanisms, this review aims to enhance the diagnostic accuracy and clinical understanding of CA, thereby improving patient management and outcomes.

Further imaging assessments may include cardiovascular magnetic resonance (CMR), which provides detailed myocardial tissue characterization. CMR is particularly useful in visualizing the diffuse subendocardial or transmural late gadolinium enhancement typical of CA. Additionally, T1 mapping during CMR can provide quantitative measures that correlate strongly with the extent of amyloid infiltration, thus supporting the diagnosis even in early stages [ 60 ].

Bone tracer cardiac scintigraphy using radiotracers like 99mTc-PYP plays a critical role in diagnosing ATTR CA. A significant uptake in these scans, especially in the absence of a monoclonal protein indicative of plasma cell dyscrasia, can confirm ATTR without the need for tissue biopsy [ 61 ]. However, when the presence of monoclonal proteins is detected, further hematological evaluation and possibly a bone marrow biopsy are necessary to differentiate AL from ATTR amyloidosis or other forms such as amyloid A (AA) amyloidosis [ 13 ].

In cases where the noninvasive diagnostic modalities are inconclusive, or clinical suspicion remains high despite negative findings, tissue biopsy remains the gold standard. This invasive procedure, typically involving an endomyocardial biopsy, allows for direct visualization and typing of amyloid deposits using Congo red staining, which exhibits apple-green birefringence under polarized light, and further confirmation through immunohistochemical or mass spectrometric methods to determine the precise type of amyloid protein involved [ 40 ].

In conclusion, diagnosing CA requires a high index of clinical suspicion prompted by specific clinical and laboratory indicators, followed by a systematic approach utilizing echocardiography, CMR, and bone scintigraphy to identify the disease. In ambiguous cases, tissue biopsy confirms the diagnosis, allowing for appropriate management and therapeutic interventions tailored to the type of amyloidosis identified.

Differential Diagnosis

The differential diagnosis of CA involves a detailed examination to distinguish it from conditions with similar clinical presentations, such as hypertrophic cardiomyopathy (HCM), constrictive pericarditis, and other forms of RCM, including sarcoidosis and light chain deposition disease [ 62 ]. Each of these conditions presents unique diagnostic challenges and requires specific investigative approaches to ensure accurate diagnosis and appropriate management [ 63 ].

HCM often presents with asymmetric septal hypertrophy, predominantly affecting the interventricular septum, and may involve genetic markers and family history elements absent in amyloidosis. Echocardiographic examination in CA typically reveals symmetrical left ventricular wall thickening with a granular sparkling appearance, distinguishing it from the asymmetrical thickening observed in HCM. Advanced imaging techniques, such as strain imaging, can further enhance differentiation, showing a relative apical sparing of longitudinal strain in CA, a pattern rarely observed in HCM [ 62 ].

Constrictive pericarditis, characterized by a thickened, calcified pericardium on imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRI), shows distinct hemodynamic features from CA. These include ventricular interdependence and a dip-and-plateau filling pattern of the ventricles, identifiable through echocardiography and CMR. In contrast, CA does not exhibit these pericardial abnormalities but may show biatrial enlargement and ventricular thickening consistent with infiltrative processes [ 64 ].

RCM other than amyloidosis, such as endomyocardial fibrosis or Loeffler’s syndrome, presents with fibrosis and eosinophilic infiltration distinct from the amyloid fibrils seen in CA. Histological findings from biopsies in RCM reveal specific patterns of fibrosis without the characteristic apple-green birefringence under polarized light, which is indicative of amyloid deposits in CA [ 65 ].

Sarcoidosis involves non-caseating granulomas identifiable on myocardial biopsy, which are absent in CA. Diagnostic criteria for cardiac sarcoidosis include advanced imaging findings such as positron emission tomography (PET) scans, which detect inflammatory activity not present in amyloidosis, aiding in their differentiation [ 66 ].

Light chain deposition disease differs from CA in that the light chain deposits do not form fibrils and, thus, do not exhibit the Congo red positivity seen in CA. Immunofluorescence or immunohistochemistry typically shows positivity for specific light chains in structures like the glomerular basement membrane, contrasting with the diffuse and extensive deposition in CA [ 67 , 68 ].

HFpEF and CA can both present with diastolic dysfunction and similar echocardiographic findings. However, distinguishing these conditions may rely on clinical context, biomarker profiles, and response to treatment, where specific markers like N-terminal pro-B-type natriuretic peptide (NT-proBNP) and echocardiographic indices such as strain patterns may help in differentiation [ 69 ].

A comprehensive diagnostic approach, integrating clinical evaluation, detailed imaging studies, and histopathological analysis, is essential to accurately differentiate CA from other mimicking conditions [ 70 ]. This systematic approach ensures that CA is appropriately diagnosed and managed, taking into consideration the complex interplay of clinical presentations and the specific characteristics of each condition.

Management and Treatment

The management of CA encompasses a broad spectrum of strategies, from pharmacological interventions and gene silencing therapies to supportive care and advanced treatment options like heart transplantation. This comprehensive approach is essential due to the complex nature of CA, which involves the deposition of amyloid proteins in the heart, leading to RCM and heart failure [ 71 ].

Ongoing surveillance of disease progression in CA is critical. This is typically achieved through a combination of biomarker assessments, including natriuretic peptides and troponins, which provide prognostic information. Cardiac imaging plays a pivotal role, with techniques such as echocardiography and CMR being integral for assessing myocardial structure and function. Advanced imaging modalities, including technetium-labeled bone scintigraphy, are increasingly utilized not only for diagnosis but also for monitoring response to therapy [ 72 ].

The pharmacological management of CA must be approached with caution. Traditional heart failure medications often pose risks due to patients’ sensitivity to volume changes and reduced cardiac output. In AL CA, common medications such as beta-blockers and calcium channel blockers may exacerbate heart failure symptoms or lead to adverse events due to their hemodynamic effects. Consequently, these agents are generally avoided or used with stringent monitoring [ 44 ].

Tafamidis has emerged as a cornerstone in the management of ATTR amyloidosis, stabilizing the transthyretin protein and preventing its misfolding and deposition as amyloid fibrils. Recent advancements have introduced gene silencing therapies that target the production of transthyretin at the RNA level, offering new hope for directly addressing the underlying pathophysiology of ATTR [ 73 ].

Acoramidis, a novel therapeutic agent, is garnering attention in the landscape of ATTR-CM management, particularly for its potential to effectively stabilize TTR tetramers. Unlike tafamidis, which shares a similar mechanism, acoramidis has demonstrated promising results in recent clinical trials. It significantly lowers hospitalization rates and offers some improvement in exercise capacity and quality of life for patients with ATTR CA. Although mortality rates did not differ significantly from those observed with placebo, the nuanced benefits in managing symptoms and potentially delaying progression provide a meaningful therapeutic option. Importantly, the robust in vitro evidence supporting acoramidis’s capacity to achieve near-complete TTR stabilization suggests its superior effectiveness over tafamidis, particularly across various genetic forms of the disease. This broad efficacy implies that acoramidis could offer a substantial clinical advantage, contributing to the evolving therapeutic strategies aimed at mitigating the burdensome effects of ATTR [ 74 ].

Among the most promising advancements in the treatment of CA are gene silencing therapies such as patisiran and vutrisiran. These therapies utilize mechanisms of RNA interference to reduce the hepatic synthesis of transthyretin, thereby diminishing the amyloid burden in the myocardium. Recent clinical trials have shown that patisiran can significantly improve cardiac markers and quality of life, although its impact on mortality and hospitalization requires further investigation [ 75 , 76 ].

For patients with refractory CA, options such as heart transplantation may be considered, though the feasibility depends on the patient’s overall health and the specific type of amyloidosis. Mechanical circulatory support devices are less commonly used due to technical challenges related to the myocardial infiltration by amyloid [ 77 ].

Management also includes non-pharmacological strategies such as dietary modifications, fluid management, and avoidance of alcohol and tobacco. In selected cases, surgical interventions may be necessary to address specific complications arising from amyloid deposition in the heart [ 78 ].

The timing of interventions in CA management significantly affects patient outcomes. Early intervention with therapies like tafamidis, patisiran, or vutrisiran, when cardiac function is less compromised, can slow disease progression and improve prognosis. Conversely, advanced-stage interventions may focus more on symptom management and supportive care. This underscores the importance of early diagnosis and timely therapeutic intervention to optimize patient outcomes [ 79 ].

The landscape of CA management is evolving rapidly, with gene silencing therapies at the forefront of this transformation. These treatments offer a mechanism-based approach to reduce the production of amyloidogenic proteins and potentially reverse some of the cardiac damage [ 79 ]. As research progresses, the integration of these new therapies with traditional approaches promises to enhance outcomes for patients suffering from this challenging and often fatal condition.

To provide a comprehensive overview, we have included Table 1 [ 73 - 76 ], summarizing recent therapies introduced in clinical trials, detailing the number of participants, outcomes related to survival and stabilization, and primary trial findings.

TTR: transthyretin; ATTR: amyloid transthyretin.

One very major problem with the new therapies is the cost, which should be considered in light of their limited effect on survival. The cost of therapies such as tafamidis, patisiran, and vutrisiran can be substantial, potentially limiting their accessibility. Tafamidis, for example, is known to be priced at around $225,000 per year, making it one of the most expensive cardiovascular drugs on the market. Patisiran and vutrisiran, while promising, also come with high costs due to their novel RNA interference technology.

An economic analysis reveals that while these therapies can significantly improve the quality of life and reduce hospitalizations, their cost-effectiveness is still under debate. For instance, tafamidis has been shown to reduce cardiovascular-related hospitalizations, but its impact on overall mortality is less pronounced. This brings into question the overall cost-benefit ratio, particularly for healthcare systems with limited resources.

In the context of a cost-benefit analysis, the primary benefits of these therapies include improved cardiac biomarkers, reduced symptoms, and better quality of life, which must be weighed against their financial burden. Policymakers and healthcare providers need to consider these factors when making decisions about the allocation of resources for the treatment of CA.

Addressing the high costs and ensuring broader access to these therapies will be crucial for maximizing their impact on patient outcomes. Future research should also focus on developing more cost-effective treatments and strategies to manage CA, which could provide significant benefits in terms of both health outcomes and economic sustainability.

The prognosis of CA varies significantly based on the type of amyloidosis, the stage at diagnosis, and the response to treatment. In AL amyloidosis with cardiac involvement, the median survival is approximately 5.5 years with contemporary management. Staging methods, such as the Mayo Clinic staging system, which incorporate biomarkers like NT-proBNP and cardiac troponin T, provide a robust framework for predicting survival. These systems demonstrate that higher biomarker levels correlate with more advanced disease and poorer outcomes [ 80 ].

In ATTR amyloidosis, both wild-type (ATTRwt) and variant (ATTRv), staging also relies heavily on NT-proBNP and troponin levels, but includes renal function as measured by estimated glomerular filtration rate (eGFR). Patients with ATTR amyloidosis show a median survival that varies significantly across stages; those in the earliest stage have a substantially longer survival compared to those in the most advanced stage. The staging system specifically for ATTRwt or ATTRv predicts median survival times of 69.2 months, 46.7 months, and 24.1 months for stages I, II, and III, respectively. This demonstrates a clear gradient of risk based on biomarker and renal function profiles [ 81 ].

The predictive factors influencing prognosis in CA are multifaceted. In AL amyloidosis, the Mayo staging system, hematologic response, and cardiac response are significant predictors of survival. Advanced disease stages and lack of early cardiac response, particularly in stage IIIb cardiac AL amyloidosis, are associated with shortened survival. Conversely, patients who achieve an early cardiac response often experience a prolonged survival, underscoring the importance of timely and effective treatment [ 82 ].

Imaging and biomarker studies are indispensable tools for prognostic assessment in CA. CMR, including techniques like late gadolinium enhancement and T1 mapping, provides critical information on myocardial involvement and fibrosis. Additionally, molecular imaging with PET and single-photon emission computed tomography (SPECT) facilitates early assessment of amyloid burden and disease progression [ 83 - 85 ].

Overall, the prognosis of CA depends on a complex interplay of disease subtype, stage at diagnosis, and therapeutic response. Advanced staging systems, coupled with the latest imaging and biomarker technologies, play a crucial role in enhancing prognostic accuracy, thereby guiding therapeutic decisions and improving patient management.

Gaps in the Literature

Despite significant advances in the diagnosis and management of CA, critical gaps in the literature persist, affecting our ability to effectively understand and treat this complex condition. These gaps span across early diagnosis, long-term treatment effects, and the integration of new diagnostic and therapeutic modalities [ 86 ].

In this regard, early diagnostic indicators for CA remain inadequately defined despite the known benefits of early detection in improving patient outcomes. While CMR with late gadolinium enhancement and advanced echocardiography techniques such as speckle tracking have shown promise, the sensitivity and specificity of these methods need further validation. Additionally, a comprehensive set of early “red flags” including clinical, biohumoral, and imaging features has been suggested to facilitate earlier diagnosis, yet a standardized diagnostic pathway incorporating these indicators has not been fully established [ 87 ].

Conversely, there are considerable gaps in understanding the long-term effects of treatments for CA. Although new medications like tafamidis have emerged, comprehensive data on their long-term effectiveness and safety are lacking. The literature calls for novel, non-toxic, and effective treatments for patients with advanced cardiac dysfunction due to amyloidosis, as current therapies are often associated with high rates of early mortality [ 88 ].

Furthermore, while the evolution of epidemiology and natural history of ATTR CA suggests some improvements in short-term outcomes such as the 2-year survival rate with contemporary diagnosis and treatment, comprehensive studies tracking long-term survival and quality of life are still lacking. This highlights the importance of early diagnosis and the timely initiation of disease-modifying treatments to potentially improve overall survival and patient outcomes [ 13 ].

Moreover, the literature indicates that while established biomarkers such as NT-proBNP and high-sensitivity troponin are valuable for the diagnosis of CA, there is a pressing need for the development and validation of novel biomarkers. Emerging technologies and biomarkers could potentially improve the early detection of CA, but gaps remain in their standardization and application in clinical practice [ 89 ].

In terms of imaging, although various noninvasive modalities like MRI, PET, and bone scintigraphy are instrumental in diagnosing CA, comparative studies to delineate their specific roles and improve diagnostic algorithms are needed. In particular, differentiation between the amyloidosis subtypes ATTR and AL remains challenging with current imaging techniques, underscoring the need for advances in this area [ 90 ].

In addition, the integration of genetic testing and personalized medicine into the management of CA represents another critical gap. While genetic testing has facilitated the diagnosis and management of ATTR-CM, comparative trials to clarify treatment options and understand the impact of genetic variations on treatment outcomes are deficient [ 91 ].

To address these gaps, future research should focus on developing standardized, sensitive, and specific diagnostic criteria that incorporate new biomarkers and imaging techniques. Additionally, longitudinal studies are necessary to evaluate the long-term efficacy and safety of new treatments. Finally, improving our understanding of the genetic aspects of amyloidosis will be critical to advancing personalized medicine approaches that could significantly impact treatment outcomes.

Future Directions

Future research and management of CA should focus on enhancing diagnosis, treatment, and patient outcomes. The emphasis is on developing noninvasive diagnostic methods, refining therapeutic options, and implementing comprehensive management strategies tailored to the disease’s complexities [ 92 ].

Advancements in imaging techniques and biomarkers are essential for early detection and accurate diagnosis of CA. Efforts should improve the specificity and sensitivity of CMR and bone scintigraphy to distinguish between ATTR and AL types without invasive biopsies. Additionally, integrating novel biomarkers into clinical practice could provide a better understanding of disease progression. These biomarkers should be validated through clinical trials to establish their roles in enhancing diagnostic accuracy and predicting treatment responses [ 93 ].

In the therapeutic domain, there is a need for treatments that slow amyloid deposition and potentially reverse cardiac tissue damage. Research should focus on refining existing therapies like tafamidis and exploring new drug classes, such as gene silencers and kinetic stabilizers. Combination therapy strategies could address the multifaceted nature of amyloidosis more effectively than monotherapy [ 94 ].

Clinical trials should evaluate the long-term efficacy and safety of emerging treatments, incorporating a range of clinical endpoints to provide a comprehensive assessment of therapeutic benefits. This will facilitate developing personalized treatment regimens considering individual patients’ genetic and biochemical makeup [ 95 ].

Enhancing patient management strategies is also crucial, including optimizing supportive care for heart failure symptoms and refining strategies for managing comorbidities such as AF and thromboembolic disease. Multidisciplinary teams are fundamental in providing comprehensive care that addresses patients’ diverse needs from diagnosis to advanced disease stages [ 96 ].

Collectively, these efforts in research and clinical practice aim to improve outcomes for patients suffering from CA.

Conclusions

CA, a condition marked by the extracellular deposition of amyloid fibrils in the heart, has garnered increasing attention due to its significant impact on global health and its complex management challenges. This review has synthesized key insights into the pathophysiology, epidemiology, and clinical management of the disease, particularly highlighting the underdiagnosed nature of transthyretin amyloidosis among elderly patients with heart failure. Recent advancements in gene silencing therapies offer a promising avenue for targeting the underlying mechanisms of amyloid production, potentially revolutionizing treatment paradigms. However, significant gaps remain in early diagnosis and long-term treatment efficacy. Given these challenges, there is a critical need for continued research and enhanced policy support to refine diagnostic strategies and develop effective treatments, ensuring better management and outcomes for patients suffering from this debilitating condition.

Acknowledgments

The authors have no acknowledgements to declare, reflecting the independent completion of the work.

Funding Statement

No funding was received for the conduct of this study or the preparation of this article, indicating that there are no financial sources to declare.

Conflict of Interest

The authors declare no conflict of interest to ensure the impartiality of the review.

Author Contributions

Jordan Llerena-Velastegui, MD: conceptualization, supervision, project administration, writing - review and editing. Kristina Zumbana-Podaneva: supervision, writing, review, and editing.

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Secondary spontaneous pneumothorax during chemotherapy with bevacizumab for cervical cancer: a case report and literature review

• Case Report - Complication
• Published: 05 September 2024

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• Shogo Nishino   ORCID: orcid.org/0000-0001-9493-7176 1 ,
• Mayu Yunokawa   ORCID: orcid.org/0000-0001-7354-6977 1 , 2 ,
• Yosuke Matsuura   ORCID: orcid.org/0000-0003-3054-6760 3 ,
• Atsushi Fusegi   ORCID: orcid.org/0000-0001-6044-2781 1 ,
• Satoki Misaka   ORCID: orcid.org/0009-0000-1149-9204 1 ,
• Yoichi Aoki   ORCID: orcid.org/0000-0003-0481-9892 1 ,
• Akiko Abe   ORCID: orcid.org/0000-0002-0241-1319 1 ,
• Makiko Omi   ORCID: orcid.org/0000-0003-1894-1864 1 &
• Hiroyuki Kanao   ORCID: orcid.org/0000-0003-1372-6145 1  

Secondary spontaneous pneumothorax (SSP) due to bevacizumab has been reported in other malignancies but not in cervical cancer. We present the case of a 57-year-old woman with stage IIIB cervical cancer who developed SSP during bevacizumab chemotherapy. Despite complete remission with cisplatin-based chemoradiotherapy, she experienced a recurrence 9 months later. A thoracoscopic surgery was performed to remove a lung nodule and bulla. Subsequently, local cervical lesion recurrence and lung metastases were noted, and paclitaxel and carboplatin combined with bevacizumab were administered. After two cycles, a grade-1 left pneumothorax occurred, attributed to bevacizumab-induced tissue fragility. The patient improved within 7 days with conservative management. Bevacizumab was discontinued, and pneumothorax did not recur. This case highlights the rare occurrence of SSP in patients with cervical cancer treated with bevacizumab and underscores the importance of appropriate management of such patients, especially those who have undergone early thoracic surgery.

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We would like to thank Editage ( www.editage.jp ) for English language editing.

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Department of Gynecologic Oncology, The Cancer Institute Hospital of Japanese Foundation of Cancer Research, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan

Shogo Nishino, Mayu Yunokawa, Atsushi Fusegi, Satoki Misaka, Yoichi Aoki, Akiko Abe, Makiko Omi & Hiroyuki Kanao

Department of Medical Oncology, The Cancer Institute Hospital of Japanese Foundation of Cancer Research, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan

Mayu Yunokawa

Department of Thoracic Surgical Oncology, The Cancer Institute Hospital of Japanese Foundation of Cancer Research, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan

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Contributions

Conceptualization: Shogo Nishino, Mayu Yunokawa; Formal Analysis: Shogo Nishino; Investigation: Shogo Nishino, Mayu Yunokawa, Satoki Misaka; Methodology: Mayu Yunokawa, Atsushi Fusegi; Project administration: Mayu Yunokawa; Supervision: Hiroyuki Kanao; Writing-original draft: Shogo Nishino; Writing-review&editing: Mayu Yunokawa, Yosuke Matsuura, Atsushi Fusegi, Yoichi Aoki, Akiko Abe, Makiko Omi, Hiroyuki Kanao.

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Nishino, S., Yunokawa, M., Matsuura, Y. et al. Secondary spontaneous pneumothorax during chemotherapy with bevacizumab for cervical cancer: a case report and literature review. Int Canc Conf J (2024). https://doi.org/10.1007/s13691-024-00696-0

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Received : 18 March 2024

Accepted : 19 June 2024

Published : 05 September 2024

DOI : https://doi.org/10.1007/s13691-024-00696-0

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