The effectiveness of mind mapping versus lecture-based learning in medical education of China’s standardized residency training: a systematic review and meta-analysis of randomized controlled studies

The traditional teaching mode Lecture Based Learning (LBL) often results in student's poor initiative and independent thinking ability and low learning interest. This study aims to investigate the application of CT 3D reconstruction and 3D printing technology combined with CBL teaching mode in the clinical teaching of orthopedics and standardized training of residents. Sixty residents of our hospital were randomly selected to conduct the teaching of joint orthopedic content in orthopedic surgery courses. They were randomly divided into three groups at the time of admission, which adopted LBL teaching mode, CBL teaching mode, CT 3D reconstruction and 3D printing technology combined with CBL teaching mode, respectively. The theoretical knowledge scores and clinical skills scores of the standardized training students in the CBL+3D printing group were significantly higher than those in the LBL or CBL group. Students in CBL+3D printing group had significantly higher recognition in self-ability evaluation. The overall teaching satisfaction of students in CBL+3D printing group was 85.00% (P < 0.05). The combination of CT 3D reconstruction and 3D printing technology with CBL teaching mode can help the students to master the theoretical knowledge and practical skills in the standardized training of joint orthopedics residents, which can effectively improve the teaching quality.

Objective To investigate the effect of taking medical students as standardized patients(SSP) on problem based leaming(PBL) teaching in clerkship.Methods Totally 161 students (grade 2008) selected from clinical medical department was divided into PBL group(n=81) and lecture-based learning(LBL) group(n=80).SSP was introduced into PBL teaching and LBL group was taught by LBL.After the clerkship,theory test was conducted in two groups and questionnaire was given to LBL group.Statistical analyses were conducted by SPSS 13.0,measurement data were analyzed by t test and enumeration data were described by frequency and constituent ratio.Results Theory test results showed that the average score of medical record analysis was (37.35 ± 5.95) in PBL group,much higher than (33.25 ± 4.89) in LBL group(P=0.001) ;the total score was (71.20 ± 8.67) in PBL group,much higher than that of (67.79 ± 9.87) in LBL group(P=0.018) as well.The average scores of choice question in 2 groups were (33.85 ± 5.05) and (34.24 ± 6.87),without significant differences(P=0.658).The constituent ratio of answer ‘OK' regarding 10 entries in questionnaire was more than 75％.The constituent ratio of answer ‘OK' regarding 3 entries(SSP matching degree,SSP without implied language or action,stimulating the learning interest) was more than 90％.Conclusions Introducing SSP PBL teaching can improve students' ability of clinical analysis and problem solving but not so effective for the basic theoretical knowledge grasp.SSP could replace standardized patients in PBL teaching. Key words: Surgery; Problem-based learning; Standardized patients; Student as standardized patients ; Clerkship

Background:The aim of this meta-analysis is to assess the effectiveness of problem-based learning (PBL) in pediatric medical education in China.Methods:We searched Chinese electronic databases, including the China National Knowledge Infrastructure, WanFang Data, the China Science Periodical Database, and the Chinese BioMedical Literature Database. We also searched English electronic databases, including PubMed, Embase, and the Cochrane Central Register of Controlled Trials. We searched for published studies that compared the effects of PBL and traditional lecture-based learning (LBL) on students’ theoretical knowledge, skill, and case analysis scores during pediatric medical education in China. All randomized controlled trials (RCTs) were included.Results:A total of 12 RCTs were included, with a total sample size of 1003 medical students. The PBL teaching model significantly increased theoretical knowledge scores (95% confidence interval [CI], 0.79–1.52; P < .00001), skill scores (95% CI, 0.87–2.25; P < .00001), and case analysis scores (P < .00001, I2 = 88%) compared with those using the LBL teaching model alone.Conclusion:The current meta-analysis shows that PBL in pediatric medical education in China appears to be more effective than the traditional teaching method in improving theoretical knowledge, skill, and case analysis scores. However, a more controlled design of RCT is needed to confirm the above conclusions in future work.

Current study was designed to compare effectiveness of lecture-based and modified team-based learning in achieving cognitive skills in resident doctors.Methodology: This comparative cross sectional study was conducted on medical floor in Mayo Hospital, Lahore. Resident doctors (RDs) including house officers (HOs) and postgraduate residents (PGRs) were divided into two groups for lecture based learning (LBL) and modified team based learning (mTBL) on the topic of “health promotion and disease prevention”. All RDs undertook individual readiness assurance test (IRAT) and final (FT) tests where FT pertained to six cognitive domains. Statistical testing for IRAT and FT scores and performance in early and advanced domains were performed taking p-value &lt; 0.05 as significant.Results: A total of 53 RDs including 58.49% HOs and 41.51% PGRs participated in the study with similar distribution among mTBL and LBL groups. The mean IRAT scores for LBL and mTBL groups were 41.03±17.79&amp;44.17±19.54, respectively (p-value 0.272). The overall FT scores were 40.26±15.17 &amp;48.02±17.57 for LBL and mTBL respectively (p-value 0.045). The FT scores in early domains were 34.81±14.93&amp;56.12±15.1 for LBL and mTBL groups (p-value 0.000). The scores of advanced domains were 35.53±12.65 and 30.56±14.73 for LBL and mTBL (p-value 0.301). PGRs performed better than HOs in early domains (p-value 0.043) but not in advanced domains. There was no difference in performance of male and female RDs. Conclusion: After a single session, mTBL significantly improved performance in early cognitive domains but not in advanced cognitive domains.

Comparison of video-based learning and lecture-based learning for training of ultrasound-guided central venous catheterization: a randomized controlled trial

BackgroundDespite great advances, China’s postgraduate education faces many problems, for example traditional lecture-based learning (LBL) method provides fewer oppotunities to apply knowledge in a working situation. Task-based learning (TBL) is an efficient strategy for increasing the connections among skills, knowledge and competences. This study aimed to evaluate the effect of a modified TBL model on problem-solving abilities among postgraduate medical students in China.MethodsWe allocated 228 first-year postgraduate students at Third Military Medical University into two groups: the TBL group and LBL group. The TBL group was taught using a TBL program for immunohistochemistry. The curriculum consisted of five phases: task design, self-learning, experimental operations, discussion and summary. The LBL group was taught using traditional LBL. After the course, learning performance was assessed using theoretical and practical tests. The students’ preferences and satisfaction of TBL and LBL were also evaluated using questionnaires.ResultsThere were notable differences in the mean score rates in the practical test (P < 0.05): the number of high scores (>80) in the TBL group was higher than that in the LBL group. We observed no substantial differences in the theoretical test between the two groups (P > 0.05). The questionnaire results indicated that the TBL students were satisfied with teaching content, teaching methods and experiment content. The TBL program was also beneficial for the postgraduates in completing their research projects. Furthermore, the TBL students reported positive effects in terms of innovative thinking, collaboration, and communication.ConclusionsTBL is a powerful educational strategy for postgraduate education in China. Our modified TBL imparted basic knowledge to the students and also engaged them more effectively in applying knowledge to solve real-world issues. In conclusion, our TBL established a good foundation for the students’ future in both medical research and clinical work.

Objective To investigate the feasibility and superiority of the lecture based learning （LBL） combined prablem-based learning （PBL） for endocrinology teaching practice. Methods Totally 150 clinic medical undergraduates were randomly divided into three groups： LBL group （n=50）, PBL group （n=50） and LBL＋PBL group （n=50）. Questionnaires, written and oral tests were employed to evaluate the teaching effect. ANOVA was used to compare the indicator scores and chi-square test was used to compare grades and passing rate. Results Teaching efficiency, mater of knowledge, capabilities of analysis, teaming and collaboration ability and medical diagnosis thinking cultivation were better in LBL and PBL group than in the other two groups. There were statistical differences in total score （F=4.69, P=0.010） and passing rate（A-2=8.94,P=0.030） among three groups. Conclusions LBL＋PBL guarantee the teaching quality and cultivate the comprehensive quality of students ; therefore it is superior to LBL and PBL. Key words: Lecture-based learning; Problem- based learning; Combined teaching; En-docrinology

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the analgesic efficacy and adverse effects of single‐dose IV ketorolac, compared with placebo or an active comparator, for moderate‐to‐severe postoperative pain in adults.

At birth, infants' lungs are fluid-filled. For newborns to have a successful transition, this fluid must be replaced by air to enable gas exchange. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving a sustained lung inflation (SLI) at the start of PPV may help clear lung fluid and establish gas volume within the lungs. This is a review update; the last version was published in 2020. To assess the benefits and harms of an initial SLI (> 1 second duration) versus standard inflations (≤ 1 second) in newborn infants receiving resuscitation with intermittent PPV. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and two trial registries on 8 April 2024. We checked the reference lists of studies and other related papers. We included randomised controlled trials (RCTs) and quasi-RCTs comparing initial SLI versus standard inflations given to infants receiving resuscitation with PPV at birth. Our critical outcomes were: death in the delivery room; death during hospitalisation. Other clinically relevant outcomes were: rate of mechanical ventilation; chronic lung disease, any grade; chronic lung disease, moderate to severe; pneumothorax during hospitalisation; intraventricular haemorrhage grade 3 or 4. We used the Cochrane risk of bias tool 1.0. We conducted meta-analyses using fixed-effect models to calculate risk ratios (RR) and 95% confidence intervals (CI). We summarised the certainty of the evidence according to GRADE methods. Fourteen trials enrolling 1766 infants met our inclusion criteria. The studies were conducted on five continents, and published between 2005 and 2024. Investigators in 12 trials (1722 infants) administered SLI with no chest compressions; 10 studies reported that peak inspiratory pressure (PIP) was sustained for 15 seconds. Levels of PIP ranged from 20 to 30 cmH₂O. Investigators in seven studies provided additional SLIs in cases of poor response. We downgraded the overall certainty of evidence for all outcomes because of limitations in study design (e.g. selection bias due to lack of allocation concealment and performance bias due to unblinded intervention), and serious imprecision of results, with wide confidence intervals and few events. One trial is ongoing. For each outcome, we downgraded the overall certainty of evidence because of limitations in study design and imprecision. Compared with intermittent ventilation, SLI with no chest compression may result in little to no difference in: • death in the delivery room (RR 1.72, 95% CI 0.82 to 3.63; I² = 0%; 6 studies, 639 participants; low-certainty evidence); • death before discharge (RR 0.99, 95% CI 0.81 to 1.21; I² = 37%; 12 studies, 1722 participants; low-certainty evidence); • chronic lung disease, any grade (RR 0.99, 95% CI 0.83 to 1.18; I² = 0%; 4 studies, 735 participants; low-certainty evidence); • moderate to severe chronic lung disease (RR 0.95, 95% CI 0.74 to 1.22; I² = 47%; 6 studies, 727 participants; low-certainty evidence); • pneumothorax during hospitalisation (RR 0.93, 95% CI 0.65 to 1.33; I² = 12%; 11 studies, 1641 participants; low-certainty evidence); • intraventricular haemorrhage grade 3-4 (RR 0.94, 95% CI 0.64 to 1.38; I² = 13%; 8 studies, 855 participants; low-certainty evidence). SLI with no chest compression may reduce the rate of mechanical ventilation (RR 0.90, 95% CI 0.80 to 1.01; I² = 0%; 7 studies, 1174 participants; low-certainty evidence). Compared with intermittent ventilation, sustained inflation without chest compression may result in little to no difference in death in the delivery room and death before discharge. Sustained inflation may reduce the rate of mechanical ventilation, and may result in little to no difference in chronic lung disease, pneumothorax, and severe intraventricular haemorrhage. There is no evidence to support the use of sustained inflation based on evidence from our review. Future studies of SLI for infants receiving respiratory support at birth should provide more detailed monitoring of the procedure, such as measurements of lung volume and presence of apnoea before or during SLI. Future RCTs should aim to enrol infants who are at higher risk of morbidity and mortality, and should stratify participants by gestational age. Researchers should also measure long-term neurodevelopmental outcomes (e.g. Bayley Scales of Infant Development, administered at two years of corrected age). This Cochrane Review had no dedicated funding. Protocol (2004): doi.org/10.1002/14651858.CD004953 Original review (2015): doi.org/10.1002/14651858.CD004953.pub2 Review update (2017): doi.org/10.1002/14651858.CD004953.pub3 Review update (2020): doi.org/10.1002/14651858.CD004953.pub4.

BackgroundThe aim of this study was to evaluate the effectiveness of team-, case-, lecture-, and evidence-based learning (TCLEBL) methods in cultivating students’ clinical and research abilities, as compared to traditional lecture-based learning (LBL) approaches.MethodsForty-one medical postgraduates were divided into two groups, a TCLEBL group and an LBL group. Teaching effectiveness was evaluated through student- and teacher-feedback questionnaires, scores from theoretical examinations and written literature reviews, and student learning burdens.ResultsCompared to the LBL approach, both teachers and students were more satisfied with the TCLEBL model (p < 0.001 for both teachers and students). The TCLEBL group performed significantly higher on the theory test compared to the LBL group (p = 0.009). There were significant differences between the LBL and TCLEBL groups, respectively, in terms of literature review and citations (12.683 ± 2.207 vs. 16.302 ± 1.095, p < 0.001), argument and perspective (12.55 ± 1.572 vs. 16.333 ± 1.354, p < 0.001), comprehensiveness of content (13.3 ± 2.268 vs. 16.683 ± 1.344, p < 0.001), and scientific rigor and accuracy (10.317 ± 1.167 vs. 12.746 ± 0.706, p < 0.001). There was no significant difference in the total extracurricular time expended between the two groups (323.75 ± 30.987 min vs. 322.619 ± 24.679 min, respectively for LBL vs. TCLEBL groups, p = 0.898).ConclusionsTCLEBL is an effective teaching method that cultivates students’ clinical and research abilities.

This study aimed to comprehensively evaluate the effect of PBL on problem-solving, self-directed learning, and critical thinking ability of pharmaceutical students through a randomized controlled trial (RCT) and meta-analysis of RCTs. In 2021, 57 third-year pharmacy students from China Pharmaceutical University were randomly divided into a PBL group and a lecture-based learning (LBL) group. Mean scores were compared between the two groups for problem-solving, self-directed learning, communication skills, critical thinking, and final exam grades. Students' feedback on the implementation of PBL was also collected. A meta-analysis was subsequently performed. Two authors independently conducted a comprehensive search of two databases (PubMed and CNKI). Eligible studies with effective data were included and the valuable data were extracted for analysis. Quality of involved studies was assessed by the Cochrane Collaboration's tool. All analyses of statistics were conducted using the 'metafor' package in R software. The PBL group had significantly higher mean scores for problem-solving (8.43±1.56) and self-directed learning (7.39±1.19) than the LBL group (7.02±1.72 and 6.41±1.28, respectively). The PBL group also showed better communication skills (8.86±1.47) than the LBL group (7.68±1.89). The mean level of critical thinking was significantly higher in the PBL group than the LBL group (p = 0.02). The PBL group also had better final exam grades (79.86±1.38) compared to the LBL group (68.1±1.76). Student feedback on PBL implementation was positive. The outcome of subsequent meta-analysis including 8 eligible studies involved 1819 participants showed that the use of PBL significantly improved problem-solving ability (SMD = 1.12, 95% CI = 0.25-1.99) and PBL was also associated with better performance in self-directed learning (SMD = 1.55, 95% CI = 0.64-2.45). However, there was no significant difference in the final exam score in the PBL group compared to the LBL control group (SMD = 0.23, 95% CI = -0.08-0.53). This study found that PBL is an effective teaching method for pharmacy students.

Background The success of digital replantation is highly dependent on the patency of the repaired vessels after microvascular anastomosis. Antithrombotic agents are frequently used for preventing vascular occlusion. Low molecular weight heparin (LMWH) has been reported to be as effective as unfractionated heparin (UFH) in peripheral vascular surgery, but with fewer adverse effects. Its benefit in microvascular surgery such as digital replantation is unclear. This is an update of the review first published in 2013. Objectives To assess if treatment with subcutaneous LMWH improves the salvage rate of the digits in patients with digital replantation after traumatic amputation. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 17 March 2020. The authors searched PubMed, China National Knowledge Infrastructure (CNKI) and Chinese Electronic Periodical Services (CEPS) on 17 March 2020 and sought additional trials from reference lists of relevant publications. Selection criteria We included randomised or quasi‐randomised controlled trials comparing treatment with LMWH versus any other treatment in participants who received digital replantation following traumatic digital amputation. Data collection and analysis Two review authors (PL, CC) independently extracted data and assessed the risk of bias of the included trials using Cochrane's 'Risk of bias' tool. Disagreements were resolved by discussion. We assessed the certainty of evidence using the GRADE approach. Main results We included two new randomised trials in this update, bringing the total number of included trials to four. They included a total of 258 participants, with at least 273 digits, from hospitals in China. Three studies compared LMWH versus UFH, and one compared LMWH versus no LMWH. The mean age of participants ranged from 24.5 to 37.6 years. In the studies reporting the sex of participants, there were a total of 145 men and 59 women. The certainty of the evidence was downgraded to low or very low because all studies were at high risk of performance or reporting bias (or both) and there was imprecision in the results due to the small numbers of participants. The three studies comparing LMWH versus UFH reported the success rate of replantation using different units of analysis (participant or digit), so we were unable to combine data from all three studies (one study reported results for both participants and digits). No evidence of a benefit in success of replantation was seen in the LMWH group when compared with UFH, regardless of whether the outcomes were reported by number of participants (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.87 to 1.10; 130 participants, 2 studies; very low‐certainty evidence); or by number of digits (RR 0.97, 95% CI 0.90 to 1.04; 200 digits, 2 studies; low‐certainty evidence). No studies reported the incidence of compromised microcirculation requiring surgical or non‐surgical therapy, or any systemic/other causes of microvascular insufficiency. There was no evidence of a clear difference between the LMWH and UFH groups in occurrence of arterial occlusion (RR 1.08, 95% CI 0.16 to 7.10; 54 participants, 1 study; very low‐certainty evidence) or venous occlusion (RR 0.81, 95% CI 0.20 to 3.27; 54 participants, 1 study; very low‐certainty evidence). Two studies reported adverse effects. The LMWH and UFH groups showed no evidence of a difference in wound bleeding (RR 0.53, 95% CI 0.23 to 1.23; 130 participants, 2 studies; low‐certainty evidence), haematuria (RR 0.43, 95% CI 0.09 to 2.11; 130 participants, 2 studies; very low‐certainty evidence), ecchymoses (RR 0.82, 95% CI 0.21 to 3.19; 130 participants, 2 studies; very low‐certainty evidence), epistaxis (RR 0.27, 95% CI 0.03 to 2.32; 130 participants, 2 studies; very low‐certainty evidence), gingival bleeding (RR 0.18, 95% CI 0.02 to 1.43; 130 participants, 2 studies; very low‐certainty evidence), and faecal occult blood (RR 0.27, 95% CI 0.03 to 2.31; 130 participants, 2 studies; very low‐certainty evidence). We could not pool data on coagulation abnormalities as varying definitions and tests were used in the three studies. One study compared LMWH versus no LMWH. The success rate of replantation, when analysed by digits, was reported as 91.2% success in the LMWH group and 82.1% in the control group (RR 1.11, 95% CI 0.93 to 1.33; 73 digits, 1 study; very low‐certainty evidence). Compromised microcirculation requiring surgical re‐exploration, analysed by digits, was 11.8% in the LMWH group and 17.9% in the control group (RR 0.86, 95% CI 0.21 to 3.58; 73 digits, 1 study; very low‐certainty evidence). Compromised microcirculation requiring incision occurred in five out of 34 digits (14.7%) in the LMWH group and eight out of 39 digits (20.5%) in the control group (RR 0.72, 95% CI 0.26 to 1.98; 73 digits; very low‐certainty evidence). Microvascular insufficiency due to arterial occlusion, analysed by digits, was 11.8% in the LMWH group and 17.9% in the control group (RR 0.66, 95% CI 0.21 to 2.05; 73 digits, 1 study; very low‐certainty evidence), and venous occlusion was 14.7% in the LMWH group and 20.5% in the control (RR 0.72, 95% CI 0.26 to 1.98; 73 digits, 1 study; very low‐certainty evidence). The study did not report complications or adverse effects. Authors' conclusions There is currently low to very low‐certainty evidence, based on four RCTs, suggesting no evidence of a benefit from LMWH when compared to UFH on the success rates of replantation or affect microvascular insufficiency due to vessel occlusion (analysed by digit or participant). LMWH had similar success rates of replantation; and the incidence rate of venous and arterial microvascular insufficiency showed no evidence of a difference between groups when LMWH was compared to no LMWH (analysed by digit). Similar rates of complications and adverse effects were seen between UFH and LMWH. There was insufficient evidence to draw conclusions on any effect on coagulation when comparing LMWH to UFH or no LMWH. The certainty of the evidence was downgraded due to performance and reporting bias, as well as imprecision in the results. Further adequately powered studies are warranted to provide high‐certainty evidence.

In children with a dual-diagnosis of epilepsy and ADHD, there is some evidence that use of the stimulant drug OROS-MPH is not associated with significant worsening of epilepsy, but higher doses of it may be associated with increased daily risk of seizures; the evidence is of low-certainty. OROS-MPH is also associated with improvement in ADHD symptoms. However, this treatment was also associated with a large proportion of treatment withdrawal compared to placebo. In relation to the non-stimulant drug omega-3, there is some evidence for reduction in seizure frequency in children who are also on risperidone and ASM, compared to children who are on risperidone and ASM alone. Evidence is inconclusive whether omega-3 increases or decreases the risk of adverse drug events. We identified only two studies - one each for OROS-MPH and omega-3 - with low to high risk of bias. We assessed the overall certainty of evidence for the outcomes of both OROS-MPH and omega-3 as low to moderate. More studies are needed. Future studies should include: 1. adult participants; 2. a wider variety of stimulant and non-stimulant drugs, such as amphetamines and atomoxetine, respectively; and 3. additional important outcomes, such as seizure-related hospitalisations and quality of life. Clusters of studies which assess the same drug - and those that build upon the evidence base presented in this review on OROS-MPH and omega-3 - are needed to allow for meta-analysis of outcomes.

Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low-certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High-quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used.

Several school-based interventions are effective in improving child diet and physical activity, and preventing excessive weight gain, and tobacco or harmful alcohol use. However, schools are frequently unsuccessful in implementing such evidence-based interventions. 1. To evaluate the benefits and harms of strategies aiming to improve school implementation of interventions to address student diet, physical activity, tobacco or alcohol use, and obesity. 2. To evaluate the benefits and harms of strategies to improve intervention implementation on measures of student diet, physical activity, obesity, tobacco use or alcohol use; describe their cost or cost-effectiveness; and any harms of strategies on schools, school staff or students. We used standard, extensive Cochrane search methods. The latest search was between 1 September 2016 and 30 April 2021 to identify any relevant trials published since the last published review. We defined 'Implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised controlled trial (RCT) or non-randomised controlled trial (non-RCT)) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by students to 'no intervention', 'usual' practice or a different implementation strategy. We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary (implementation) and secondary (student health behaviour and obesity) outcomes using a decision hierarchy. Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). For RCTs, we conducted meta-analyses of primary and secondary outcomes using a random-effects model, or in instances where there were between two and five studies, a fixed-effect model. The synthesis of the effects for non-randomised studies followed the 'Synthesis without meta-analysis' (SWiM) guidelines. We included an additional 11 trials in this update bringing the total number of included studies in the review to 38. Of these, 22 were conducted in the USA. Twenty-six studies used RCT designs. Seventeen trials tested strategies to implement healthy eating, 12 physical activity and six a combination of risk factors. Just one trial sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials used multiple implementation strategies, the most common being educational materials, educational outreach and educational meetings. The overall certainty of evidence was low and ranged from very low to moderate for secondary review outcomes. Pooled analyses of RCTs found, relative to a control, the use of implementation strategies may result in a large increase in the implementation of interventions in schools (SMD 1.04, 95% CI 0.74 to 1.34; 22 RCTs, 1917 participants; low-certainty evidence). For secondary outcomes we found, relative to control, the use of implementation strategies to support intervention implementation may result in a slight improvement on measures of student diet (SMD 0.08, 95% CI 0.02 to 0.15; 11 RCTs, 16,649 participants; low-certainty evidence) and physical activity (SMD 0.09, 95% CI -0.02 to 0.19; 9 RCTs, 16,389 participants; low-certainty evidence). The effects on obesity probably suggest little to no difference (SMD -0.02, 95% CI -0.05 to 0.02; 8 RCTs, 18,618 participants; moderate-certainty evidence). The effects on tobacco use are very uncertain (SMD -0.03, 95% CIs -0.23 to 0.18; 3 RCTs, 3635 participants; very low-certainty evidence). One RCT assessed measures of student alcohol use and found strategies to support implementation may result in a slight increase in use (odds ratio 1.10, 95% CI 0.77 to 1.56; P = 0.60; 2105 participants). Few trials reported the economic evaluations of implementation strategies, the methods of which were heterogeneous and evidence graded as very uncertain. A lack of consistent terminology describing implementation strategies was an important limitation of the review. The use of implementation strategies may result in large increases in implementation of interventions, and slight improvements in measures of student diet, and physical activity. Further research is required to assess the impact of implementation strategies on such behavioural- and obesity-related outcomes, including on measures of alcohol use, where the findings of one trial suggest it may slightly increase student risk. Given the low certainty of the available evidence for most measures further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.