To the Editor The authors are to be congratulated for conducting this important but challenging systematic review.1 However, while accepting its degree of complexity, we are at variance with the confidence expressed by the authors in the strengths of their study, including a thorough search of the literature and exclusion of lower-quality reports assessed using the Jadad score.
A thorough literature search is a key requirement of a high-quality systematic review and, as the authors confirm, should show all the evidence available at the time of the study.1 Although their search appeared comprehensive, language of publication was clearly a restriction; ie, only studies in English, Spanish, and Portuguese were included. The exclusion of studies based on language of publication is a significant source of bias, which has been well documented, and in this review, the language restriction excludes studies published in the German language.2,3 Hand searching of pre-1987 issues of Mykosen would have identified additional eligible trials, most of which are written in German, and which, based on the flowchart included as the first figure in the article, would have represented a not insignificant percentage of the total number of included trials. The review excluded a number of German studies equivalent to the number of Spanish and Portuguese studies that were included, clearly illustrating the impact of language bias and the not inconsequential gap in the evidence included in this systematic review.
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