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• v.11(5); 2017 May

Critical Appraisal of Clinical Research

Azzam al-jundi.

1 Professor, Department of Orthodontics, King Saud bin Abdul Aziz University for Health Sciences-College of Dentistry, Riyadh, Kingdom of Saudi Arabia.

Salah Sakka

2 Associate Professor, Department of Oral and Maxillofacial Surgery, Al Farabi Dental College, Riyadh, KSA.

Evidence-based practice is the integration of individual clinical expertise with the best available external clinical evidence from systematic research and patient’s values and expectations into the decision making process for patient care. It is a fundamental skill to be able to identify and appraise the best available evidence in order to integrate it with your own clinical experience and patients values. The aim of this article is to provide a robust and simple process for assessing the credibility of articles and their value to your clinical practice.

Introduction

Decisions related to patient value and care is carefully made following an essential process of integration of the best existing evidence, clinical experience and patient preference. Critical appraisal is the course of action for watchfully and systematically examining research to assess its reliability, value and relevance in order to direct professionals in their vital clinical decision making [ 1 ].

Critical appraisal is essential to:

• Combat information overload;
• Identify papers that are clinically relevant;
• Continuing Professional Development (CPD).

Carrying out Critical Appraisal:

Assessing the research methods used in the study is a prime step in its critical appraisal. This is done using checklists which are specific to the study design.

Standard Common Questions:

• What is the research question?
• What is the study type (design)?
• Selection issues.
• What are the outcome factors and how are they measured?
• What are the study factors and how are they measured?
• What important potential confounders are considered?
• What is the statistical method used in the study?
• Statistical results.
• What conclusions did the authors reach about the research question?
• Are ethical issues considered?

The Critical Appraisal starts by double checking the following main sections:

I. Overview of the paper:

• The publishing journal and the year
• The article title: Does it state key trial objectives?
• The author (s) and their institution (s)

The presence of a peer review process in journal acceptance protocols also adds robustness to the assessment criteria for research papers and hence would indicate a reduced likelihood of publication of poor quality research. Other areas to consider may include authors’ declarations of interest and potential market bias. Attention should be paid to any declared funding or the issue of a research grant, in order to check for a conflict of interest [ 2 ].

II. ABSTRACT: Reading the abstract is a quick way of getting to know the article and its purpose, major procedures and methods, main findings, and conclusions.

• Aim of the study: It should be well and clearly written.
• Materials and Methods: The study design and type of groups, type of randomization process, sample size, gender, age, and procedure rendered to each group and measuring tool(s) should be evidently mentioned.
• Results: The measured variables with their statistical analysis and significance.
• Conclusion: It must clearly answer the question of interest.

III. Introduction/Background section:

An excellent introduction will thoroughly include references to earlier work related to the area under discussion and express the importance and limitations of what is previously acknowledged [ 2 ].

-Why this study is considered necessary? What is the purpose of this study? Was the purpose identified before the study or a chance result revealed as part of ‘data searching?’

-What has been already achieved and how does this study be at variance?

-Does the scientific approach outline the advantages along with possible drawbacks associated with the intervention or observations?

IV. Methods and Materials section : Full details on how the study was actually carried out should be mentioned. Precise information is given on the study design, the population, the sample size and the interventions presented. All measurements approaches should be clearly stated [ 3 ].

V. Results section : This section should clearly reveal what actually occur to the subjects. The results might contain raw data and explain the statistical analysis. These can be shown in related tables, diagrams and graphs.

VI. Discussion section : This section should include an absolute comparison of what is already identified in the topic of interest and the clinical relevance of what has been newly established. A discussion on a possible related limitations and necessitation for further studies should also be indicated.

Does it summarize the main findings of the study and relate them to any deficiencies in the study design or problems in the conduct of the study? (This is called intention to treat analysis).

• Does it address any source of potential bias?
• Are interpretations consistent with the results?
• How are null findings interpreted?
• Does it mention how do the findings of this study relate to previous work in the area?
• Can they be generalized (external validity)?
• Does it mention their clinical implications/applicability?
• What are the results/outcomes/findings applicable to and will they affect a clinical practice?
• Does the conclusion answer the study question?
• -Is the conclusion convincing?
• -Does the paper indicate ethics approval?
• -Can you identify potential ethical issues?
• -Do the results apply to the population in which you are interested?
• -Will you use the results of the study?

Once you have answered the preliminary and key questions and identified the research method used, you can incorporate specific questions related to each method into your appraisal process or checklist.

1-What is the research question?

For a study to gain value, it should address a significant problem within the healthcare and provide new or meaningful results. Useful structure for assessing the problem addressed in the article is the Problem Intervention Comparison Outcome (PICO) method [ 3 ].

P = Patient or problem: Patient/Problem/Population:

It involves identifying if the research has a focused question. What is the chief complaint?

E.g.,: Disease status, previous ailments, current medications etc.,

I = Intervention: Appropriately and clearly stated management strategy e.g.,: new diagnostic test, treatment, adjunctive therapy etc.,

C= Comparison: A suitable control or alternative

E.g.,: specific and limited to one alternative choice.

O= Outcomes: The desired results or patient related consequences have to be identified. e.g.,: eliminating symptoms, improving function, esthetics etc.,

The clinical question determines which study designs are appropriate. There are five broad categories of clinical questions, as shown in [ Table/Fig-1 ].

[Table/Fig-1]:

Categories of clinical questions and the related study designs.

2- What is the study type (design)?

The study design of the research is fundamental to the usefulness of the study.

In a clinical paper the methodology employed to generate the results is fully explained. In general, all questions about the related clinical query, the study design, the subjects and the correlated measures to reduce bias and confounding should be adequately and thoroughly explored and answered.

Participants/Sample Population:

Researchers identify the target population they are interested in. A sample population is therefore taken and results from this sample are then generalized to the target population.

The sample should be representative of the target population from which it came. Knowing the baseline characteristics of the sample population is important because this allows researchers to see how closely the subjects match their own patients [ 4 ].

Sample size calculation (Power calculation): A trial should be large enough to have a high chance of detecting a worthwhile effect if it exists. Statisticians can work out before the trial begins how large the sample size should be in order to have a good chance of detecting a true difference between the intervention and control groups [ 5 ].

• Is the sample defined? Human, Animals (type); what population does it represent?
• Does it mention eligibility criteria with reasons?
• Does it mention where and how the sample were recruited, selected and assessed?
• Does it mention where was the study carried out?
• Is the sample size justified? Rightly calculated? Is it adequate to detect statistical and clinical significant results?
• Does it mention a suitable study design/type?
• Is the study type appropriate to the research question?
• Is the study adequately controlled? Does it mention type of randomization process? Does it mention the presence of control group or explain lack of it?
• Are the samples similar at baseline? Is sample attrition mentioned?
• All studies report the number of participants/specimens at the start of a study, together with details of how many of them completed the study and reasons for incomplete follow up if there is any.
• Does it mention who was blinded? Are the assessors and participants blind to the interventions received?
• Is it mentioned how was the data analysed?
• Are any measurements taken likely to be valid?

Researchers use measuring techniques and instruments that have been shown to be valid and reliable.

Validity refers to the extent to which a test measures what it is supposed to measure.

(the extent to which the value obtained represents the object of interest.)

• -Soundness, effectiveness of the measuring instrument;
• -What does the test measure?
• -Does it measure, what it is supposed to be measured?
• -How well, how accurately does it measure?

Reliability: In research, the term reliability means “repeatability” or “consistency”

Reliability refers to how consistent a test is on repeated measurements. It is important especially if assessments are made on different occasions and or by different examiners. Studies should state the method for assessing the reliability of any measurements taken and what the intra –examiner reliability was [ 6 ].

3-Selection issues:

The following questions should be raised:

• - How were subjects chosen or recruited? If not random, are they representative of the population?
• - Types of Blinding (Masking) Single, Double, Triple?
• - Is there a control group? How was it chosen?
• - How are patients followed up? Who are the dropouts? Why and how many are there?
• - Are the independent (predictor) and dependent (outcome) variables in the study clearly identified, defined, and measured?
• - Is there a statement about sample size issues or statistical power (especially important in negative studies)?
• - If a multicenter study, what quality assurance measures were employed to obtain consistency across sites?
• - Are there selection biases?
• • In a case-control study, if exercise habits to be compared:
• - Are the controls appropriate?
• - Were records of cases and controls reviewed blindly?
• - How were possible selection biases controlled (Prevalence bias, Admission Rate bias, Volunteer bias, Recall bias, Lead Time bias, Detection bias, etc.,)?
• • Cross Sectional Studies:
• - Was the sample selected in an appropriate manner (random, convenience, etc.,)?
• - Were efforts made to ensure a good response rate or to minimize the occurrence of missing data?
• - Were reliability (reproducibility) and validity reported?
• • In an intervention study, how were subjects recruited and assigned to groups?
• • In a cohort study, how many reached final follow-up?
• - Are the subject’s representatives of the population to which the findings are applied?
• - Is there evidence of volunteer bias? Was there adequate follow-up time?
• - What was the drop-out rate?
• - Any shortcoming in the methodology can lead to results that do not reflect the truth. If clinical practice is changed on the basis of these results, patients could be harmed.

Researchers employ a variety of techniques to make the methodology more robust, such as matching, restriction, randomization, and blinding [ 7 ].

Bias is the term used to describe an error at any stage of the study that was not due to chance. Bias leads to results in which there are a systematic deviation from the truth. As bias cannot be measured, researchers need to rely on good research design to minimize bias [ 8 ]. To minimize any bias within a study the sample population should be representative of the population. It is also imperative to consider the sample size in the study and identify if the study is adequately powered to produce statistically significant results, i.e., p-values quoted are <0.05 [ 9 ].

4-What are the outcome factors and how are they measured?

• -Are all relevant outcomes assessed?
• -Is measurement error an important source of bias?

5-What are the study factors and how are they measured?

• -Are all the relevant study factors included in the study?
• -Have the factors been measured using appropriate tools?

Data Analysis and Results:

- Were the tests appropriate for the data?

- Are confidence intervals or p-values given?

• How strong is the association between intervention and outcome?
• How precise is the estimate of the risk?
• Does it clearly mention the main finding(s) and does the data support them?
• Does it mention the clinical significance of the result?
• Is adverse event or lack of it mentioned?
• Are all relevant outcomes assessed?
• Was the sample size adequate to detect a clinically/socially significant result?
• Are the results presented in a way to help in health policy decisions?
• Is there measurement error?
• Is measurement error an important source of bias?

Confounding Factors:

A confounder has a triangular relationship with both the exposure and the outcome. However, it is not on the causal pathway. It makes it appear as if there is a direct relationship between the exposure and the outcome or it might even mask an association that would otherwise have been present [ 9 ].

6- What important potential confounders are considered?

• -Are potential confounders examined and controlled for?
• -Is confounding an important source of bias?

7- What is the statistical method in the study?

• -Are the statistical methods described appropriate to compare participants for primary and secondary outcomes?
• -Are statistical methods specified insufficient detail (If I had access to the raw data, could I reproduce the analysis)?
• -Were the tests appropriate for the data?
• -Are confidence intervals or p-values given?
• -Are results presented as absolute risk reduction as well as relative risk reduction?

Interpretation of p-value:

The p-value refers to the probability that any particular outcome would have arisen by chance. A p-value of less than 1 in 20 (p<0.05) is statistically significant.

• When p-value is less than significance level, which is usually 0.05, we often reject the null hypothesis and the result is considered to be statistically significant. Conversely, when p-value is greater than 0.05, we conclude that the result is not statistically significant and the null hypothesis is accepted.

Confidence interval:

Multiple repetition of the same trial would not yield the exact same results every time. However, on average the results would be within a certain range. A 95% confidence interval means that there is a 95% chance that the true size of effect will lie within this range.

8- Statistical results:

• -Do statistical tests answer the research question?

Are statistical tests performed and comparisons made (data searching)?

Correct statistical analysis of results is crucial to the reliability of the conclusions drawn from the research paper. Depending on the study design and sample selection method employed, observational or inferential statistical analysis may be carried out on the results of the study.

It is important to identify if this is appropriate for the study [ 9 ].

• -Was the sample size adequate to detect a clinically/socially significant result?
• -Are the results presented in a way to help in health policy decisions?

Clinical significance:

Statistical significance as shown by p-value is not the same as clinical significance. Statistical significance judges whether treatment effects are explicable as chance findings, whereas clinical significance assesses whether treatment effects are worthwhile in real life. Small improvements that are statistically significant might not result in any meaningful improvement clinically. The following questions should always be on mind:

• -If the results are statistically significant, do they also have clinical significance?
• -If the results are not statistically significant, was the sample size sufficiently large to detect a meaningful difference or effect?

9- What conclusions did the authors reach about the study question?

Conclusions should ensure that recommendations stated are suitable for the results attained within the capacity of the study. The authors should also concentrate on the limitations in the study and their effects on the outcomes and the proposed suggestions for future studies [ 10 ].

• -Are the questions posed in the study adequately addressed?
• -Are the conclusions justified by the data?
• -Do the authors extrapolate beyond the data?
• -Are shortcomings of the study addressed and constructive suggestions given for future research?
• -Bibliography/References:

Do the citations follow one of the Council of Biological Editors’ (CBE) standard formats?

10- Are ethical issues considered?

If a study involves human subjects, human tissues, or animals, was approval from appropriate institutional or governmental entities obtained? [ 10 , 11 ].

Critical appraisal of RCTs: Factors to look for:

• Allocation (randomization, stratification, confounders).
• Follow up of participants (intention to treat).
• Data collection (bias).
• Sample size (power calculation).
• Presentation of results (clear, precise).
• Applicability to local population.

[ Table/Fig-2 ] summarizes the guidelines for Consolidated Standards of Reporting Trials CONSORT [ 12 ].

[Table/Fig-2]:

Summary of the CONSORT guidelines.

Critical appraisal of systematic reviews: provide an overview of all primary studies on a topic and try to obtain an overall picture of the results.

In a systematic review, all the primary studies identified are critically appraised and only the best ones are selected. A meta-analysis (i.e., a statistical analysis) of the results from selected studies may be included. Factors to look for:

• Literature search (did it include published and unpublished materials as well as non-English language studies? Was personal contact with experts sought?).
• Quality-control of studies included (type of study; scoring system used to rate studies; analysis performed by at least two experts).
• Homogeneity of studies.

[ Table/Fig-3 ] summarizes the guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses PRISMA [ 13 ].

[Table/Fig-3]:

Summary of PRISMA guidelines.

Critical appraisal is a fundamental skill in modern practice for assessing the value of clinical researches and providing an indication of their relevance to the profession. It is a skills-set developed throughout a professional career that facilitates this and, through integration with clinical experience and patient preference, permits the practice of evidence based medicine and dentistry. By following a systematic approach, such evidence can be considered and applied to clinical practice.

Financial or other Competing Interests

Systematic Reviews and Meta-Analyses: Critical Appraisal

• Get Started
• Exploratory Search
• Where to Search
• How to Search
• Grey Literature
• What about errata and retractions?
• Eligibility Screening

Critical Appraisal

• Data Extraction
• Synthesis & Discussion
• Assess Certainty
• Share & Archive

All relevant studies must undergo a critical appraisal to evaluate the risk of bias , or internal and external validity, of all relevant references.

This step often occurs simultaneously with the Data Extraction  phase. It is a vital stage of the systematic review process to uphold the cornerstone of reducing bias .

Risk of Bias Tools

• Presenting Results

Critical Appraisal 

Critical appraisal is also referred to as quality assessment , risk of bias assessment , and similar variations. Sometimes the critical appraisal phase is confused with the assessment of certainty of evidence  - although related, these are independent  stages of the systematic review process.

According to the Center for Evidence-Based Medicine (CEBM): 

"Critical appraisal is the process of carefully and systematically assessing the outcome of scientific research (evidence) to judge its trustworthiness, value and relevance in a particular context. Critical appraisal looks at the way a study is conducted and examines factors such as internal validity , generalizability and relevance."

Systematic reviews require a formal, systematic, uniform appraisal of the quality - or  risk of bias  - of all   relevant  studies. In a critical appraisal, you are examining the methods   not  the results .

Process Details

Use risk of bias tools  f or this stage - these tools are often formatted as checklists. You can find more about risk of bias tools in the next tab! If a refresher of some common biases, definitions, and examples is helpful, check out the Catalogue of Bias  from the University of Oxford and CEBM.

Just like the other stages of a systematic review,  2 reviewers  should assess risk of bias in each reference . As such, your team should calculate and report interrater reliability , deciding ahead of time how to resolve conflicts. Oftentimes the critical appraisal occurs at the same time as data extraction .

In addition to the formal risk of bias assessment, your team should also consider meta-biases like publication bias, selective reporting, etc. Search for errata and retractions related to included research, and consider other limitations of and concerns about the included studies and how this may impact the reliability of your review.

Note: Subjectivity of Critical Appraisal 

The critical appraisal is inherently subjective , from the selection of the RoB tool(s) to the final assessment of each study. Therefore, it is important to consider how tools compare, and how this process may impact the results of your review. Check out these studies evaluating Risk of Bias Tools:

Page MJ, McKenzie JE, Higgins JPT  Tools for assessing risk of reporting biases in studies and syntheses of studies: a systematic review   BMJ Open 2018;8:e019703. doi:  10.1136/bmjopen-2017-019703

Losilla, J.-M., Oliveras, I., Marin-Garcia, J. A., & Vives, J. (2018).  Three risk of bias tools lead to opposite conclusions in observational research synthesis.   Journal of Clinical Epidemiology ,  101 , 61–72.  https://doi.org/10.1016/j.jclinepi.2018.05.021

Margulis, A. V., Pladevall, M., Riera-Guardia, N., Varas-Lorenzo, C., Hazell, L., Berkman, N., Viswanathan, M., & Perez-Gutthann, S. (2014).  Quality assessment of observational studies in a drug-safety systematic review, comparison of two tools: The Newcastle-Ottawa Scale and the RTI item bank .  Clinical Epidemiology , 359.  https://doi.org/10.2147/CLEP.S66677

Select Risk of Bias Tool(s)

When you think of a critical appraisal in a systematic review and/or meta-analysis, think of assessing the  risk of bias  of included studies. The potential biases to consider will vary by study design. Therefore, risk of bias tool(s) should be selected based on the designs of included studies.  If you include more than one study design , you'll include more than one risk of bias tool.  Whenever possible, select tools developed for a discipline relevant to your topic.

Risk of bias tools  are simply checklists used to consider bias specific to a study design, and sometimes discipline. 

• Cochrane Risk of Bias Tool  | randomized trials, health
• Collaboration for Environmental Evidence (CEE) Critical Appraisal Tool, Prototype  | environmental management focused
• Crowe Critical Appraisal Tool  | mixed methods
• Meta-QAT  | public health focused
• Meta-QAT Grey Literature Companion | grey literature
• Mixed Method Appraisal Tool (MMAT) | mixed method ( more detail )
• Newcastle-Ottawa Scale | non-randomized studies
• RTI Item Bank  | observational studies
• SYRCLE's Risk of Bias Tool | animal studies
• Quality Checklist for Blogs | blogs
• Quality Checklist for Podcasts | podcasts

Risk of Bias Toolsets

Risk of bias tool sets  are a series of tools developed by the same group or organization, where each tool addresses a specific study design. The organization is usually discipline specific. Note that many also include a systematic review and/or meta-analysis quality assessment tool, but that these tools will not be useful during this stage as existing reviews will not be folded into your synthesis.

Critical Appraisal Skills Programme (CASP) Checklists include tools for:

• Randomized Controlled Trials 
• Qualitative Studies
• Cohort Study
• Diagnostic Study
• Case Control Study
• Economic Evaluation
• Clinical Prediction Rule 

National Institutes of Health (NIH) Study Quality Assessment Tools include tools for:

• Controlled intervention studies
• Observational cohort and cross-sectional studies
• Case-control studies
• Before-after (pre-post) studies without control
• Case series studies

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) includes tools for:

• Case-control
• Cross-sectional
• Conference abstracts

Joanna Briggs Institute (JBI) Manual for Evidence Synthesis includes the following tools found in respective relevant chapters:

• Qualitative research (appendix 2.1)
• Randomized controlled trials (appendix 3.1)
• Quasi-experimental studies (non-randomized experimental studies; appendix 3.3)
• Text and opinion (appendix 4.1)  with explanation (Appendix 4.2)
• Prevalence studies (appendix 5.1)
• Cohort studies (appendix 7.1)
• Case-control studies (appendix 7.2)
• Case series (appendix 7.3)
• Case reports (appendix 7.4)
• Cross sectional studies (appendix 7.5)
• Diagnostic test accuracy (appendix 9.1)

Latitudes Network 

• Systematic Reviews ( ROBIS )
• Randomized Controlled Trials ( RoB 2 ) 
• Cohort studies - interventions ( ROBINS-I )
• Cohort studies - exposure ( ROBINS-E ) 
• Diagnostic accuracy studies ( QUADAS-2 ; QUADAS-C ) 
• Prognostic accuracy studies ( QUAPAS ) 
• Prediction models ( PROBAST ) 
• Reliability studies ( COSMIN )

Risk of Bias Tool Repositories

Risk of bias tool repositories  are curated lists of existing tools - kind of like what we've presented above. Although we update this guide with new tools as we find them, these repositories may contain additional resources:

• Quality Assessment and Risk of Bias Tool Repository , from Duke University's Medical Center Library & Archives
• Interactive Tableau Dataset of 68 Risk of Bias Tools , from the National Toxicology Program

Presenting Critical Appraisal Results

Risk of bias within each reference should be presented in a table like the one seen below. Studies are presented along the y-axis and biases considered (what is addressed by the tool) along the x-axis, such that each row belongs to a study , and each column belongs to a bias (or domain/category of biases).

It is also best practice to present the bias across the included set of literature  (seen below). Each bias or bias category  is represented as a row and each row is associated with a bar showing the  percentage of the total included literature  that was rated as low risk, some risk, high risk, or unable to determine the risk. 

The images above can be created using the ROBVIS package of metaverse for evidence synthesis in R. You can create your own graphics without using this software.

Methodological Guidance

• Health Sciences
• Animal, Food Sciences
• Social Sciences
• Environmental Sciences

Cochrane Handbook  -  Part 2: Core Methods

Chapter 7 : Considering bias and conflicts of interest among the included studies

• 7.2 Empirical evidence of bias
• 7.3 General procedures for risk-of-bias assessment
• 7.4 Presentation of assessment of risk of bias
• 7.5 Summary assessments of risk of bias 
• 7.6 Incorporating assessment of risk of bias into analyses 
• 7.7 Considering risk of bias due to missing results
• 7.8 Considering source of funding and conflict of interest of authors of included studies 

Chapter 8: Assessing risk of bias in randomized trial

• 8.2 Overview of RoB 2
• 8.3 Bias arising from the randomization process
• 8.4 Bias due to deviations from intended interventions
• 8.5 Bias due to missing outcome data 
• 8.6 Bias in measurement of the outcome
• 8.7 Bias in selection of the reported result
• 8.8 Differences from the previous version of the tool

Chapter 25:  Risk of bias in non-randomized studies

SYREAF Resources

Step 3: identifying eligible papers.

Conducting systematic reviews of intervention questions II: Relevance screening, data extraction, assessing risk of bias , presenting the results and interpreting the findings.  Sargeant JM, O’Connor AM. Zoonoses Public Health. 2014 Jun;61 Suppl 1:39-51. doi: 10.1111/zph.12124. PMID: 24905995

Campbell -  MECCIR

C51. Assessing risk of bias / study quality ( protocol & review / final manuscript )

C52. Assessing risk of bias / study quality in duplicate  ( protocol & review / final manuscript )

C53. Supporting judgements of risk of bias / study quality ( review / final manuscript )

C54. Providing sources of information for risk of bias / study quality assessments ( review / final manuscript )

C55. Differentiating between performance bias and detection bias  ( protocol & review / final manuscript )

C56. If applicable, assessing risk of bias due to lack of blinding for different outcomes ( review / final manuscript )

C57. If applicable, assessing completeness of data for different outcomes ( review / final manuscript )

C58. If applicable, summarizing risk of bias when using the Cochrane Risk of Bias tool ( review / final manuscript )

C59. Addressing risk of bias / study quality in the synthesis  ( review / final manuscript )

C60. Incorporating assessments of risk of bias  ( review / final manuscript )

CEE  -  Guidelines and Standards for Evidence synthesis in Environmental Management

Section 7.  critical appraisal of study validity.

CEE Standards for conduct and reporting

7.1.2   Internal validity

7.1.3  External validity 

Reporting in Protocol and Final Manuscript

• Final Manuscript

In the Protocol |  PRISMA-P

Risk of bias individual studies (item 14).

...planned approach to assessing risk of bias should include the constructs being assessed and a definition for each, reviewer judgment options (high, low, unclear), the number of assessors ...training, piloting, previous risk of bias assessment experience...method(s) of assessment (independent or in duplicate)...

Protocol for reporting results

" ...summarise risk of bias assessments across studies or outcomes ..."

Protocol for reporting  impact on synthesis

"...describe how risk of bias assessments will be incorporated into data synthesis (that is, subgroup or sensitivity analyses) and their potential influence on findings of the review (Item 15c) in the protocol..."

In the Final Manuscript |  PRISMA

For the critical appraisal stage, PRISMA requires specific items to be addressed in both the methods and results section.

Study Risk of Bias Assessment (Item 11; report in methods )

Essential items.

• Specify the tool(s) (and version) used to assess risk of bias in the included studies.
• Specify the methodological domains/components/items of the risk of bias tool(s) used.
• Report whether an overall risk of bias judgment that summarised across domains/components/items was made, and if so, what rules were used to reach an overall judgment.
• If any adaptations to an existing tool to assess risk of bias in studies were made (such as omitting or modifying items), specify the adaptations.
• If a new risk of bias tool was developed for use in the review, describe the content of the tool and make it publicly accessible.
• Report how many reviewers assessed risk of bias in each study, whether multiple reviewers worked independently (such as assessments performed by one reviewer and checked by another), and any processes used to resolve disagreements between assessors.
• Report any processes used to obtain or confirm relevant information from study investigators.
• If an automation tool was used to assess risk of bias in studies, report how the automation tool was used (such as machine learning models to extract sentences from articles relevant to risk of bias88), how the tool was trained , and details on the tool’s performance and internal validation

Risk of Bias in Studies (Item 18; report in results )

• Present tables or figures indicating for each study the risk of bias in each domain /component/item assessed and overall study-level risk of bias.
• Present justification for each risk of bias judgment—for example, in the form of relevant quotations from reports of included studies.

Additional Items

If assessments of risk of bias were done for specific outcomes or results in each study , consider displaying risk of bias judgments on a forest plot, next to the study results, so that the limitations of studies contributing to a particular meta-analysis are evident (see Sterne et al86 for an example forest plot).

We host a workshop each fall on critical appraisal, check out our latest recording !

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• Last Updated: Apr 12, 2024 12:41 PM
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• Published: 31 January 2022

The fundamentals of critically appraising an article

• Sneha Chotaliya 1  

BDJ Student volume  29 ,  pages 12–13 ( 2022 ) Cite this article

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Sneha Chotaliya

We are often surrounded by an abundance of research and articles, but the quality and validity can vary massively. Not everything will be of a good quality - or even valid. An important part of reading a paper is first assessing the paper. This is a key skill for all healthcare professionals as anything we read can impact or influence our practice. It is also important to stay up to date with the latest research and findings.

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Chambers R, 'Clinical Effectiveness Made Easy', Oxford: Radcliffe Medical Press , 1998

Loney P L, Chambers L W, Bennett K J, Roberts J G and Stratford P W. Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can 1998; 19 : 170-176.

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White S, Halter M, Hassenkamp A and Mein G. 2021. Critical Appraisal Techniques for Healthcare Literature . St George's, University of London.

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Chotaliya, S. The fundamentals of critically appraising an article. BDJ Student 29 , 12–13 (2022). https://doi.org/10.1038/s41406-021-0275-6

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Critical Appraisal

• First Online: 01 March 2024

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• Animesh Hazari 2  

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Critical appraisal is a systematic process used to evaluate the quality, validity, and relevance of research studies or articles. It is a fundamental step in evidence-based practice and helps researchers, healthcare professionals, and others assess the trustworthiness of research findings. Critical appraisal involves assessing various aspects of a study to determine its overall quality and whether its results can be applied to specific clinical or research questions. The purpose of critical appraisal is just to bring a critical review of the conducted and published work and not to purposely point out inaccuracy to establish one’s own identity. It is similar to a critical review for any broadcast such as cinema, where experts evaluate all aspects to rate it. Similarly, a critical review of research is the evaluation of research through experts in that field. In this chapter, we will try to learn the components of research which are critically reviewed by the researchers and the correct way to do so.

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Aromataris E, Fernandez R, Godfrey C, Holly C, Kahlil H, Tungpunkom P. Summarizing systematic reviews: methodological development, conduct and reporting of an Umbrella review approach. Int J Evid Based Healthc. 2015;13(3):132-40.

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Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179–187.

Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis P, Lisy K, Mu P-F. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis. JBI, 2020.

Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and incidence data. Int J Evid Based Healthc. 2015;13(3):147–153.

Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis. JBI, 2020.

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14.1.1 Appendix 14.1: JBI Critical Appraisal Checklist for Randomized Controlled Trials (Tufanaru et al. 2020 )

Reviewer ______________________________________

Date _______________________________

Author _______________________________________ Year _________ Record Number _________

Overall appraisal:   Include   □   Exclude   □   Seek further info   □

Comments (Including reason for exclusion)

14.1.2 Appendix 14.2: JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (Aromataris et al. 2015 )

__________________________________________________________________________________________________________________________________________________________________________________________

14.1.3 Appendix 14.3: JBI Critical Appraisal Checklist for Qualitative Research (Lockwood et al. 2015 )

14.1.4 appendix 14.4: jbi critical appraisal checklist for studies reporting prevalence data (munn et al. 2015 ).

________________________________________________________________________________________________________________________________________________________________________________________________

14.1.5 Appendix 14.5: JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies (Moola et al. 2020 )

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Hazari, A. (2023). Critical Appraisal. In: Research Methodology for Allied Health Professionals. Springer, Singapore. https://doi.org/10.1007/978-981-99-8925-6_14

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Best Practice for Literature Searching

• Literature Search Best Practice
• What is literature searching?
• What are literature reviews?
• Hierarchies of evidence
• 1. Managing references
• 2. Defining your research question
• 3. Where to search
• 4. Search strategy
• 5. Screening results
• 6. Paper acquisition
• 7. Critical appraisal
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What is critical appraisal?

We critically appraise information constantly, formally or informally, to determine if something is going to be valuable for our purpose and whether we trust the content it provides.

In the context of a literature search, critical appraisal is the process of systematically evaluating and assessing the research you have found in order to determine its quality and validity. It is essential to evidence-based practice.

More formally, critical appraisal is a systematic evaluation of research papers in order to answer the following questions:

• Does this study address a clearly focused question?
• Did the study use valid methods to address this question?
• Are there factors, based on the study type, that might have confounded its results?
• Are the valid results of this study important?
• What are the confines of what can be concluded from the study?
• Are these valid, important, though possibly limited, results applicable to my own research?

What is quality and how do you assess it?

In research we commissioned in 2018, researchers told us that they define ‘high quality evidence’ by factors such as:

• Publication in a journal they consider reputable or with a high Impact Factor.
• The peer review process, coordinated by publishers and carried out by other researchers.
• Research institutions and authors who undertake quality research, and with whom they are familiar.

In other words, researchers use their own experience and expertise to assess quality.

However, students and early career researchers are unlikely to have built up that level of experience, and no matter how experienced a researcher is, there are certain times (for instance, when conducting a systematic review) when they will need to take a very close look at the validity of research articles.

There are checklists available to help with critical appraisal.  The checklists outline the key questions to ask for a specific study design.  Examples can be found in the  Critical Appraisal  section of this guide, and the Further Resources section.  

You may also find it beneficial to discuss issues such as quality and reputation with:

• Your principal investigator (PI)
• Your supervisor or other senior colleagues
• Journal clubs. These are sometimes held by faculty or within organisations to encourage researchers to work together to discover and critically appraise information.
• Topic-specific working groups

The more you practice critical appraisal, the quicker and more confident you will become at it.

• << Previous: What are literature reviews?
• Next: Hierarchies of evidence >>
• Last Updated: Sep 15, 2023 2:17 PM
• URL: https://ifis.libguides.com/literature_search_best_practice

• Finding and using knowledge
• Finding information
• Quality assure

Critical appraisal

Quality assurance using critical appraisal enables the identification of research articles which are sufficiently well-designed to inform practice. The technique consists of the identification of studies which cross a quality threshold followed by the extraction of their most important points. This page includes a critical appraisal skills programme CASP checklist, CASP elearning modules, and practical exercises.

Critical appraisal enables the identification of research articles which are sufficiently well-designed to inform practice. The technique consists of the identification of studies which cross a quality threshold followed by the extraction of their most important points.

The process involves :

• systematically evaluating scientific literature ;
• identifying original research or meta-analyses which are methodically sound ;
• selecting the items from the previous step which have a useful application in your daily work.

The application of the critical appraisal process results in the removal of barriers between research and practice and thus, supports the development of evidence based practice.

Retrieved research articles need to be assessed before a decision is made about their re-use. The three key principles in critically appraising research articles are :

• Validity applies both to the design and the methods of research. Validity in data collection means that findings truly represent the phenomenon the researcher claims to measure.
• Reliability is the measure of how consistently a research study or instrument accomplishes its intended purpose. It is synonymous with the consistency of a test, survey, observation, or other measuring device.
• Relevance concerns whether a piece of research responds to some genuine need. In other words, are the results of academic interest only or is there a practical application for the findings?

Refine Condense the knowledge into concise and relevant ‘nuggets’ that represent the key insights, lessons learned and practices of the knowledge sources. If multiple sources of knowledge are harvested, identify common and opposing knowledge and highlight these.

CASP critical appraisal checklists Collection of critical appraisal tools designed by the Critical Appraisal Skills Programme (CASP) to be used when reading research. Includes checklists for: Systematic Reviews, Randomised Controlled Trials, Cohort Studies, Case Control Studies, Economic Evaluations, Diagnostic Studies, Qualitative studies and Clinical Prediction Rule

Open University PROMPT checklist PROMPT: Presentation, Relevance, Objectivity, Method, Provenance, Timeliness provideS a structured approach to critical evaluation of information

Understanding health research This tool will guide you through a series of questions to help you to review and interpret a published health research paper

RGU Critical Appraisal guide Guides you through questions to consider with links to more help

CEBM: Which study design? Short article from the Centre for Evidence-Based Medicine (CEBM) to help you identify what type of study a paper is

NHS GGC Library Network: Critical Appraisal Tools pathway Collection of links to checklists and other useful tools to help with critical appraisal

Full fact Independant fact checker website, evaluating we claims made by politicians, public institutions and journalists, as well as viral content online

NHS Inform Reliable health information for patients and service users

• Evidence Based Medicine toolkit  (BMJ Best Practice)
• Critical appraisal guide  (NHS Northumbria Library)
• Quiz: An introduction to critical appraisal (Cochrane Common Mental Disorders Group)
• Students 4 Best Evidence  (S4BE)

eLearning modules

• eLearning: Introduction to conducting systematic reviews  (Cochrane)
• eLearning: Evidence Essentials online modules aimed at the public on how to read and understand RCTs and systematic reviews (Cochrane)
• eLearning: Understanding Evidence (NCCMT)

Video collections

• NCCMT: Understanding research evidence
• Barts Health NHS Trust: Bite size critical appraisal videos
• UCL: Using the CASP checklist for appraisal of qualitative research

Help with statistics

• CASP Glossary
• S4BE: Critical Thinking
• S4BE: How to read a forest plot
• How to read a paper the basics of evidence-based medicine : Trisha Greenhalgh (sign in with NHSScotland OpenAthens to read)
• Evidence based medicine journal  (sign in with NHSScotland OpenAthens to read)
• A nurses’ guide to the hierarchy of research designs and evidence  (Rebecca Ingham-Broomfield)

Choosing a topic

Ideally your audience will choose an article of interest to them. Below are some sources which can provide ideas

• Officially “retired” but articles can still be found on the Wayback Machine internet archive e.g.
• Cancer treatment response may be affected by gut bacteria
• Marriage may help lower dementia risk
• Focused on heart health research that has appeared in media
• Students for best evidence: Health in the media

Reusable materials

• Reusable critical appraisal presentation and terminology list ( Link )
• Accessing and appraising evidence slides template ( Download , 20 MB)
• Critical appraisal practical exercises ( Download , 32 KB)

Discover with Dr. Eleftherios Gkioulekas

Presentation: Critical appraisal of multi-drug therapy in the ambulatory management of patients with COVID-19 and hypoxemia

By eleftherios gkioulekas, ph.d..

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This is a short research presentation (only about 1 hour and 50 minutes) on the paper that I have co-authored with Dr. Peter McCullough and Dr. Colleen Aldous [1] , on the Hazan and Stone/Gill ivermectin-based multidrug protocols, which have already been proven to result in the rapid recovery of oxygen levels in hypoxemic patients within 24 to 48 hours.  Currently, our paper is undergoing the peer review process, and we hope to have it published eventually. However, our results have crystallized at this point and are ready to be presented.

The main statistical result is that the available data is sufficient to show clear and convincing evidence of some hospitalization rate reduction efficacy and preponderance of evidence in support of some mortality rate reduction efficacy, associated with the use of these protocols on hypoxemic patients. In combination with previous work, this establishes several Bradford Hill criteria of causality, needed for proving treatment efficacy. However, our paper is very broad-ranging, and we also situate these results in the context of the broader controversy regarding the use of ivermectin in the treatment of COVID-19. The presentation includes a detailed explanation of the case series threshold analysis method, which was introduced in my previous paper [2] .

Dr. McCullough wrote an earlier substack article on the same work, giving his medical perspective as an experienced treating physician of COVID-19 patients:

As I was treating and advising collectively on thousands of cases over 2020 and 2021 I became very comfortable with understanding that a low oxygen saturation <94% was not a trigger for alarm. Provided the work of breathing was not too difficult and the ability to think clearly and follow instructions was solid, patients could be treated at home with supplemental oxygen then the McCullough Protocol which includes full anticoagulation. I recall treating a physician and her husband ages 58 and 60, both with severe COVID-19 pneumonia and O2 saturations in the 70's for weeks during the Delta outbreak spanning August-September, 2021. At times saturations would dip below 70% while getting up to the kitchen or bathroom. Both of them knew they were safer at home on multidrug treatment than going to the hospital. Many hospitals had protocols that would have immediately paralyzed and sedated this couple then placed on them mechanical ventilators. This could have been the kiss of death. Yes, the couple survived with no complications and our collective confidence grew that "permissive hypoxemia" was well tolerated and very different from other forms of consolidative pneumonia, heart failure, and COPD. This new form of hypoxemia we were observing was due to micro-blood clots in the lungs. It means the alveoli were not clogged with fluid, but the problem was blood flow to the capillaries. So by supporting the patients and providing anticoagulation, we could ride out the storm at home.

It is noteworthy that Dr. Shankara Chetty reported in his paper [3] a similar rapid recovery of oxygen levels using a non-ivermectin based protocol, which can be attributed to his use of promethazine and his precise timing of treatment.  It is truly tragic that these ideas were not quickly deployed for worldwide use throughout the four years of the COVID-19 pandemic. On the contrary, both Dr. Shankara Chetty and Dr. Jackie Stone were confronted with reprisals, instigated by academic scientists, that appear to be uninterested in studying the available real-world evidence.

Discover with Dr. Eleftherios Gkioulekas is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

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[1] E. Gkioulekas, P.A. McCullough, C. Aldous: "Critical appraisal of multi-drug therapy in the ambulatory management of patients with COVID-19 and hypoxemia" , preprint

[2] E. Gkioulekas, P.A. McCullough, V. Zelenko: "Statistical analysis methods applied to early outpatient COVID-19 treatment case series data" , COVID 2(8) (2022), 1139-1182

[3] S. Chetty, "Elucidating the pathogenesis and Rx of COVID reveals a missing element" , Modern Medicine 45 (5) (2020), 28-31

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Critical Appraisal

Jan 02, 2020

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Critical Appraisal. Acknowledgement. Acknowledgment to Dr Sharmini Selvarajah and Dr Ho Tze Ming for preparation of the core contents of this presentation. Critical Appraisal. What it is?

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• study design
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Acknowledgement Acknowledgment to Dr Sharmini Selvarajah and Dr Ho Tze Ming for preparation of the core contents of this presentation.

Critical Appraisal • What it is? Systematically assessing literature to assess its (trustworthiness), relevance, validity and applicability to specific situations. • What it isn’t? • Assessment of results only • Based only on statistical analyses

Why is it necessary? • It is an essential skill for clinicians to find and use research evidence reliably and efficiently for purpose of evidence-based medical practices and research Reference: http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/what_is_critical_appraisal.pdf

Why is it necessary? • “we need reliable information about what might harm or help us when we make healthcare decisions. Research involves gathering data, then collating and analyzing it to produce meaningful information. However, not all research is good quality and many studies are biased and their results untrue. This can lead us to draw false conclusions.” Reference: http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/what_is_critical_appraisal.pdf

Why is it necessary? • Studies which don't report their methods fully overstate the benefits of treatments by around 25% • Khan et al. Arch Intern med, 1996; Maher et al, Lancet 1998. • Studies funded by a pharmaceutical company were found to be 4 times as likely to give results that were favourable to the company than independent studies • Lexchin et al, BMJ, 2003 Source: Sarah Lawson, November 2010. Critical appraisal of quantitative research

Why is it necessary? • “If healthcare professionals and patients are going to make the best decisions they need to be able to: • Decide which studies are relevant; • Decide whether studies have been undertaken in a way that makes their findings reliable; • Make sense of the results; and • Know what these results mean in the context of the decision they are making.” Reference: http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/what_is_critical_appraisal.pdf

What you need in order to do critical appraisals • Know the subject and current information • Knowledge on study designs • Different study designs are used for different research questions • Different study designs have different sources of biases • Knowledge on statistics • There are different methods of presenting the same data

What you need in order to do critical appraisals of literature • Generally literature in peer-reviewed journals have been appraised by peers. • Have a clear intention or purpose, such as the title or objectives of planned study • Use available appraisal tools as a start; tools only help to organize the appraisal process but final decision is still with the investigator

How to appraise? • Based on types of studies: ie: systematic review, RCT • Is the study valid?[validity] • Study question relevant, ie: equipoise? Study design and methodology appropriate? bias? Is statistical analyses correct? Data justify conclusions? • What are the results?[ reliability] • Does the result show a statistically better outcome • Are the results useful? [applicability] • Valid to your study population? generalizable to local setting?

How to appraise? PICO tool: Population, Intervention, Comparison, Outcome Clinical problem Define the question Search Evaluate Decide Appraise Critical appraisal

TEN QUESTIONS TO ASK WHEN CRITICALLY APPRAISING A RESEARCH ARTICLE • Is the study question relevant? • Does the study add anything new? • What type of research question is being asked? • Was the study design appropriate for the research question? • Did the study methods address the most important potential sources of bias? • Was the study performed according to the original protocol? • Does the study test a stated hypothesis? • Were the statistical analyses performed correctly? • Do the data justify the conclusions? • Are there any conflicts of interest? Ref: JM Young & MJ Solomon, Nature Clinical Practice Gastroenterology & Hepatology (2009) 6, 82-91

Starting critical appraisals • Use available tools as a start • E.g. • Centre for Evidence-Based-Medicine critical appraisal tools • http://www.cebm.net/critical-appraisal/ • http://www.sign.ac.uk/methodology/checklists.html • http://www.casp-uk.net/#!casp-tools-checklists/c18f8

Thank you Any Questions?

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March 27, 2024

Russian offensive campaign assessment, march 27, 2024.

March 27, 2024, 5:10pm ET

Click here to see ISW’s interactive map of the Russian invasion of Ukraine. This map is updated daily alongside the static maps present in this report.

Click here to see ISW’s 3D control of terrain topographic map of Ukraine. Use of a computer (not a mobile device) is strongly recommended for using this data-heavy tool.

Click here to access ISW’s archive of interactive time-lapse maps of the Russian invasion of Ukraine. These maps complement the static control-of-terrain map that ISW produces daily by showing a dynamic frontline. ISW will update this time-lapse map archive monthly.

Note: The data cut-off for this product was 2:15pm ET on March 27. ISW will cover subsequent reports in the March 28 Russian Offensive Campaign Assessment.

The UN Human Rights Monitoring Mission in Ukraine (HRMMU) released its 38th report on the human rights situation in Ukraine on March 26, confirming several of ISW’s longstanding assessments about Russia’s systematic violations of international human rights and humanitarian law in occupied territories and towards Ukrainian prisoners of war (POWs). [1] The HRMMU report details activities between December 1, 2023 and February 29 2024, and includes new findings about Russia’s abuse of Ukrainian POWs during this timeframe, based on interviews with 60 recently released male POWs. [2] Nearly all of the POWs that HRMMU interviewed detailed how they were tortured by Russian forces with beatings and electric shocks and threatened with execution, and over half of the interviewees experienced sexual violence. HRMMU also reported that it has evidence of Russian forces executing at least 32 POWs in 12 different incidents during the reporting period and independently verified three of the executions. ISW observed open-source evidence of several POW executions during this reporting period: the execution of three Ukrainian POWs near Robotyne, Zaporizhia Oblast on December 27, 2023; the execution of one Ukrainian POW near Klishchiivka, Donetsk Oblast on February 9, 2024; the executions of three Ukrainian POWs near Robotyne, the execution of six Ukrainian POWs near Avdiivka, Donetsk Oblast, and the executions of two Ukrainian POWs near Vesele, Donetsk Oblast on or around February 18, 2024; and the execution of nine Ukrainian POWs near Ivanivske, Donetsk Oblast, on February 25. [3] The summary execution and mistreatment of POWs is a violation of Article 3 of the Geneva Convention relative to the Treatment of Prisoners of War. [4] The HRMMU report also details the forced Russification of Ukrainian populations in occupied areas, including the imposition of Russian political, legal, and administrative systems onto occupied Ukraine in violation of Russia’s international legal obligations as an occupying power. [5] ISW has reported at length on the specifics of Russia’s illegal occupation of Ukraine, consistent with the findings of the UN HRMMU report. [6]

Russian officials are tying the US and the West to a broader set of “terrorist” attacks against Russia following the Crocus City Hall attack, likely to intensify rhetoric about alleged Western and Ukrainian threats to generate greater domestic support for the war in Ukraine. The Russian Investigative Committee and Prosecutor General’s Office stated on March 27 that they will consider an appeal from the Russian State Duma to investigate American and Western financing and organization of terrorist attacks against Russia. [7] The Russian Investigative Committee, Prosecutor General’s Office, and the Duma Deputies that made the appeal did not explicitly reference the Crocus City Hall attack. [8] Kremlin officials have previously tied Ukraine and the West to the Crocus City Hall attack but have yet to make a formal accusation, and the Kremlin may refrain from issuing an official accusation as all available evidence continues to show that the Islamic State (IS) is very likely responsible for the attack. [9] Russian officials routinely describe Ukrainian military strikes against legitimate military targets in occupied Ukraine and Russia as terrorism and consistently claim that Western actors help organize these strikes. [10] The Kremlin likely aims to seize on wider Russian social fears and anger following the Crocus City Hall attack by portraying Ukraine, the US, and the West as immediate terrorist threats. The Kremlin likely hopes that perceptions of Ukrainian and Western involvement in the Crocus City Hall attack will increase domestic support for the war in Ukraine, and Russian officials will likely invoke a broader view of what they consider terrorism to further cast Ukrainians as terrorists and the West as a sponsor of terrorism. [11] The Kremlin may still formally accuse Ukraine of conducting the Crocus City Hall attack if it believes that these other informational efforts are insufficient to generate the domestic response it likely desires. [12]

Russian authorities are increasing legal pressure against migrants in Russia following recent Russian officials’ proposals for harsher, measures against migrant communities in response to the March 22 Crocus City Hall attack. BBC News Russian Service stated that there has been a significant increase in the number of cases related to violations of the rules of entry for foreign citizens into Russia following the Crocus City Hall attack. [13] BBC News Russian Service reported on March 27 that 784 such cases have been registered since the morning of March 25, as compared with 1,106 during the entire previous week. A Russian lawyer who often works with Tajik citizens reportedly told BBC News Russian Service that over 100 people waited for a Moscow district court to hear their cases on March 25 alone and that Russian authorities are especially targeting migrants from Tajikistan during searches. BBC News Russian Service reported that representatives of the Tajik diaspora in Russia are expecting Russian authorities to conduct a large wave of deportations following the Crocus City Hall attack. A Russian insider source claimed on March 27 that unspecified actors gave the Moscow Ministry of Internal Affairs (MVD) an “unspoken” order to “not spare” migrants and for MVD employees to use their own judgement in the field. [14] The insider source claimed that a source suggested that Russian authorities are not preparing to conduct raids on migrant communities but will apply the “strictest measures” to migrants in “controversial situations.” Kremlin newswire TASS stated on March 27 that Russian police and Rosgvardia conducted a raid at the Wildberries warehouse in Elektrostal, Moscow Oblast to check the documents of migrant workers, and Russian opposition outlet Baza reported that Russian authorities detained 21 people during the raid. [15] Several Russian ultranationalist milbloggers complained that the way Russian-language schools in Tajikistan are teaching about Russia’s historical imperial occupation of Tajikistan is discouraging Tajik migrants from integrating into Russian society, essentially blaming migrants for the alienation that Russian society subjects them to. [16] Select Russian officials recently called for the introduction of several anti-migrant policies, which Russian authorities are unlikely to enact given Russia’s reliance on migrants for its force generation and labor needs. [17] Russian authorities may continue the practice of raiding migrant workplaces and increase crackdowns at border crossings to temporarily placate emotional cries for retribution following the March 22 attack as the Kremlin continues to develop a cogent and practical response.

Key Takeaways:

• The UN Human Rights Monitoring Mission in Ukraine (HRMMU) released its 38th report on the human rights situation in Ukraine on March 26, confirming several of ISW’s longstanding assessments about Russia’s systematic violations of international human rights and humanitarian law in occupied territories and towards Ukrainian prisoners of war (POWs).
• Russian officials are tying the US and the West to a broader set of “terrorist” attacks against Russia following the Crocus City Hall attack, likely to intensify rhetoric about alleged Western and Ukrainian threats to generate greater domestic support for the war in Ukraine.
• Russian authorities are increasing legal pressure against migrants in Russia following recent Russian officials’ proposals for harsher, measures against migrant communities in response to the March 22 Crocus City Hall attack.
• Russian forces recently made confirmed advances near Avdiivka and southwest of Donetsk City on March 27.
• Russian Storm-Z personnel continue to complain about their poor treatment by the Russian Ministry of Defense (MoD) as the MoD tries to posture efficacy in its force generation and social benefit allocation system.

We do not report in detail on Russian war crimes because these activities are well-covered in Western media and do not directly affect the military operations we are assessing and forecasting. We will continue to evaluate and report on the effects of these criminal activities on the Ukrainian military and the Ukrainian population and specifically on combat in Ukrainian urban areas. We utterly condemn Russian violations of the laws of armed conflict and the Geneva Conventions and crimes against humanity even though we do not describe them in these reports.  

• Russian Main Effort – Eastern Ukraine (comprised of two subordinate main efforts)
• Russian Subordinate Main Effort #1 – Capture the remainder of Luhansk Oblast and push westward into eastern Kharkiv Oblast and encircle northern Donetsk Oblast
• Russian Subordinate Main Effort #2 – Capture the entirety of Donetsk Oblast
• Russian Supporting Effort – Southern Axis
• Russian Air, Missile, and Drone Campaign
• Russian Mobilization and Force Generation Efforts
• Russian Technological Adaptations
• Activities in Russian-occupied areas
• Ukrainian Defense Industrial Base Efforts

Russian Information Operations and Narratives

• Significant Activity in Belarus

Russian Main Effort – Eastern Ukraine

Russian Subordinate Main Effort #1 – Luhansk Oblast (Russian objective: Capture the remainder of Luhansk Oblast and push westward into eastern Kharkiv Oblast and northern Donetsk Oblast)

Positional engagements continued along the Kupyansk-Svatove-Kreminna line on March 27, but there were no confirmed changes to the frontline in this area. Ukrainian and Russian sources stated that positional engagements continued northeast of Kupyansk near Synkivka and Lake Lyman; southeast of Kupyansk near Ivanivka; west of Kreminna near Terny and Yampolivka; and south of Kreminna near Bilohorivka. [18] Russian milbloggers claimed that Russian forces advanced near Terny, but ISW has not observed visual confirmation of this claim. [19] Chechen Republic Head Ramzan Kadyrov stated that elements of the Chechen Akhmat Spetsnaz “Aida” detachment are operating near Bilohorivka. [20]

Ukrainian officials reported that Russian forces struck Kharkiv City with a D-30 universal joint glide munition (UMPB), a guided glide bomb, on March 27. [21] Ukrainian officials noted that the strike was the first Russian glide bomb strike against Kharkiv City since the beginning of the full-scale invasion in 2022. [22] Ukrainian Kharkiv Oblast Military Administration Head Oleh Synehubov stated that the UMPB D-30 has a range of up to 90 kilometers and that Russian forces can launch the bomb from aircraft or ground-based Smerch multiple rocket launch systems (MLRS). [23] Russian forces struck Myrnohrad, Donetsk Oblast with three UMPB D-30SN guided glide bombs on March 10. [24]

Russian Subordinate Main Effort #2 – Donetsk Oblast (Russian objective: Capture the entirety of Donetsk Oblast, the claimed territory of Russia’s proxies in Donbas)

Russian forces reportedly advanced west of Bakhmut, although there were no confirmed changes to the frontline in the area on March 27. Russian milbloggers claimed that Russian forces advanced west of Bakhmut along a railway line and a section of the O0506 (Khromove-Chasiv Yar) highway by 1.15 kilometers in depth and 1.85 kilometers in width. [25] A Russian milblogger claimed that elements of the 98th Airborne (VDV) Division are advancing near Ivanivske and are within 500 meters of the city limits of Chasiv Yar (west of Bakhmut). [26] Russian Defense Minister Sergei Shoigu credited elements of the Russian 102nd Motorized Rifle Regiment (150th Motorized Rifle Division, 8th Combined Arms Army [CAA], Southern Military District [SMD]) with seizing Ivanivske on March 24, although ISW has yet to observe visual evidence confirming that Russian forces have seized Ivanivske. [27] Positional fighting continued northeast of Bakhmut near Vesele; northwest of Bakhmut near Bohdanivka; west of Bakhmut near Ivanivske; southwest of Bakhmut near Klishchiivka and Andriivka; and south of Bakhmut near Shumy and Pivdenne. [28] A Ukrainian military observer reported that Russian forces have intensified transfers of equipment and personnel along ground lines of communication (GLOCs) through Kadiivka, Pervomaisk, and Popasna (all east of Bakhmut), but did not specify the destination of these transfers. [29] Kadiivka, Pervomaisk, and Popasna all lie along the T0504 Luhansk City-Bakhmut highway that runs directly from the Russian rear in occupied Luhansk Oblast into Bakhmut, however.

Russian forces recently advanced west of Avdiivka amid continued positional fighting in the area on March 27. Geolocated footage published on March 27 indicates that Russian forces recently advanced within Berdychi (northwest of Avdiivka) and in Orlivka (west of Avdiivka). [30] Russian milbloggers claimed that Russian forces entered Semenivka (northwest of Avdiivka) and are attacking Ukrainian positions within the settlement but that Ukrainian forces are actively counterattacking in the area. [31] A Russian milblogger claimed that Russian forces advanced 200 meters west of Orlivka on the western bank of the Durna River, 200 meters west of Tonenke (west of Avdiivka), 200 meters in the direction of Umanske (west of Avdiivka), 300 meters south of Tonenke towards Pervomaiske (southwest of Avdiivka), and 100 meters south of Nevelske (southwest of Avdiivka). [32] ISW has not observed visual confirmation of these claims. Positional fighting continued northwest of Avdiivka near Berdychi and Semenivka; west of Avdiivka near Orlivka, Tonenke, and Umanske; and southwest of Avdiivka near Vodyane, Nevelske, and Pervomaiske. [33]

Russian forces recently advanced southwest of Donetsk City amid continued positional fighting west and southwest of Donetsk City on March 27. Geolocated footage published on March 27 indicates that Russian forces recently advanced within central Novomykhailivka (southwest of Donetsk City). [34] Positional fighting continued west of Donetsk City near Heorhiivka and Krasnohorivka and southwest of Donetsk City near Novomykhailivka and Pobieda. [35] Elements of the Russian 5th Motorized Rifle Brigade (1st Donetsk People’s Republic [DNR] Army Corps [AC]) are reportedly operating near Krasnohorivka. [36]

Positional engagements continued south of Velyka Novosilka near Staromayorske and Urozhaine in the Donetsk-Zaporizhia Oblast border area on March 27. [37]

Russian Supporting Effort – Southern Axis (Russian objective: Maintain frontline positions and secure rear areas against Ukrainian strikes)

Positional engagements continued in western Zaporizhia Oblast on March 27, but there were no confirmed changes to the frontline. Positional engagements continued near Robotyne, near Mala Tokmachka (northeast of Robotyne), northeast of Novoprokopivka (south of Robotyne), and northwest of Verbove (east of Robotyne). [38] Elements of the Russian 71st Motorized Rifle Regiment (42nd Motorized Rifle Division, 58th Combined Arms Army [CAA], Southern Military District [SMD]) reportedly continue operating within Robotyne. [39]

Positional engagements continued in east (left) bank Kherson Oblast, including near Krynky, on March 27. [40]

Russian Air, Missile, and Drone Campaign (Russian Objective: Target Ukrainian military and civilian infrastructure in the rear and on the frontline)

Russian forces conducted a series of drone and missile strikes against Ukraine on the night of March 26 to 27 and on March 27. The Ukrainian Air Force reported that Russian forces launched 13 Shahed-136/131 drones from Kursk Oblast and that Ukrainian forces shot down 10 drones over Kharkiv, Sumy, and Kyiv oblasts on the night of March 26 to 27. [41] Ukrainian officials reported that Russian drones struck civilian infrastructure in Izyum, Kharkiv Oblast. [42] Ukrainian Kharkiv Oblast Head Oleh Synehubov stated that a Russian Kh-35U subsonic anti-ship cruise missile struck Kharkiv City on the morning of March 27. [43] Ukraine’s Eastern Air Command reported that Ukrainian forces shot down an unspecified Russian cruise missile over Dnipropetrovsk Oblast on March 27. [44] Ukrainian officials stated that Russian forces struck an industrial enterprise in Mykolaiv City with an Iskander-M ballistic missile on the afternoon of March 27. [45]

Ukraine’s Southern Operational Command Spokesperson Colonel Nataliya Humenyuk stated that Russian forces have stored “several dozen” Zircon missiles in military facilities in occupied Crimea. [46] Ukrainian Air Force Spokesperson Major Ilya Yevlash stated that Ukrainian air defense systems, such as Patriot and SAMP/T systems, can intercept Zircon missiles when they slow down to about 3,700 kilometers per hour on approach to a target. [47]

Russian Mobilization and Force Generation Efforts (Russian objective: Expand combat power without conducting general mobilization)

Russian Storm-Z personnel continue to complain about their poor treatment by the Russian Ministry of Defense (MoD) as the MoD tries to present the efficacy of its force generation and social benefit allocation system. Russian opposition outlet Mobilization News posted a video appeal from Storm-Z fighters from Kaluga Oblast on March 27 wherein one fighter claimed that after signing contracts with the Russian MoD, Russian command sent a Storm-Z unit of 230 people to the frontline, of whom only 38 survived combat. [48] The Storm-Z fighter complained that he has been unable to receive combat veteran status or promised payments from the Russian authorities for his service. [49] Mobilization News released another video on March 27 wherein relatives of killed and wounded Storm-Z fighters complain to Russian President Vladimir Putin that Russian authorities have not issued the Storm-Z fighters combat status or granted payments in the event of their death or injury in Ukraine. [50] The relatives of the Storm-Z fighters blamed the Russian MoD and Defense Minister Sergei Shoigu for the poor treatment and lack of benefits for Storm-Z fighters. The Russian MoD relies heavily on Storm-Z recruits from penal colonies to carry out costly infantry-led frontal assaults against Ukrainian positions and is very unlikely to address complaints concerning their poor treatment. The Russian MoD claimed on March 27 that it is issuing electronic combat veteran certificates and streamlining and digitizing the process for veterans to obtain payments and social benefits — but these privileges evidently do not apply evenly to all personnel who have signed contracts with the Russian MoD. [51]

Russian news outlet Vedemosti reported that US-sanctioned Russian company Baikal Electronics is struggling to domestically package semiconductor chips to produce processors and that over half of its domestically produced processors are defective. [52] Vedemosti reported that Baikal Electronics began to experiment with domestically packaging chips in Russia at the end of 2021 and that outdated equipment and a lack of experienced employees caused the large amount of processor defects.

Russian Technological Adaptations (Russian objective: Introduce technological innovations to optimize systems for use in Ukraine)

Russian drone developer Albatross LLC told Kremlin newswire TASS that Russian forces used the Albatross M5 long-range reconnaissance drones to guide aviation and artillery strikes while repelling recent pro-Ukrainian Russian raids into Belgorod Oblast. [53] Albatross LLC noted that the modernized Albatross M5 drone has a maximum range of 60-80 kilometers.

Russian state news outlet RIA Novosti reported that Russian T-72B3, T-72B3M, T-80BVM, and T-90M tanks operating in Ukraine use Reflex-M guided weapon systems with the Invar-M/M1 anti-tank guided missiles to strike Ukrainian and Western-made vehicles. [54]

Ukrainian Defense Industrial Efforts (Ukrainian objective: Develop its defense industrial base to become more self-sufficient in cooperation with US, European, and international partners)

ISW is not publishing coverage of Ukrainian defense industrial efforts today.

Activities in Russian-occupied areas (Russian objective: Consolidate administrative control of annexed areas; forcibly integrate Ukrainian citizens into Russian sociocultural, economic, military, and governance systems)

ISW is not publishing coverage of activities in Russian-occupied areas of Ukraine today.

Russian officials are weaponizing international responses to the Crocus City Hall attack to accuse the West of espousing Russophobic policies and to baselessly blame Ukraine of involvement in the attack. Russian Ambassador to Austria Dmitry Lyubinsky claimed on March 27 that while the Austrian government reacted to the Crocus City Hall attack, it did not use the words “terrorist attack” or condemn the attack. [55] Lyubinsky accused Austria of having “taken a very special position in its hypocrisy” and a “daze of permissiveness” towards Ukraine and reiterated the Kremlin narrative baselessly connecting Ukraine to the attack. Russian Foreign Ministry Spokesperson Maria Zakharova reported that Russia has received 24-hour non-stop words of support from around the globe following the attack, but immediately pivoted to accuse Ukraine of involvement in the attack and blame NATO members of monopolizing the global fight against terror. [56]

Significant activity in Belarus (Russian efforts to increase its military presence in Belarus and further integrate Belarus into Russian-favorable frameworks and Wagner Group activity in Belarus)

Nothing significant to report.

Note: ISW does not receive any classified material from any source, uses only publicly available information, and draws extensively on Russian, Ukrainian, and Western reporting and social media as well as commercially available satellite imagery and other geospatial data as the basis for these reports. References to all sources used are provided in the endnotes of each update.

[1] https://ukraine.un.org/sites/default/files/2024-03/2024-03-26%20OHCHR%2038th%20Periodic%20Report.pdf

[2] https://ukraine.un.org/en/264368-un-says-russia-continues-torture-execute-ukrainian-pows

[3] https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-february-20-2024 ; https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-february-18-2024 ; https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-february-10-2024 ; https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-january-3-2024 ; https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-february-20-2024 ; https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-december-27-2023

[4] https://www.ohchr.org/en/instruments-mechanisms/instruments/geneva-convention-relative-treatment-prisoners-war

[5] https://ukraine.un.org/sites/default/files/2024-03/2024-03-26%20OHCHR%2038th%20Periodic%20Report.pdf

[6] https://www.understandingwar.org/sites/default/files/24-210-01%20ISW%20Occupation%20playbook.pdf

[7] https://t.me/tass_agency/240300 ; https://t.me/astrapress/52521 ; https://t.me/tass_agency/240322

[8] https://ria dot ru/20240327/rassledovanie-1936142056.html ; https://meduza dot io/news/2024/03/27/deputaty-gosdumy-potrebovali-ot-sk-rassledovat-akty-terrorizma-kotorye-ssha-sovmestno-so-stranami-nato-i-spetssluzhbami-ukrainy-osuschestvlyayut-v-rossii

[9] https://isw.pub/UkrWar032324 ; https://isw.pub/UkrWar032424 ; https://isw.pub/UkrWar032524 ; https://isw.pub/UkrWar032624

[10] https://t.me/tass_agency/239253%C2%A0;%C2%A0https://isw.pub/UkrWar020624%C2%A0;%C2%A0https://isw.pub/UkrWar031824%C2%A0 ; https://www.reuters.com/world/europe/putin-calls-ukrainian-attack-belgorod-terrorism-promises-more-strikes-2024-01-01/ ; https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-march-23-2024 ; https://isw.pub/RusCampaignOct10

[11] https://isw.pub/UkrWar032324

[12] https://isw.pub/UkrWar032324

[13] https://t.me/bbcrussian/62850

[14] https://t.me/vchkogpu/47045

[15] https://t.me/bazabazon/26432 ; https://t.me/bazabazon/26440 ; https://meduza dot io/news/2024/03/27/politsiya-i-rosgvardiya-priehali-s-reydom-na-sklad-wildberries-v-podmoskovnoy-elektrostali-u-rabotnikov-proveryayut-dokumenty-nekotoryh-uvozyat-v-voenkomat ; https://t.me/tass_agency/240303 ; https://t.me/tass_agency/240290

[16] https://t.me/rybar/58588 ; https://t.me/notes_veterans/16295 ; https://t.me/historiographe/12011 ; https://t.me/voenacher/63252

[17] https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-march-26-2024 ; https://understandingwar.org/backgrounder/russian-offensive-campaign-assessment-march-24-2024

[18] https://www.facebook.com/GeneralStaff.ua/posts/pfbid02rxTJAPqhSGh5mqY7C4XDTQiRjiVX25K4Tmx6tT6GCypPhjw8tmKBZAmRa5jaETbGl ; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02ReTBwNLG8czu42xB89ixKbv1WzZE2LqsgMcXwngSeHHpRjAXoaR3esPk1eCxZiZ8l ; https://t.me/mod_russia/37036 ; https://t.me/wargonzo/19025 ; https://t.me/luhanskaVTSA/17835 ; https://t.me/wargonzo/19025

[19] https://t.me/dva_majors/38313 ; https://t.me/DnevnikDesantnika/8702

[20] https://t.me/RKadyrov_95/4620

[21] https://suspilne dot media/714544-zelenskij-zminiv-sekretara-rnbo-zvit-oon-sodo-stracenih-ukrainskih-polonenih-763-den-vijni-onlajn/?anchor=live_1711553688&utm_source=copylink&utm_medium=ps ; https://armyinform dot com.ua/2024/03/27/boyeprypas-yakym-rosiyany-vdaryly-po-harkovu-mozhe-letity-na-vidstan-do-90-km-oleg-synyegubov/

[22] https://suspilne dot media/714544-zelenskij-zminiv-sekretara-rnbo-zvit-oon-sodo-stracenih-ukrainskih-polonenih-763-den-vijni-onlajn/?anchor=live_1711553688&utm_source=copylink&utm_medium=ps; https://armyinform dot com.ua/2024/03/27/boyeprypas-yakym-rosiyany-vdaryly-po-harkovu-mozhe-letity-na-vidstan-do-90-km-oleg-synyegubov/

[23] https://armyinform dot com.ua/2024/03/27/boyeprypas-yakym-rosiyany-vdaryly-po-harkovu-mozhe-letity-na-vidstan-do-90-km-oleg-synyegubov/

[24] https://isw.pub/UkrWar031024

[25] https://t.me/RVvoenkor/64758; https://t.me/basurin_e/10068 ; https://t.me/rusich_army/13845

[26] https://t.me/rusich_army/13845

[27] https://t.me/mod_russia/37029 ; https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-march-23-2024

[28] https://t.me/mod_russia/37044 ; https://t.me/mod_russia/37051 ; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02Lh7wn9dDbMDZcCSUP4kHDoHuABYPPUB5vnfakuyQw21x2MKXQ1fcsLqAgYeuSQVWl ; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02rxTJAPqhSGh5mqY7C4XDTQiRjiVX25K4Tmx6tT6GCypPhjw8tmKBZAmRa5jaETbGl; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02ReTBwNLG8czu42xB89ixKbv1WzZE2LqsgMcXwngSeHHpRjAXoaR3esPk1eCxZiZ8l ; https://t.me/DnevnikDesantnika/8702 ; https://t.me/negumanitarnaya_pomosch_Z/16170 ; https://t.me/wargonzo/19025 ; https://t.me/rusich_army/13845 ;

[29] https://t.me/samotniyskhid/4868

[30] https://t.me/creamy_caprice/4888; https://t.me/kultshturmovika_ukraine/1773 ; https://t.me/creamy_caprice/4889; https://t.me/c/1595839251/3625; https://x.com/GeoConfirmed/status/1772981767139430744?s=20

[31] https://t.me/DnevnikDesantnika/8702 ; https://t.me/dva_majors/38373 ; https://t.me/negumanitarnaya_pomosch_Z/16183 ; https://t.me/DnevnikDesantnika/8724 ; https://t.me/rybar/58575

[32] https://t.me/DnevnikDesantnika/8720

[33] https://www.facebook.com/GeneralStaff.ua/posts/pfbid02rxTJAPqhSGh5mqY7C4XDTQiRjiVX25K4Tmx6tT6GCypPhjw8tmKBZAmRa5jaETbGl; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02ReTBwNLG8czu42xB89ixKbv1WzZE2LqsgMcXwngSeHHpRjAXoaR3esPk1eCxZiZ8l ; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02Lh7wn9dDbMDZcCSUP4kHDoHuABYPPUB5vnfakuyQw21x2MKXQ1fcsLqAgYeuSQVWl ; https://t.me/mod_russia/37044 ; https://t.me/mod_russia/37051 ; https://t.me/dva_majors/38313 ; https://t.me/DnevnikDesantnika/8720 ; https://t.me/DnevnikDesantnika/8702 ; https://t.me/wargonzo/19025 ; https://t.me/voenkorKotenok/55225

[34] https://t.me/tivaz_artillery/3650; https://t.me/creamy_caprice/4893

[35] https://www.facebook.com/GeneralStaff.ua/posts/pfbid02Lh7wn9dDbMDZcCSUP4kHDoHuABYPPUB5vnfakuyQw21x2MKXQ1fcsLqAgYeuSQVWl ; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02rxTJAPqhSGh5mqY7C4XDTQiRjiVX25K4Tmx6tT6GCypPhjw8tmKBZAmRa5jaETbGl; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02ReTBwNLG8czu42xB89ixKbv1WzZE2LqsgMcXwngSeHHpRjAXoaR3esPk1eCxZiZ8l ; https://t.me/dva_majors/38313 ; https://t.me/wargonzo/19025 ; https://t.me/boris_rozhin/118101 ; https://t.me/voenkorKotenok/55225

[36] https://t.me/boris_rozhin/118105

[37] https://www.facebook.com/GeneralStaff.ua/posts/pfbid02rxTJAPqhSGh5mqY7C4XDTQiRjiVX25K4Tmx6tT6GCypPhjw8tmKBZAmRa5jaETbGl; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02ReTBwNLG8czu42xB89ixKbv1WzZE2LqsgMcXwngSeHHpRjAXoaR3esPk1eCxZiZ8l ; https://t.me/mod_russia/37044 ; https://t.me/mod_russia/37052 ; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02Lh7wn9dDbMDZcCSUP4kHDoHuABYPPUB5vnfakuyQw21x2MKXQ1fcsLqAgYeuSQVWl

[38] https://www.facebook.com/GeneralStaff.ua/posts/pfbid02Lh7wn9dDbMDZcCSUP4kHDoHuABYPPUB5vnfakuyQw21x2MKXQ1fcsLqAgYeuSQVWl ; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02rxTJAPqhSGh5mqY7C4XDTQiRjiVX25K4Tmx6tT6GCypPhjw8tmKBZAmRa5jaETbGl; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02ReTBwNLG8czu42xB89ixKbv1WzZE2LqsgMcXwngSeHHpRjAXoaR3esPk1eCxZiZ8l ; https://t.me/SJTF_Odes/7591 ; https://t.me/rybar/58575 ; https://t.me/dva_majors/38313 ; https://t.me/DnevnikDesantnika/8715 ; https://t.me/DnevnikDesantnika/8692 ; https://t.me/wargonzo/19025

[39] https://t.me/batalyon15/4045

[40] https://www.facebook.com/GeneralStaff.ua/posts/pfbid02rxTJAPqhSGh5mqY7C4XDTQiRjiVX25K4Tmx6tT6GCypPhjw8tmKBZAmRa5jaETbGl; https://www.facebook.com/GeneralStaff.ua/posts/pfbid02ReTBwNLG8czu42xB89ixKbv1WzZE2LqsgMcXwngSeHHpRjAXoaR3esPk1eCxZiZ8l ; https://t.me/dva_majors/38313

[41] https://t.me/kpszsu/12330

[42] https://t.me/pgo_gov_ua/22717 ; https://armyinform.com dot ua/2024/03/27/vijska-rf-atakuvaly-izyum-shahedamy-poshkodzheno-gimnaziyu-poraneno-ohoronczya/ ; https://t.me/synegubov/8827?single

[43] https://t.me/synegubov/8827

[44] https://www.facebook.com/pvkshid/posts/pfbid0LGmUtBDdzmxud8zZ23FDoN8eKarYJkLS6YrsSUzB62HVo7uSrXWhxPxnnzAhuSUyl

[45] https://t.me/mykolaivskaODA/8840 ; https://t.me/dsns_mykolaiv/4948 ; https://t.me/SJTF_Odes/7600

[46] https://armyinform.com dot ua/2024/03/27/u-sylah-oborony-povidomyly-pro-kilkist-rosijskyh-czyrkoniv-u-krymu/

[47] https://armyinform.com dot ua/2024/03/27/u-povitryanyh-sylah-povidomyly-pro-sposoby-zbyttya-rosijskyh-czyrkoniv/

[48] https://t.me/mobilizationnews/18111

[49] https://t.me/mobilizationnews/18111

[50] https://t.me/mobilizationnews/18114

[51] https://t.me/mod_russia/37031

[52] https://www.severreal.org/a/bolshe-poloviny-rossiyskih-protsessorov-baykal-okazalis-brakovannymi/32879476.html ; https://www.vedomosti dot ru/technology/articles/2024/03/26/1027924-razrabotchik-protsessorov-baikal-lokalizuet-odin-iz-etapov-proizvodstva

[53] https://t.me/tass_agency/240240 ; https://t.me/tass_agency/240241 ; https://t.me/tass_agency/240268

[54] https://ria dot ru/20240327/rakety-1936068479.html

[55] https://t.me/RusBotWien_RU/4869

[56] https://t.me/MID_Russia/38112

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