Screening tests for gestational diabetes: a systematic review for the U.S. Preventive Services Task Force.

BACKGROUND: A 50-g oral glucose challenge test (OGCT) is a widely accepted screening method for gestational diabetes mellitus (GDM), but other options are being considered. PURPOSE: To systematically review the test characteristics of various screening methods for GDM across a range of recommended diagnostic glucose thresholds. DATA SOURCES: 15 electronic databases from 1995 to May 2012, reference lists, Web sites of relevant organizations, and gray literature. STUDY SELECTION: Two reviewers independently identified English-language prospective studies that compared any screening test for GDM with any reference standard. DATA EXTRACTION: One reviewer extracted and a second reviewer verified data from 51 cohort studies. Two reviewers independently assessed methodological quality. DATA SYNTHESIS: The sensitivity, specificity, and positive and negative likelihood ratios for the OGCT at a threshold of 7.8 mmol/L (140 mg/dL) were 70% to 88%, 69% to 89%, 2.6 to 6.5, and 0.16 to 0.33, respectively. At a threshold of 7.2 mmol/L (130 mg/dL), the test characteristics were 88% to 99%, 66% to 77%, 2.7 to 4.2, and 0.02 to 0.14, respectively. For a fasting plasma glucose threshold of 4.7 mmol/L (85 mg/dL), they were 87%, 52%, 1.8, and 0.25, respectively. Glycated hemoglobin level had poorer test characteristics than fasting plasma glucose level or the OGCT. No studies compared the OGCT with International Association of the Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria. LIMITATIONS: The lack of a gold standard for confirming GDM limits comparisons. Few data exist for screening tests before 24 weeks' gestation. CONCLUSION: The OGCT and fasting plasma glucose level (at a threshold of 4.7 mmol/L [85 mg/dL]) by 24 weeks' gestation are good at identifying women who do not have GDM. The OGCT is better at identifying women who have GDM. The OGCT has not been validated for the IADPSG diagnostic criteria.

Benefits and harms of treating gestational diabetes mellitus: a systematic review and meta-analysis for the U.S. Preventive Services Task Force and the National Institutes of Health Office of Medical Applications of Research.

BACKGROUND: Outcomes of treating gestational diabetes mellitus (GDM) are not well-established. PURPOSE: To summarize evidence about the maternal and neonatal benefits and harms of treating GDM. DATA SOURCES: 15 electronic databases from 1995 to May 2012, gray literature, Web sites of relevant organizations, trial registries, and reference lists. STUDY SELECTION: English-language randomized, controlled trials (n = 5) and cohort studies (n = 6) of women without known preexisting diabetes. DATA EXTRACTION: One reviewer extracted data, and a second reviewer verified them. Two reviewers independently assessed methodological quality and evaluated strength of evidence for primary outcomes by using a Grading of Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS: All studies compared diet modification, glucose monitoring, and insulin as needed with no treatment. Women who were treated had more prenatal visits than those in control groups. Moderate evidence showed fewer cases of preeclampsia, shoulder dystocia, and macrosomia in the treated group. Evidence was insufficient for maternal weight gain and birth injury. Low evidence showed no difference between groups for neonatal hypoglycemia. Evidence was insufficient for long-term metabolic outcomes among offspring. No difference was found for cesarean delivery (low evidence), induction of labor (insufficient evidence), small-for-gestational-age neonates (moderate evidence), or admission to a neonatal intensive care unit (low evidence). LIMITATIONS: Evidence is low or insufficient for many outcomes of greatest clinical importance. The strongest evidence supports reductions in intermediate outcomes; however, other factors (for example, maternal weight and gestational weight gain) may impart greater risk than GDM, particularly when glucose levels are modestly elevated. CONCLUSION: Treating GDM results in less preeclampsia, shoulder dystocia, and macrosomia; however, current evidence does not show an effect on neonatal hypoglycemia or future poor metabolic outcomes. There is little evidence of short-term harm of treating GDM other than an increased demand for services.

Factors influencing intentions to stay and retention of nurse managers: a systematic review.

AIMS: This systematic review aimed to explore factors known to influence intentions to stay and retention of nurse managers in their current position. BACKGROUND: Retaining staff nurses and recruiting nurses to management positions are well documented; however, there is sparse research examining factors that influence retention of nurse managers. EVALUATIONS: Thirteen studies were identified through a systematic search of the literature. Eligibility criteria included both qualitative and quantitative studies that examined factors related to nurse manager intentions to stay and retention. Quality assessments, data extraction and analysis were completed on all studies included. Twenty-one factors were categorized into three major categories: organizational, role and personal. KEY ISSUES: Job satisfaction, organizational commitment, organizational culture and values, feelings of being valued and lack of time to complete tasks leading to work/life imbalance, were prominent across all categories. CONCLUSION: These findings suggest that intentions to stay and retention of nurse managers are multifactoral. However, lack of robust literature highlights the need for further research to develop strategies to retain nurse managers. ImplICATIONS FOR NURSE MANAGEMENT: Health-care organizations and senior decision-makers should feel a responsibility to support front-line managers in relation to workload and span of control, and in understanding work/life balance issues faced by managers.

Screening and diagnosing gestational diabetes mellitus.

BACKGROUND: There is uncertainty as to the optimal approach for screening and diagnosis of gestational diabetes mellitus (GDM). Based on systematic reviews published in 2003 and 2008, the U.S. Preventive Services Task Force concluded that there was insufficient evidence upon which to make a recommendation regarding routine screening of all pregnant women. OBJECTIVES: (1) Identify properties of screening tests for GDM, (2) evaluate benefits and harms of screening for GDM, (3) assess the effects of different screening and diagnostic thresholds on outcomes for mothers and their offspring, and (4) determine the benefits and harms of treatment for a diagnosis of GDM. DATA SOURCES: We searched 15 electronic databases from 1995 to May 2012, including MEDLINE and Cochrane Central Register of Controlled Trials (which contains the Cochrane Pregnancy and Childbirth Group registry); gray literature; Web sites of relevant organizations; trial registries; and reference lists. METHODS: Two reviewers independently conducted study selection and quality assessment. One reviewer extracted data, and a second reviewer verified the data. We included published randomized and nonrandomized controlled trials and prospective and retrospective cohort studies that compared any screening or diagnostic test with any other screening or diagnostic test; any screening with no screening; women who met various thresholds for GDM with those who did not meet various criteria, where women in both groups did not receive treatment; any treatment for GDM with no treatment. We conducted a descriptive analysis for all studies and meta-analyses when appropriate. Key outcomes included preeclampsia, maternal weight gain, birth injury, shoulder dystocia, neonatal hypoglycemia, macrosomia, and long-term metabolic outcomes for the child and mother. RESULTS: The search identified 14,398 citations and included 97 studies (6 randomized controlled trials, 63 prospective cohort studies, and 28 retrospective cohort studies). Prevalence of GDM varied across studies and diagnostic criteria: American Diabetes Association (75 g) 2 to 19 percent; Carpenter and Coustan 3.6 to 38 percent; National Diabetes Data Group 1.4 to 50 percent; and World Health Organization 2 to 24.5 percent. Lack of a gold standard for the diagnosis of GDM and little evidence about the accuracy of screening strategies for GDM remain problematic. The 50 g oral glucose challenge test with a glucose threshold of 130 mg/dL versus 140 mg/dL improves sensitivity and reduces specificity. Both thresholds have high negative predictive values (NPV) but variable positive predictive values (PPVs) across a range of prevalence. There was limited evidence for the screening of GDM diagnosed less than 24 weeks' gestation (three studies). One study compared the International Association of Diabetes in Pregnancy Study Groups' (IADPSG) diagnostic criteria with a two-step strategy. Sensitivity was 82 percent, specificity was 94 percent. Only two studies examined the effects on health outcomes from screening for GDM. One retrospective cohort study (n=1,000) showed more cesarean deliveries in the screened group. A survey within a prospective cohort study (n=93) found the same incidence of macrosomia (≥4.3 kg) in screened and unscreened groups (7 percent each group). Thirty-eight studies examined health outcomes for women who met different criteria for GDM and did not undergo treatment. Methodologically strong studies showed a continuous positive relationship between increasing glucose levels and the incidence of primary cesarean section and macrosomia. One of these studies also found significantly fewer cases of preeclampsia, cesarean section, shoulder dystocia and/or birth injury, clinical neonatal hypoglycemia, and hyperbilirubinemia for women without GDM compared with those meeting IADPSG criteria. Among the other studies, fewer cases of preeclampsia were observed for women with no GDM and women who were false positive versus those meeting Carpenter and Coustan criteria. For maternal weight gain, few comparisons showed differences. For fetal birth trauma, single studies showed no differences for women with Carpenter and Coustan GDM and World Health Organization impaired glucose tolerance versus women without GDM. Women diagnosed based on National Diabetes Data Group GDM had more fetal birth trauma compared with women without GDM. Fewer cases of macrosomia were seen in the group without GDM compared with Carpenter and Coustan GDM, Carpenter and Coustan 1 abnormal oral glucose tolerance test, National Diabetes Data Group GDM, National Diabetes Data Group false positives, and World Health Organization impaired glucose tolerance. Fewer cases of neonatal hypoglycemia were found among patient groups without GDM compared with those meeting Carpenter and Coustan criteria. There was more childhood obesity for Carpenter and Coustan GDM versus patient groups with no GDM. Eleven studies compared diet modification, glucose monitoring, and insulin as needed with no treatment. Moderate evidence showed fewer cases of preeclampsia in the treated group. The evidence was insufficient for maternal weight gain and birth injury. Moderate evidence found less shoulder dystocia with treatment for GDM. Low evidence showed no difference for neonatal hypoglycemia between treated and untreated GDM. Moderate evidence showed benefits of treatment for reduction of macrosomia (>4,000 g). There was insufficient evidence for long-term metabolic outcomes among offspring. Five studies provided data on harms of treating GDM. No difference was found for cesarean delivery, induction of labor, small for gestational age, or admission to a neonatal intensive care unit. There were significantly more prenatal visits among those treated. CONCLUSIONS: While evidence supports a positive association with increasing plasma glucose on a 75 g or 100 g oral glucose tolerance test and macrosomia and primary cesarean section, clear thresholds for increased risk were not found. The 50 g oral glucose challenge test has high NPV but variable PPV. Treatment of GDM results in less preeclampsia and macrosomia. Current evidence does not show that treatment of GDM has an effect on neonatal hypoglycemia or future poor metabolic outcomes. There is little evidence of short-term harm from treating GDM other than an increased demand for services. Research is needed on the long-term metabolic outcome for offspring as a result of GDM and its treatment, and the "real world" effects of GDM treatment on use of care.

Can the global uptake of palliative care innovations be improved? Insights from a bibliometric analysis of the Edmonton Symptom Assessment System.

Clinical research is undertaken to improve care for palliative patients, but little is known about how to support the broad uptake of resultant innovations. The objectives of this paper are to: (1) explore the uptake of the Edmonton Symptom Assessment System throughout the global palliative care community through the lens of a bibliometric review - a research method that maps out the journey of new knowledge uptake by evaluating where key articles are cited in published literature; (2) construct hypotheses on attributes of the global community of palliative care learners; and (3) make inferences on approaches that could improve knowledge transfer. While preliminary, results of the study suggest several specific approaches that could support widespread uptake of innovations in palliative care: targeting publication in high impact, international journals; explicitly focusing on how the innovation is applied to best practice; encouraging additional research to expand on early studies; consciously targeting key professional groups and organizations to promote discussion in the grey literature; and early translation and promotion within multiple languages.

Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review.

CONTEXT: Numerous policy and research reports call for leadership to build quality work environments, implement new models of care, and bring health and wellbeing to an exhausted and stretched nursing workforce. Rarely do they indicate how leadership should be enacted, or examine whether some forms of leadership may lead to negative outcomes. We aimed to examine the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments. METHODS: The search strategy of this multidisciplinary systematic review included 10 electronic databases. Published, quantitative studies that examined leadership behaviours and outcomes for nurses and organizations were included. Quality assessments, data extractions and analysis were completed on all included studies. FINDINGS: 34,664 titles and abstracts were screened resulting in 53 included studies. Using content analysis, 64 outcomes were grouped into five categories: staffsatisfaction with work, role and pay, staff relationships with work, staff health and wellbeing, work environment factors, and productivity and effectiveness. Distinctive patterns between relational and task focused leadership styles and their outcomes for nurses and their work environments emerged from our analysis. For example, 24 studies reported that leadership styles focused on people and relationships (transformational, resonant, supportive, and consideration) were associated with higher nurse job satisfaction, whereas 10 studies found that leadership styles focused on tasks (dissonant, instrumental and management by exception) were associated with lower nurse job satisfaction. Similar trends were found for each category of outcomes. CONCLUSION: Our results document evidence of various forms of leadership and their differential effects on the nursing workforce and work environments. Leadership focused on task completion alone is not sufficient to achieve optimum outcomes for the nursing workforce. Efforts by organizations and individuals to encourage and develop transformational and relational leadership are needed to enhance nurse satisfaction, recruitment, retention, and healthy work environments, particularly in this current and worsening nursing shortage.

Healthcare succession planning: an integrative review.

Succession planning is a business strategy that has recently gained attention in the healthcare literature, primarily because of nursing shortage concerns and the demand for retaining knowledgeable personnel to meet organizational needs. Little research has been conducted in healthcare settings that clearly defines best practices for succession planning frameworks. To effectively carry out such organizational strategies during these challenging times, an integrative review of succession planning in healthcare was performed to identify consistencies in theoretical approaches and strategies for chief nursing officers and healthcare managers to initiate. Selected articles were compared with business succession planning to determine whether healthcare strategies were similar to best practices already established in business contexts. The results of this integrative review will aid leaders and managers to use succession planning as a tool in their recruitment, retention, mentoring, and administration activities and also provide insights for future development of healthcare succession planning frameworks.