Factors influencing nurse manager retention, intent to stay or leave and turnover: A systematic review update.

AIMS: To understand factors influencing nurse manager retention or intention to leave, develop a preliminary theoretical model and identify strategies and interventions for workforce planning. DESIGN: Systematic review update of literature with integrated design of mixed research synthesis. METHODS: We included peer-reviewed articles examining factors influencing retention or intention to leave for front-line, middle or patient care nurse managers. Authors independently screened articles for inclusion and assessed included articles for quality. We adhered to a convergent synthesis approach. DATA SOURCES: Nine databases included MEDLINE, EMBASE, PsychINFO, CINAHL Plus with Full Text, ERIC, Health Source Nursing/Academic Edition, Scopus, ProQuest Dissertations and Theses and LILACS in January 2023. RESULTS: Thirty-five studies published between 1990 and 2022, 22 quantitative and 13 qualitative or mixed methods, were included. 155 factors influencing nurse manager retention, intention to stay, or turnover were reported. Job satisfaction was most frequently examined (n = 7), followed by factors such as empowerment (n = 3), decision-making (n = 3) and resilience (n = 2). We developed a preliminary theoretical model demonstrating staff relations and leadership, organizational and job characteristics, socio-demographics, personal characteristics, well-being and nurse manager relationship with work influence managers' intention to stay or to leave. CONCLUSIONS: Nurse managers who were empowered, satisfied with their work, received constructive feedback and found meaning in their roles showed greater intent to stay. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Nurse administrators can ensure managers are provided with authority to make decisions that promote autonomy. Work cultures that allow for regular meaningful constructive feedback from staff and leaders may contribute to nurse managers feeling valued. IMPACT: Understanding factors that influence job retention or intention to leave may help nurse managers and their supervisors identify areas for strategy and intervention design to ensure sustainability of this workforce. REPORTING METHOD: PRISMA 2020 Guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Screening for the primary prevention of fragility fractures among adults aged 40 years and older in primary care: systematic reviews of the effects and acceptability of screening and treatment, and the accuracy of risk prediction tools.

BACKGROUND: To inform recommendations by the Canadian Task Force on Preventive Health Care, we reviewed evidence on the benefits, harms, and acceptability of screening and treatment, and on the accuracy of risk prediction tools for the primary prevention of fragility fractures among adults aged 40 years and older in primary care. METHODS: For screening effectiveness, accuracy of risk prediction tools, and treatment benefits, our search methods involved integrating studies published up to 2016 from an existing systematic review. Then, to locate more recent studies and any evidence relating to acceptability and treatment harms, we searched online databases (2016 to April 4, 2022 [screening] or to June 1, 2021 [predictive accuracy]; 1995 to June 1, 2021, for acceptability; 2016 to March 2, 2020, for treatment benefits; 2015 to June 24, 2020, for treatment harms), trial registries and gray literature, and hand-searched reviews, guidelines, and the included studies. Two reviewers selected studies, extracted results, and appraised risk of bias, with disagreements resolved by consensus or a third reviewer. The overview of reviews on treatment harms relied on one reviewer, with verification of data by another reviewer to correct errors and omissions. When appropriate, study results were pooled using random effects meta-analysis; otherwise, findings were described narratively. Evidence certainty was rated according to the GRADE approach. RESULTS: We included 4 randomized controlled trials (RCTs) and 1 controlled clinical trial (CCT) for the benefits and harms of screening, 1 RCT for comparative benefits and harms of different screening strategies, 32 validation cohort studies for the calibration of risk prediction tools (26 of these reporting on the Fracture Risk Assessment Tool without [i.e., clinical FRAX], or with the inclusion of bone mineral density (BMD) results [i.e., FRAX + BMD]), 27 RCTs for the benefits of treatment, 10 systematic reviews for the harms of treatment, and 12 studies for the acceptability of screening or initiating treatment. In females aged 65 years and older who are willing to independently complete a mailed fracture risk questionnaire (referred to as "selected population"), 2-step screening using a risk assessment tool with or without measurement of BMD probably (moderate certainty) reduces the risk of hip fractures (3 RCTs and 1 CCT, n = 43,736, absolute risk reduction [ARD] = 6.2 fewer in 1000, 95% CI 9.0-2.8 fewer, number needed to screen [NNS] = 161) and clinical fragility fractures (3 RCTs, n = 42,009, ARD = 5.9 fewer in 1000, 95% CI 10.9-0.8 fewer, NNS = 169). It probably does not reduce all-cause mortality (2 RCTs and 1 CCT, n = 26,511, ARD = no difference in 1000, 95% CI 7.1 fewer to 5.3 more) and may (low certainty) not affect health-related quality of life. Benefits for fracture outcomes were not replicated in an offer-to-screen population where the rate of response to mailed screening questionnaires was low. For females aged 68-80 years, population screening may not reduce the risk of hip fractures (1 RCT, n = 34,229, ARD = 0.3 fewer in 1000, 95% CI 4.2 fewer to 3.9 more) or clinical fragility fractures (1 RCT, n = 34,229, ARD = 1.0 fewer in 1000, 95% CI 8.0 fewer to 6.0 more) over 5 years of follow-up. The evidence for serious adverse events among all patients and for all outcomes among males and younger females (<65 years) is very uncertain. We defined overdiagnosis as the identification of high risk in individuals who, if not screened, would never have known that they were at risk and would never have experienced a fragility fracture. This was not directly reported in any of the trials. Estimates using data available in the trials suggest that among "selected" females offered screening, 12% of those meeting age-specific treatment thresholds based on clinical FRAX 10-year hip fracture risk, and 19% of those meeting thresholds based on clinical FRAX 10-year major osteoporotic fracture risk, may be overdiagnosed as being at high risk of fracture. Of those identified as being at high clinical FRAX 10-year hip fracture risk and who were referred for BMD assessment, 24% may be overdiagnosed. One RCT (n = 9268) provided evidence comparing 1-step to 2-step screening among postmenopausal females, but the evidence from this trial was very uncertain. For the calibration of risk prediction tools, evidence from three Canadian studies (n = 67,611) without serious risk of bias concerns indicates that clinical FRAX-Canada may be well calibrated for the 10-year prediction of hip fractures (observed-to-expected fracture ratio [O:E] = 1.13, 95% CI 0.74-1.72, I2 = 89.2%), and is probably well calibrated for the 10-year prediction of clinical fragility fractures (O:E = 1.10, 95% CI 1.01-1.20, I2 = 50.4%), both leading to some underestimation of the observed risk. Data from these same studies (n = 61,156) showed that FRAX-Canada with BMD may perform poorly to estimate 10-year hip fracture risk (O:E = 1.31, 95% CI 0.91-2.13, I2 = 92.7%), but is probably well calibrated for the 10-year prediction of clinical fragility fractures, with some underestimation of the observed risk (O:E 1.16, 95% CI 1.12-1.20, I2 = 0%). The Canadian Association of Radiologists and Osteoporosis Canada Risk Assessment (CAROC) tool may be well calibrated to predict a category of risk for 10-year clinical fractures (low, moderate, or high risk; 1 study, n = 34,060). The evidence for most other tools was limited, or in the case of FRAX tools calibrated for countries other than Canada, very uncertain due to serious risk of bias concerns and large inconsistency in findings across studies. Postmenopausal females in a primary prevention population defined as <50% prevalence of prior fragility fracture (median 16.9%, range 0 to 48% when reported in the trials) and at risk of fragility fracture, treatment with bisphosphonates as a class (median 2 years, range 1-6 years) probably reduces the risk of clinical fragility fractures (19 RCTs, n = 22,482, ARD = 11.1 fewer in 1000, 95% CI 15.0-6.6 fewer, [number needed to treat for an additional beneficial outcome] NNT = 90), and may reduce the risk of hip fractures (14 RCTs, n = 21,038, ARD = 2.9 fewer in 1000, 95% CI 4.6-0.9 fewer, NNT = 345) and clinical vertebral fractures (11 RCTs, n = 8921, ARD = 10.0 fewer in 1000, 95% CI 14.0-3.9 fewer, NNT = 100); it may not reduce all-cause mortality. There is low certainty evidence of little-to-no reduction in hip fractures with any individual bisphosphonate, but all provided evidence of decreased risk of clinical fragility fractures (moderate certainty for alendronate [NNT=68] and zoledronic acid [NNT=50], low certainty for risedronate [NNT=128]) among postmenopausal females. Evidence for an impact on risk of clinical vertebral fractures is very uncertain for alendronate and risedronate; zoledronic acid may reduce the risk of this outcome (4 RCTs, n = 2367, ARD = 18.7 fewer in 1000, 95% CI 25.6-6.6 fewer, NNT = 54) for postmenopausal females. Denosumab probably reduces the risk of clinical fragility fractures (6 RCTs, n = 9473, ARD = 9.1 fewer in 1000, 95% CI 12.1-5.6 fewer, NNT = 110) and clinical vertebral fractures (4 RCTs, n = 8639, ARD = 16.0 fewer in 1000, 95% CI 18.6-12.1 fewer, NNT=62), but may make little-to-no difference in the risk of hip fractures among postmenopausal females. Denosumab probably makes little-to-no difference in the risk of all-cause mortality or health-related quality of life among postmenopausal females. Evidence in males is limited to two trials (1 zoledronic acid, 1 denosumab); in this population, zoledronic acid may make little-to-no difference in the risk of hip or clinical fragility fractures, and evidence for all-cause mortality is very uncertain. The evidence for treatment with denosumab in males is very uncertain for all fracture outcomes (hip, clinical fragility, clinical vertebral) and all-cause mortality. There is moderate certainty evidence that treatment causes a small number of patients to experience a non-serious adverse event, notably non-serious gastrointestinal events (e.g., abdominal pain, reflux) with alendronate (50 RCTs, n = 22,549, ARD = 16.3 more in 1000, 95% CI 2.4-31.3 more, [number needed to treat for an additional harmful outcome] NNH = 61) but not with risedronate; influenza-like symptoms with zoledronic acid (5 RCTs, n = 10,695, ARD = 142.5 more in 1000, 95% CI 105.5-188.5 more, NNH = 7); and non-serious gastrointestinal adverse events (3 RCTs, n = 8454, ARD = 64.5 more in 1000, 95% CI 26.4-13.3 more, NNH = 16), dermatologic adverse events (3 RCTs, n = 8454, ARD = 15.6 more in 1000, 95% CI 7.6-27.0 more, NNH = 64), and infections (any severity; 4 RCTs, n = 8691, ARD = 1.8 more in 1000, 95% CI 0.1-4.0 more, NNH = 556) with denosumab. For serious adverse events overall and specific to stroke and myocardial infarction, treatment with bisphosphonates probably makes little-to-no difference; evidence for other specific serious harms was less certain or not available. There was low certainty evidence for an increased risk for the rare occurrence of atypical femoral fractures (0.06 to 0.08 more in 1000) and osteonecrosis of the jaw (0.22 more in 1000) with bisphosphonates (most evidence for alendronate). The evidence for these rare outcomes and for rebound fractures with denosumab was very uncertain. Younger (lower risk) females have high willingness to be screened. A minority of postmenopausal females at increased risk for fracture may accept treatment. Further, there is large heterogeneity in the level of risk at which patients may be accepting of initiating treatment, and treatment effects appear to be overestimated. CONCLUSION: An offer of 2-step screening with risk assessment and BMD measurement to selected postmenopausal females with low prevalence of prior fracture probably results in a small reduction in the risk of clinical fragilityfracture and hip fracture compared to no screening. These findings were most applicable to the use of clinical FRAX for risk assessment and were not replicated in the offer-to-screen population where the rate of response to mailed screening questionnaires was low. Limited direct evidence on harms of screening were available; using study data to provide estimates, there may be a moderate degree of overdiagnosis of high risk for fracture to consider. The evidence for younger females and males is very limited. The benefits of screening and treatment need to be weighed against the potential for harm; patient views on the acceptability of treatment are highly variable. SYSTEMATIC REVIEW REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO): CRD42019123767.

Healthcare aide-focused interventions to improve pain management in long-term care homes: A systematic review.

OBJECTIVES: Pain is common in long-term care residents. We examined the effectiveness of interventions involving healthcare aides that aim to manage pain for these residents. DESIGN: A systematic review which follows PRISMA reporting guidelines. SETTING AND PARTICIPANTS: We examined controlled trials and intervention studies that included long-term care residents aged ≥60 years who received interventions to reduce chronic pain. Interventions were either delivered by healthcare aides at the resident level or were directed at healthcare aides to improve their pain management practices for residents. METHODS: We searched 7 databases to identify relevant studies. After screening 400 articles, we reviewed 131 full-text articles and included them if they reported a pain management intervention and measured pain with a standardized pain scale. Data were synthesized narratively. Risk of bias was assessed using the Mixed Methods Assessment Tool. RESULTS: In total, 9 studies were examined in the narrative review. Six studies described pain interventions involving education, new pain protocols and/or new assessment tools delivered to healthcare aides. Three studies described pain interventions delivered by healthcare aides to residents, which included a new incontinence care routine, light touch massage, and a bathing intervention. CONCLUSIONS AND IMPLICATIONS: Interventions involving healthcare aides may be beneficial to pain management for long-term care residents as they have the potential to reduce residents' pain and improve both pain assessment and reporting practices. Further research is warranted on specific elements that contribute to an improvement in residents' pain and to the overall role of healthcare aides care of residents.

Evidence available for patient-identified priorities in depression research: results of 11 rapid responses.

OBJECTIVES: Patient priority setting projects (PPSPs) can reduce research agenda bias. A key element of PPSPs is a review of available literature to determine if the proposed research priorities have been addressed, identify research gaps, recognise opportunities for knowledge translation (KT) and avoid duplication of research efforts. We conducted rapid responses for 11 patient-identified priorities in depression to provide a map of the existing evidence. DESIGN: Eleven rapid responses. DATA SOURCES: Single electronic database (PubMed). ELIGIBILITY CRITERIA: Each rapid response had unique eligibility criteria. For study designs, we used a stepwise inclusion process that started with systematic reviews (SRs) if available, then randomised controlled trials and observational studies as necessary. RESULTS: For all but one of the rapid responses we identified existing SRs (median 7 SRs per rapid response, range 0-179). There were questions where extensive evidence exists (ie, hundreds of primary studies), yet uncertainties remain. For example, there is evidence supporting the effectiveness of many non-pharmacological interventions (including psychological interventions and exercise) to reduce depressive symptoms. However, targeted research is needed that addresses comparative effectiveness of promising interventions, specific populations of interest (eg, children, minority groups) and adverse effects. CONCLUSIONS: We identified an extensive body of evidence addressing patient priorities in depression and mapped the results and limitations of existing evidence, areas of uncertainty and general directions for future research. This work can serve as a solid foundation to guide future research in depression and KT activities. Integrated knowledge syntheses bring value to the PPSP process; however, the role of knowledge synthesis in PPSPs and methodological approaches are not well defined at present.

Programme theory development and formative evaluation of a provincial knowledge translation unit.

BACKGROUND: Research shows a significant gap between healthcare research and evidence-based healthcare policy and practice. Knowledge translation (KT) has an important role in addressing this gap by bolstering evidence-informed healthcare. Canada's Strategy for Patient-Oriented Research (SPOR) is a nationally mandated and supported initiative developed to respond to the gap between research and practice. One aspect of SPOR is the provincial/territorial SUpport for People and Patient-Oriented Research and Trials (SUPPORT) Units, intended to assist local health researchers and systems to reach the goal of improving the quality and quantity of patient-oriented research in Canada. This article presents the programme theory development and a formative evaluation of the KT Platform in Alberta's SPOR SUPPORT Unit. METHODS: We used a mixed-methods approach to develop the KT Platform's programme theory and subsequently conducted the formative evaluation. An extensive needs assessment, comprised of 59 qualitative interviews with researchers and health systems employees in Canada with an interest in KT, served as the basis for our programme theory design. Three years after launching the KT Platform, we hired an evaluation consultant to conduct a formative evaluation of the Platform's programme theory and operations. The evaluation was performed by conducting nine interviews with KT Platform service users (n = 6) and KT experts acting in advisory capacities to the KT Platform (n = 3). RESULTS: The KT Platform developed a '4C Model' as a summary of the Platform's programme theory. This model is designed to meet local needs for capacity-building, a community of practice, consultation services, and contributions to KT science. This suite of services was found to help the local health system implement health evidence with measurable positive health outcomes. However, the community remains hesitant about their capacity as individuals to design and perform important KT activities independently. CONCLUSIONS: With the mandate and support provided by SPOR, the KT Platform was able to design a strong programme theory based on evidence from an extensive needs assessment of the local community. The resulting 4C Model has provided a framework for KT work to assist in improving local health outcomes and can be considered by others designing KT programmes as a useful model to follow. Ongoing monitoring and assessment are required to continue to identify and respond to local needs.

Exercise for the prevention and treatment of low back, pelvic girdle and lumbopelvic pain during pregnancy: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this review was to investigate the relationship between prenatal exercise, and low back (LBP), pelvic girdle (PGP) and lumbopelvic (LBPP) pain. DESIGN: Systematic review with random effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were eligible (except case studies and reviews) if they were published in English, Spanish or French, and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [eg, dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcome (prevalence and symptom severity of LBP, PGP and LBPP). RESULTS: The analyses included data from 32 studies (n=52 297 pregnant women). 'Very low' to 'moderate' quality evidence from 13 randomised controlled trials (RCTs) showed prenatal exercise did not reduce the odds of suffering from LBP, PGP and LBPP either in pregnancy or the postpartum period. However, 'very low' to 'moderate' quality evidence from 15 RCTs identified lower pain severity during pregnancy and the early postpartum period in women who exercised during pregnancy (standardised mean difference -1.03, 95% CI -1.58, -0.48) compared with those who did not exercise. These findings were supported by 'very low' quality evidence from other study designs. CONCLUSION: Compared with not exercising, prenatal exercise decreased the severity of LBP, PGP or LBPP during and following pregnancy but did not decrease the odds of any of these conditions at any time point.

Impact of prenatal exercise on maternal harms, labour and delivery outcomes: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review of the relationships between prenatal exercise and maternal harms including labour/delivery outcomes. DESIGN: Systematic review with random effects meta-analysis and meta-regression. DATASOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise, alone ["exercise-only"] or in combination with other intervention components [e.g., dietary; "exercise + co-intervention"]) and outcome (preterm/prelabour rupture of membranes, caesarean section, instrumental delivery, induction of labour, length of labour, vaginal tears, fatigue, injury, musculoskeletal trauma, maternal harms (author defined) and diastasis recti). RESULTS: 113 studies (n=52 858 women) were included. 'Moderate' quality evidence from exercise-only randomised controlled trials (RCTs) indicated a 24% reduction in the odds of instrumental delivery in women who exercised compared with women who did not (20 RCTs, n=3819; OR 0.76, 95% CI 0.63 to 0.92, I 2= 0 %). The remaining outcomes were not associated with exercise. Results from meta-regression did not identify a dose-response relationship between frequency, intensity, duration or volume of exercise and labour and delivery outcomes. SUMMARY/CONCLUSIONS: Prenatal exercise reduced the odds of instrumental delivery in the general obstetrical population. There was no relationship between prenatal exercise and preterm/prelabour rupture of membranes, caesarean section, induction of labour, length of labour, vaginal tears, fatigue, injury, musculoskeletal trauma, maternal harms and diastasis recti.

Effectiveness of exercise interventions in the prevention of excessive gestational weight gain and postpartum weight retention: a systematic review and meta-analysis.

OBJECTIVE: Gestational weight gain (GWG) has been identified as a critical modifier of maternal and fetal health. This systematic review and meta-analysis aimed to examine the relationship between prenatal exercise, GWG and postpartum weight retention (PPWR). DESIGN: Systematic review with random effects meta-analysis and meta-regression. Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs in English, Spanish or French were eligible (except case studies and reviews) if they contained information on the population (pregnant women without contraindication to exercise), intervention (frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [eg, dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume or type of exercise) and outcomes (GWG, excessive GWG (EGWG), inadequate GWG (IGWG) or PPWR). RESULTS: Eighty-four unique studies (n=21 530) were included. 'Low' to 'moderate' quality evidence from randomised controlled trials (RCTs) showed that exercise-only interventions decreased total GWG (n=5819; -0.9 kg, 95% CI -1.23 to -0.57 kg, I2=52%) and PPWR (n=420; -0.92 kg, 95% CI -1.84 to 0.00 kg, I2=0%) and reduced the odds of EGWG (n=3519; OR 0.68, 95% CI 0.57 to 0.80, I2=12%) compared with no exercise. 'High' quality evidence indicated higher odds of IGWG with prenatal exercise-only (n=1628; OR 1.32, 95% CI 1.04 to 1.67, I2=0%) compared with no exercise. CONCLUSIONS: Prenatal exercise reduced the odds of EGWG and PPWR but increased the risk of IGWG. However, the latter result should be interpreted with caution because it was based on a limited number of studies (five RCTs).

Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis.

OBJECTIVE: Gestational diabetes mellitus (GDM), gestational hypertension (GH) and pre-eclampsia (PE) are associated with short and long-term health issues for mother and child; prevention of these complications is critically important. This study aimed to perform a systematic review and meta-analysis of the relationships between prenatal exercise and GDM, GH and PE. DESIGN: Systematic review with random effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies) if published in English, Spanish or French, and contained information on the Population (pregnant women without contraindication to exercise), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [e.g., dietary; "exercise + co-intervention"]), Comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and Outcomes (GDM, GH, PE). RESULTS: A total of 106 studies (n=273 182) were included. 'Moderate' to 'high'-quality evidence from randomised controlled trials revealed that exercise-only interventions, but not exercise+cointerventions, reduced odds of GDM (n=6934; OR 0.62, 95% CI 0.52 to 0.75), GH (n=5316; OR 0.61, 95% CI 0.43 to 0.85) and PE (n=3322; OR 0.59, 95% CI 0.37 to 0.9) compared with no exercise. To achieve at least a 25% reduction in the odds of developing GDM, PE and GH, pregnant women need to accumulate at least 600 MET-min/week of moderate-intensity exercise (eg, 140 min of brisk walking, water aerobics, stationary cycling or resistance training). SUMMARY/CONCLUSIONS: In conclusion, exercise-only interventions were effective at lowering the odds of developing GDM, GH and PE.

Impact of prenatal exercise on both prenatal and postnatal anxiety and depressive symptoms: a systematic review and meta-analysis.

OBJECTIVE: To examine the influence of prenatal exercise on depression and anxiety during pregnancy and the postpartum period. DESIGN: Systematic review with random effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the Population (pregnant women without contraindication to exercise), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise), Comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and Outcome (prenatal or postnatal depression or anxiety). RESULTS: A total of 52 studies (n=131 406) were included. 'Moderate' quality evidence from randomised controlled trials (RCTs) revealed that exercise-only interventions, but not exercise+cointerventions, reduced the severity of prenatal depressive symptoms (13 RCTs, n=1076; standardised mean difference: -0.38, 95% CI -0.51 to -0.25, I2=10%) and the odds of prenatal depression by 67% (5 RCTs, n=683; OR: 0.33, 95% CI 0.21 to 0.53, I2=0%) compared with no exercise. Prenatal exercise did not alter the odds of postpartum depression or the severity of depressive symptoms, nor anxiety or anxiety symptoms during or following pregnancy. To achieve at least a moderate effect size in the reduction of the severity of prenatal depressive symptoms, pregnant women needed to accumulate at least 644 MET-min/week of exercise (eg, 150 min of moderate intensity exercise, such as brisk walking, water aerobics, stationary cycling, resistance training). SUMMARY/CONCLUSIONS: Prenatal exercise reduced the odds and severity of prenatal depression.

Impact of prenatal exercise on neonatal and childhood outcomes: a systematic review and meta-analysis.

OBJECTIVE: We aimed to identify the relationship between maternal prenatal exercise and birth complications, and neonatal and childhood morphometric, metabolic and developmental outcomes. DESIGN: Systematic review with random-effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were eligible (except case studies and reviews) if published in English, Spanish or French, and contained information on the relevant population (pregnant women without contraindication to exercise), intervention (subjective/objective measures of frequency, intensity, duration, volume or type of exercise, alone ('exercise-only') or in combination with other intervention components (eg, dietary; 'exercise+cointervention')), comparator (no exercise or different frequency, intensity, duration, volume, type or trimester of exercise) and outcomes (preterm birth, gestational age at delivery, birth weight, low birth weight (<2500 g), high birth weight (>4000 g), small for gestational age, large for gestational age, intrauterine growth restriction, neonatal hypoglycaemia, metabolic acidosis (cord blood pH, base excess), hyperbilirubinaemia, Apgar scores, neonatal intensive care unit admittance, shoulder dystocia, brachial plexus injury, neonatal body composition (per cent body fat, body weight, body mass index (BMI), ponderal index), childhood obesity (per cent body fat, body weight, BMI) and developmental milestones (including cognitive, psychosocial, motor skills)). RESULTS: A total of 135 studies (n=166 094) were included. There was 'high' quality evidence from exercise-only randomised controlled trials (RCTs) showing a 39% reduction in the odds of having a baby >4000 g (macrosomia: 15 RCTs, n=3670; OR 0.61, 95% CI 0.41 to 0.92) in women who exercised compared with women who did not exercise, without affecting the odds of growth-restricted, preterm or low birth weight babies. Prenatal exercise was not associated with the other neonatal or infant outcomes that were examined. CONCLUSIONS: Prenatal exercise is safe and beneficial for the fetus. Maternal exercise was associated with reduced odds of macrosomia (abnormally large babies) and was not associated with neonatal complications or adverse childhood outcomes.

Prenatal exercise (including but not limited to pelvic floor muscle training) and urinary incontinence during and following pregnancy: a systematic review and meta-analysis.

OBJECTIVE: To examine the relationships between prenatal physical activity and prenatal and postnatal urinary incontinence (UI). DESIGN: Systematic review with random effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the Population (pregnant women without contraindication to exercise), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [e.g., dietary; "exercise + co-intervention"]), Comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and Outcome (prenatal or postnatal UI). RESULTS: 24 studies (n=15 982 women) were included. 'Low' to 'moderate' quality evidence revealed prenatal pelvic floor muscle training (PFMT) with or without aerobic exercise decreased the odds of UI in pregnancy (15 randomised controlled trials (RCTs), n=2764 women; OR 0.50, 95% CI 0.37 to 0.68, I2=60%) and in the postpartum period (10 RCTs, n=1682 women; OR 0.63, 95% CI 0.51, 0.79, I2=0%). When we analysed the data by whether women were continent or incontinent prior to the intervention, exercise was beneficial at preventing the development of UI in women with continence, but not effective in treating UI in women with incontinence. There was 'low' quality evidence that prenatal exercise had a moderate effect in the reduction of UI symptom severity during (five RCTs, standard mean difference (SMD) -0.54, 95% CI -0.88 to -0.20, I2=64%) and following pregnancy (three RCTs, 'moderate' quality evidence; SMD -0.54, 95% CI -0.87 to -0.22, I2=24%). CONCLUSION: Prenatal exercise including PFMT reduced the odds and symptom severity of prenatal and postnatal UI. This was the case for women who were continent before the intervention. Among women who were incontinent during pregnancy, exercise training was not therapeutic.

Harms of Antipsychotics in Children and Young Adults: A Systematic Review Update.

OBJECTIVE: To update and extend our previous systematic review on first- (FGAs) and second-generation antipsychotics (SGAs) for treatment of psychiatric and behavioral conditions in children, adolescents, and young adults (aged ≤24 years). This article focuses on the evidence for harms. METHOD: We searched (to April 2016) 8 databases, gray literature, trial registries, Food and Drug Administration reports, and reference lists. Two reviewers conducted study screening and selection independently, with consensus for selection. One reviewer extracted and another verified all data; 2 reviewers independently assessed risk of bias. We conducted meta-analyses when appropriate and network meta-analysis across conditions for changes in body composition. Two reviewers reached consensus for ratings on the strength of evidence for prespecified outcomes. RESULTS: A total of 135 studies (95 trials and 40 observational) were included, and 126 reported on harms. FGAs caused slightly less weight gain and more extrapyramidal symptoms than SGAs. SGAs as a class caused adverse effects, including weight gain, high triglyceride levels, extrapyramidal symptoms, sedation, and somnolence. They appeared to increase the risk for high cholesterol levels and type 2 diabetes. Many outcomes for individual drug comparisons were of low or insufficient strength of evidence. Olanzapine caused more short-term gains in weight and body mass index than several other SGAs. The dose of SGAs may not make a difference over the short term for some outcomes. CONCLUSIONS: Clinicians need to weigh carefully the benefit-to-harm ratio when using antipsychotics, especially when treatment alternatives exist. More evidence is needed on the comparative harms between antipsychotics over the longer term.

Safe Care for Pediatric Patients: A Scoping Review Across Multiple Health Care Settings.

Children are particularly vulnerable to patient safety concerns due to pediatric-specific and general health care challenges. This scoping review identifies and describes the vulnerabilities of those aged 0 to 18 years to iatrogenic harm in various health care settings. Six databases were searched from 1991 to 2012. Primary studies were categorized using predetermined groupings. Categories were tallied and descriptive statistics were employed. A total of 388 primary studies exploring interventions that improved patient safety, deficiencies, or errors leading to safety concerns were included. The most common issues were medication (189 studies, 48.7%) and general medical (81 studies, 20.9%) errors. Sixty studies (15.5%) evaluated or described patient safety interventions, 206 studies (53.1%) addressed health care systems and technologies, 17 studies (4.4%) addressed caregiver perspectives and 20 studies (5.2%) discussed analytic models for patient safety. Further work is needed to ensure consistency of definitions in patient safety research to facilitate comparison and collation of results.

Classification schemes for knowledge translation interventions: a practical resource for researchers.

BACKGROUND: As implementation science advances, the number of interventions to promote the translation of evidence into healthcare, health systems, or health policy is growing. Accordingly, classification schemes for these knowledge translation (KT) interventions have emerged. A recent scoping review identified 51 classification schemes of KT interventions to integrate evidence into healthcare practice; however, the review did not evaluate the quality of the classification schemes or provide detailed information to assist researchers in selecting a scheme for their context and purpose. This study aimed to further examine and assess the quality of these classification schemes of KT interventions, and provide information to aid researchers when selecting a classification scheme. METHODS: We abstracted the following information from each of the original 51 classification scheme articles: authors' objectives; purpose of the scheme and field of application; socioecologic level (individual, organizational, community, system); adaptability (broad versus specific); target group (patients, providers, policy-makers), intent (policy, education, practice), and purpose (dissemination versus implementation). Two reviewers independently evaluated the methodological quality of the development of each classification scheme using an adapted version of the AGREE II tool. Based on these assessments, two independent reviewers reached consensus about whether to recommend each scheme for researcher use, or not. RESULTS: Of the 51 original classification schemes, we excluded seven that were not specific classification schemes, not accessible or duplicates. Of the remaining 44 classification schemes, nine were not recommended. Of the 35 recommended classification schemes, ten focused on behaviour change and six focused on population health. Many schemes (n = 29) addressed practice considerations. Fewer schemes addressed educational or policy objectives. Twenty-five classification schemes had broad applicability, six were specific, and four had elements of both. Twenty-three schemes targeted health providers, nine targeted both patients and providers and one targeted policy-makers. Most classification schemes were intended for implementation rather than dissemination. CONCLUSIONS: Thirty-five classification schemes of KT interventions were developed and reported with sufficient rigour to be recommended for use by researchers interested in KT in healthcare. Our additional categorization and quality analysis will aid in selecting suitable classification schemes for research initiatives in the field of implementation science.

Descriptive analysis of cochrane child-relevant systematic reviews: an update and comparison between 2009 and 2013.

BACKGROUND: Systematic reviews support health systems and clinical decision-making by identifying and summarizing all existing studies on a particular topic. In 2009, a comprehensive description of child-relevant systematic reviews published in the Cochrane Database of Systematic Reviews was compiled. This study aims to provide an update, and to describe these systematic reviews according to their content and methodological approaches. METHODS: All child-relevant systematic reviews published by the Cochrane Collaboration in the Cochrane Database of Systematic Reviews (CDSR) as of March, 2013 were identified and described in relation to their content and methodological approaches. This step equated to an update of the Child Health Field Review Register (CHFRR). The content of the updated CHFRR was compared to the published 2009 CHFRR description regarding clinical and methodological characteristics, using bivariate analyses. As the Cochrane Collaboration has recognized that disease burden should guide research prioritization, we extracted data from the Global and National Burden of Diseases and Injuries Among Children and Adolescents Between 1990 and 2013 study in order to map the distribution of the burden of disease in child health to the distribution of evidence across Review Groups in the CHFRR. RESULTS: Of the 5,520 potential Cochrane systematic reviews identified, 1,293 (23.4%) were child-relevant (an increase of 24% since 2009). Overall, these reviews included 16,738 primary studies. The most commonly represented Review Groups were Airways (11.5%), Cystic Fibrosis and Genetic Diseases (7.9%), Acute Respiratory Infections (7.8%), Developmental, Psychological and Learning Problems (6.7%), and Infectious Diseases (6.2%). Corresponding authors were most often from Europe (51%), North America (15%), and Australia (15%). The majority of systematic reviews examined pharmacological interventions alone (52% compared to 59% in 2009). Out of 611 reviews that were assessed as up-to-date, GRADE was used in 204 (35%) reviews to assess the overall quality of the evidence, which was often moderate (35.6%) or low (37.8%) for primary outcomes. Ninety percent of reviews that were assessed as up to date used the Cochrane Risk of Bias tool, or a modified version, to assess methodological quality. Most reviews conducted one or more meta-analyses (73%). Among the 25 leading causes of death globally, the Review Groups associated with the largest number of causes were: 1) Infectious Diseases, 2) Anaesthesia, Critical, and Emergency Care, 3) Injuries, 4) Pregnancy and Childbirth (PC), and 5) Neonatal. There were large discrepancies between the number of causes of mortality that each Review Group was associated with and the total amount of evidence each Review Group contributed to the CHFRR. Ninety-eight percent of the causes of mortality in 2013 were from developing nations, but only 224 (17.3%) reviews had corresponding authors from developing countries. CONCLUSION: The content and methodological characteristics of child-relevant systematic reviews in the Cochrane CHFRR have been described in detail. There were modest advances in methods between 2009 and 2013. Systematic reviews contained in the CDSR offer an important resource for researcher's, clinicians and policy makers by synthesizing an extensive body of primary research. Further content analysis will allow the identification of clinical topics of greatest priority for future systematic reviews in child health.

Grey literature in systematic reviews: a cross-sectional study of the contribution of non-English reports, unpublished studies and dissertations to the results of meta-analyses in child-relevant reviews.

BACKGROUND: Systematic reviews (SRs) are an important source of information about healthcare interventions. A key component of a well-conducted SR is a comprehensive literature search. There is limited evidence on the contribution of non-English reports, unpublished studies, and dissertations and their impact on results of meta-analyses. METHODS: Our sample included SRs from three Cochrane Review Groups: Acute Respiratory Infections (ARI), Infectious Diseases (ID), Developmental Psychosocial and Learning Problems (DPLP) (n = 129). Outcomes included: 1) proportion of reviews that searched for and included each study type; 2) proportion of relevant studies represented by each study type; and 3) impact on results and conclusions of the primary meta-analysis for each study type. RESULTS: Most SRs searched for non-English studies; however, these were included in only 12% of reviews and represented less than 5% of included studies. There was a change in results in only four reviews (total sample = 129); in two cases the change did not have an impact on the statistical or clinical significance of results. Most SRs searched for unpublished studies but the majority did not include these (only 6%) and they represented 2% of included studies. In most cases the impact of including unpublished studies was small; a substantial impact was observed in one case that relied solely on unpublished data. Few reviews in ARI (9%) and ID (3%) searched for dissertations compared to 65% in DPLP. Overall, dissertations were included in only nine SRs and represented less than 2% of included studies. In the majority of cases the change in results was negligible or small; in the case where a large change was noted, the estimate was more conservative without dissertations. CONCLUSIONS: The majority of SRs searched for non-English and unpublished studies; however, these represented a small proportion of included studies and rarely impacted the results and conclusions of the review. Inclusion of these study types may have an impact in situations where there are few relevant studies, or where there are questionable vested interests in the published literature. We found substantial variation in whether SRs searched for dissertations; in most reviews that included dissertations, these had little impact on results.

The contribution of databases to the results of systematic reviews: a cross-sectional study.

BACKGROUND: One of the best sources for high quality information about healthcare interventions is a systematic review. A well-conducted systematic review includes a comprehensive literature search. There is limited empiric evidence to guide the extent of searching, in particular the number of electronic databases that should be searched. We conducted a cross-sectional quantitative analysis to examine the potential impact of selective database searching on results of meta-analyses. METHODS: Our sample included systematic reviews (SRs) with at least one meta-analysis from three Cochrane Review Groups: Acute Respiratory Infections (ARI), Infectious Diseases (ID), Developmental Psychosocial and Learning Problems (DPLP) (n = 129). Outcomes included: 1) proportion of relevant studies indexed in each of 10 databases; and 2) changes in results and statistical significance of primary meta-analysis for studies identified in Medline only and in Medline plus each of the other databases. RESULTS: Due to variation across topics, we present results by group (ARI n = 57, ID n = 38, DPLP n = 34). For ARI, identification of relevant studies was highest for Medline (85 %) and Embase (80 %). Restricting meta-analyses to trials that appeared in Medline + Embase yielded fewest changes in statistical significance: 53/55 meta-analyses showed no change. Point estimates changed in 12 cases; in 7 the change was less than 20 %. For ID, yield was highest for Medline (92 %), Embase (81 %), and BIOSIS (67 %). Restricting meta-analyses to trials that appeared in Medline + BIOSIS yielded fewest changes with 1 meta-analysis changing in statistical significance. Point estimates changed in 8 of 31 meta-analyses; change less than 20 % in all cases. For DPLP, identification of relevant studies was highest for Medline (75 %) and Embase (62 %). Restricting meta-analyses to trials that appeared in Medline + PsycINFO resulted in only one change in significance. Point estimates changed for 13 of 33 meta-analyses; less than 20 % in 9 cases. CONCLUSIONS: Majority of relevant studies can be found within a limited number of databases. Results of meta-analyses based on the majority of studies did not differ in most cases. There were very few cases of changes in statistical significance. Effect estimates changed in a minority of meta-analyses but in most the change was small. Results did not change in a systematic manner (i.e., regularly over- or underestimating treatment effects), suggesting that selective searching may not introduce bias in terms of effect estimates.

Behavioral Programs for Type 1 Diabetes Mellitus: A Systematic Review and Meta-analysis.

BACKGROUND: Whether behavioral approaches for self-management programs benefit individuals with type 1 diabetes mellitus is unclear. PURPOSE: To determine the effects of behavioral programs for patients with type 1 diabetes on behavioral, clinical, and health outcomes and to investigate factors that might moderate effect. DATA SOURCES: 6 electronic databases (1993 to June 2015), trial registries and conference proceedings (2011 to 2014), and reference lists. STUDY SELECTION: 36 prospective, controlled studies involving participants of any age group that compared behavioral programs with usual care, active controls, or other programs. DATA EXTRACTION: One reviewer extracted and another verified data. Two reviewers assessed quality and strength of evidence (SOE). DATA SYNTHESIS: Moderate SOE showed reduction in glycated hemoglobin (HbA1c) at 6 months after the intervention compared with usual care (mean difference, -0.29 [95% CI, -0.45 to -0.13] percentage points) and compared with active controls (-0.44 [CI, -0.69 to -0.19] percentage points). At the end of the intervention and 12-month follow-up or longer, there were no statistically significant differences in HbA1c (low SOE) for comparisons with usual care or active control. Compared with usual care, generic quality of life at program completion did not differ (moderate SOE). Other outcomes had low or insufficient SOE. Adults appeared to benefit more for glycemic control at program completion (-0.28 [CI, -0.57 to 0.01] percentage points) than did youth (-0.12 [CI, -0.43 to 0.19] percentage points). Program intensity appeared not to influence effectiveness; some individual delivery appears beneficial. LIMITATIONS: All studies had medium or high risk of bias. There was scarce evidence for many outcomes. CONCLUSION: Behavioral programs for type 1 diabetes offer some benefit for glycemic control, at least at short-term follow-up, but improvement for other outcomes has not been shown. (PROSPERO registration number: CRD42014010515). PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERD registration number: CRD42014010515).

Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis.

BACKGROUND: Behavioral programs may improve outcomes for individuals with type 2 diabetes mellitus, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs. PURPOSE: To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes. DATA SOURCES: 6 databases (1993 to January 2015), conference proceedings (2011 to 2014), and reference lists. STUDY SELECTION: Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs. DATA EXTRACTION: One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias. DATA SYNTHESIS: Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ≥ 11 contact hours) led to clinically important improvements in glycemic control (≥ 0.4% reduction in hemoglobin A1c [HbA1c]), whereas most diabetes self-management education programs without added support-especially those offering 10 or fewer contact hours-provided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ≥ 75% nonwhite participants). LIMITATIONS: All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions. CONCLUSION: Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515).