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Pasteurization kills harmful microorganisms found in milk. While consumption of unpasteurized milk and its products is discouraged due to increased risk of infections, some individuals prefer unpasteurized dairy products. Our objective was to estimate the burden of illness from outbreaks arising from consumption of unpasteurized and pasteurized dairy products in Canada and the United States.We conducted a systematic review of dairy-associated outbreaks in Canada and the USA from 2007 onward. We searched MEDLINE, Embase, Cochrane Library, TRIP Database for guidelines, and North American government agency websites up to October 2020. We included outbreak reports where the pathogenic microbe was confirmed in both the patient and the dairy product through laboratory testing.Thirty-two disease outbreaks were linked to dairy consumption. Twenty outbreaks involving unpasteurized products resulted in 449 confirmed cases of illness, 124 hospitalizations, and five deaths. Twelve outbreaks involving pasteurized products resulted in 174 confirmed cases of illness, 134 hospitalizations, 17 deaths, and seven fetal losses. Listeria accounted for 10 out of 12 outbreaks from pasteurized products from 2007 through 2020.Public warnings about the risk of unpasteurized dairy consumption need to continue and pregnant women and immunocompromised hosts need to be made aware of foods at high risk of contamination with Listeria.RéSUMé: OBJECTIF: La pasteurisation tue les micro-organismes dangereux contenus dans le lait. Même si la consommation du lait non pasteurisé et ses produits fût déconseillée en raison d’un risque accru d’infection, certaines personnes préfèrent des produits laitiers non pasteurisés. Notre objectif était d’évaluer le fardeau de maladie des éclosions résultant de la consommation des produits laitiers non pasteurisés et pasteurisés au Canada et aux États-Unis. MéTHODE: Nous avons mené une revue systématique des éclosions liées aux produits laitiers au Canada et aux États-Unis depuis 2007. Nous avons cherché dans MEDLINE, Embase, Cochrane Library, TRIP Database et les sites web des agences gouvernementales Nord-Américaines pour la période 2007 jusqu’au mois d’octobre 2020. Nous avons inclus des rapports d’éclosion lorsque les essais en laboratoire ont confirmé la présence du microbe pathogène dans le patient ainsi que dans le produit laitier. RéSULTATS: Trente-deux éclosions étaient liées à la consommation des produits laitiers. Les produits non pasteurisés étaient impliqués dans 20 éclosions, avec 449 cas de maladie confirmés, 124 hospitalisations et 5 morts. Les produits pasteurisés étaient impliqués dans 12 éclosions, avec 174 cas de maladie confirmés, 134 hospitalisations, 17 morts et sept morts fœtales. Listeria comptait pour 10 des 12 éclosions des produits pasteurisés de 2007 à 2020. CONCLUSION: Les avis publics au sujet du risque de la consommation des produits laitiers non pasteurisés devraient continuer et les femmes enceintes et les hôtes immunodéprimés devraient être informés de la nourriture à haut risque de la contamination avec Listeria.

Since the first national guideline for managing obesity in adults and children in Canada was published in 2007, new evidence has emerged and guideline standards have evolved. Our purpose is to describe the protocol used to update the Canadian clinical practice guideline for managing pediatric obesity.This guideline will update the pediatric components of the 2007 Canadian clinical practice guideline for the management of obesity. In partnership with Obesity Canada, we began preliminary work in 2019; activities are scheduled for completion in 2022. The guideline will follow standards developed by the National Academy of Medicine and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group. Guideline development will be informed by 5 complementary literature reviews: a scoping review that focuses on clinical assessment in pediatric obesity management and 4 systematic reviews to synthesize evidence regarding families' values and preferences as well as the safety and effectiveness of interventions (psychological and behavioural; pharmacotherapeutic; and surgical). We will use standard systematic review methodology, including summarizing and assessing the certainty of evidence and determining the strength of recommendations. Competing interests will be managed proactively according to recommendations from the Guidelines International Network. Diverse stakeholders, including families and clinicians, will be engaged throughout guideline development.The guideline will support Canadian families and clinicians to make informed, value-sensitive and evidence-based clinical decisions related to managing pediatric obesity. The guideline and accompanying resources for end-users will be published in English and French, and we will partner with Obesity Canada to optimize dissemination using integrated and end-of-project knowledge translation.

Background Acute liver failure is a rare syndrome with significant morbidity and mortality, particularly in absence of transplantation as a rescue therapy. An important mechanism contributing to mortality is hyperammonemia which drives cerebral edema and raised intracranial pressure. Multiple therapies for managing hyperammonemia have been trialed. Continuous renal replacement therapy is effective in treating hyperammonemia in other disease states (notably inborn errors of metabolism). Its efficacy in acute liver failure has been suggested but further investigation is required to prove this. The objective of this systematic review will be to determine the efficacy of continuous renal replacement therapy in patients with acute liver failure and its effect on mortality and transplant-free survival. Methods MEDLINE, EMBASE, Web of Science, and Cochrane Database will be searched. Identified studies will include all patients with acute liver failure in a critical care unit treated with continuous renal replacement therapy. Primary outcome will be effectiveness of ammonia clearance and mortality. Patients treated with any other modality of ammonia lowering therapy (such as plasma exchange or Molecular Adsorbent Recirculating System) will be excluded. Narrative synthesis of the identified studies will occur and if clinical homogeneity is identified, data will be pooled for meta-analysis using a DerSimonian-Laird random effects model. Discussion We present a protocol for a systematic review seeking to establish a link between transplant-free survival in acute liver failure and the use of continuous renal replacement therapy. Given the anticipated paucity of literature on this subject, both narrative and quantitative syntheses are planned. Systematic review registration (PROSPERO) CRD42019122520, registered April 16, 2019.

Backgroud An increasing number of original studies suggest that exposure to shift work and long working hours during pregnancy could be associated with the risk of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. Objective To examine the influences of shift work and longer working hours during pregnancy on maternal and fetal health outcomes. Data Sources Five electronic databases and three gray literature sources were searched up to March 15, 2019. Methods of Study Selection: Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy); exposure (rotating shift work [shifts change according to a set schedule], fixed night shift [typical working period is between 11:00 pm to 11:00 am] or longer working hours [h] [>40 h per week]);comparator (fixed day shift [typical working period between 8:00 am- 6:00 pm] or standard working hours [≤40 h per week]); and outcomes (preterm delivery, low birth weight [birth weight Tabulation, Integration, and Results From 3305 unique citations, 62 observational studies (196,989 women) were included. “Low” to “very low” certainty evidence from these studies revealed that working rotating shifts was associated with an increased odds of preterm delivery (OR=1.13, 95% CI: 1.00 to 1.28, I 2 =31%), having a small for gestational age baby (OR=1.18, 95% CI: 1.01 to 1.38, I 2 =0%), preeclampsia (OR=1.75, 95% CI: 1.01 to 3.01, I 2 =75%) and gestational hypertension (OR=1.19, 95% CI: 1.10 to 1.29, I 2 =0%), compared to those who worked a fixed day shift. Working fixed night shifts was associated with an increased odds of preterm delivery (OR=1.21, 95% CI: 1.03 to 1.42, I 2 =36%) and miscarriage (OR=1.23, 95% CI: 1.03 to 1.47, I 2 =37%). Compared with standard hours, working longer hours was associated with an increased odds of miscarriage (OR=1.38, 95% CI: 1.08 to 1.77, I 2 =73%), preterm delivery (OR=1.21, 95% CI: 1.11 to 1.33, I 2 =30%), an infant of low birth weight (OR=1.43, 95% CI: 1.11 to 1.84, I 2 =0%), or an infant of small for gestational age (OR=1.16, 95% CI: 1.00 to 1.36, I 2 =57%). Dose-response analysis showed women working more than 55.5 hours per week (versus 40) had a 10% increase in the odds of having a preterm delivery. Conclusion Pregnant women who work rotating shifts, fixed night shifts, or longer hours have an increased risk of adverse pregnancy outcomes.

Background As the Coronavirus Disease-2019 (COVID-19) pandemic continues, healthcare providers struggle to manage both COVID-19 and non-COVID patients while still providing high-quality care. We conducted a systematic review/meta-analysis to describe the effects of the COVID-19 pandemic on patients with non-COVID illness and on healthcare systems compared to non-pandemic epochs. Methods We searched Ovid MEDLINE/EMBASE/Cochrane Database of Systematic Reviews/CENTRAL/CINAHL (inception to December 31, 2020). All study types with COVID-pandemic time period (after December 31, 2019) with comparative non-pandemic time periods (prior to December 31, 2019). Data regarding study characteristics/case-mix/interventions/comparators/ outcomes (primary: mortality; secondary: morbidity/hospitalizations/disruptions-to-care. Paired reviewers conducted screening and abstraction, with conflicts resolved by discussion. Effect sizes for specific therapies were pooled using random-effects models. Risk of bias was assessed by Newcastle-Ottawa Scale, with evidence rating using GRADE methodology. Results Of 11,581 citations, 167 studies met eligibility. Our meta-analysis showed an increased mortality of 16% during the COVID pandemic for non-COVID illness compared with 11% mortality during the pre-pandemic period (RR 1.38, 95% CI: 1.28–1.50; absolute risk difference: 5% [95% CI: 4–6%], p Conclusions There was a significant increase in mortality during the COVID pandemic compared to pre-pandemic times for non-COVID illnesses. When significant changes were reported, there was increased morbidity, decreased hospitalizations and increased disruptions in standards-of-care. Systematic review registration PROSPERO CRD42020201256 (Sept 2, 2020).

Objective: To determine whether children with neuromuscular disorders using long-term non-invasive ventilation, continuous or bilevel positive airway pressure, have improved health outcomes compare...

BACKGROUND: Health administrative databases are essential to define patient populations, make socioeconomic predictions, and facilitate medical research and healthcare planning. The accuracy of this data is dependent on valid codes/coding algorithms. AIMS: The aim of this study was to systematically identify and summarize the validity of International Classification of Diseases (ICD) codes for identifying patients with cirrhosis in administrative data. METHODS: Electronic databases, MEDLINE (via Ovid), EMBASE (via Ovid), the Web of Science, and CINAHL (via EBSCO-host), were searched for validation studies which compared ICD codes related to cirrhosis to a clinical reference standard, and reported statistical measures of performance. RESULTS: Fourteen studies were included in the review. There was a large variation in the algorithms used to validate ICD codes to diagnose cirrhosis. Despite the variation, the positive predictive value (PPV) was greater than 84% and the specificity was greater than 75% in the majority of the studies. The negative predictive value (NPV) was lower, but still was associated with values greater than 70% in the majority of studies. Sensitivity data varied significantly with values ranging from 0.27 to 99%. CONCLUSIONS: Evaluated ICD codes for cirrhosis, including codes for chronic liver disease, cirrhosis-specific codes, and cirrhosis-related complications, have demonstrated variable sensitivity and reasonable specificity for the identification of cirrhosis. Additional research is needed to maximize the identification of persons with cirrhosis to avoid underestimating the burden of disease.

To assess randomized controlled trials evaluating the impact of nurse practitioner-led cardiovascular care.Systematic review of nurse practitioner-led care in patients with cardiovascular disease has not been completed.Systematic review and meta-analysis.The Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, Web of Science, Scopus and ProQuest were systematically searched for studies published between January 2007 - June 2017.Cochrane methodology was used for risk of bias, data extraction and meta-analysis. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation approach.Out of 605 articles, five articles met the inclusion criteria. There was no statistical difference between nurse practitioner-led care and usual care for 30-day readmissions, health-related quality of life and length of stay. A 12% reduction in Framingham risk score was identified.There are a few randomized control trials assessing nurse practitioner-led cardiovascular care.Low to moderate quality evidence was identified with no statistically significant associated outcomes of care. Nurse practitioner roles need to be supported to conduct and publish high-quality research.目的: 在于评估随机对照试验,从而评估执业护士主导型护理心血管护理的影响。 背景: 尚未完成对心血管疾病患者进行执业护士主导型护理的系统综述。 设计: 系统综述和荟萃分析。 资料来源: 在 Cochrane Central Register of Controlled Trials (CENTRAL)、Medline、Embase、CINAHL、Web of Science、Scopus和ProQuest上系统地搜索了2007年1月至2017年6月间发表的研究。 综述方法: Cochrane方法学用于偏倚风险、数据提取和荟萃分析。证据质量的评估采用了GRADE(Grading of Recommendations Assessment, Development and Evaluation)法。 结果: 在605篇文章中,有5篇符合纳入标准。执业护士主导型护理和30天再度入院的常规护理、健康相关生活质量和住院天数之间没有统计学差异。确定Framingham 风险评分降低了12%。 结论: 有一些随机对照试验评估了执业护士主导型心血管护理。 影响: 确定了低等至中等质量的证据,没有统计学意义的相关护理结果。需要支持执业护士的角色,从而开展和发布高质量研究。.

Background Living systematic reviews (LSRs) can expedite evidence synthesis by incorporating new evidence in real time. However, the methods needed to identify new studies in a timely manner are not well established. Objectives To explore the value of complementary search approaches in terms of search performance, impact on results and conclusions, screening workload, and feasibility compared to the reference standard. Methods We developed three complementary search approaches for a systematic review on treatments for bronchiolitis: Automated Full Search, PubMed Similar Articles, and Scopus Citing References. These were automated to retrieve results monthly; pairs of reviewers screened the records and commented on feasibility. After 1 year, we conducted a full update search (reference standard). For each complementary approach, we compared search performance (proportion missed, number needed to read [NNR]) and reviewer workload (number of records screened, time required) to the reference standard. We investigated the impact of the new trials on the effect estimate and certainty of evidence for the primary outcomes. We summarized comments about feasibility. Results Via the reference standard, reviewers screened 505 titles/abstracts, 24 full texts, and identified four new trials (NNR 127; 12.4 h). Of the complementary approaches, only the Automated Full Search located all four trials; these were located 6 to 12 months sooner than via the reference standard but did not alter the results nor certainty in the evidence. The Automated Full Search was the most resource-intensive approach (816 records screened; NNR 204; 17.1 h). The PubMed Similar Articles and Scopus Citing References approaches located far fewer records (452 and 244, respectively), thereby requiring less screening time (9.4 and 5.2 h); however, each approach located only one of the four new trials. Reviewers found it feasible and convenient to conduct monthly screening for searches of this yield (median 15–65 records/month). Conclusions The Automated Full Search was the most resource-intensive approach, but also the only to locate all of the newly published trials. Although the monthly screening time for the PubMed Similar Articles and Scopus Citing Articles was far less, most relevant records were missed. These approaches were feasible to integrate into reviewer work processes. Systematic review registration Open Science Framework. 10.17605/OSF.IO/6M28H.

IntroductionIn December 2019, the first cases of COVID-19 associated with SARS-CoV-2 viral infection were described in Wuhan, Hubei Province, China. Since then, it has spread rapidly affecting 188 countries and was declared a pandemic by the WHO on 11 March 2020. Preliminary reports suggest up to 30% of patients require intensive care unit (ICU) admission and case fatality rate estimate is 2.3%–7.2%. The primary reason for ICU admission is hypoxaemic respiratory failure, while factors associated with ICU admission include increased age, presence of comorbidities and cytokine storm. Case series and retrospective trials initially assessed proposed treatments with randomised controlled trials now reporting early outcomes. We conduct a systematic review and meta-analysis to identify epidemiological factors, treatments and complications that predict mortality among critically ill patients with COVID-19.Methods and analysisOur comprehensive search strategy was developed in consultation with a research librarian. We will search electronic databases: Ovid Medline, Ovid Embase, Ovid Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Wiley Cochrane Library. The search strategy combines concepts from COVID-19, validated COVID-19 search filters and geographical locations of large outbreaks. Citation screening, selection, quality assessment and data abstraction will be performed in duplicate. Clinically homogenous epidemiological characteristics, interventions and complications will be pooled in statistical meta-analysis. Within the framework of a living systematic review, the search and data analysis will be updated every 6 months.Ethics and disseminationOur systematic review will synthesise literature on risk factors and interventions associated with mortality in critically ill patients with COVID-19. Results will be presented at national and international conferences and submitted for peer-reviewed publication. The pooled analysis can provide guidance to inform clinical guidelines for care of critically ill patients with COVID-19. Iterative updates will be made public through open access. Research ethics approval is not required.PROSPERO registration numberCRD42020176672.

Aim To systematically review the literature to compare the performance of head ultrasound (HUS) and magnetic resonance imaging (MRI) in their ability to detect brain injury and their predictive value for neurodevelopmental outcomes. Methods This was a systematic review based on literature search in three electronic databases (MEDLINE, EMBASE, Cochrane Library) and additional sources for studies on routine brain injury screening in preterm neonates published during 2000 - May 2020. Studies were included if they reported on the comparative performance of HUS and MRI in detecting preterm brain injury and/or their predictive value for neurodevelopmental outcomes. Findings from the included studies underwent narrative synthesis. Results Forty-six studies were included. In comparison to HUS, MRI detected more anomalies and provided more details on the severity and the extent of preterm brain injury, particularly for white matter injury and cerebellar hemorrhage. Neonatal neuroimaging predicted outcomes with high negative predictive value but relatively low positive predictive value. The prognostic value of neonatal neuroimaging varied according to several factors including modality and timing of imaging, and tools used for grading brain injury. Conclusion Compared to HUS, MRI offers a better characterization of preterm brain injury and may enhance the ability to predict neurodevelopmental outcomes.

OBJECTIVE To conduct a systematic review of the literature for strategies designed to reduce attrition in managing paediatric obesity. METHODS We searched Ovid Medline (1946 to May 6, 2020), Ovid Embase (1974 to May 6, 2020), EBSCO CINAHL (inception to May 6, 2020), Elsevier Scopus (inception to April 14, 2020), and ProQuest Dissertations & Theses (inception to April 14, 2020). Reports were eligible if they included any obesity management intervention, included 2 to 18 year olds with overweight or obesity (or if the mean age of participants fell within this age range), were in English, included experimental study designs, and had attrition reduction as a main outcome. Two team members screened studies, abstracted data, and appraised study quality. RESULTS Our search yielded 5,415 original reports; six met inclusion criteria. In three studies, orientation sessions (n = 2) and motivational interviewing (MI) (n = 1) were used as attrition-reduction strategies before treatment enrollment; in three others, text messaging (n = 2) and MI (n = 1) supplemented existing obesity management interventions. Attrition-reduction strategies led to decreased attrition in two studies, increased in one, and no difference in three. For the two strategies that reduced attrition, (a) pre-treatment orientation and (b) text messaging between children and intervention providers were beneficial. The quality of the six included studies varied (good [n = 4]; poor [n = 2]). CONCLUSION Some evidence suggests that attrition can be reduced. The heterogeneity of approaches applied and small number of studies included highlight the need for well-designed, experimental research to test the efficacy and effectiveness of strategies to reduce attrition in managing paediatric obesity.

Background Long-term prescription of opioids by healthcare professionals has been linked to poor individual patient outcomes and high resource utilization. Supportive strategies in this population regarding acute healthcare settings may have substantial impact. Methods We performed a systematic review and meta-analysis of primary studies. The studies were included according to the following criteria: 1) age 18 and older; 2) long-term prescribed opioid therapy; 3) acute healthcare setting presentation from a complication of opioid therapy; 4) evaluating a supportive strategy; 5) comparing the effectiveness of different interventions; 6) addressing patient or healthcare related outcomes. We performed a qualitative analysis of supportive strategies identified. We pooled patient and system related outcome data for each supportive strategy. Results A total of 5664 studies were screened and 19 studies were included. A total of 9 broad categories of supportive strategies were identified. Meta-analysis was performed for the “supports for patients in pain” supportive strategy on two system-related outcomes using a ratio of means. The number of emergency department (ED) visits were significantly reduced for cohort studies (n = 6, 0.36, 95% CI [0.20–0.62], I2 = 87%) and randomized controlled trials (RCTs) (n = 3, 0.71, 95% CI [0.61–0.82], I2 = 0%). The number of opioid prescriptions at ED discharge was significantly reduced for RCTs (n = 3, 0.34, 95% CI [0.14–0.82], I2 = 78%). Conclusion For patients presenting to acute healthcare settings with complications related to long-term opioid therapy, the intervention with the most robust data is “supports for patients in pain”.

IntroductionChildhood obstructive sleep apnoea (OSA) is a highly prevalent disorder that may directly contribute to the development of obesity, hypertension and renal injury. Although those associations seem to be clearer in adults, studies in children have revealed conflicting results and updated synthesis of the evidence is lacking. The aim of this systematic review is to summarise the available evidence on the effect of OSA on obesity, systemic blood pressure and kidney function, to help to elucidate whether respiratory interventions to correct OSA would have the potential to improve those outcomes.Methods and analysisA systematic literature review search was created by a medical librarian and peer-reviewed by a second librarian prior to running. Ovid Medline, Ovid Embase, CINAHL via EbscoHOST, Wiley Cochrane Library and ProQuest Dissertations and Theses Global were searched on 25 February 2020. Titles and abstracts will be screened by two independent reviewers for inclusion, followed by full-text screening of relevant articles. Studies in children will be included if they report data on OSA and weight, systemic blood pressure or kidney parameters. The extracted data will be combined for analysis and the information subcategorised in groups based on outcome. Risk of bias will be determined using tools specific to study methodology and certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach.Ethics and disseminationThis study will provide essential information for healthcare professionals to better understand the relationship between childhood OSA and changes in body mass index, systemic blood pressure and kidney function indicators. Our findings will be disseminated through conferences and publications. The results of this review may guide the initiation of new strategies and the development of future research studies. This research did not involve human subjects and therefore did not undergo research ethical review.PROSPERO registration numberCRD42020171186.

Background We investigated the feasibility of using a machine learning tool’s relevance predictions to expedite title and abstract screening. Methods We subjected 11 systematic reviews and six rapid reviews to four retrospective screening simulations (automated and semi-automated approaches to single-reviewer and dual independent screening) in Abstrackr, a freely-available machine learning software. We calculated the proportion missed, workload savings, and time savings compared to single-reviewer and dual independent screening by human reviewers. We performed cited reference searches to determine if missed studies would be identified via reference list scanning. Results For systematic reviews, the semi-automated, dual independent screening approach provided the best balance of time savings (median (range) 20 (3–82) hours) and reliability (median (range) proportion missed records, 1 (0–14)%). The cited references search identified 59% (n = 10/17) of the records missed. For the rapid reviews, the fully and semi-automated approaches saved time (median (range) 9 (2–18) hours and 3 (1–10) hours, respectively), but less so than for the systematic reviews. The median (range) proportion missed records for both approaches was 6 (0–22)%. Conclusion Using Abstrackr to assist one of two reviewers in systematic reviews saves time with little risk of missing relevant records. Many missed records would be identified via other means.

BackgroundLong-term prescription of opioids by healthcare professionals has been linked to poor individual patient outcomes and high resource utilization. Harm reduction strategies in this population in regard to acute healthcare settings may have substantial impact.MethodsWe performed a systematic review and meta-analysis of primary studies. The studies were included according to the following criteria: 1) age 18 and older; 2) long-term/chronic prescribed opioid therapy; 3) acute healthcare setting presentation from a complication of opioid therapy; 4) evaluating a harm reduction strategy; 5) comparing the effectiveness of different interventions; 6) addressing patient or healthcare related outcomes. We performed a qualitative analysis of harm reduction strategies identified. We pooled patient and system related outcome data for each harm reduction strategy.ResultsA total of 5664 studies were screened and 21 studies were included. A total of 11 broad categories of harm reduction strategies were identified. Meta-analysis was performed for the “supports for patients in pain” harm reduction strategy on two system-related outcomes using a ratio of means. The number of emergency department (ED) visits were significantly reduced for cohort studies (n=6, 0.36, 95% CI [0.20-0.62], I2 = 87%) and randomized controlled trials (RCTs) (n=3, 0.71, 95% CI [0.61-0.82], I2 = 0%). The number of opioid prescriptions at ED discharge was significantly reduced for RCTs (n=3, 0.34, 95% CI [0.14-0.82], I2 = 78%).InterpretationFor patients presenting to acute healthcare settings with complications related to long-term opioid therapy, the intervention with the most robust data is “supports for patients in pain”.Study registrationCRD42018088962

IntroductionRenal replacement therapy (RRT) is associated with high mortality and costs; however, no clinical guidelines currently provide specific recommendations for clinicians on when and how to stop RRT in recovering patients. Our objective was to systematically review the current evidence for clinical and biochemical parameters that can be used to predict successful discontinuation of RRT.MethodsA systematic review and meta-analysis were performed with a peer-reviewed search strategy combining the themes of renal replacement therapy (IHD, CRRT, SLED), predictors of successful discontinuation or weaning (defined as an extended period of time free from further RRT), and patient outcomes. Major databases were searched and citations were screened using predefined criteria. Studied parameters were reported and, where possible, data was analyzed in the pooled analysis.ResultsOur search yielded 23 studies describing 16 variables for predicting the successful discontinuation of RRT. All studies were observational in nature. None were externally validated. Fourteen studies described conventional biochemical criteria used as surrogates of glomerular filtration rate (serum urea, serum creatinine, creatinine clearance, urine urea excretion, urine creatinine excretion). Thirteen studies described physiologic parameters such as urine output before and after cessation of RRT, and 13 studies reported on newer kidney biomarkers, such as serum cystatin C and serum neutrophil gelatinase-associated lipocalin (NGAL). Six studies reported sensitivity and specificity characteristics of multivariate models. Urine output prior to discontinuation of RRT was the most-studied variable, with nine studies reporting. Pooled analysis found a sensitivity of 66.2% (95% CI, 53.6–76.9%) and specificity of 73.6% (95% CI, 67.5–79.0%) for urine output to predict successful RRT discontinuation. Due to heterogeneity in the thresholds of urine output used across the studies, an optimal threshold value could not be determined.ConclusionsNumerous variables have been described to predict successful discontinuation of RRT; however, available studies are limited by study design, variable heterogeneity, and lack of prospective validation. Urine output prior to discontinuation of RRT was the most commonly described and robust predictor. Further research should focus on the determination and validation of urine output thresholds, and the evaluation of additional clinical and biochemical parameters in multivariate models to enhance predictive accuracy.

Background Predicting successful liberation from mechanical ventilation (MV) in critically ill patients is challenging. Brain natriuretic peptide (BNP) has been proposed to help guide decision-making for readiness to liberate from MV following a spontaneous breathing trial (SBT). Methods We performed a systematic review and meta-analysis of randomized and prospective observational studies that measured BNP levels at the time of SBT in patients receiving MV. The primary endpoint was successful liberation from MV (absence of reintubation or non-invasive ventilation at 48 h). Statistical analyses included bi-variate and Moses-Littenberg models and DerSimonian-Laird pooling of areas under ROC curve (AUROC). Results A total of 731 articles were screened. Eighteen adult and 2 pediatric studies were fulfilled pre-specified eligibility. The measure of the relative variation of BNP during SBT (ΔBNP%) after exclusion of SBT failure by clinical criteria in adults yielded a sensitivity and specificity of 0.889 [0.831–0.929] and 0.828 [0.730–0.896] for successful liberation from MV, respectively, with a pooled AUROC of 0.92 [0.88–0.97]. The pooled AUROC for any method of analysis for absolute variation of BNP (ΔBNP), pre-SBT BNP, and post-SBT BNP were 0.89 [0.83–0.95], 0.77 [0.63–0.91], and 0.85 [0.80–0.90], respectively. Conclusion The relative change in BNP during a SBT has potential value as an incremental tool after successful SBT to predict successful liberation from MV in adults. There is insufficient data to support the use of BNP in children or as an alternate test to clinical indices of SBT, or the use of ΔBNP, BNP-pre, and BNP-post as an alternate or incremental test. Trial registration PROSPERO CRD42018087474 (6 February 2018)

Background To systematically review the literature on clinical interventions that influence vaginal birth after cesarean (VBAC) rates. Methods We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting VBAC, uterine rupture and uterine dehiscence rates. One reviewer extracted data and a second reviewer verified for accuracy. Meta-analysis was conducted using Mantel-Haenszel (random effects model) relative risks (VBAC rate) and risk differences (uterine rupture and dehiscence). Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT). Results Twenty-nine studies (six trials and 23 cohorts) examined different clinical interventions affecting rates of vaginal deliveries among women with a prior cesarean delivery (CD). Methodological quality was good overall for the trials; however, concerns among the cohort studies regarding selection bias, comparability of groups and outcome measurement resulted in higher risk of bias. Interventions for labor induction, with or without cervical ripening, included pharmacologic (oxytocin, prostaglandins, misoprostol, mifepristone, epidural analgesia), non-pharmacologic (membrane sweep, amniotomy, balloon devices), and combined (pharmacologic and non-pharmacologic). Single studies with small sample sizes and event rates contributed to most comparisons, with no clear differences between groups on rates of VBAC, uterine rupture and uterine dehiscence. Conclusions This systematic review evaluated clinical interventions directed at increasing the rate of vaginal delivery among women with a prior CD and found low to very low certainty in the body of evidence for cervical ripening and/or labor induction techniques. There is insufficient high-quality evidence to inform optimal clinical interventions among women attempting a trial of labor after a prior CD.

Backgroud An increasing number of original studies suggest that exposure to shift work and long working hours during pregnancy could be associated with the risk of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. Objective To examine the influences of shift work and longer working hours during pregnancy on maternal and fetal health outcomes. Data Sources Five electronic databases and three gray literature sources were searched up to March 15, 2019. Methods of Study Selection: Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy); exposure (rotating shift work [shifts change according to a set schedule], fixed night shift [typical working period is between 11:00 pm to 11:00 am] or longer working hours [h] [>40 h per week]);comparator (fixed day shift [typical working period between 8:00 am- 6:00 pm] or standard working hours [≤40 h per week]); and outcomes (preterm delivery, low birth weight [birth weight Tabulation, Integration, and Results From 3305 unique citations, 62 observational studies (196,989 women) were included. “Low” to “very low” certainty evidence from these studies revealed that working rotating shifts was associated with an increased odds of preterm delivery (OR=1.13, 95% CI: 1.00 to 1.28, I 2 =31%), having a small for gestational age baby (OR=1.18, 95% CI: 1.01 to 1.38, I 2 =0%), preeclampsia (OR=1.75, 95% CI: 1.01 to 3.01, I 2 =75%) and gestational hypertension (OR=1.19, 95% CI: 1.10 to 1.29, I 2 =0%), compared to those who worked a fixed day shift. Working fixed night shifts was associated with an increased odds of preterm delivery (OR=1.21, 95% CI: 1.03 to 1.42, I 2 =36%) and miscarriage (OR=1.23, 95% CI: 1.03 to 1.47, I 2 =37%). Compared with standard hours, working longer hours was associated with an increased odds of miscarriage (OR=1.38, 95% CI: 1.08 to 1.77, I 2 =73%), preterm delivery (OR=1.21, 95% CI: 1.11 to 1.33, I 2 =30%), an infant of low birth weight (OR=1.43, 95% CI: 1.11 to 1.84, I 2 =0%), or an infant of small for gestational age (OR=1.16, 95% CI: 1.00 to 1.36, I 2 =57%). Dose-response analysis showed women working more than 55.5 hours per week (versus 40) had a 10% increase in the odds of having a preterm delivery. Conclusion Pregnant women who work rotating shifts, fixed night shifts, or longer hours have an increased risk of adverse pregnancy outcomes.

Backgroud An increasing number of studies suggest that exposure to physically demanding work during pregnancy could be associated with increased risks of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. Objective To examine the influence of occupational activities during pregnancy on maternal and fetal health outcomes. Data sources Five electronic databases and three gray literature sources were searched up to March 15, 2019. Methods Of Study Selection Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy), occupational exposures (heavy lifting, prolonged standing, prolonged walking, prolonged bending, and heavy physical workload), comparator (no exposure to the listed physical work demands), and outcomes (preterm birth, low birth weight, small for gestational age, miscarriage, gestational hypertension, pre-eclampsia, gestational diabetes mellitus, stillbirth, and intrauterine growth restriction). Tabulation, Integration, And Results Eighty observational studies (N=853,149) were included. ‘Low’ to ‘very low’ certainty evidence revealed that lifting objects ≥ 11 kilograms (kg) was associated with an increased odds ratio (OR) of miscarriage (OR: 1.31, 95% CI: 1.08 to 1.58, I2=79%), and pre-eclampsia (OR: 1.35, 95% CI: 1.07 to 1.71, I2=0%). Lifting objects for a combined weight of > 100kg per day was associated with an increased odds of preterm delivery (OR: 1.31, 95% CI: 1.11 to 1.56, I2=0%) and having a low-birth-weight neonate (OR: 2.08, 95% CI: 1.06 to 4.11, I2=73%). Prolonged standing was associated with increased odds of preterm delivery (OR: 1.11, 95% CI: 1.02 to 1.22, I2=30%), and having a small-for-gestational-age neonate (OR: 1.17, 95% CI: 1.01 to 1.35, I2=41%. A heavy physical workload was associated with increased odds of preterm delivery (OR: 1.23, 95% CI: 1.07 to 1.41, I2=32%), and having a low-birth-weight neonate (OR: 1.79, 95% CI: 1.11 to 2.87, I2=87%). All other associations were not statistically significant. Dose-response analysis showed women standing more than 2.5 hours per day (versus no standing) had a 10% increase in the odds of having a preterm delivery. Conclusion Physically demanding work during pregnancy is associated with an increased risk of adverse pregnancy outcomes.

IntroductionChildhood respiratory syncytial virus (RSV) infection is a global phenomenon that can lead to fatal respiratory illness. Palivizumab is a drug that is routinely used in affluent countries as a prophylaxis against RSV infection; nevertheless, breakthrough infections are often reported. In light of new findings on potential RSV resistance to palivizumab, an up-to-date synthesis of evidence on effectiveness is needed. Furthering existing reviews, a broadened scope to better reflect effectiveness in a ‘real world’ clinical context is also important. This systematic review and meta-analysis will enhance our understanding of the effectiveness of palivizumab in varying populations of children. Findings from this review will inform recommendations for best practices regarding palivizumab use for childhood RSV infection as well as research priorities in RSV vaccine development.Methods and analysisWe will conduct a systematic review of primary population-based studies that examine the incidence of palivizumab breakthrough infections in children, published between 1997 to present. In collaboration with a research librarian, four electronic databases (MEDLINE, Embase, Cochrane Library, Web of Science) and additional sources will be searched. Study screening and quality assessment will be performed in duplicate. Data will be extracted by one reviewer, with partial and random verification by a second reviewer. The primary outcomes to assess breakthrough RSV infection will be hospitalisation, length of stay and the need for intensive care unit admission and mechanical ventilation in children receiving palivizumab. The secondary outcome will be RSV-associated mortality. We will conduct a meta-analysis using pooled effectiveness data, and include subgroup analyses by patient comorbidities and drug compliance. Sensitivity analyses for risk of bias and study design will also be performed.Ethics and disseminationThis systematic review will only include data from previously published literature and is therefore exempt from ethics approval. Final results will be disseminated through peer-reviewed publication and presented at academic conferences and scientific meetings engaging paediatric researchers and healthcare providers. Should findings from this review necessitate updates to current clinical practice guidelines, we intend to establish a working group to engage relevant health administrators and decision makers.PROSPERO registration numberCRD42019122120.

Introduction Opioids are routinely used to treat a variety of chronic conditions associated with pain. However, they are a class of medications with a significant potential for adverse health effects, with and without misuse. Opioid misuse, as defined as inappropriate use of appropriately prescribed opioids, is becoming more well-recognized publicly but does not have clear treatment options. Opioid misuse has been linked to variety of poor outcomes and its consequences have a significant impact on healthcare resource utilization. The evidence on harm reduction strategies to mitigate adverse events prompting presentation to acute care settings for patients presenting with long-term opioid use is sparse. Methods and analysis We will perform a systematic review and meta-analysis to catalog effective harm reduction strategies and identify the most effective ones to reduce avoidable healthcare utilization in patients on long-term opioid therapy who present to acute health care settings with complications attributed to opioid misuse. A search strategy will be developed and executed by an information specialist; electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) and additional sources will be searched. Search themes will include opioids, chronic drug use, and acute healthcare settings. Citation screening, selection, quality assessment, and data abstraction will be performed in duplicate. A comprehensive inventory of harm reduction strategies will be developed. Data will be collected on patient-related outcomes associated with each identified harm reduction strategy. When sufficiently homogeneous data on interventions, population, and outcomes is available, it will be pooled for aggregate analysis. Evaluation of the methodological quality of individual studies and of the quality of the body of evidence will be performed. Our primary objective will be to identify harm reduction strategies that have been shown to result in clinically relevant and statistically significant improvements in patient outcomes and/or decreased healthcare utilization. Discussion This study will better characterize harm reduction strategies for patients on long-term prescribed opioids presenting to acute healthcare settings. It will also add new knowledge and generate greater understanding of key knowledge gaps of the long-term prescribed opioid use and its impact on healthcare utilization. Systematic review registration CRD42018088962. Electronic supplementary material The online version of this article (10.1186/s13643-019-0997-5) contains supplementary material, which is available to authorized users.

Perceptions about the causes and consequences of concussion, and individual representations and interpretations of these factors, can influence the post-concussive recovery process. The goal of this project was to synthesize evidence on perceptions related to concussions as experienced by children, adolescents, and parents, and to evaluate how these perceptions impact post-concussive recovery in physical, behavioural, cognitive, and psychological domains. We undertook a systematic review based on the Cochrane Handbook, conducting a comprehensive search of six databases and Google Scholar. Duplicate, independent screening was employed and the quality of studies was assessed using the Mixed Methods Appraisal Tool (MMAT). A total of 1552 unique records were identified, and six records (5 scientific articles and 1 thesis, published between 1990 and 2018; N = 26 to 412, age range from 2 to 18 years) were included. Perceptions about concussions were assessed differently between studies, with a range in types of measures and respondents. Some evidence suggested that perceptions could negatively impact concussion recovery, mostly post-concussive symptoms. However, results were not consistent between studies and the methodological quality was variable (and often low). There is limited evidence of the impact of perceptions of children, adolescents, and their parents on concussion recovery. Priorities for future research investigating concussion recovery should include recruiting representative samples, accounting for potential confounders, and measuring perceptions in children, adolescents and parents using validated measures. Higher quality studies are needed to better understand the role of perceptions in concussion recovery and to inform clinical care.

Background Rates of cesarean deliveries have been increasing, and contributes to the rising number of elective cesarean deliveries in subsequent pregnancies with associated maternal and neonatal risks. Multiple guidelines recommend that women be offered a trial of labor after a cesarean (TOLAC). The objective of the study is to systematically review the literature on adjunct clinical interventions that influence vaginal birth after cesarean (VBAC) rates. Methods We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any adjunct clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting changes in TOLAC or VBAC rates. One reviewer extracted data and a second reviewer verified for accuracy. Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT). Results Twenty-three studies of overall moderate to good methodological quality examined adjunct clinical interventions affecting TOLAC and/or VBAC rates: system-level interventions (three studies), provider-level interventions (three studies), guidelines or information for providers (seven studies), provider characteristics (four studies), and patient-level interventions (six studies). Provider-level interventions (opinion leader education, laborist, and obstetrician second opinion for cesarean sections) and provider characteristics (midwifery antenatal care, physicians on night float call schedules, and deliveries by family physicians) were associated with increased rates of VBAC. Few studies employing heterogeneous designs, sample sizes, interventions and comparators limited confidence in the effects. Studies of system-level and patient-level interventions, and guidelines/information for providers reported mixed findings. Conclusions Limited evidence indicates some provider-level interventions and provider characteristics may increase rates of attempted and successful TOLACs and/or VBACs, whereas other adjunct clinical interventions such as system-level interventions, patient-level interventions, and guidelines/information for healthcare providers show mixed findings. Electronic supplementary material The online version of this article (10.1186/s12884-018-2065-x) contains supplementary material, which is available to authorized users.

BACKGROUND: Children with intestinal failure are dependent on total parenteral nutrition (TPN) via a central venous catheter (CVC) for survival. These patients require long-term use of CVCs, and are at high risk of catheter-related bloodstream infections (CRBSIs). Prevention of these infections is imperative, as they result in line removal and loss of an access site. Eventually there may be no available sites for a CVC, and a child will need an intestinal transplant. Antimicrobial locks (AML) are solutions instilled in CVCs to prevent CRBSI. Presently, there are many different solutions available, and limited evidence guiding the optimal choice, frequency, and duration of prophylactic AML solution in children with intestinal failure. A guideline for appropriate prophylactic AML use has the potential to decrease rates of CRBSIs and reduce morbidity and mortality in pediatric intestinal failure patients. AIMS: In children with intestinal failure who require a CVC, does using an AML solution decrease the rate of new CRBSI? METHODS: A systematic review of available literature on AMLs used for CRBSI prophylaxis in children with intestinal failure will be performed to determine the optimal AML(s) choice(s) for use in this population. Randomized and nonrandomized trials, case studies, and cohort studies that use comparator groups (including historical controls) with study participants including children (age 0–17) with intestinal failure, who have a CVC (2 days or greater) for TPN will be screened. If the data is sufficiently homogenous, both clinically and methodologically, we will pool outcomes in a meta-analysis using a DerSimonian Laird random effects model. If possible we also plan to do network meta-analyses (NMA), simultaneously pooling common outcomes across multiple interventions. RESULTS: The primary outcomes of interest are the rate of new CRBSI with AML versus controls, as well as a comparison of each type of AML versus controls. Secondary outcomes that will be assessed include: unplanned CVC removal (all cause), CVC removal due to CRBSI, recurrence of CRBSI with the same pathogen, all adverse events/side effects attributed to antimicrobial lock solutions by the authors, development of infections with antibiotic resistance at any point (in particular resistance to antibiotics used in the AML solution), length of hospital stay attributed to CRBSI, need for intensive care, any other morbidities or outcomes that were compared in cases and controls and mortality. CONCLUSIONS: This research in progress aims to provide clinicians with guidance on the use of AML for prophylaxis of CRBSI in pediatric patients with intestinal failure. We will provide data for the efficacy of this practice and clarify which solutions have the best outcomes. FUNDING AGENCIES: None

Don Juzwishin,1 Madiha Mueen,2 Antonio Miguel Cruz,3,4 Tracy Ruptash,5 Shannon Barnard,6 Meghan Sebastianski,1 Rosmin Esmail,7 Lili Liu4 1Health Technology Assessment and Innovation, Alberta Health Services, 2Department of Family Medicine, University of Alberta, Edmonton, AB, Canada; 3School of Medicine and Health Sciences, Universidad del Rosario, Bogotá D.C., Colombia; 4Department of Occupational Therapy, Faculty of Rehabilitation Medicine, Edmonton, 5Continuing Care Special Initiatives, Seniors Health, Community, Seniors, Addiction and Mental Health, Alberta Health Services, Grande Prairie, AB, 6Integrated Home Care, Alberta Health Services, 7Health Technology Assessment and Adoption,Alberta Health Services, Calgary, AB, Canada Abstract: Becoming lost or its risk is a problem for dementia clients, their families and caregivers. The purpose of the paper is to describe, analyze and share lessons from a pilot project to use global positioning system devices to manage the risk of becoming lost and, at the same time, maintaining client autonomy. The study informs technology implementation approaches and strategies for innovative health technologies. The project used a prospective mixed-methods approach including a pre and post paper-based questionnaire, focus groups and individual interviews. Technology uptake was examined post knowledge transfer using the After Action Review method, which has shown utility in military and health care settings. Project successes and weaknesses are identified to inform future approaches of innovative health technology pilot projects. Lessons from the pilot emphasize the need for innovators to understand the multifaceted context they are entering, enlist the support of leaders, dedicate a project lead, support autonomous decision making and problem solving, meet regularly to monitor progress and address issues and support peer-to-peer collaboration. Keywords: evaluation, innovation, GPS, technology, adoption&nbsp

ObjectivesPatient 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.DesignEleven rapid responses.Data sourcesSingle electronic database (PubMed).Eligibility criteriaEach 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.ResultsFor 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.ConclusionsWe 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.

ObjectiveTo systematically review screening and treatment effectiveness, and patient preferences, to inform recommendations by the Canadian Task Force on Preventive Health Care on screening for asymptomatic bacteriuria in pregnancy.DesignWe searched multiple databases (inception to September 2017) and grey literature sources for studies on screening effectiveness and patient preferences. For treatment with antibiotics, we searched three databases for systematic reviews and obtained search results of the Cochrane Pregnancy and Childbirth Group’s Trials Register to update a Cochrane review. Study selection, risk of bias assessment and evaluation of the quality for each outcome using Grading of Recommendations Assessment, Development and Evaluation was completed independently by two reviewers with consensus. Meta-analysis was conducted when appropriate as were analyses based on planned subgroup variables.OutcomesFor screening and treatment effectiveness: maternal and perinatal mortality, maternal and neonatal sepsis, pyelonephritis, spontaneous abortion, preterm delivery, low birth weight and serious adverse events. Valuation of outcomes for patient preferences.ResultsFour studies compared outcomes before and after the introduction of a screening programme or between different screening programmes. All evidence on screening effectiveness was considered very low quality. Women have conflicting opinions about antibiotic use during pregnancy. Fifteen trials compared antibiotic treatment with no treatment or placebo in women with confirmed bacteriuria. Low-quality evidence found that treatment lowered rates of pyelonephritis (12 trials, relative risk [RR] 0.24; 95% CI 0.13 to 0.42; absolute risk reduction [ARR] 17.6%; number needed to treat [NNT] 6, 95% CI 5 to 7) and low birth weight (seven trials, RR 0.63; 95% CI 0.45 to 0.90; ARR 4.4%; NNT 23, 95% CI 15 to 85).ConclusionsAntibiotic treatment for women having significant bacteriuria likely reduces the incidence of pyelonephritis and low birth weight, but we are uncertain about the magnitude of the effect and about the extent to which we can apply these results to asymptomatic populations and screening programmes.PROSPERO registration numberCRD42016045263.