Systematic Reviews and Meta-analyses in Regional Anesthesia and Pain Medicine (Part I): Guidelines for Preparing the Review Protocol.

Comprehensive resources exist on how to plan a systematic review and meta-analysis. The objective of this article is to provide guidance to authors preparing their systematic review protocol in the fields of regional anesthesia and pain medicine. The focus is on systematic reviews of health care interventions, with or without an aggregate data meta-analysis. We describe and discuss elements of the systematic review methodology that review authors should prespecify, plan, and document in their protocol before commencing the review. Importantly, authors should explain their rationale for planning their systematic review and describe the PICO framework-participants (P), interventions (I), comparators (C), outcomes (O)-and related elements central to constructing their clinical question, framing an informative review title, determining the scope of the review, designing the search strategy, specifying the eligibility criteria, and identifying potential sources of heterogeneity. We highlight the importance of authors defining and prioritizing the primary outcome, defining eligibility criteria for selecting studies, and documenting sources of information and search strategies. The review protocol should also document methods used to evaluate risk of bias, quality (certainty) of the evidence, and heterogeneity of results. Furthermore, the authors should describe their plans for managing key data elements, the statistical construct used to estimate the intervention effect, methods of evidence synthesis and meta-analysis, and conditions when meta-analysis may not be possible, including the provision of practical solutions. Authors should provide enough detail in their protocol so that the readers could conduct the study themselves.

Systematic Reviews and Meta-analyses in Regional Anesthesia and Pain Medicine (Part II): Guidelines for Performing the Systematic Review.

In Part I of this series, we provide guidance for preparing a systematic review protocol. In this article, we highlight important steps and supplement with exemplars on conducting and reporting the results of a systematic review. We suggest how authors can manage protocol violations, multiplicity of outcomes and analyses, and heterogeneity. The quality (certainty) of the evidence and strength of recommendations should follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. It is our goal that Part II of this series provides valid guidance to authors and peer reviewers who conduct systematic reviews to adhere to important constructs of transparency, structure, reproducibility, and accountability. This will likely result in more rigorous systematic reviews being submitted for publication to the journals like Regional Anesthesia & Pain Medicine and Anesthesia & Analgesia .

The Effects of Exercise on Bone Mineral Density in Men: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

The aim of this systematic review and meta-analysis was to provide an updated analysis, including the use of more robust methods, on the effects of exercise on bone mineral density in men. Randomised Control Trials of > 24 weeks and published in English up to 01/05/20 were retrieved from 3 electronic databases, cross-referencing, and expert review. The primary outcome measures were changes in FN, LS, and lower limb BMD Standardised effect sizes were calculated from each study and pooled using the inverse heterogeneity model. A statistically significant benefit of exercise was observed on FN BMD [g = 0.21 (0.03, 0.40), Z = 2.23 p = 0.03], with no observed statistically significant benefit of exercise on LS BMD [g = 0.10 (- 0.07, 0.26), Z = 1.15 p = 0.25]. This analysis provided additional evidence to recommend ground- and/or joint-reaction force exercises for improving or maintaining FN, but not LS BMD. Additional well-designed RCTs are unlikely to alter this evidence, although interventions that include activities that directly load the lumbar spine are needed to ensure this is not a potential method of improving LS BMD.

Are There Interindividual Differences in Anxiety as a Result of Aerobic Exercise Training in Adults With Fibromyalgia? An Ancillary Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: To determine whether true interindividual response differences (IIRD) exist with respect to changes in anxiety because of aerobic exercise training in adults with fibromyalgia (FM). DATA SOURCES: Data from a previous meta-analytical database of randomized controlled trials of exercise in adults with arthritis and other rheumatic diseases. STUDY SELECTION: Randomized controlled trials limited to aerobic exercise training on anxiety in adults 18 years or older with FM were included. DATA EXTRACTION: Change outcome SDs treated as point estimates for anxiety were used to calculate true IIRD from each study. In addition, treatment effect data were extracted. DATA SYNTHESIS: The inverse variance heterogeneity model was used to pool all results. For the 5 studies and 321 participants in which results were pooled, statistically significant treatment effect reductions in anxiety were observed (mean, -0.77 points, 95% CI, -1.25 to -0.77). However, no significant IIRD were found (mean, 0.6 points, 95% CI, -1.2 to 1.5). The 95% prediction interval for true IIRD in a future study was -1.7 to 0.8. The percent chance, ie, probability, of a clinically meaningful difference in variability, was 61.5% (only possibly clinically important). CONCLUSIONS: The results of the current study suggest that aerobic exercise is associated with reductions in anxiety among adults with fibromyalgia. However, there is currently a lack of convincing evidence to support the notion that true IIRD exist. Therefore, a search for potential mediators and moderators associated with aerobic exercise and changes in anxiety among adults with FM may not be warranted. However, additional research is needed before any true level of certainty can be established. This includes (1) the assessment of IIRD in future randomized controlled trials, (2) randomized controlled trials of longer duration, and (3) an increase in the proportion of men included in randomized controlled trials.

A systematic review with meta-analysis of parental interventions for human papillomavirus vaccine uptake.

OBJECTIVES: With the growing ability of pharmacists to vaccinate against HPV, this systematic review with meta-analysis examined the efficacy of interventions targeting parents of children and adolescents in the US to increase HPV vaccine uptake. DATA SOURCES: A systematic search of PubMed, Web of Science, SCOPUS, CINAHL, and Medline was conducted from January 2006 to January 2022. STUDY SELECTION: We included parent-based randomized controlled trials (RCTs) in the US that measured actual HPV vaccine initiation and completion from patients' medical records. DATA EXTRACTION: The revised Cochrane risk-of-bias tool for randomized trials (RoB2) was used to assess studies for risk of bias, and the Michie and Prestwich Theory Coding Scheme will be used to assess the extent of theory use. Results were pooled using the inverse-variance heterogeneity model (IVhet). RESULTS: Of 770 studies, 13 were included for data extraction, and 12 were included in the meta-analysis. Parent-based interventions, when compared to controls, did not demonstrate a statistically significant increase in HPV vaccine initiation (OR = 1.24, 95% CI [0.86, 1.77]) or completion (OR = 1.23, 95% CI [0.78, 1.96]). However, sensitivity analysis suggested parent-based RCTs could improve HPV vaccine initiation (OR = 1.19, 95% CI [0.16, 1.22]) but not completion (OR = 1.25, 95% CI [0.86, 1.81]), after removing cluster RCTs. Reminders/recall interventions showed a significant increase in HPV vaccine initiation (OR = 1.19, 95% CI [0.16, 1.22]) and completion (OR = 1.52, 95% CI [1.04, 2.21]). Eight studies reported theory use in intervention development. No statistically significant differences were observed between atheoretical versus non-theory-based trials. CONCLUSION: Overall, parent-based interventions do not increase HPV vaccine uptake. Reminder and recall systems have the potential to improve HPV vaccine initiation and completion, and pharmacies can leverage these tools to improve vaccination. Behavioral theories and pharmacy-based HPV vaccination appear to be under-utilized.

Isometric exercise and inter-individual response differences on resting systolic and diastolic blood pressure in adults: a meta-analysis of randomized controlled trials.

PURPOSE: Isometric exercise (IE) has been shown to reduce resting systolic blood pressure (SBP) and diastolic blood pressure (DBP) in adults. However, no one to date has determined whether true inter-individual response differences (IIRD) versus random variability exist with respect to IE and resting SBP and DBP in adults ≥18 years of age. The purpose of the current study was to address this gap. METHODS AND MATERIALS: Using the meta-analytic approach, randomised controlled trials from a recent meta-analysis that examined the effects of IE on resting SBP and DBP were included. Change outcome standard deviations for SBP and DBP from IE and control groups were used to calculate true IIRD from each study. The inverse variance heterogeneity (IVhet) model was used to pool results. RESULTS: Pooled changes for true IIRD in SBP (16 studies, 411 participants) were 3.3 mmHg (95% confidence interval, -3.1 to 5.6 mmHg) while tau (τ) was 4.2. For DBP, true IIRD (16 studies, 411 participants) were 2.3 mmHg (95% confidence interval, -0.7 to 3.3 mmHg) while tau (τ) was 2.2. The 95% prediction interval for true IIRD in a future study was -5.8 to 7.4 mmHg for SBP and -2.7 to 4.2 mmHg for DBP. The percent chance, i.e. probability, of a clinically meaningful difference of 2 mmHg was 68% for SBP and 75% for DBP, both of which were only considered as 'possibly clinically important'. CONCLUSION: While IE reduces resting SBP and DBP in adults, the results of the current study suggest that random variability versus true IIRD account for any potential differences as a result of IE on changes in resting SBP and DBP in adults. Thus, a search for potential moderators and mediators, including potential genetic interactions associated with IE, may not be warranted.

Interventions to improve physical activity in colorectal cancer survivors: protocol for a systematic review and meta-analysis of randomized controlled trials.

AIM: To examine the effectiveness of physical activity (PA) interventions on changes in PA among colorectal cancer survivors, including an examination of theoretical versus atheoretical-driven approaches, with a special focus on their effectiveness across ethnic and racial minorities. DESIGN: Systematic review with aggregated data meta-analyses. DATA SOURCES: Using six databases (Cochrane Central Register of Controlled Trials, PubMed, PsycINFO, CINAHL with full text, Scopus and Web of Science), we will screen for randomized controlled trials written in English from May 1, 1993 up to December 31, 2020. REVIEW METHODS: Dual study-selection and data abstraction will be performed. The Behavior Change Technique Taxonomy (v1) will be used to examine behavior change techniques among selected studies, while the Theory Coding Scheme will be used to assess the extent of theory use. Risk of bias will be assessed using the revised Cochrane risk-of-bias tool for randomized trials, while the strength of the evidence will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation instrument. In addition, intervention delivery will be appraised using the Template for Intervention Description and Replication. Changes in PA from each study will be calculated using the standardized mean difference effect size (Hedge's g). Results will be pooled using the inverse-variance heterogeneity model. Heterogeneity (Cochran's Q) and inconsistency (I2 ) will be examined, while small-study effects (publication bias) will be evaluated using the Doi plot and LFK Index. Meta-regression will also be conducted to examine for potential associations between changes in physical activity and selected covariates (theoretical versus atheoretical-driven approaches, race/ethnicity). DISCUSSION: This systematic review will identify specific racial/ethnic minorities for whom interventions are most effective and summarize the evidence of the effectiveness of theoretical vs. theoretical based intervention. IMPACT: This systematic review can direct policymakers and practitioners towards actions that are likely to bring about positive physical activity behaviour change.

Number of Physically Inactive Adults With Arthritis in the United States Who Could Improve Physical Function and Pain Control by Exercising.

We estimated the number of physically inactive US adults with arthritis by state and nationally who could improve their physical function and pain control by participating in an exercise program. Our calculations were based on number-needed-to-treat, arthritis prevalence, physical inactivity, and 2010 US Census data. Estimates were lowest in the District of Columbia (physical function, n = 4,412; pain, n = 2,451) and highest in Texas (physical function, n = 325,504; pain, n = 180,835). Overall estimates were 4,119,792 for physical function and 2,288,771 for pain control. State-level estimates are important for allocating resources, public health program planning, and future research.

Systematic reviews and meta-analysis in nutrition research.

There exists an ever-increasing number of systematic reviews, with or without meta-analysis, in the field of nutrition. Concomitant with this increase is the increased use of such to guide future research as well as both practice and policy-based decisions. Given this increased production and consumption, a need exists to educate both producers and consumers of systematic reviews, with or without meta-analysis, on how to conduct and evaluate high-quality reviews of this nature in nutrition. The purpose of this paper is to try and address this gap. In the present manuscript, the different types of systematic reviews, with or without meta-analyses, are described as well as the description of the major elements, including methodology and interpretation, with a focus on nutrition. It is hoped that this non-technical information will be helpful to producers, reviewers and consumers of systematic reviews, with or without meta-analysis, in the field of nutrition.

Association Between Breastfeeding and Childhood Cardiovascular Disease Risk Factors.

Introduction The immediate benefits of breastfeeding are well-established but the long-term health benefits are less well-known. West Virginia (WV) has a higher prevalence of cardiovascular disease (CVD) and lower breastfeeding rates compared to national averages. There is a paucity of research examining the relationship between breastfeeding and subsequent childhood CVD risk factors, an issue of particular relevance in WV. Methods This study used longitudinally linked data from three cross-sectional datasets in WV (N = 11,980). The information on breastfeeding was obtained retrospectively via parental recall when the child was in the fifth grade. The outcome variables included blood pressure measures [systolic blood pressure (SBP), diastolic blood pressure (DBP)] and lipid profile [total cholesterol (TC), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), non-HDL, and triglycerides (TG)]. Multiple regression analyses were performed, adjusting for childhood body mass index (BMI) and additional covariates. Results Only 43% of mothers self-reported ever breastfeeding. The unadjusted analysis showed that children who were ever vs. never breastfed had significantly lower SBP (b = - 1.39 mmHg; 95% CI - 1.97, - 0.81), DBP (b = - 0.79 mmHg; 95% CI - 1.26, - 0.33), log-TG (b = - 0.08; 95% CI - 0.1, - 0.05), and higher HDL (b = 0.95 mg/dL; 95% CI 0.33, 1.56). After adjustment for the child's BMI, socio-demographic and lifestyle factors, log-TG remained significantly associated with breastfeeding (b = - 0.04; 95% CI - 0.06, - 0.01; p = 0.01). Conclusion The observed protective effect of any breastfeeding on childhood TG level was small but significant. This finding provides some support for a protective effect of breastfeeding on later CVD risk.

Systematic reviews and cancer research: a suggested stepwise approach.

Systematic reviews, with or without meta-analysis, play an important role today in synthesizing cancer research and are frequently used to guide decision-making. However, there is now an increase in the number of systematic reviews on the same topic, thereby necessitating a systematic review of previous systematic reviews. With a focus on cancer, the purpose of this article is to provide a practical, stepwise approach for systematically reviewing the literature and publishing the results. This starts with the registration of a protocol for a systematic review of previous systematic reviews and ends with the publication of an original or updated systematic review, with or without meta-analysis, in a peer-reviewed journal. Future directions as well as potential limitations of the approach are also discussed. It is hoped that the stepwise approach presented in this article will be helpful to both producers and consumers of cancer-related systematic reviews and will contribute to the ultimate goal of preventing and treating cancer.

Exercise and cancer-related fatigue in adults: a systematic review of previous systematic reviews with meta-analyses.

BACKGROUND: Conduct a systematic review of previous systematic reviews with meta-analysis to determine the effects of exercise (aerobic, strength or both) on cancer-related-fatigue (CRF) in adults with any type of cancer. METHODS: Systematic reviews with meta-analyses of previous randomized controlled trials published through July of 2016 were included by searching six electronic databases and cross-referencing. Dual-selection and data abstraction were conducted. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) instrument. Standardized mean differences (SMD) that were pooled using random-effects models were included as the effect size. In addition, 95% prediction intervals (PI), number needed-to-treat (NNT) and percentile improvements were calculated. RESULTS: Sixteen studies representing 2 to 48 SMD effect sizes per analysis (mean ± SD, 7 ± 8, median = 5) and 37 to 3254 participants (mean ± SD, 633 ± 690, median = 400) were included. Length of training lasted from 3 to 52 weeks (mean ± SD, 14.6 ± 3.1, median = 14), frequency from 1 to 10 times per week (mean ± SD, 3.4 ± 0.8, median = 3), and duration from 10 to 120 min per session (mean ± SD, 44.3 ± 5.5, median = 45). Adjusted AMSTAR scores ranged from 44.4% to 80.0% (mean ± SD, 68.8% ± 12.0%, median = 72.5%). Overall, mean SMD improvements in CRF ranged from -1.05 to -0.01, with 22 of 55 meta-analytic results (52.7%) statistically significant (non-overlapping 95% CI). When PI were calculated for results with non-overlapping 95% CI, only 3 of 25 (12%) yielded non-overlapping 95% PI favoring reductions in CRF. Number needed-to-treat and percentile improvements ranged from 3 to 16 and 4.4 to 26.4, respectively. CONCLUSIONS: A lack of certainty exists regarding the benefits of exercise on CRF in adults. However, exercise does not appear to increase CRF in adults. TRIAL REGISTRATION: PROSPERO Registration # CRD42016045405 .

Health-related quality of life in patients receiving long-term opioid therapy: a systematic review with meta-analysis.

PURPOSE: Over 25 million Americans reported having daily pain and between 5 and 8 million Americans used opioids to treat chronic pain in 2012. This is the first systematic review with meta-analysis to determine the effects of long-term opioid use on the Physical Component Summary (PCS) score and Mental Component Summary (MCS) scores of a Health-Related Quality of Life instrument in adults without opioid use disorder. METHODS: The a priori eligibility criteria for the PubMed (MEDLINE), Scopus, and PsyINFO searches were (1) randomized controlled trial, (2) at least one opioid intervention group, (3) minimum of 4-week duration of opioid use, (4) comparative control group, and (5) adults ≥18 years that do not have dominant disease. The unit of analysis was the standardized mean difference effect size (Hedges's g). All results were pooled using random-effects models. RESULTS: Of the 340 non-duplicate citations screened, 19 articles comprising 26 treatment comparisons and 6168 individuals (treatment n = 3160; comparators n = 3008 with duplicates removed) met the inclusion criteria for the systematic review. Thirteen treatment comparisons were available for the meta-analysis. Across all PCS analyses, small, statistically significant improvements were observed (opioid versus opioid only: g = 0.27, 95% CI 0.05-0.50, opioid versus placebo only: g = 0.18, 95% CI 0.08-0.28, and all studies combined: g = 0.22, 95% CI 0.11-0.32). There were small but not statistically significant changes on the MCS scores. Overall, high heterogeneity was present. CONCLUSIONS: PCS scores improve with no change in MCS scores. However, long-term opioid trials are rare and only two trials included lasted longer than 1 year.

Childhood obesity and adult cardiovascular disease risk factors: a systematic review with meta-analysis.

BACKGROUND: Overweight and obesity is a major public health concern that includes associations with the development of cardiovascular disease (CVD) risk factors during childhood and adolescence as well as premature mortality in adults. Despite the high prevalence of childhood and adolescent obesity as well as adult CVD, individual studies as well as previous systematic reviews examining the relationship between childhood obesity and adult CVD have yielded conflicting results. The purpose of this study was to use the aggregate data meta-analytic approach to address this gap. METHODS: Studies were included if they met the following criteria: (1) longitudinal and cohort studies (including case-cohort), (2) childhood exposure and adult outcomes collected on the same individual over time, (3) childhood obesity, as defined by the original study authors, (4) English-language articles, (5) studies published up to June, 2015, (6) one or more of the following CVD risk factors [systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), non-high-density lipoprotein cholesterol (non-HDL), and triglycerides (TG)], (7) outcome(s) not self-reported, and (8) exposure measurements (child's adiposity) assessed by health professionals, trained investigators, or self-reported. Studies were retrieved by searching three electronic databases as well as citation tracking. Fisher's r to z score was calculated for each study for each outcome. Pooled effect sizes were calculated using random-effects models while risk of bias was assessed using the STROBE instrument. In order to try and identify sources of heterogeneity, random-effects meta-regression was also performed. RESULTS: Of the 4840 citations reviewed, a total of 23 studies were included in the systematic review and 21 in the meta-analysis. The findings suggested that childhood obesity is significantly and positively associated with adult SBP (Zr = 0.11; 95% CI: 0.07, 0.14), DBP (Zr = 0.11; 95% CI: 0.07, 0.14), and TG (Zr =0.08; 95% CI: 0.03, 0.13), and significantly and inversely associated with adult HDL (Zr = -0.06; 95% CI: -0.10, -0.02). For those studies that adjusted for adult body mass index (BMI), associations were reversed, suggesting that adult BMI may be a potential mediator. Nine studies had more than 33% of items that placed them at an increased risk for bias. CONCLUSIONS: The results of this study suggest that childhood obesity may be a risk factor for selected adult CVD risk factors. However, a need exists for additional, higher-quality studies that include, but are not limited to, both unadjusted and adjusted measures such as BMI before any definitive conclusions can be reached. SYSTEMATIC REVIEW AND META-ANALYSIS: PROSPERO 2015: CRD42015019763 .

Needle exchange programs for the prevention of hepatitis C virus infection in people who inject drugs: a systematic review with meta-analysis.

BACKGROUND: Previous research on the effectiveness of needle exchange programs (NEP) in preventing hepatitis C virus (HCV) in people who inject drugs (PWID) has shown mixed findings. The purpose of this study was to use the meta-analytic approach to examine the association between NEP use and HCV prevention in PWIDs. METHODS: Study inclusion criteria were (1) observational studies, (2) PWIDs, (3) NEP use, (4) HCV status ascertained by serological testing, (5) studies published in any language since January 1, 1989, and (6) data available for measures of association. Studies were located by searching four electronic databases and cross-referencing. Study quality was assessed using the Newcastle Ottawa (NOS) scale. A ratio measure of association was calculated for each result from cohort or case-control studies and pooled using a random effects model. Odds ratio (OR) and hazard ratio (HR) models were analyzed separately. Results were considered statistically significant if the 95% confidence interval (CI) did not cross 1. Heterogeneity was estimated using Q and I 2 with alpha values for Q ≤ 0.10 considered statistically significant. RESULTS: Of the 555 citations reviewed, 6 studies containing 2437 participants were included. Studies had an average NOS score of 7 out of 9 (77.8%) stars. Concerns over participant representativeness, unclear adjustments for confounders, and bias from participant nonresponse and loss to follow-up were noted. Results were mixed with the odds ratio model indicating no consistent association (OR, 0.51, 95% CI, 0.05-5.15), and the hazard ratio model indicating a harmful effect (HR, 2.05, 95% CI, 1.39-3.03). Substantial heterogeneity (p ≤ 0.10) and moderate to large inconsistency (I 2 ≥ 66%) were observed for both models. CONCLUSIONS: The impact of NEPs on HCV prevention in PWIDs remains unclear. There is a need for well-designed research studies employing standardized criteria and measurements to clarify this issue. TRIAL REGISTRATION: PROSPERO CRD42016035315.

Guided Imagery for Arthritis and Other Rheumatic Diseases: A Systematic Review of Randomized Controlled Trials.

Many individuals suffering from arthritis and other rheumatic diseases (AORD) supplement pharmacologic treatments with psychosocial interventions. One promising approach, guided imagery, has been reported to have positive results in randomized controlled trials (RCTs) and is a highly scalable treatment for those with AORD. The main purpose of this study was to conduct a systematic review of RCTs that have examined the effects of guided imagery on pain, function, and other outcomes such as anxiety, depression, and quality of life in adults with AORD. Ten electronic bibliographic databases were searched for reports of RCTs published between 1960 and 2013. Selection criteria included adults with AORD who participated in RCTs that used guided imagery as a partial or sole intervention strategy. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Instrument. Results were synthesized qualitatively. Seven studies representing 306 enrolled and 287 participants who completed the interventions met inclusion criteria. The average age of the participants was 62.9 years (standard deviation = 12.2). All interventions used guided imagery scripts that were delivered via audio technology. The interventions ranged from a one-time exposure to 16 weeks in duration. Risk of bias was low or unclear in all but one study. All studies reported statistically significant improvements in the observed outcomes. Guided imagery appears to be beneficial for adults with AORD. Future theory-based studies with cost-benefit analyses are warranted.

Effects of exercise on BMI z-score in overweight and obese children and adolescents: a systematic review with meta-analysis.

BACKGROUND: Overweight and obesity are major public health problems in children and adolescents. The purpose of this study was to conduct a systematic review with meta-analysis to determine the effects of exercise (aerobic, strength or both) on body mass index (BMI) z-score in overweight and obese children and adolescents. METHODS: Studies were included if they were randomized controlled exercise intervention trials ≥ 4 weeks in overweight and obese children and adolescents 2 to 18 years of age, published in any language between 1990-2012 and in which data were available for BMI z-score. Studies were retrieved by searching eleven electronic databases, cross-referencing and expert review. Two authors (GAK, KSK) selected and abstracted data. Bias was assessed using the Cochrane Risk of Bias Assessment Instrument. Exercise minus control group changes were calculated from each study and weighted by the inverse of the variance. All results were pooled using a random-effects model with non-overlapping 95% confidence intervals (CI) considered statistically significant. Heterogeneity was assessed using Q and I2 while funnel plots and Egger's regression test were used to assess for small-study effects. Influence and cumulative meta-analysis were performed as well as moderator and meta-regression analyses. RESULTS: Of the 4,999 citations reviewed, 835 children and adolescents (456 exercise, 379 control) from 10 studies representing 21 groups (11 exercise, 10 control) were included. On average, exercise took place 4 x week for 43 minutes per session over 16 weeks. Overall, a statistically significant reduction equivalent to 3% was found for BMI z-score (Χ¯, -0.06, 95% CI, -0.09 to -0.03; Q = 24.9, p = 0.01; I(2)=59.8%). No small-study effects were observed and results remained statistically significant when each study was deleted from the model once. Based on cumulative meta-analysis, results have been statistically significant since 2009. None of the moderator or meta-regression analyses were statistically significant. The number-needed-to treat was 107 with an estimated 116,822 million obese US children and adolescents and approximately 1 million overweight and obese children and adolescents worldwide potentially improving their BMI z-score by participating in exercise. CONCLUSIONS: Exercise improves BMI z-score in overweight and obese children and adolescents and should be recommended in this population group. However, a need exists for additional studies on this topic.

Effects of exercise on depressive symptoms in adults with arthritis and other rheumatic disease: a systematic review of meta-analyses.

BACKGROUND: Depression is a major public health problem among adults with arthritis and other rheumatic disease. The purpose of this study was to conduct a systematic review of previous meta-analyses addressing the effects of exercise (aerobic, strength or both) on depressive symptoms in adults with osteoarthritis, rheumatoid arthritis, fibromyalgia and systemic lupus erythematous. METHODS: Previous meta-analyses of randomized controlled trials were included by searching nine electronic databases and cross-referencing. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) Instrument. Random-effects models that included the standardized mean difference (SMD) and 95% confidence intervals (CIs) were reported. The alpha value for statistical significance was set at p ≤ 0.05. The U3 index, number needed to treat (NNT) and number of US people who could benefit were also calculated. RESULTS: Of the 95 citations initially identified, two aggregate data meta-analyses representing 6 and 19 effect sizes in as many as 870 fibromyalgia participants were included. Methodological quality was 91% and 82%, respectively. Exercise minus control group reductions in depressive symptoms were found for both meta-analyses (SMD, -0.61, 95% CI, -0.99 to -0.23, p = 0.002; SMD, -0.32, 95% CI, -0.53 to -0.12, p = 0.002). Percentile improvements (U3) were equivalent to 22.9 and 12.6. The number needed to treat was 6 and 9 with an estimated 0.83 and 0.56 million US people with fibromyalgia potentially benefitting. CONCLUSIONS: Exercise improves depressive symptoms in adults with fibromyalgia. However, a need exists for additional meta-analytic work on this topic.

How active are rural children and adolescents during PE class? An examination of light physical activity.

BACKGROUND: Few studies have examined non-exercise activity thermogenesis (NEAT) or light physical activity among a group of rural youth, particularly during physical education (PE) class. The purpose of this study was to determine whether the percent of PE class time spent in NEAT is related to school level (elementary versus high school) in a group of rural youth. METHODS: Accelerometer data from 357 students (192 elementary, 165 high school) were included in the analysis. Mixed model linear regression was performed to examine the effect of school level on the percent of PE class time spent in NEAT. Covariates included gender, PE teacher, and the duration of the PE class. RESULTS: School level was a significant predictor of the percent of PE class time spent in NEAT. Specifically, elementary school students spent more of their PE class time in NEAT than high school students (p < .001). No other significant predictors were identified. CONCLUSIONS: The results of this study suggest an association between lower levels of light (NEAT) physical activity among high school versus elementary school students during PE class.