Visual process models are meant to facilitate comprehension of business processes. However, in practice, process models can be difficult to understand. The main goal of this article is to clarify the sources of cognitive effort in comprehending process models. The article undertakes a comprehensive descriptive review of empirical and theoretical work in order to categorize and summarize systematically existing findings on the factors that influence comprehension of visual process models. Methodologically, the article builds on a review of forty empirical studies that measure objective comprehension of process models, seven studies that measure subjective comprehension and user preferences, and thirty-two articles that discuss the factors that influence the comprehension of process models. The article provides information systems researchers with an overview of the empirical state of the art of process model comprehension and provides recommendations for new research questions to be addressed and methods to be used in future experiments.

Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease that has a highly variable disease course. Three biologic agents, adalimumab, etanercept, and infliximab, have been developed for the treatment of AS. We conducted three studies: 1) an exploratory analysis of a year-long longitudinal dataset to gain insight into the variability of disease activity, physical function, and well-being and to explore the relationship between these outcome measures; 2) a systematic review of the available evidence for the efficacy of biologic treatment; 3) a systematic review of potential adverse effects of this treatment. We found that repeated measures of disease activity, function and well-being fluctuate considerably between patients, with complex patterns occurring over time within patients. There was mostly high quality evidence that these biologics are efficacious against placebo. We did not find evidence of an increase in serious adverse events or serious infections from short-term randomized controlled trials.

Background: Postpartum depression (PPD) is a complex mental health disorder that affects women during their childbearing years. It is a serious medical condition that occurs in approximately 13–20% of women after birth and has an adverse effect on both the mother and the infant. Certain dietary deficiencies in a pregnant or postnatal woman’s diet may cause postnatal depression. It is unclear whether Omega-3 polyunsaturated fatty acids (n-3 PUFAs) are effective for treating or preventing PPD. Objectives: To assess the best available evidence to date regarding the effect of n-3 PUFAs on the etiology, prevention and treatment of postnatal depression. Methods: A systematic review and narrative synthesis was conducted in order to address the gaps in knowledge. For the systematic review, a broad search of electronic databases of published quantitative literature was conducted. Quality appraisal was performed using the tools produced by the effective public health practice project (EPHPP). The narrative synthesis consists of four elements: 1) developing a theory; 2) developing a preliminary synthesis; 3) exploring relationships in the data; 4) assessing the robustness of the synthesis. Results: Out of 181 potential articles, a total of 17 studies met the inclusion criteria. The overwhelming majority of the studies found that n-3 PUFAs had no association with PPD evaluations versus only few ones observed a beneficial effect of n-3 PUFAs supplementation on depressive symptoms. Significant heterogeneity was observed among included studies which can be explained by dissimilar study designs, differences in study duration, time period of measurement and number of participants, and in varied dosages and types of supplemental n-3 PUFAs. Conclusions: Overall, This systematic review and narrative synthesis failed to find a significant positive association between n-3 PUFAs intake and PPD. However further investigation of the specific molecular mechanisms underlying the function of n-3 PUFAs in the brain and the factors related to the pathophysiological nature of depression is warranted.

‘Rapid review’ is an accelerated evidence synthesis approach that has emerged to meet the needs of knowledge users in healthcare settings who require timely input to support evidence-informed policy and practice questions. Although use of rapid reviews continues to expand, there is a paucity of research on this topic. This thesis addresses three identified knowledge gaps: 1) To address the lack of an established definition for rapid reviews, a modified Delphi process was used to pursue expert consensus on the defining characteristics of rapid reviews and an operational definition; 2) To further our understanding of the prevalent opinions and perceptions towards rapid reviews, a Q methodology was used to characterize the viewpoints of research producers and knowledge users; and, 3) To extend our knowledge on the characteristics, conduct and reporting quality of rapid reviews, compliance with currently accepted checklists (AMSTAR, PRISMA) was explored in a sample of recent rapid reviews.

Background: With usual supplementation practices, most children are Vitamin D Deficient (VDD) following Congenital Heart Disease (CHD) surgery and alternative regimens need consideration. Methods/Results: i) A systematic review identified 88 pediatric trials of high dose vitamin D. Studies evaluating the Institute of Medicine (IOM) Tolerable Upper Intake Level (UL) did not rapidly normalize levels, while loading therapy (≥ 40000 IU) did so within 3 days. Hypercalcemia occurred more often with doses above 400000 IU. ii) A double blind RCT was designed to determine whether pre-operative administration of the IOM UL can prevent post-operative VDD. Results after the first 30 participants completed study procedures demonstrated it was possible to recruit (1.8 patients per month) and complete study procedures (i.e. blood collection). Unfortunately few participants (45%) received more than 30 doses of study drug. Conclusion: Prevention of post-operative VDD in the majority of CHD patients will require alternatives to the IOM recommendations.

Objective Postpartum hemorrhage (PPH) is a major cause of maternal mortality world-wide; misoprostol is a relatively cheap, easily administered, and an efficient medication to be given after the delivery of the baby to prevent PPH, thus posing it as a first choice in resource-poor communities. The aim of this study is to answer questions regarding the most appropriate dose (400 µg versus 600 µg), effect of labour settings (community or clinical), and management of labour on misoprostol effectiveness and safety in preventing PPH. Methods We developed a search strategy and conducted a search within five key databases. Two reviewers screened the articles for predefined inclusion/exclusion criteria, quality, and performed data extraction. Discrepancy was dealt with by reaching consensus. In article 1, we only included randomized controlled trials, we performed a random-effects Bayesian network meta-analysis comparing 400 µg to 600 µg misoprostol over five outcomes of interest: blood loss ≥500 ml, blood loss ≥1000 ml, using additional uterotonics, shivering, and pyrexia. In article 2, we included any experimental trial, we performed a random effects model meta-analysis, pooling the incidence of PPH from each misoprostol arm. Subsequently, a meta-regression model was performed on identified potential effect-modifiers, including clinical settings and labour management. Results Of 444 identified records, 46 trials met the inclusion/exclusion criteria in article 1, and 56 trials in article 2. The odds ratio (OR) of misoprostol 400 µg vs. 600 µg for bleeding ≥ 500 ml is 0.86 [95% Credible Intervals: 0.46 − 1.54], for bleeding ≥ 1000 ml the OR is 0.83 [95% CrI 0.54 – 1.26], for additional uterotonics is 0.75 [95% CrI 0.40 – 1.40], for pyrexia and shivering an OR of 0.57 [95% CrI 0.15 – 2.18] and 0.63 [95% CrI 0.29 – 1.31] respectively. The overall incidence of PPH was 6.62 per 100 pregnancies (95%CI 4.71 per 100 – 8.53 per 100). Labour settings and other aspects of active management of labour had no statistically significant effect on the incidence of post-partum hemorrhage. Conclusion We found no difference between the administration of misoprostol 400 µg or 600 µg for the prevention of PPH and side effects of misoprostol, as well as no effect of labour settings and management of labour on misoprostol effectiveness.

Intensive Behavioural Intervention (IBI) is one of the most widely used treatments for children with an autism spectrum disorder (ASD). While IBI has been recognized as the treatment of choice for very young children with an ASD, its sensible use among school age children is a matter of dispute. The aim of this thesis was to determine the clinical effectiveness of IBI, as compared with no treatment or treatment-as-usual, for the management of cognitive functioning and adaptive skills in preschool and school age children with an ASD, as well as to examine predictors of treatment response. Peer-reviewed, English language publications were identified using MEDLINE, EMBASE, PsychINFO, CINAHL, and ERIC from 1995 to September 1, 2014. Grey literature and reference lists of published papers were also searched for relevant records. Retrieved citations were screened by two independent reviewers, and data extraction was performed by a single reviewer with verification by a second reviewer. The methodological quality and procedural fidelity of included studies was assessed by one reviewer, and a subset of included studies were pooled in a random-effects meta-analysis using the standardized mean difference (SMD) effect size. A total of 24 unique studies were selected for inclusion in this review, comprising a total of 1,816 participants. Findings revealed that IBI improves full-scale IQ (SMD ES = 0.66, 95% CI 0.46 to 0.85, p<0.00001; 13 studies) and adaptive skills (SMD ES = 0.57, 95% CI 0.33 to 0.82, p<0.00001; 12 studies) in preschool and school age children with an ASD, with seemingly higher clinical benefits in children aged under 4 years at intake. Better outcomes with IBI are predicted by children’s relatively younger age, increased cognitive and adaptive ability, as well as a milder severity of symptoms at treatment entry. Results warrant careful interpretation in light of several methodological limitations and inadequate monitoring of procedural fidelity.

Type 2 diabetes mellitus (T2DM) continues to be a national challenge for Canadians. African and Caribbean Immigrants are among the most affected groups and those at risk of developing comorbidities and related complications. It continues to prove challenging to treat T2DM for the affected individuals. Effectively treating the disease can help mitigate risk factors for related comorbidities and complications while improving the quality of life for those affected. There is increasing research, outside of Canada, showing the evidence for the effectiveness of culturally sensitive and adapted interventions to immigrant patients affected with T2DM. In light of the effectiveness of such interventions in many industrialized nations, a systematic review (SR) can offer the best evidence for the scope and consideration of such treatment approaches in Canada. This SR aimed to determine whether community-based diabetic interventions in Canada, are culturally sensitive to African and Caribbean minorities living with type II diabetes. A narrative synthesis was employed to report the effect of interventions seeking to affect outcomes of T2DM patients in Canada. Of the 63 articles included for full review, 60 were excluded for not meeting the criteria of having the target population explicitly identified and also not having any mention of cultural sensitivity. Three articles were included for the final review because the target population was explicitly identified. The final results showed that all interventions were found not to be culturally sensitive to African and Caribbean T2DM patients in Canada. Our results suggest a lack in Canadian literature. To the best of our knowledge, this is the very first systematic review on this subject matter in Canada. This review provides dependable information and recommendations to researchers, educators, clinicians, and policy makers for future research with T2DM African and Caribbean patients in Canada. RÉSUMÉ Le diabète de type 2 demeure un défi national pour les Canadiens. Les immigrants d’origine d’Afrique et des Caraïbes sont parmi les groupes les plus frappés et l'un des plus à risque de développer des troubles comorbides et de complications liées au diabète. Traiter le diabète continue à poser un défi chez les personnes affectées. Traiter efficacement cette maladie peut contribuer à réduire des principaux facteurs de risque quant aux troubles comorbides et complications, tout en améliorant la qualité de vie chez les personnes affectées. Un nombre grandissant de recherche, hors du Canada, démontrent avec des preuves concluantes que les interventions sensibles et culturellement adaptées aux immigrants affectés par le diabète sont efficaces. Étant donné l'efficacité de ces interventions dans nombreux pays industrialisés, une revue systématique peut nous offrir la meilleure preuve pour l'envergure relative à ce genre de traitement au Canada. La présente étude méthodique vise à déterminer si les interventions contre le diabète, en milieu communautaires au Canada, sont culturellement adaptées aux minorités ethniques d’origines d’Afrique et des Caraïbes souffrant de diabète de type II. Une synthèse narrative a été utilisée afin de signaler les effets des interventions par rapport aux résultats des patients souffrant du diabète de type 2. Parmi les 63 articles considérés pour une évaluation complète, 60 ont été exclus car ni la population cible ou la mention de la sensibilité culturelle n’a été explicitement identifiée. Trois articles ont été inclus pour l’évaluation finale car la population cible fut explicitement identifiée. Aucune des interventions n’est culturellement sensible aux patients Africains et Caribéen affecté par le diabète de type 2. Nos résultats démontrent un écart dans la littérature Canadienne. A ce que nous sachons, cette revue systématique est la première qui touche à cette question au Canada. Cette revue fournie des données fiables et recommandations qui permettront aux chercheurs, enseignants, cliniciens, et aux décideurs en matière de politiques de santé pour des recherches futures auprès des patients Africains et Caribéen souffrants du diabète de type 2 au Canada.

In view of the recent implementation of a publicly funded rotavirus vaccination program in Ontario, we undertook studies to help guide the design of a safety evaluation of the vaccine with respect to intussusception. We used administrative data to develop and validate an algorithm for intussusception, and quantified its incidence in Ontario. We also conducted a systematic review of study designs used to evaluate post-licensure vaccine safety, and discussed each design’s strengths and weaknesses. The validated algorithm for intussusception was sensitive (89.3%) and highly specific (>99.9%). We observed the highest mean incidence (34 / 100,000) in males <1 year of age. While other designs are more robust, the inability to ascertain individual vaccination status from Ontario’s administrative data dictated our selection of an ecological design for safety evaluation of rotavirus vaccine. Data assimilated from this thesis represent a critical step toward the timely evaluation of rotavirus vaccine safety in Ontario.

Introduction: Thromboprophylaxis recommendations for hospitalized cancer are based on trials done for the general medically patients, as there are no randomized clinical trials(RCTs) looking at thromboprophylaxis in medically ill patients with cancer. Methods: To determine if thromboprophylaxis is safe and effective to prevent VTE these patients, a Systematic Review(SR) was done. A survey was performed to assess: clinical equipoise, trial design and minimally clinically important difference(MCID) for a potential trial. Lastly, a pilot study for an RCT was designed. Results: The pooled RR of VTE was 0.91 (95%CI:0.21 to 4.0;I2:68%) among hospitalized cancer patients receiving thromboprophylaxis compared to placebo. 63.9% believe there is clinical equipoise and 58.3% would consider participating in a RCT comparing different agents/dosing. The MCID for absolute reduction in symptomatic VTE between two arms was 2% and for “acceptable” increase in major bleeding events was 1%. Conclusion: The risk-benefit ratio of current doses of thromboprophylaxis administered to hospitalized cancer patients is unclear and additional RCTs are necessary.