AbstractSpecial Educational Needs (SEN) provision for school children provides extra support and reasonable adjustments for children and young people with additional educational, behavioural or health needs to ensure equal education opportunities; for example those born with a healthcare need such as cleft lip and palate may be provided SEN to aid with challenges in communications. However, there is limited knowledge of whether SEN provisions impact academic or health outcomes in such a population and conducting a randomised controlled trial to establish this evidence is not plausible. In lieu of randomised controlled trials, target trial emulation methods can be used in attempt to answer causal questions using observational data whilst reducing confounding and other biases likely to arise with such data. The Education and Child Health Insights from Linked Data (ECHILD) dataset could be used as part of trial emulation methods to understand the impact of SEN provisions on academic and healthcare outcomes. ECHILD is the first dataset to hold longitudinal school, health and social care data on all pupils in England, obtained by linking the National Pupil Database (NPD) with Hospital Episode Statistics (HES). In this protocol, we describe how the ECHILD dataset could be used to explore and conduct a target trial emulation to evaluate whether children who were born with cleft lip and palate would have different unplanned hospital utilisation if they received or did not receive SEN provisions by Year 1 (specifically by January in their second year of school) when they are aged 5 or 6.MethodsFocussing on the population of children who are identified as having been born with cleft lip and palate, an intervention of varying levels of SEN provision (including no SEN provision) by January of the second year of school, and an outcome of unplanned hospital utilisation, we apply a trial emulation design to reduce confounding when using observational data to investigate the causal impact of SEN on unplanned hospital admissions. Our target population is children born 2001-2014 who had a recording of cleft lip and palate in HES and who started their second year of primary school (Year 1) in a state school between 2006 and 2019; children with a first recording of cleft lip and palate after Year 1 were excluded (these were pupils who likely immigrated to England after birth). We intend to use a time window of SEN provision assignment between the start of school (reception) and by the January school census in Year 1. Using target trial emulation, we aim to estimate the average treatment effect of SEN provision on the number of unplanned hospital admissions (including admissions to accident and emergency) between the January school census in Year 1 and Year 6 (the end of primary school, when children are 10-11 years old).Ethics and disseminationPermissions to use linked, de-identified data from Hospital Episode Statistics and the National Public Database were granted by DfE (DR200604.02B) and NHS Digital (DARS-NIC-381972). Ethical approval for the ECHILD project was granted by the National Research Ethics Service (17/LO/1494), NHS Health Research Authority Research Ethics Committee (20/EE/0180) and UCL Great Ormond Street Institute of Child Health’s Joint Research and Development Office (20PE06). Stakeholders (academics, clinicians, educators and child/young people advocacy groups) will consistently be consulted to refine populations, interventions and outcomes of studies that use the ECHILD dataset to conduct target trial emulation. Scientific, lay and policy briefings will be produced to inform public health policy through partners in the Department of Education and the Department of Health and Social Care.

BACKGROUND: Guidelines recommend measuring blood pressure (BP) in both arms, adopting the higher arm readings for diagnosis and management. Data to support this recommendation are lacking. We evaluated associations of higher and lower arm systolic BPs with diagnostic and treatment thresholds, and prognosis in hypertension, using data from the Inter-arm Blood Pressure Difference-Individual Participant Data Collaboration. METHODS: One-stage multivariable Cox regression models, stratified by study, were used to examine associations of higher or lower reading arm BPs with cardiovascular mortality, all-cause mortality, and cardiovascular events, in individual participant data meta-analyses pooled from 23 cohorts. Cardiovascular events were modelled for Framingham and atherosclerotic cardiovascular disease risk scores. Model fit was compared throughout using Akaike information criteria. Proportions reclassified across guideline recommended intervention thresholds were also compared. RESULTS: We analyzed 53 172 participants: mean age 60 years; 48% female. Higher arm BP, compared with lower arm, reclassified 12% of participants at either 130 or 140 mm Hg systolic BP thresholds (both P

OBJECTIVES: Patient and public involvement (PPI) in health research is required by some funders and publications but we know little about how common it is. In this study we estimated the frequency of PPI inclusion in health research papers and analysed how it varied in relation to research topics, methods, funding sources and geographical regions. DESIGN: Cross-sectional. METHODS: Our sample consisted of 3000 research papers published in 2020 in a general health-research journal (BMJ Open) that requires a statement on whether studies included PPI. We classified each paper as 'included PPI' or 'did not include PPI' and analysed the association of this classification with location (country or region of the world), methods used, research topic (journal section) and funding source. We used adjusted regression models to estimate incident rate ratios of PPI inclusion in relation to these differences. RESULTS: 618 (20.6%) of the papers in our sample included PPI. The proportion of papers including PPI varied in relation to location (from 44.5% (95% CI 40.8% to 48.5%) in papers from the UK to 3.4% (95% CI 1.5% to 5.3%) in papers from China), method (from 38.6% (95% CI 27.1% to 50.1%) of mixed-methods papers to 5.3% (95% CI -1.9% to 12.5%) of simulation papers), topic (from 36.9% (95% CI 29.1% to 44.7%) of papers on mental health to 3.4% (95% CI -1.3% to 8.2%) of papers on medical education and training, and funding source (from 57.2% (95% CI 51.8% to 62.6%) in papers that received funding from the UK's National Institute for Health Research to 3.4% (95% CI 0.7% to 6.0%) in papers that received funding from a Chinese state funder). CONCLUSIONS: Most research papers in our sample did not include PPI and PPI inclusion varied widely in relation to location, methods, topic and funding source.

IntroductionBlood pressure (BP) is normally measured on the upper arm, and guidelines for the diagnosis and treatment of high BP are based on such measurements. Leg BP measurement can be an alternative when brachial BP measurement is impractical, due to injury or disability. Limited data exist to guide interpretation of leg BP values for hypertension management; study-level systematic review findings suggest that systolic BP (SBP) is 17 mm Hg higher in the leg than the arm. However, uncertainty remains about the applicability of this figure in clinical practice due to substantial heterogeneity.AimsTo examine the relationship between arm and leg SBP, develop and validate a multivariable model predicting arm SBP from leg SBP and investigate the prognostic association between leg SBP and cardiovascular disease and mortality.Methods and analysisIndividual participant data (IPD) meta-analyses using arm and leg SBP measurements for 33 710 individuals from 14 studies within the Inter-arm blood pressure difference IPD (INTERPRESS-IPD) Collaboration. We will explore cross-sectional relationships between arm and leg SBP using hierarchical linear regression with participants nested by study, in multivariable models. Prognostic models will be derived for all-cause and cardiovascular mortality and cardiovascular events.Ethics and disseminationData originate from studies with prior ethical approval and consent, and data sharing agreements are in place—no further approvals are required to undertake the secondary analyses proposed in this protocol. Findings will be published in peer-reviewed journal articles and presented at conferences. A comprehensive dissemination strategy is in place, integrated with patient and public involvement.PROSPERO registration numberCRD42015031227.

Discussion of public and patient involvement (PPI) in health economics (HE) research is growing. There is much literature on PPI principles and standards, but little specifically regarding involving patients in HE research. Here, we outline "PACTS", a set of principles, developed with a PPI group, for considering patient involvement in HE research. Planning: Involvement is best built in to research plans from the outset. This includes setting specific goals for involvement activities, and clearly communicating the background and purpose of involvement. Approach selection: We describe two main approaches to involvement-discussion-based and task-based. Discussion-based approaches are useful for generating broad insights and revealing "unknown unknowns". Task-based approaches offer a more focused means of shedding light on "known unknowns". Continuous involvement: Involving patients throughout the research process and across a range of projects helps build expertise for patients and insight for HE researchers. Team building: Meaningful involvement creates a shared sense of ownership of the research and, over time, helps to develop a team ethos, enhancing the positive impacts of involvement. Sensitivity: HE research can be perceived as technical and impersonal. Addressing this requires sensitivity, clarity, and an honest and open approach. There is increased recognition that patient contributors are experts at providing a "lived experience" perspective, in the way that clinicians are experts at providing an overview of conditions and HEs are experts in the methodology of their discipline. We hope these "PACTS Principles" complement existing PPI approaches and provide a useful foundation for health economists considering patient involvement.

Information received by women regarding physical activity during and after pregnancy often lacks clarity and may be conflicting and confusing. Without clear, engaging, accessible guidance centred on the experiences of pregnancy and parenting, the benefits of physical activity can be lost. We describe a collaborative process to inform the design of evidence-based, user-centred physical activity resources which reflect diverse experiences of pregnancy and early parenthood. Two iterative, collaborative phases involving patient and public involvement (PPI) workshops, a scoping survey (n = 553) and stakeholder events engaged women and maternity, policy and physical activity stakeholders to inform pilot resource development. These activities shaped understanding of challenges experienced by maternity and physical activity service providers, pregnant women and new mothers in relation to supporting physical activity. Working collaboratively with women and stakeholders, we co-designed pilot resources and identified important considerations for future resource development. Outcomes and lessons learned from this process will inform further work to support physical activity during pregnancy and beyond, but also wider health research where such collaborative approaches are important. We hope that drawing on our experiences and sharing outcomes from this work provide useful information for researchers, healthcare professionals, policy makers and those involved in supporting physical activity behaviour.

. Plain English summary
. Background
. Patient and public involvement means researchers working with members of the public, patients or carers to jointly plan and carry out research.
. Aim
. This article is written by members of three involvement groups, and the university employees that they work with. We wanted to jointly reflect on what enables our collaborative work, and what the challenges are for everyone involved.
. What we did and how we did it
. We wanted to establish what the literature defines as ‘good’ public involvement and compare this with processes and practices in our involvement groups. We therefore carried out a literature review and each group met separately to discuss what characterises good involvement, and what the challenges are. From these discussions we developed a set of descriptions about each group. We compared the literature review findings with what came out of the discussions within the involvement groups.
. Findings
. Some of the involvement principles from the literature were similar to the priorities of the involvement groups. In addition, the groups identified characteristics of ‘good’ involvement practice that were not reported in the literature: passion and enthusiasm, informal and welcoming meeting spaces, and opportunities to share lived experiences. In this article we present examples of how principles for good involvement are practiced in these groups, and difficulties we have experienced.
.
. Abstract
. Background
. Patient and public involvement is important for producing relevant and accessible health research. Evidence of impact from involvement is growing, but there is also a need for research on how to create conditions for meaningful collaborations between researchers and public advisers.
. Objective
. We report on a co-produced self-reflective evaluation of involvement practices in three UK research programmes.
. Methods
. A structured review identified research-based principles for ‘good’ public involvement in research. In parallel, members of three involvement groups co-developed statements on how the groups work, and enablers and challenges to collaborative research. The author team analysed these statements using the findings from the review.
. Results
. We identified 11 international articles reporting research-based principles for involvement published between 2013 and 2017. We identified five ‘values’ and seven ‘practice principles’ for ‘good’ involvement. There was convergence between these principles and the priorities of the involvement groups. But the groups also identified additional good involvement practice that were not reported by the literature: passion, enthusiasm, informal and welcoming meeting spaces, and opportunities to share lived experiences. We present examples of how principles for good involvement are practiced in these groups, and highlight principles that have been challenging to implement.
. Conclusions
. Ongoing appraisal of public involvement is crucial. We present a process for self-evaluation, illuminate what ‘good’ means to researchers and public advisers involved in research, and identify areas for improvement. We conclude that provision of resources that enable support to public advisers in turn enable universities and research teams to implement other principles of good involvement.
.

BACKGROUND: Parents of babies admitted to neonatal units experience an arduous emotional journey. Feelings of helplessness, fear, sadness, guilt, grief and anger are common. These feelings can lead to anxiety, depression and post-traumatic stress which may persist long after discharge from the unit. Support from a parent with first-hand experience able to empathise with problems and challenges may help. This systematic review will identify quantitative and qualitative evidence to address the role of parent-to-parent support interventions for families of babies cared for in neonatal units, and combine the findings in an integrated synthesis. METHODS: We are working in collaboration with a study-specific Parent Advisory Group (PAG) of parents who have relevant and varied lived experience of having a baby in neonatal care and those who have been involved in providing peer support. With the PAG, we will carry out a systematic review bringing together all existing research on parent-to-parent support for parents of babies cared for in neonatal units. This will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The protocol has been produced in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension (PRISMA-P). We have co-produced a plain language protocol summary with the PAG which details the different stages of the project, and this is available via our website ( http://clahrc-peninsula.nihr.ac.uk/research/parent-to-parent-support ) for anyone interested in learning more about the detail of the project. DISCUSSION: all outputs will be available on the NIHR CLAHRC South West Peninsula (PenCLAHRC) website and promoted via PenCLAHRC networks as well as organisations that have been contacted throughout the project. PAG members will be involved in writing and reviewing the academic paper and final report and in co-producing dissemination products such as plain language summaries. The PAG will influence the main conclusions of the systematic review, aid interpretation and help to communicate results in the most appropriate ways. We will hold an impact conference with representatives from neonatal units, national neonatal networks, commissioners of services and parents to discuss what the findings mean for clinical practice and service provision. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018090569.

INTRODUCTION: Individual cohort studies in various populations and study-level meta-analyses have shown interarm differences (IAD) in blood pressure to be associated with increased cardiovascular and all-cause mortality. However, key questions remain, such as follows: (1) What is the additional contribution of IAD to prognostic risk estimation for cardiovascular and all-cause mortality? (2) What is the minimum cut-off value for IAD that defines elevated risk? (3) is there a prognostic value of IAD and do different methods of IAD measurement impact on the prognostic value of IAD? We aim to address these questions by conducting an individual patient data (IPD) meta-analysis. METHODS AND ANALYSIS: This study will identify prospective cohort studies that measured blood pressure in both arms during recruitment, and invite authors to contribute IPD datasets to this collaboration. All patient data received will be combined into a single dataset. Using one-stage meta-analysis, we will undertake multivariable time-to-event regression modelling, with the aim of developing a new prognostic model for cardiovascular risk estimation that includes IAD. We will explore variations in risk contribution of IAD across predefined population subgroups (eg, hypertensives, diabetics), establish the lower limit of IAD that is associated with additional cardiovascular risk and assess the impact of different methods of IAD measurement on risk prediction. ETHICS AND DISSEMINATION: This study will not include any patient identifiable data. Included datasets will already have ethical approval and consent from their sponsors. Findings will be presented to international conferences and published in peer reviewed journals, and we have a comprehensive dissemination strategy in place with integrated patient and public involvement. PROSPERO REGISTRATION NUMBER: CRD42015031227.

BACKGROUND: Research involving the public as partners often proves difficult to locate due to the variations in terms used to describe public involvement, and inability of medical databases to index this concept effectively. OBJECTIVE: to design a search filter to identify literature where patient and public involvement (PPI) was used in health research. METHODS: a reference standard of 172 PPI papers was formed. The references were divided into a development set and a test set. Search terms were identified from common words, phrases and synonyms in the development set. These terms were combined as a search strategy for medline via OvidSP, which was then tested for sensitivity against the test set. The resultant search filter was then assessed for sensitivity, specificity and precision using a previously published systematic review. RESULTS: the search filter was found to be highly sensitive 98.5% in initial testing. When tested against results generated by a 'real-life' systematic review, the filter had a specificity of 81%. However, sensitivity dropped to 58%. Adjustments to the population group of terms increased the sensitivity to 73%. CONCLUSION: the PPI filter designed for medline via OvidSP could aid information specialists and researchers trying to find literature specific to PPI.

OBJECTIVES: This study explored the divergence and convergence between funded research about type 1 diabetes and the research agenda of people living with the condition and their carers. DESIGN, METHOD, SETTING: a secondary analysis was undertaken of existing data from two UK organisations who regularly work with patients and carers to identify research priorities. The research ideas of people with diabetes were identified in two ways: in 15 research question generation workshops involving approximately 100 patients and carers, and in a James Lind Alliance Type 1 Diabetes Priority Setting Partnership with approximately 580 patients, carers and clinicians (clinician question submissions were excluded from analysis). A total of 859 individual research questions were collected from patients and carers. Diabetes research funding activity was identified through extensive online searches which provided a total of 172 relevant research projects for analysis. RESULTS: the data were thematically analysed and areas of priority for research identified and compared between the patient and funded research agendas. The overall finding of this study is that there is substantial convergence between the two research agendas, alongside some important areas of divergence. The key areas of divergence were found in care delivery, injection issues, psychosocial impacts and women's health. We also demonstrate how an apparently convergent priority can host significant differences in emphasis between patient-generated and funded research agendas. CONCLUSIONS: We offer a comparison of a funded research agenda with one that has been derived directly from people with type 1 diabetes without initial framing by researchers. This provided a rare opportunity to explore the viewpoints of the end-users of research and compare them to realised research as determined by researchers and research organisations.

AIM/BACKGROUND: to describe the two-stage prioritization process being used by the UK National Institute for Health Research's Collaboration for Leadership in Applied Health Research and Care for the South-West Peninsula (or PenCLAHRC) - a joint health service and university partnership and reflect on implications for the wider context of priority setting in health-care research. METHOD: PenCLAHRC's process establishes the priorities of Stakeholders including service users across a regional health system for locally relevant health services research and implementation. Health research questions are collected from clinicians, academics and service users in Devon and Cornwall (UK) using a web-based question formulation tool. There is a two-stage prioritization process which uses explicit criteria and a wide Stakeholder group, including service users to identify important research questions relevant to the south-west peninsula locality. RESULTS: to date, a wide variety of health research topics have been prioritized by the PenCLAHRC Stakeholders. The research agenda reflects the interests of academics, clinicians and service users in the local area. Potential challenges to implementation of the process include time constraints, variable quality of questions (including the language of research) and initiating and maintaining engagement in the process. Shared prioritization of local health research needs can be achieved between Stakeholders from a wide range of perspectives. CONCLUSIONS: the processes developed have been successful and, with minor changes, will continue to be used during subsequent rounds of prioritization. Engagement of Stakeholders in establishing a research agenda encourages the most relevant health questions to be asked and may improve implementation of research findings and take up by service users.

Children and young people can be valuable partners in research, giving their unique perspectives on what and how research should be done. However, disabled children are less commonly involved in research than their non-disabled peers. This review investigated how disabled children have been involved as research partners; specifically how they have been recruited, the practicalities and challenges of involvement and how these have been overcome, and impacts of involvement for research, and disabled children and young people. The INVOLVE definition of involvement and the Equality and Human Rights Commission definition of disability were used. Relevant bibliographic databases were searched. Websites were searched for grey literature. Included studies had involved disabled children and young people aged 5-25 years in any study design. Reviews, guidelines, reports and other documents from the grey literature were eligible for inclusion. Twenty-two papers were included: seven reviews, eight original research papers, three reports, three guidelines and one webpage. Nine examples of involvement were identified. Recommendations included developing effective communication techniques, using flexible methods that can be adapted to needs and preferences, and ensuring that sufficient support and funding is available for researchers undertaking involvement. Positive impacts of involvement for disabled children included increased confidence, self-esteem and independence. Positive impacts for research were identified. Involving disabled children in research can present challenges; many of these can be overcome with sufficient time, planning and resources. More needs to be done to find ways to involve those with non-verbal communication. Generally, few details were reported about disabled children and young people's involvement in studies, and the quality of evidence was low. Although a range of positive impacts were identified, the majority of these were authors' opinions rather than data. There remains scope for methodological research to inform appropriate approaches to public and patient involvement in childhood disability research.

PURPOSE: Exercise-after-stroke programmes are increasingly being provided to encourage more physical exercise among stroke survivors, but little is known about what motivates people with stroke to participate in them. This research aimed to identify factors that motivate long-term stroke survivors to exercise, and the implications for programme design. METHODS: in two separate studies, focus groups and individual interviews were used to investigate the views of long-term stroke survivors on exercise and participating in exercise programmes. Their data were analysed thematically, and the findings of the studies were synthesised. RESULTS: Eleven stroke survivors and two partners took part in two focus groups; six other stroke survivors (one with a partner) were interviewed individually. Factors reported to influence motivation were the psychological benefits of exercise, a desire to move away from a medicalised approach to exercise, beliefs about stroke recovery, and on-going support to sustain commitment. A number of potential implications of these themes for exercise programme design were identified. CONCLUSIONS: a range of personal beliefs and attitudes and external factors may affect the motivation to exercise, and these vary between individuals. Addressing these factors in the design of exercise programmes for long-term stroke survivors may enhance their appeal and so encourage greater engagement in exercise. IMPLICATIONS FOR REHABILITATION: Exercise programmes may be more attractive to long-term stroke survivors if the psychological well-being benefits of participation are emphasised in their promotion. Some participants will be more attracted by programmes that are de-medicalised, for example, by being located away from clinical settings, and led by or involving suitably-trained non-clinicians. Programmes offered in different formats may attract stroke survivors with different beliefs about the value of exercise in stroke recovery. Programmes should provide explicit support strategies for on-going engagement in exercise.

BACKGROUND: the cost to the NHS of missed or inappropriate hospital appointments is considerable. Alternative methods of appointment scheduling might be more flexible to patients' needs without jeopardising health and service quality. The objective was to systematically review evidence of patient initiated clinics in secondary care on patient reported outcomes among patients with chronic/recurrent conditions. METHODS: Seven databases were searched from inception to June 2013. Hand searching of included studies references was also conducted. Studies comparing the effects of patient initiated clinics with traditional consultant led clinics in secondary care for patients with long term chronic or recurrent diseases on health related quality of life and/or patient satisfaction were included. Data was extracted by one reviewer and checked by a second. Results were synthesised narratively. RESULTS: Seven studies were included in the review, these covered a total of 1,655 participants across three conditions: breast cancer, inflammatory bowel disease and rheumatoid arthritis. Quality of reporting was variable. Results showed no significant differences between the intervention and control groups for psychological and health related quality of life outcomes indicating no evidence of harm. Some patients reported significantly more satisfaction using patient-initiated clinics than usual care (p

BACKGROUND: Missed or inappropriate hospital appointments cost the UK National Health Service millions of pounds each year and delay treatment for other patients. Innovative methods of appointment scheduling that are more flexible to patient needs, may improve service quality and preserve resources. METHODS: a systematic review of the evidence for the clinical effectiveness of patient initiated clinics in managing long term care for people with chronic or recurrent conditions in secondary care. Seven databases were searched including MEDLINE, Embase and PsycINFO (using the OVID interface), the Cochrane Library of Systematic Reviews and CENTRAL, Science Citation Index Expanded, Social Sciences Citation Index, and Conference Proceedings Citation Index (via the Web of Science interface) from inception to June 2013. Studies comparing patient initiated clinics with traditional consultant-led clinics in secondary care for people with long term chronic or recurrent diseases were included. Included studies had to provide data on clinical or resource use outcomes. Data were extracted and checked by two reviewers using a piloted, standardised data extraction form. RESULTS: Eight studies (n = 1927 individuals) were included. All were conducted in the UK. There were few significant differences in clinical outcomes between the intervention and control groups. In some instances, using the patient initiated clinics model was associated with savings in time and resource use. The risk of harm from using the patient initiated clinic model of organising outpatient care is low. Studies with longer follow-up periods are needed to assess the long term costs and the ongoing risk of potential harms. CONCLUSIONS: the UK policy context is ripe for evidence-based, patient-centred services to be implemented, especially where the use of health care resources can be optimised without reducing the quality of care. Implementation of patient initiated clinics should remain cautious, with importance placed on ongoing evaluation of long term outcomes and costs.

Objective: to compare the effectiveness of interventions aimed at reducing the rate of acute paediatric hospital admissions. Design: Systematic review. Data sources: Medline, Embase, PsychINFO, the Cochrane Library, Science Citation Index Expanded from inception to September 2010; hand searches of the reference lists of included papers and other review papers identified in the search. Review methods: Controlled trials were included. Articles were screened for inclusion independently by two reviewers. Data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Results: Seven papers were included. There is some evidence to suggest that short stay units may reduce admission rates. However, there is a general lack of detail in the reporting of interventions and the methods used in their evaluation which precludes detailed interpretation and extrapolation of the results. The authors found no evidence that the use of algorithms and guidelines to manage the admission decision was effective in reducing acute admission rates. Furthermore, the authors were unable to locate any eligible papers reporting the effects on admission rates of admission decision by paediatric consultant, telephone triage by paediatric consultant or the establishment of next day emergency paediatric clinics. Conclusion: There is little published evidence upon which to base an optimal strategy for reducing paediatric admission rates. The evidence that does exist is subject to substantial bias. There is a pressing need for high quality, well conducted research to enable informed service change.

OBJECTIVE: to compare the effectiveness of interventions aimed at reducing the rate of acute paediatric hospital admissions. DESIGN: Systematic review. DATA SOURCES: Medline, Embase, PsychINFO, the Cochrane Library, Science Citation Index Expanded from inception to September 2010; hand searches of the reference lists of included papers and other review papers identified in the search. REVIEW METHODS: Controlled trials were included. Articles were screened for inclusion independently by two reviewers. Data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. RESULTS: Seven papers were included. There is some evidence to suggest that short stay units may reduce admission rates. However, there is a general lack of detail in the reporting of interventions and the methods used in their evaluation which precludes detailed interpretation and extrapolation of the results. The authors found no evidence that the use of algorithms and guidelines to manage the admission decision was effective in reducing acute admission rates. Furthermore, the authors were unable to locate any eligible papers reporting the effects on admission rates of admission decision by paediatric consultant, telephone triage by paediatric consultant or the establishment of next day emergency paediatric clinics. CONCLUSION: There is little published evidence upon which to base an optimal strategy for reducing paediatric admission rates. The evidence that does exist is subject to substantial bias. There is a pressing need for high quality, well conducted research to enable informed service change.

The objective of this study was to assess the evidence for or against the effectiveness of cupping as a treatment option for pain. Fourteen databases were searched. Randomized clinical trials (RCTs) testing cupping in patients with pain of any origin were considered. Trials using cupping with or without drawing blood were included, while trials comparing cupping with other treatments of unproven efficacy were excluded. Trials with cupping as concomitant treatment together with other treatments of unproven efficacy were excluded. Trials were also excluded if pain was not a central symptom of the condition. The selection of studies, data extraction and validation were performed independently by three reviewers. Seven RCTs met all the inclusion criteria. Two RCTs suggested significant pain reduction for cupping in low back pain compared with usual care (P <. 01) and analgesia (P <. 001). Another two RCTs also showed positive effects of cupping in cancer pain (P <. 05) and trigeminal neuralgia (P <. 01) compared with anticancer drugs and analgesics, respectively. Two RCTs reported favorable effects of cupping on pain in brachialgia compared with usual care (P =. 03) or heat pad (P <. 001). The other RCT failed to show superior effects of cupping on pain in herpes zoster compared with anti-viral medication (P =. 065). Currently there are few RCTs testing the effectiveness of cupping in the management of pain. Most of the existing trials are of poor quality. Therefore, more rigorous studies are required before the effectiveness of cupping for the treatment of pain can be determined.

Our objective was to compare the effects on mental and physical wellbeing, health related quality of life and long-term adherence to physical activity, of participation in physical activity in natural environments compared with physical activity indoors. We conducted a systematic review using the following data sources: Medline, Embase, Psychinfo, GreenFILE, SportDISCUS, the Cochrane Library, Science Citation Index Expanded, Social Sciences Citation Index, Arts and Humanities Citation Index, Conference Proceedings Citation Index--Science and BIOSIS from inception to June 2010. Internet searches of relevant Web sites, hand searches of relevant journals, and the reference lists of included papers and other review papers identified in the search were also searched for relevant information. Controlled trials (randomized and nonrandomized) were included. To be eligible trials had to compare the effects of outdoor exercise initiatives with those conducted indoors and report on at least one physical or mental wellbeing outcome in adults or children. Screening of articles for inclusion, data extraction, and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Due to the heterogeneity of identified studies a narrative synthesis was performed. Eleven trials (833 adults) were included. Most participants (6 trials; 523 adults) were young students. Study entry criteria and methods were sparsely reported. All interventions consisted of a single episode of walking or running indoors with the same activity at a similar level conducted outdoors on a separate occasion. A total of 13 different outcome measures were used to evaluate the effects of exercise on mental wellbeing, and 4 outcome measures were used to assess attitude to exercise. Most trials (n = 9) showed some improvement in mental wellbeing on one or other of the outcome measures. Compared with exercising indoors, exercising in natural environments was associated with greater feelings of revitalization and positive engagement, decreases in tension, confusion, anger, and depression, and increased energy. However, the results suggested that feelings of calmness may be decreased following outdoor exercise. Participants reported greater enjoyment and satisfaction with outdoor activity and declared a greater intent to repeat the activity at a later date. None of the identified studies measured the effects of physical activity on physical wellbeing or the effect of natural environments on exercise adherence. The hypothesis that there are added beneficial effects to be gained from performing physical activity outdoors in natural environments is very appealing and has generated considerable interest. This review has shown some promising effects on self-reported mental wellbeing immediately following exercise in nature which are not seen following the same exercise indoors. However, the interpretation and extrapolation of these findings is hampered by the poor methodological quality of the available evidence and the heterogeneity of outcome measures employed. The review demonstrates the paucity of high quality evidence on which to base recommendations and reveals an undoubted need for further research in this area. Large, well designed, longer term trials in populations who might benefit most from the potential advantages of outdoor exercise are needed to fully elucidate the effects on mental and physical wellbeing. The influence of these effects on the sustainability of physical activity initiatives also awaits investigation.

OBJECTIVE: to determine the efficacy of topical capsaicin in treating pruritus in any medical condition. DATA SOURCES: Cochrane library, Medline, Embase, Cinahl and Amed, up to April 2008. No language restrictions. STUDY SELECTION: Randomized, controlled trials comparing topically applied capsaicin with placebo or other standard treatment in patients with pruritus, independently selected by two reviewers. DATA EXTRACTION: Independently extracted by two reviewers. Quality assessed using the Jadad scale. DATA SYNTHESIS: Six randomized controlled trials were identified for inclusion. Three were for hemodialysis-related pruritus and provided insufficient data for the efficacy of topical capsaicin to be evaluated. A crossover study of capsaicin for treating idiopathic intractable pruritus ani reported a statistically significant difference in responder rates favoring capsaicin over placebo for itching scores but included insufficient data for the validity of this result to be assessed. A study on notalgia paresthetica reported a statistically significant difference in the first phase of a crossover study favoring capsaicin over placebo in a visual analogue scale for itch intensity but failed to report data for a second outcome measure. The final study on brachioradial pruritus used an inappropriate design and reported no significant reduction in itch between capsaicin and placebo. CONCLUSION: at present, there is no convincing evidence for the use of capsaicin to treat pruritus in any medical condition. Further research is needed, and should attempt to address methodological issues identified through this review including unblinding and the suitability of crossover designs.

Although chiropractic is most commonly used for spinal problems, many chiropractors use manipulations for the treatment of non-spinal conditions. Carpal tunnel syndrome (CTS) has been identified as one such condition. This systematic review evaluates the evidence for or against the effectiveness of chiropractic as a treatment for CTS. Eight electronic databases were searched from inception until November 2008. Reference lists of retrieved articles were hand-searched. Chiropractic associations were contacted in order to identify further non-published studies. No language restrictions were applied. of 26 potentially relevant studies, only one trial of chiropractic for CTS met al. l the inclusion criteria. The trial was of poor quality and reported no significant differences between the groups on any outcome measure. However, our re-analyses indicated a significant difference in favour of the control treatment (non-steroidal anti-inflammatory drugs [NSAIDs] use). Adverse effects were noted in both groups. There is insufficient evidence to suggest that chiropractic is effective for the treatment of CTS. Therapy should continue to focus on the use of NSAIDs, corticosteroid injection, splinting and surgical release of the median nerve. Further research into the utility of chiropractic for CTS is required. © 2009, British Association of Hand Therapists Limited. All rights reserved.

Systematic reviews (SRs) are considered the best tools for summarizing the evidence for or against the effectiveness of health care interventions. The principles and methods of SRs apply equally to both, mainstream and complementary/alternative medicine (CAM). Certain challenges are, however, more commonly encountered in CAM or even specific to it; this article is aimed at raising awareness of these among systematic reviewers. When searching for literature, specific issues relating to specialist databases, indexing, access, foreign language studies, and certain forms of publication bias need to be considered. Researchers also need to be aware of the difficulties of comparing CAM studies and address the variability between studies. CAM modalities are highly diversified and great variations exist in the standardization of herbal products and other dietary supplements. Individualization of treatment as well as different classifications of disease and different diagnostic methods need to be addressed. Expectation bias is high in CAM, and finding appropriate controls and blinding are often challenging. It is important that these issues are taken into account early on in the planning stages of an SR so that proper consideration can be given to the search strategies, inclusion/exclusion criteria and methods of analysis with the overall aim of reducing bias.

BACKGROUND: the researchers involved in this study work at Exeter Health library and at the Complementary Medicine Unit, Peninsula School of Medicine and Dentistry (PCMD). Within this collaborative environment it is possible to access the electronic resources of three institutions. This includes access to AMED and other databases using different interfaces. OBJECTIVES: the aim of this study was to investigate whether searching different interfaces to the AMED allied health and complementary medicine database produced the same results when using identical search terms. METHODS: the following Internet-based AMED interfaces were searched: DIALOG DataStar; EBSCOhost and OVID SP_UI01.00.02. Search results from all three databases were saved in an endnote database to facilitate analysis. A checklist was also compiled comparing interface features. RESULTS: in our initial search, DIALOG returned 29 hits, OVID 14 and Ebsco 8. If we assume that DIALOG returned 100% of potential hits, OVID initially returned only 48% of hits and EBSCOhost only 28%. In our search, a researcher using the Ebsco interface to carry out a simple search on AMED would miss over 70% of possible search hits. Subsequent EBSCOhost searches on different subjects failed to find between 21 and 86% of the hits retrieved using the same keywords via DIALOG DataStar. In two cases, the simple EBSCOhost search failed to find any of the results found via DIALOG DataStar. CONCLUSIONS: Depending on the interface, the number of hits retrieved from the same database with the same simple search can vary dramatically. Some simple searches fail to retrieve a substantial percentage of citations. This may result in an uninformed literature review, research funding application or treatment intervention. In addition to ensuring that keywords, spelling and medical subject headings (MeSH) accurately reflect the nature of the search, database users should include wildcards and truncation and adapt their search strategy substantially to retrieve the maximum number of appropriate citations possible. Librarians should be aware of these differences when making purchasing decisions, carrying out literature searches and planning user education.

OBJECTIVE: the aim of this study was to assess the effectiveness of yoga as a treatment option for menopausal symptoms. METHODS: We searched the literature using 14 databases from their inception to July 2008 and included all types of clinical studies regardless of their design. The methodological quality of all studies was assessed using a modified Jadad score. RESULTS: Seven studies met our inclusion criteria. Two randomized clinical trials compared the effects of yoga with those of walking or physical exercise. The meta-analysis of these data failed to show specific effects of yoga on menopausal complaints including psychological, somatic, and vasomotor symptoms. Two randomized clinical trials found no effects of yoga on total menopausal symptoms compared with wait-list control or no treatment. The remaining studies were either non-randomized (n = 1) or uncontrolled clinical trials (n = 3). They reported favorable effects of yoga on menopausal symptoms. These data collectively show that the results of rigorous studies of the effects of yoga for menopausal symptoms are unconvincing. CONCLUSION: the evidence is insufficient to suggest that yoga is an effective intervention for menopause. Further research is required to investigate whether there are specific benefits of yoga for treating menopausal symptoms.

BACKGROUND: People with depressive disorders or subsyndromal symptoms of depression (SSD) often use complementary and alternative therapies, including massage therapy (MT). This systematic review evaluates the evidence, from randomised clinical trials (RCTs), for the effectiveness of multiple sessions of classical European (Swedish) MT for the treatment of depression. METHODS: Eligible RCTs were identified via eight electronic databases and manual searches of references. Two reviewers independently selected trials, assessed trial quality and extracted data. RESULTS: Four RCTs met our inclusion criteria. Three of these RCTs compared MT with relaxation therapies, but provided insufficient data and analyses to contribute meaningfully to the evaluation of MT for depression. The fourth included RCT used MT as a control condition to evaluate a depression-specific acupuncture treatment. This trial provided limited evidence that, in the early stages of treatment, MT is less effective than acupuncture for treating depression, a treatment which itself is not accepted for this condition. CONCLUSIONS: Despite previous research suggesting that MT may be an effective treatment for depression, there is currently a lack of evidence to support this assertion from RCTs that have selected participants for depression or SSD.

Health care professionals, patients, and care givers require access to good quality, reliable information about integrative oncology. Despite the vast resources available, it can be difficult to find objective, evidence-based information. This article provides an overview of reliable integrative oncology information from various resources. Selection methods are detailed and evaluation performed using a validated instrument. Resources that met the selection criteria and produced high evaluation scores are reviewed in detail. Resources include research databases, clinical databases, online information systems, and print media.

The effectiveness of acupuncture remains a controversial issue. The aim of this article is to evaluate trends over time in the development of the evidence-base of acupuncture. A comparison of two series of systematic reviews was conducted. The first related to the evidence-base in 2000, the second related to 2005. Both employed virtually the same methodology and criteria for evaluation. The results indicate that the evidence base has increased for 13 of the 26 conditions included in this comparison. For 7 indications it has become more positive (i.e. favoring acupuncture) and for 6 it had changed in the opposite direction. It is concluded, that acupuncture research is active. The emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions.

Back pain is the most common reason for using complementary therapies. This analysis of the trial evidence is aimed at determining whether the evidence base for or against complementary therapies for back pain is getting stronger. Two series of systematic reviews conducted with the same methodology 5 years apart were compared. The results suggest that the weight of the evidence has increased between 2000 and 2005 for a number of interventions. The direction of the evidence, however, remained unchanged for all but one therapy. We conclude that the value of complementary therapies in the management of back pain remains encouraging but not fully convincing.

AIM: the aim of this article is to compare the evidence relating to the effectiveness of complementary/alternative medicine (CAM) in palliative cancer care as it existed in 2000 and 2005. METHODS: Our comparison is based on systematic reviews using the same methodology at these two points in time. RESULTS: the results reveal a buoyant research activity in this sector. Consequently, new evidence for 19 CAM modalities has emerged between 2000 and 2005. For some treatments, the evidence is encouraging but for very few, it is as yet fully convincing. CONCLUSION: it follows that further research is warranted, particularly in areas where the data already looks encouraging.

The aim of this article is to evaluate trends in the development of the evidence-base for the effectiveness of massage therapy. For this purpose, a comparison of two systematic reviews was conducted. The first related to the evidence-base in 2000, the second to 2005. Both employed the same methodology and criteria for evaluation. The results indicate that, in several areas, the evidence has become more solid and, for anxiety and back pain, it has become more positive. For a host of other indications, the evidence seems encouraging, but more studies are required to test the effectiveness of massage therapy as well as its use for specific conditions. © 2007 SAGE Publications, Inc.

The effectiveness of mind-body therapies is sometimes doubted. The aim of this article is to evaluate trends in the development of the evidence base for autogenic training, hypnotherapy, and relaxation therapy. For this purpose, a comparison of 2 series of systematic reviews was conducted. The first is related to the evidence base in 2000, the second to that in 2005. Both employed virtually the same methodology and criteria for evaluation. The results of our comparisons show considerable changes during the observation period. The weight of the evidence has become stronger for several indications, and the direction of the evidence has been altered in a positive sense in several conditions. Applying the rules of evidence-based medicine, the following mind-body therapies are now supported by strong evidence: hypnotherapy for labor pain and relaxation therapy for anxiety and insomnia, as well as for nausea and vomiting induced by chemotherapy. It is concluded that an evidence-based approach for mind-body therapies is constructive and can generate positive results.