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Competing Interests: Competing interests: DN has received expenses and fees for his media work. He holds grant funding from the NIHR School of Primary Care Research and the Royal College of General Practitioners. On occasion, he receives expenses for teaching EBM. ISW reports personal fees from various universities and hospitals around Indonesia for teaching EBM, outside the submitted work. SC occasionally receives expenses for teaching EBM at academic conferences and hospitals around Japan. EJ receives a regular income for his employed NHS work through Yealm Medical Centre and PenARC. He receives expenses for teaching EBM. In March 2019 he received a one-off consultancy fee for 2-days work for Zavamed (work unrelated to this article). PH works as a teacher in EBP and is currently conducting a PhD research that is funded by Avans University of Applied Science. He receives expenses for lectures at seminars and workshops on EBP. HA has received funding from Health Education England to attend the EBHC 2019 meeting. She is also a visiting tutor of Evidence-Based Child Health at the UCL Great Ormond Street Institute of Child Health, London. RCB works as a teacher in EBP and receives a regular income for her employed NIPH (Department of Reviews and health technology assessments) work. None to declare – AL, WMB, C-CC, FB, CE, HTM, SGJ, RT, M-LELB, LP, AKS, PGvP, FB, KAOT, LA.

In recent decades, evidence-based medicine has become one of the foundations of clinical practice, making it necessary that healthcare practitioners develop keen critical appraisal skills for scientific papers. Worksheets to guide clinicians through this critical appraisal are often used in journal clubs, a key part of continuing medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of medical ethics papers. Medicine is increasingly ethically complex, and there is a growing medical ethics literature that modern practitioners need to be able to use in their practice. In addition, clinical ethics services are commonplace in healthcare institutions, and the lion's share of the work done by these services is done by clinicians in addition to their usual roles. Education to support this work is important. In this paper, we present a worksheet designed to help busy healthcare practitioners critically appraise ethics papers relevant to clinical practice. In the first section, we explain what is different about ethics papers. We then describe how to work through the steps in our critical appraisal worksheet: identifying the point at issue; scrutinising definitions; dissecting the arguments presented; considering counterarguments; and finally deciding on relevance. Working through this reflective worksheet will help healthcare practitioners to use the ethics literature effectively in clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. Practising these critical reasoning skills will also increase practitioners' capacity to think through difficult ethical decisions in daily clinical practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In this article we signpost readers to 10 papers we consider essential reading for anyone starting out on an evidence-based medicine journey. We have considered papers consisting a mix of old and new, seminal and cutting-edge that offer insight into what evidence-based medicine is, where it came from, why it matters and what it has achieved. This is balanced against some of the common criticisms of evidence-based medicine and efforts to tackle them. We have also highlighted papers acknowledging the importance of teaching and learning of the principles of evidence-based medicine and how health professionals can better use evidence in clinical decisions with patients., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Although paediatric-onset IBD is becoming more common, few medications have a registered paediatric indication. There are multiple hurdles to performing clinical trials in children, emphasising the importance of choosing an appropriate outcome measure, which can facilitate enrolment, and thereby also drug approval. The aim of this consensus statement is to highlight paediatric specific issues and key factors critical for the optimal conduct of paediatric IBD trials. Design The Paediatric European Crohn's and Colitis Organisation (ECCO) committee has established an international expert panel to determine the best outcome measures in paediatric IBD, following a literature search and a modified Delphi process. All recommendations were endorsed by at least 80% agreement. Results Recognising the importance of mucosal healing (MH), the panel defined steroid-free MH as primary outcome measure for all drugs of new category with one or two postintervention endoscopies per trial (at 8-12 weeks and/or 54 weeks). Since endoscopic evaluation is a barrier for recruitment in children, trials with medications already shown to induce MH in children or adults, could use paediatric-specific disease activity scores as primary outcome, including a modified Paediatric Crohn's Disease Activity Index in Crohn's disease and the Paediatric Ulcerative Colitis Activity Index in UC. Secondary outcomes should include safety issues, MR enterography-based damage and inflammatory scores (in Crohn's disease), faecal calprotectin, quality of life scales, and a patient-reported outcome. Conclusions It is crucial to perform paediatric trials early in the development of new drugs in order to reduce off-label use of IBD medication in children. The thoughtful choice of feasible and standardised outcome measures can help move us towards this goal. [ABSTRACT FROM AUTHOR]

Background: Athletic groin pain (AGP) is an encompassing term for the multitude of chronic conditions presenting as pain in the inguinal region. The purpose of this review was to compare the return to play rates (RTPrate) and return to play times (RTPtime) between surgical and rehabilitation interventions in the treatment of AGP.Methods: A systematic review of English language peer review journals was carried out between 1980 to June 2013 using PubMed, Embase, CINHAL and Google Scholar searching for all papers relating to AGP (and its various pseudonyms) and all surgical and rehabilitative interventions which reported RTPrate and/or RTPtime. AGP literature has been subdivided by many eponymous diagnoses but anatomical diagnostic groupings of (1) abdominal wall, (2) adductor and (3) pubic related pain were used in this review. Meta-analysis was then carried out on the data to compare results between the surgical and rehabilitation groups.Results: Fifty-six papers out of the 561 discovered in the initial search were included in the review with 3332 athletes included. Evidence was mostly level IV. Using the Black and Downs checklist we found poor study quality overall with a high risk of bias especially among surgical studies. The results showed comparable RTPrate between surgical and rehabilitative interventions within the three diagnostic groups. Rehabilitation had significantly quicker RTPtime for pubic related groin pain compared to surgery (10.5 weeks and 23.1 weeks respectively). The abdominal group had the fastest return of the three groups for the rehabilitation and surgery.Conclusions: The review suggested better outcomes with rehabilitation for pubic-related groin pain with no difference between the adductor and abdominal groups. The review highlighted the poor quality and risk of bias in the literature making accurate comparison difficult. [ABSTRACT FROM AUTHOR]

Objective To develop search strategies for identifying papers on patient safety in MEDLINE, EMBASE and CINAHL. Methods Six journals were electronically searched for papers on patient safety published between 2000 and 2006. Identified papers were divided into two gold standards: one to build and the other to validate the search strategies. Candidate terms for strategy construction were identified using a word frequency analysis of titles, abstracts and keywords used to index the papers in the databases. Searches were run for each one of the selected terms independently in every database. Sensitivity, precision and specificity were calculated for each candidate term. Terms with sensitivity greater than 10% were combined to form the final strategies. The search strategies developed were run against the validation gold standard to assess their performance. A final step in the validation process was to compare the performance of each strategy to those of other strategies found in the literature. Results We developed strategies for all three databases that were highly sensitive (range 95%–100%), precise (range 40%–60%) and balanced (the product of sensitivity and precision being in the range of 30%–40%). The strategies were very specific and outperformed those found in the literature. Conclusion The strategies we developed can meet the needs of users aiming to maximise either sensitivity or precision, or seeking a reasonable compromise between sensitivity and precision, when searching for papers on patient safety in MEDLINE, EMBASE or CINAHL. [ABSTRACT FROM PUBLISHER]

Context The apparent inconsistency between the widespread use of quality improvement collaboratives and the available evidence heightens the importance of thoroughly understanding the relative strength of the approach. More insight into factors influencing outcome would mean future collaboratives could be tailored in ways designed to increase their chances of success. This review describes potential determinants of team success and how they relate to effectiveness. Method We searched Medline, CINAHL, Embase, Cochrane, and PsycINFO databases from January 1995 to June 2006. The 1995-2006 search was updated in June 2009. Reference lists of included papers were reviewed to identify additional papers. We included papers that were written in English, contained data about the effectiveness of collaboratives, had a healthcare setting, met our definition for collaborative, and quantitatively assessed a relationship between any determinant and any effect parameter. Findings Of 1367 abstracts identified, 23 papers (reporting on 26 collaboratives) provided information on potential determinants and their relationship with effectiveness. We categorised potential determinants of success using the definition for collaboratives as a template. Numerous potential determinants were tested, but only a few related to empirical effectiveness. Some aspects of teamwork and participation in specific collaborative activities enhanced short- term success. If teams remained intact and continued to gather data, chances of long-term success were higher. There is no empirical evidence of positive effects of leadership support, time and resources. Conclusions These outcomes provide guidance to organisers, participants and researchers of collaboratives. To advance knowledge in this area we propose a more systematic exploration of potential determinants by applying theory and practice-based knowledge and by performing methodologically sound studies that clearly set out to test such determinants. [ABSTRACT FROM AUTHOR]

Background Health and social care standards have been widely adopted as a quality improvement intervention. Standards are typically made up of evidence- based statements that describe safe, high- quality, person- centred care as an outcome or process of care delivery. They involve stakeholders at multiple levels and multiple activities across diverse services. As such, challenges exist with their implementation. Existing literature relating to standards has focused on accreditation and regulation programmes and there is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. This systematic review aimed to identify and describe the most frequently reported enablers and barriers to implementing (inter)nationally endorsed standards, in order to inform the selection of strategies that can optimise their implementation. Methods Database searches were conducted in Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SocINDEX, Google Scholar, OpenGrey and GreyNet International, complemented by manual searches of standard- setting bodies' websites and hand searching references of included studies. Primary qualitative, quantitative descriptive and mixed methods studies that reported enablers and barriers to implementing nationally or internationally endorsed standards were included. Two researchers independently screened search outcomes and conducted data extraction, methodological appraisal and CERQual (Confidence in Evidence from Reviews of Qualitative research) assessments. An inductive analysis was conducted using Sandelowski's meta- summary and measured frequency effect sizes (FES) for enablers and barriers. Results 4072 papers were retrieved initially with 35 studies ultimately included. Twenty- two thematic statements describing enablers were created from 322 descriptive findings and grouped under six themes. Twenty- four thematic statements describing barriers were created from 376 descriptive findings and grouped under six themes. The most prevalent enablers with CERQual assessments graded as high included: available support tools at local level (FES 55%); training courses to increase awareness and knowledge of the standards (FES 52%) and knowledge sharing and interprofessional collaborations (FES 45%). The most prevalent barriers with CERQual assessments graded as high included: a lack of knowledge of what standards are (FES 63%), staffing constraints (FES 46%), insufficient funds (FES 43%). [ABSTRACT FROM AUTHOR]

Question There is a large worldwide gap between the service need and provision for mental, neurological and substance use disorders. WHO's Mental Health Gap Action Programme (mhGAP) intervention guide (IG), provides evidence-based guidance and tools for assessment and integrated management of priority disorders. Our 2017 systematic review identifed 33 peer-reviewed studies describing mhGAP- IG implementation in low- income and middle- income countries. Study selection and analysis We searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, ScieELO, Cochrane, PubMed databases, 3ie, Google Scholar and citations of our review, on 24 November 2020. We sought evidence, experience and evaluations of the mhGAP-IG, app or mhGAP Humanitarian IG, from any country, in any language. We extracted data from included papers, but heterogeneity prevented meta-analysis. Findings Of 2621 results, 162 new papers reported applications of the mhGAP-IG. They described mhGAP training courses (59 references), clinical applications (n=49), research uses (n=27), contextual adaptations (n=13), economic studies (n=7) and other educational applications (n=7). Most were conducted in the African region (40%) and South- East Asia (25%). Studies demonstrated improved knowledge, attitudes and confdence post- training and improved symptoms and engagement with care, post-implementation. Research studies compared mhGAP-IG-enhanced usual care with task-shared psychological interventions and adaptation studies optimised mhGAP-IG implementation for different contexts. Economic studies calculated human resource requirements of scaling up mhGAP-IG implementation and other educational studies explored its potential for repurposing. Conclusions The diverse, expanding global mhGAP- IG literature demonstrates substantial impact on training, patient care, research and practice. Priorities for future research should be less-studied regions, severe mental illness and contextual adaptation of brief psychological interventions. [ABSTRACT FROM AUTHOR]

Background All mental health professionals are encouraged to practise evidence-based medicine, but in an era of overwhelming research output, information management is key. Until now, no one has assessed the role of secondary journals, which aim to synthesise and present recent evidence, so as to promote evidence-based practice. Objective We conducted a cross-sectional study via an online survey, to evaluate the quality of the content of Evidence-Based Mental Health (EBMH), as an example of a secondary journal, and the impact it has on evidence-based practice. Methods We sent an online questionnaire to the commentators and the original study authors of all commentaries published in EBMH over the past 5 years (from 2011 to 2015, inclusive). The questions primarily concerned the quality of the included papers and their respective commentary, in addition to the ability of the commentaries to help disseminate research findings and promote evidence-based practice. Findings We sent out 894 anonymous questionnaires and the overall response rate was 30%. The commentator and study author groups were largely homogeneous. Both groups were satisfied with the format and content of the commentaries, although over 60% of the authors were unaware of the commentary on their study before the survey. Notably, 80% of authors and 87% of commentators felt that the commentaries were useful in disseminating the findings of the original studies and implementing evidence-based practice. Conclusions and clinical implications The commentators and original study authors view EBMH not as a vehicle for criticism, but instead as a trustworthy publication that crystallises important findings and presents them in digestible form with the aim of promoting key advances in mental health. Next, we aim to assess the extent to which the readership of this journal agrees. [ABSTRACT FROM AUTHOR]

Objective Several tools have been developed to evaluate the extent to which the findings from a network meta-analysis would be valid; however, applying these tools is a time-consuming task and often requires specific expertise. Clinicians have little time for critical appraisal, and they need to understand the key elements that help them select network meta-analyses that deserve further attention, optimising time and resources. This paper is aimed at providing a practical framework to assess the methodological robustness and reliability of results from network meta-analysis. Methods As a working example, we selected a network meta-analysis about drug treatments for generalised anxiety disorder, which was published in 2011 in the British Medical Journal. The same network meta-analysis was previously used to illustrate the potential of this methodology in a methodological paper published in JAMA. Results We reanalysed the 27 studies included in this network following the methods reported in the original article and compared our findings with the published results. We showed how different methodological approaches and the presentation of results can affect conclusions from network metaanalysis. We divided our results into three sections, according to the specific issues that should always be addressed in network meta-analysis: (1) understanding the evidence base, (2) checking the statistical analysis and (3) checking the reporting of findings. Conclusions The validity of the results from network meta-analysis depends on the plausibility of the transitivity assumption. The risk of bias introduced by limitations of individual studies must be considered first and judgement should be used to infer about the plausibility of transitivity. Inconsistency exists when treatment effects from direct and indirect evidence are in disagreement. Unlike transitivity, inconsistency can be always evaluated statistically, and it should be specifically investigated and reported in the published paper. Network meta-analysis allows researchers to list treatments in preferential order; however, in this paper we demonstrated that rankings could be misleading if based on the probability of being the best. Clinicians should always be interested in the effect sizes rather than the naive rankings. [ABSTRACT FROM AUTHOR]

The study aimed to develop evidence-based recommendations regarding the evaluation and use of biosimilars to treat rheumatological diseases. The task force comprised an expert group of specialists in rheumatology, dermatology and gastroenterology, and pharmacologists, patients and a regulator from ten countries. Four key topics regarding biosimilars were identified through a process of discussion and consensus. Using a Delphi process, specific questions were then formulated to guide a systematic literature review. Relevant English-language publications through November 2016 were searched systematically for each topic using Medline; selected papers and pertinent reviews were examined for additional relevant references; and abstracts presented at the 2015 and 2016 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) annual scientific meetings were searched for those about biosimilars. The experts used evidence obtained from these studies to develop a set of overarching principles and consensus recommendations. The level of evidence and grade of recommendation were determined for each. By the search strategy, 490 references were identified. Of these, 29 full-text papers were included in the systematic review. Additionally, 20 abstracts were retrieved from the ACR and EULAR conference abstract databases. Five overarching principles and eight consensus recommendations were generated, encompassing considerations regarding clinical trials, immunogenicity, extrapolation of indications, switching between bio-originators and biosimilars and among biosimilars, and cost. The level of evidence and grade of recommendation for each varied according to available published evidence. Five overarching principles and eight consensus recommendations regarding the evaluation and use of biosimilars to treat rheumatological diseases were developed using research-based evidence and expert opinion. [ABSTRACT FROM AUTHOR]

Background Modern medical care requires numerous patient handovers/handoffs. Handover error is recognised as a potential hazard in patient care, and the information error rate has been estimated at 13%. While accurate, reliable handover is essential to high quality care, uncertainty exists as to how intrahospital handover can be improved. This systematic review aims to evaluate the effectiveness of interventions aimed at improving the quality and/ or safety of the intrahospital handover process. Methods We searched for articles on handover improvement interventions in EMBASE, MEDLINE, HMIC and CINAHL between January 2002 and July 2012. We considered studies of: staff knowledge and skills, staff behavioural change, process change or patient outcomes. Results 631 potentially relevant papers were identified from which 29 papers were selected for inclusion (two randomised controlled trials and 27 uncontrolled studies). Most studies addressed shift-change handover and used a median of three outcome measures, but there was no outcome measure common to all. Poor study design and inconsistent reporting methods made it difficult to reach definite conclusions. Information transfer was improved in most relevant studies, while clinical outcome improvement was reported in only two of 10 studies. No difference was noted in the likelihood of success across four types of intervention. Conclusions The current literature does not confirm that any methodology reliably improves the outcomes of clinical handover, although information transfer may be increased. Better study designs and consistency of the terminology used to describe handover and its improvement are urgently required. [ABSTRACT FROM AUTHOR]

Background and Aims: During the last decades, much attention has been paid to off-label and unlicensed prescriptions in paediatrics. However, on-label prescribing can also cause health issues. In this paper, the case of first-generation H1-antihistamines is investigated, notably the range of indications for which products are licensed in different European countries and the evidence base (or lack thereof) for each indication, as well as reported adverse drug reactions.Methods: Review of the Summary of Product Characteristics of first-generation H1-antihistamines with a focus on paediatric use. This is plotted against the evidence available in the literature.Results: This investigation shows a large variability in labelled indications and licensing ages when compared in five different European countries. Moreover, most of the indications are not based on clinical trials evaluating efficacy and safety of these drugs in children.Conclusions: Many of the licensed indications of first-generation antihistamines do not appear to be evidence based. [ABSTRACT FROM AUTHOR]

The evidence-based approach is considered the gold standard of medical guidance. However, for some topics, it may be inappropriate to address them in an evidence-based guideline, as evidence for most of their aspects is absent or limited. Other topics may require only technical recommendations on how to perform a procedure, which are generally not covered in the published literature.In addition to an existing guideline programme, the European Society of Human Reproduction and Embryology has recently developed a manual for the development of (consensus-based) recommendations for good practice. The manual sets out a standardised methodology based on universal guideline principles with the aim of framing and improving the methodological quality of recommendations for good practice documents. The current paper outlines the relevance of recommendations for good practice, the methodology for developing these documents, and the differences and similarities with evidence-based guidelines., Competing Interests: Competing interests: NV and NLC are employed by ESHRE. All authors declare no financial relationships with any organisation that might have an interest in the submitted work in the previous 3 years, no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background A key objective of the Guidelines International Network (GIN) is to reduce duplication of effort. To address this objective, a working group was established to define a minimum dataset for inclusion in all evidence tables. Methods A literature review was conducted to identify existing evidence tables, and GIN member organisations were asked to provide the tables they use. The results were used to develop a minimum dataset (template) for studies addressing intervention questions. The template was pilot-tested by a group of guideline developers and reviewed at GIN conferences. Results The literature search yielded 65 articles. These dealt with reporting standards and trial quality (eg, CONSORT statement) rather than which data should be extracted from studies. However, the checklist items given were considered useful. Nineteen GIN members provided evidence tables; 17 tables were used for analysis. The number of items included in the tables ranged from 8 to 19, with several items common to all tables. Within individual items, the level of detail varied widely. The draught template included a majority of items relating to objective data. Pilot testing revealed that the median time to read a paper and complete the template was 2 h for a randomised controlled trial and 2½ h for a non-randomised, controlled intervention study. The median rating for both relevance and clarity of items was high. Conclusion The template listing the items needed to summarise an interventional study is now available for large-scale testing by all organisations. [ABSTRACT FROM PUBLISHER]

One-third of the global population is aged under 20 years. For children with life-limiting conditions, palliative care services are required. However, despite 80% of global need occurring in low- and middle-income countries (LMICs), the majority of children's palliative care (CPC) is provided in high-income countries. This paper reviews the status of CPC services in LMICs--highlighting examples of best practice among service models in Malawi, Indonesia and Belarus--before reviewing the status of the extant research in this field. It concludes that while much has been achieved in palliative care for adults, less attention has been devoted to the education, clinical practice, funding and research needed to ensure children and young people receive the palliative care they need. [ABSTRACT FROM AUTHOR]

Implementing evidence-based medicine (EBM) in a busy hospital department is challenging, but when successful, may contribute to quality of care. This paper is a narrative review of the successes and challenges of deliberate implementation of EBM in a paediatric department in a general teaching hospital in Zwolle, the Netherlands. Key elements in this project were providing basic EBM education to the entire team of consultants and nurse practitioners, structurally embedding EBM activities into our weekly schedule and development of local practice guidelines. This deliberate practice of EBM principles has changed the way we treat common paediatric problems. It likely reduced unwarranted practice variation and promoted a reserved attitude towards the use of unnecessary diagnostics, which might improve delivery of effective, cost-conscious care. The project also positively influenced our group culture and learning environment. In accordance with previous reports, lack of time and reluctance to change routines and habits hindered the practice of EBM in our department. In our experience, these barriers can be overcome by promoting a team-wide endorsement of EBM, a willingness to acknowledge uncertainty and by deliberate practice. If these can be achieved, systematic application of EBM principles in a busy hospital department is feasible and worthwhile., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

The burden of non-communicable diseases, such as osteoarthritis (OA), continues to increase for individuals and society. Regrettably, in many instances, healthcare professionals fail to manage OA optimally. There is growing disparity between the strength of evidence supporting interventions for OA and the frequency of their use in practice. Physical activity and exercise, weight management and education are key management components supported by evidence yet lack appropriate implementation. Furthermore, a recognition that treatment earlier in the disease process may halt progression or reverse structural changes has not been translated into clinical practice. We have largely failed to put pathways and procedures in place that promote a proactive approach to facilitate better outcomes in OA. This paper aims to highlight areas of evidence-based practical management that could improve patient outcomes if used more effectively. [ABSTRACT FROM AUTHOR]

This review seeks to explore and explain what health policy research is and why it matters, through pooling the evidence and providing case examples. Alongside examining the types of research involved, and their rationale the paper identifies the challenges taking part in this sort of research may create. Finally the paper suggests how to make clinical research more accessible to policy makers. [ABSTRACT FROM AUTHOR]

The traditional separation of the producers of research evidence in academia from the users of that evidence in healthcare organisations has not succeeded in closing the gap between what is known about the organisation and delivery of health services and what is actually done in practice. As a consequence, there is growing interest in alternative models of knowledge creation and mobilisation, ones which emphasise collaboration, active participation of all stakeholders, and a commitment to shared learning. Such models have robust historical, philosophical and methodological foundations but have not yet been embraced by many of the people working in the health sector. This paper presents an emerging model of participation, the Researcher-in-Residence. The model positions the researcher as a core member of a delivery team, actively negotiating a body of expertise which is different from, but complementary to, the expertise of managers and clinicians. Three examples of in-residence models are presented: an anthropologist working as a member of an executive team, operational researchers working in a front-line delivery team, and a Health Services Researcher working across an integrated care organisation. Each of these examples illustrates the contribution that an embedded researcher can make to a service-based team. They also highlight a number of unanswered questions about the model, including the required level of experience of the researcher and their areas of expertise, the institutional facilitators and barriers to embedding the model, and the risk that the independence of an embedded researcher might be compromised. The Researcher-in-Residence model has the potential to engage both academics and practitioners in the promotion of evidence-informed service improvement, but further evaluation is required before the model should be routinely used in practice. [ABSTRACT FROM AUTHOR]

Anxiety disorders are highly prevalent among children and adolescents and frequently result in impairments across multiple domains of life. While psychosocial interventions, namely cognitive-behavioural therapy (CBT), have been found to be highly effective in treating these conditions, significant numbers of youth simply do not have access to these evidence-based interventions, and of those who do, a substantial proportion (up to 40%) fail to achieve remission. Thus, there is a pressing need for innovation in both the delivery of evidence-based treatments and efforts to enhance treatment outcomes for those who do not respond to standard care. This paper reviews current innovations attempting to address these issues, including evidence for brief, low-intensity approaches to treatment; internet delivered CBT and brief, high-intensity CBT. Moreover, we propose a model of stepped care delivery of evidence-based mental health interventions for children and youth with anxiety. In general, a stepped care approach begins with a lower intensity, evidence-based treatment that entails minimal therapist involvement (ie, brief, low-intensity self-help or internet delivered CBT) and then proceeds to more intensive treatments with greater therapist involvement (ie, brief high-intensity CBT), but only for those individuals who show a poor response at each step along the way. Future research is needed in order to evaluate such a model, and importantly, to identify predictors and moderators of response at each step, in order to inform an evidence-based, fully-integrated stepped care approach to service delivery. [ABSTRACT FROM AUTHOR]

Background: Being married is associated with healthier lifestyle behaviours and lower mortality and may reduce risk for dementia due to life-course factors. We conducted a systematic review and meta-analysis of studies of the association between marital status and the risk of developing dementia.Methods: We searched medical databases and contacted experts in the field for relevant studies reporting the relationship, adjusted for age and sex, between marital status and dementia. We rated methodological quality and conducted random-effects meta-analyses to summarise relative risks of being widowed, divorced or lifelong single, compared with being married. Secondary stratified analyses with meta-regression examined the impact of clinical and social context and study methodology on findings.Results: We included 15 studies with 812 047 participants. Compared with those who are married, lifelong single (relative risk=1.42 (95% CI 1.07 to 1.90)) and widowed (1.20 (1.02 to 1.41)) people have elevated risk of dementia. We did not find an association in divorced people.Further analyses showed that less education partially confounds the risk in widowhood and worse physical health the elevated risk in lifelong single people. Compared with studies that used clinical registers for ascertaining dementia diagnoses, those which clinically examined all participants found higher risk for being unmarried.Conclusions: Being married is associated with reduced risk of dementia than widowed and lifelong single people, who are also underdiagnosed in routine clinical practice. Dementia prevention in unmarried people should focus on education and physical health and should consider the possible effect of social engagement as a modifiable risk factor. [ABSTRACT FROM AUTHOR]

Despite recent advances in HIV prevention and treatment, high HIV incidence persists among people who inject drugs (PWID). Difficult legal and political environments and lack of services for PWID likely contribute to high HIV incidence. Some advocates question whether any HIV prevention research is ethically justified in settings where healthcare system fails to provide basic services to PWID and where implementation of research findings is fraught with political barriers. Ethical challenges in research with PWID include concern about whether research evidence will be translated into practice; concerns that research might exacerbate background risks; and ethical challenges regarding the standard of HIV prevention in research. While these questions arise in other research settings, for research with PWID, these questions are especially controversial. This paper analyses four ethical questions in determining whether research could be ethically acceptable: (1) Can researchers ensure that research does not add to the burden of social harms and poor health experienced by PWID? (2) Should research be conducted in settings where it is uncertain whether research findings will be translated into practice? (3) When best practices in prevention and care are not locally available, what standard of care and prevention is ethically appropriate? (4) Does the conduct of research in settings with oppressive policies constitute complicity? We outline specific criteria to address these four ethical challenges. We also urge researchers to join the call to action for policy change to provide proven safe and effective HIV prevention and harm reduction interventions for PWID around the world. [ABSTRACT FROM AUTHOR]

Guidelines are integral to reducing variation in paediatric care by ensuring that children receive the right care, every time. However, for reasons discussed in this paper, clinicians do not always follow evidence-based guidelines. Strategies to improve guideline usage tend to focus on dissemination and education. These approaches, however, do not address some of the more complex factors that influence whether a guideline is used in clinical practice. In this article, part of the Equipped Quality Improvement series, we outline the literature on barriers to guideline adherence and present practical solutions to address these barriers. Examples outlined include the use of care bundles, integrated care pathways and quality improvement collaboratives. A sophisticated information technology system can improve the use of evidence-based guidelines and provide organisations with valuable data for learning and improvement. Key to success is the support of an organisation that places reliability of service delivery as the way business is done. To do this requires leadership from clinicians in multidisciplinary teams and a system of continual improvement. By learning from successful approaches, we believe that all healthcare organisations can ensure the right care for each patient, every time. [ABSTRACT FROM AUTHOR]

Background: Doctors sometimes encounter parents who object to prescribed treatment for their children, and request suboptimal substitutes be administered instead (suboptimal being defined as less effective and/or more expensive). Previous studies have focused on parental refusal of treatment and when this should be permitted, but the ethics of requests for suboptimal treatment has not been explored.Methods: The paper consists of two parts: an empirical analysis and an ethical analysis. We performed an online survey with a sample of the general public to assess respondents' thresholds for acceptable harm and expense resulting from parental choice, and the role that religion played in their judgement. We also identified and applied existing ethical frameworks to the case described in the survey to compare theoretical and empirical results.Results: Two hundred and forty-two Mechanical Turk workers took our survey and there were 178 valid responses (73.6%). Respondents' agreement to provide treatment decreased as the risk or cost of the requested substitute increased (p<0.001). More than 50% of participants were prepared to provide treatment that would involve a small absolute increased risk of death for the child (<5%) and a cost increase of US$<500, respectively. Religiously motivated requests were significantly more likely to be allowed (p<0.001). Existing ethical frameworks largely yielded ambiguous results for the case. There were clear inconsistencies between the theoretical and empirical results.Conclusion: Drawing on both survey results and ethical analysis, we propose a potential model and thresholds for deciding about the permissibility of suboptimal treatment requests. [ABSTRACT FROM AUTHOR]

Objective Over 20 experts on economics, epidemiology, public policy and tobacco control were asked by the International Agency for Research on Cancer (IARC) to evaluate the strength of the available evidence on the effects of tax and price policies to prevent and reduce tobacco use. Methods Draft papers presenting and assessing the evidence on the following topics were developed by the experts in an 8-month period prior to the meeting: tobacco industry pricing strategies and tax related lobbying; tax, price and aggregate demand for tobacco; tax, price and adult tobacco use, use among young people and use among the poor; tax avoidance and tax evasion; and the economic and health impact of tobacco taxation. Subsequently, papers were peer reviewed, revised and resubmitted for final discussion at a 6-day meeting at IARC in Lyon, France, where a consensus evaluation of 18 concluding statements using the pre-established criteria of the IARC Cancer Prevention Handbooks took place. Studies published (or accepted for publication) in the openly available scientific literature were the main source of evidence for the review and evaluation; other types of publications were included when appropriate. Results In support of 12 of the 18 conclusions, the experts agreed that there was sufficient evidence of effectiveness of increased tobacco excise taxes and prices in reducing overall tobacco consumption and prevalence of tobacco use and improvement of public health, including by preventing initiation and uptake among young people, promoting cessation among current users and lowering consumption among those who continue to use. For the remaining six concluding statements the evidence was strong (four statements) or limited (two statements). Conclusions The evidence presented and assessed in IARC Handbook volume 14 documents the effectiveness of tax and price policies in the control of tobacco use and improvement of public health. [ABSTRACT FROM AUTHOR]

Background Reductions in the eligibility requirements and generosity of disability benefits have been introduced in several Organisation for Economic Cooperation and Development (OECD) countries in recent years, on the assumption that this will increase work incentives for people with chronic illness and disabilities. This paper systematically reviews the evidence for this assumption in the context of well-developed welfare systems. Method Systematic review of all empirical studies from five OECD countries from 1970 to December 2009 investigating the effect of changes in eligibility requirements or level of disability benefits on employment of disabled people. Results Sixteen studies were identified. Only one of five studies found that relaxed eligibility was significantly associated with a decline in employment. The most robust study found no significant effect. On generosity, eight out of 11 studies reported that benefit levels had a significant negative association with employment. The most robust study demonstrated a small but significant negative association. Conclusion There was no firm evidence that changes in benefit eligibility requirements affected employment. While there was some evidence indicating that benefit level was negatively associated with employment, there was insufficient evidence of a high enough quality to determine the extent of that effect. Policy makers and researchers need to address the lack of a robust empirical basis for assessing the employment impact of these welfare reforms as well as potentially wider poverty impacts. [ABSTRACT FROM AUTHOR]