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BackgroundStandard treatment for deep vein thrombosis (DVT) aims to reduce immediatecomplications. Use of thrombolytic clot removal strategies (i.e., thrombolysis (clotdissolving drugs) with or without additional endovascular techniques), could reducethe long-term complications of post-thrombotic syndrome (PTS) including pain,swelling, skin discolouration, or venous ulceration in the affected leg. This is thefourth update of the review first published in 2004.ObjectivesCochrane Vascular Group: Thrombolytic strategies versus standard antic... https://archie.cochrane.org/sections/documents/view?document=043700...1 of 102 02/12/2020, 13:17To assess the effects of thrombolytic clot removal strategies and anticoagulationcompared to anticoagulation alone for the management of people with acute deepvein thrombosis (DVT) of the lower limb.Search methodsThe Cochrane Vascular Information Specialist searched the Cochrane VascularSpecialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databasesand World Health Organization International Clinical Trials Registry Platform andClinicalTrials.gov trials registers to 21 April 2020. We also undertook referencechecking to identify additional studies.Selection criteriaRandomised controlled trials (RCTs) examining thrombolysis (with or withoutadjunctive clot removal strategies) and anticoagulation versus anticoagulation alonefor acute DVT were considered.Data collection and analysisFor this update, CB screened the references identified by the search by title andabstract. Articles selected for full text assessment were independently assessed bytwo of three review authors or editorial support (CB, LW, MA, MS). Data wereextracted and checked by two of three authors or editorial support (CB, LW, MA, MS).We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomousoutcomes, we calculated the risk ratio (RR) and corresponding 95% confidenceinterval (CI). The primary outcomes of interest were clot lysis, bleeding and postthrombotic syndrome. Data were pooled using a fixed-effect model unlessheterogeneity was identified in which case a random-effects model was used. Weused GRADE to assess the overall certainty of the evidence supporting the outcomesassessed in this review.Main resultsTwo new studies were added for this update, therefore a total of 19 RCTs with 1943participants are now included. These studies differed in the thrombolytic agent, dosesof agent and in the technique used to deliver it. Systemic, loco-regional and catheterdirectedthrombolysis (CDT) were all included. For this update, CDT interventionsalso included those involving pharmacomechanical thrombolysis. Three of the 19included studies reported one or more domain at high risk of bias. We combined theresults as any (all) thrombolysis compared to standard anticoagulation.Complete clot lysis occurred more frequently in the thrombolysis group at earlyfollow-up (RR 4.75; 95% CI 1.83 to 12.33, 592 participants, 8 studies) and atintermediate follow-up (RR 2.42; 95% CI 1.42 to 4.12, 654 participants, 7 studies;moderate-certainty evidence). Two studies reported on clot lysis at late follow-up withno benefit from thrombolysis seen at this time point (RR 3.25, 95% CI 0.17 to 62.63,2 studies). No differences between strategies were detected by subgroup analysis atany of these time points (P = 0.41, P = 0.37 and P = 0.06 respectively).Those receiving thrombolysis had increased bleeding complications (6.7% versus2.2%) (RR 2.45, 95% CI 1.58 to 3.78; 1943 participants, 19 studies; moderate-Cochrane Vascular Group: Thrombolytic strategies versus standard antic... https://archie.cochrane.org/sections/documents/view?document=043700...2 of 102 02/12/2020, 13:17certainty evidence). No differences between strategies were detected by subgroupanalysis (P = 0.25).Up to five years after treatment slightly less PTS occurred in those receivingthrombolysis, 50% compared with 53% in the standard anticoagulation (RR 0.78,95% CI 0.66 to 0.93; 1393 participants, 6 studies; moderate-certainty evidence). Thisreduction in PTS was still observed at late follow-up (beyond five years), in twostudies (RR 0.56, 95% CI 0.43 to 0.73; 211 participants; moderate-certaintyevidence).We investigated if the level of DVT (iliofemoral, femoropopliteal or non-specified) hadan effect on the incidence of PTS by subgroup analysis. No benefit of thrombolysiswas seen for either iliofemoral or femoropopliteal DVT (6 studies; test for subgroupdifferences: P = 0.29). Systemic thrombolysis and CDT had similar levels ofeffectiveness. Studies of CDT included four trials in femoral and iliofemoral DVT, andresults from these are consistent with those from trials of systemic thrombolysis inDVT at other levels of occlusion.Authors' conclusionsComplete clot lysis occurred more frequently after thrombolysis (with or withoutadditional clot removal strategies) and PTS incidence was slightly reduced. Bleedingcomplications also increased with thrombolysis, but this risk has decreased over timewith the use of stricter exclusion criteria. Evidence suggests that systemicadministration of thrombolytics and CDT have similar effectiveness. Using GRADEassessment, the evidence was judged to be of moderate-certainty due to many trialshaving low numbers of participants. Future studies are needed to investigatetreatment regimes in terms of agent, dose and adjunctive clot removal methods;prioritising patient important outcomes including PTS and quality of life to aid clinicaldecision making.

Objective: The study aimed to design and evaluate a health behaviour change intervention for looked after young people, targeting sexual health, smoking, exercise, healthy eating and non-dependent alcohol and drug use. Design: A pre–post intervention evaluation was undertaken exploring health behaviours and wellbeing. Methodology: The one-to-one intervention was individually tailored to each person. Young people eligible for the intervention were aged 11 years and over and were ‘looked after’, meaning they were under a supervision order with a local authority in Scotland, or were a care leaver. A total of 144 young people referred to the intervention service between March 2009 and January 2014 were eligible for the evaluation. Evaluation data were analysed using standard statistical tests on SPSS. Results: Behaviour change techniques, including goal setting, action planning, barrier identification/problem solving and motivational interviewing contributed to improvements in all areas. Difficulties with consent and follow-up were highlighted as barriers to effective evaluation. Conclusion: Improving the current health of looked after young people with a view to prevent future ill health using a tailored intervention with behaviour change techniques enables this group to improve health behaviours, despite numerous challenges in working with these vulnerable clients.

BACKGROUND: Exercise programmes are a relatively inexpensive, low‐risk option compared with other, more invasive therapies for treatment of leg pain on walking (intermittent claudication (IC)). This is the fourth update of a review first published in 1998. OBJECTIVES: Our goal was to determine whether an exercise programme was effective in alleviating symptoms and increasing walking treadmill distances and walking times in people with intermittent claudication. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events, and improving quality of life. SEARCH METHODS: For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (last searched 15 November 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10) via the Cochrane Register of Studies Online, along with trials registries. SELECTION CRITERIA: Randomised controlled trials of an exercise regimen versus control or versus medical therapy for people with IC due to peripheral arterial disease (PAD). We included any exercise programme or regimen used for treatment of IC, such as walking, skipping, and running. Inclusion of trials was not affected by duration, frequency, or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain‐free walking distance and maximum walking time or maximum walking distance), ankle brachial index (ABI), quality of life, morbidity, or amputation; if none of these was reported, we did not include the trial in this review. DATA COLLECTION AND ANALYSIS: For this update (2017), RAL and AH selected trials and extracted data independently. We assessed study quality by using the Cochrane 'Risk of bias' tool. We analysed continuous data by determining mean differences (MDs) and 95% confidence intervals (CIs), and dichotomous data by determining risk ratios (RRs) and 95% CIs. We pooled data using a fixed‐effect model unless we identified significant heterogeneity, in which case we used a random‐effects model. We used the GRADE approach to assess the overall quality of evidence supporting the outcomes assessed in this review. MAIN RESULTS: We included two new studies in this update and identified additional publications for previously included studies, bringing the total number of studies meeting the inclusion criteria to 32, and involving a total of 1835 participants with stable leg pain. The follow‐up period ranged from two weeks to two years. Types of exercise varied from strength training to polestriding and upper or lower limb exercises; supervised sessions were generally held at least twice a week. Most trials used a treadmill walking test for one of the primary outcome measures. The methodological quality of included trials was moderate, mainly owing to absence of relevant information. Most trials were small and included 20 to 49 participants. Twenty‐seven trials compared exercise versus usual care or placebo, and the five remaining trials compared exercise versus medication (pentoxifylline, iloprost, antiplatelet agents, and vitamin E) or pneumatic calf compression; we generally excluded people with various medical conditions or other pre‐existing limitations to their exercise capacity. Meta‐analysis from nine studies with 391 participants showed overall improvement in pain‐free walking distance in the exercise group compared with the no exercise group (MD 82.11 m, 95% CI 71.73 to 92.48, P < 0.00001, high‐quality evidence). Data also showed benefit from exercise in improved maximum walking distance (MD 120.36 m, 95% CI 50.79 to 189.92, P < 0.0007, high‐quality evidence), as revealed by pooling data from 10 studies with 500 participants. Improvements were seen for up to two years. Exercise did not improve the ABI (MD 0.04, 95% CI 0.00 to 0.08, 13 trials, 570 participants, moderate‐quality evidence). Limited data were available for the outcomes of mortality and amputation; trials provided no evidence of an effect of exercise, when compared with placebo or usual care, on mortality (RR 0.92, 95% CI 0.39 to 2.17, 5 trials, 540 participants, moderate‐quality evidence) or amputation (RR 0.20, 95% CI 0.01 to 4.15, 1 trial, 177 participants, low‐quality evidence). Researchers measured quality of life using Short Form (SF)‐36 at three and six months. At three months, the domains 'physical function', 'vitality', and 'role physical' improved with exercise; however this was a limited finding, as it was reported by only two trials. At six months, meta‐analysis showed improvement in 'physical summary score' (MD 2.15, 95% CI 1.26 to 3.04, P = 0.02, 5 trials, 429 participants, moderate‐quality evidence) and in 'mental summary score' (MD 3.76, 95% CI 2.70 to 4.82, P < 0.01, 4 trials, 343 participants, moderate‐quality evidence) secondary to exercise. Two trials reported the remaining domains of the SF‐36. Data showed improvements secondary to exercise in 'physical function' and 'general health'. The other domains ‐ 'role physical', 'bodily pain', 'vitality', 'social', 'role emotional', and 'mental health' ‐ did not show improvement at six months. Evidence was generally limited in trials comparing exercise versus antiplatelet therapy, pentoxifylline, iloprost, vitamin E, and pneumatic foot and calf compression owing to small numbers of trials and participants. Review authors used GRADE to assess the evidence presented in this review and determined that quality was moderate to high. Although results showed significant heterogeneity between trials, populations and outcomes were comparable overall, with findings relevant to the claudicant population. Results were pooled for large sample sizes ‐ over 300 participants for most outcomes ‐ using reproducible methods. AUTHORS' CONCLUSIONS: High‐quality evidence shows that exercise programmes provided important benefit compared with placebo or usual care in improving both pain‐free and maximum walking distance in people with leg pain from IC who were considered to be fit for exercise intervention. Exercise did not improve ABI, and we found no evidence of an effect of exercise on amputation or mortality. Exercise may improve quality of life when compared with placebo or usual care. As time has progressed, the trials undertaken have begun to include exercise versus exercise or other modalities; therefore we can include fewer of the new trials in this update.

BACKGROUND: Standard treatment for deep vein thrombosis (DVT) aims to reduce immediate complications. Use of thrombolytic clot removal strategies (i.e. thrombolysis (clot dissolving drugs), with or without additional endovascular techniques), could reduce the long‐term complications of post‐thrombotic syndrome (PTS) including pain, swelling, skin discolouration, or venous ulceration in the affected leg. This is the fourth update of a Cochrane Review first published in 2004. OBJECTIVES: To assess the effects of thrombolytic clot removal strategies and anticoagulation compared to anticoagulation alone for the management of people with acute deep vein thrombosis (DVT) of the lower limb. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries to 21 April 2020. We also checked the references of relevant articles to identify additional studies. SELECTION CRITERIA: We considered randomised controlled trials (RCTs) examining thrombolysis (with or without adjunctive clot removal strategies) and anticoagulation versus anticoagulation alone for acute DVT. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as recommended by Cochrane. We assessed the risk of bias in included trials with the Cochrane 'Risk of bias' tool. Certainty of the evidence was evaluated using GRADE. For dichotomous outcomes, we calculated the risk ratio (RR) with the corresponding 95% confidence interval (CI). We pooled data using a fixed‐effect model, unless we identified heterogeneity, in which case we used a random‐effects model. The primary outcomes of interest were clot lysis, bleeding and post thrombotic syndrome. MAIN RESULTS: Two new studies were added for this update. Therefore, the review now includes a total of 19 RCTs, with 1943 participants. These studies differed with respect to the thrombolytic agent, the doses of the agent and the techniques used to deliver the agent. Systemic, loco‐regional and catheter‐directed thrombolysis (CDT) strategies were all included. For this update, CDT interventions also included those involving pharmacomechanical thrombolysis. Three of the 19 included studies reported one or more domain at high risk of bias. We combined the results as any (all) thrombolysis interventions compared to standard anticoagulation. Complete clot lysis occurred more frequently in the thrombolysis group at early follow‐up (RR 4.75; 95% CI 1.83 to 12.33; 592 participants; eight studies) and at intermediate follow‐up (RR 2.42; 95% CI 1.42 to 4.12; 654 participants; seven studies; moderate‐certainty evidence). Two studies reported on clot lysis at late follow‐up with no clear benefit from thrombolysis seen at this time point (RR 3.25, 95% CI 0.17 to 62.63; two studies). No differences between strategies (e.g. systemic, loco‐regional and CDT) were detected by subgroup analysis at any of these time points (tests for subgroup differences: P = 0.41, P = 0.37 and P = 0.06 respectively). Those receiving thrombolysis had increased bleeding complications (6.7% versus 2.2%) (RR 2.45, 95% CI 1.58 to 3.78; 1943 participants, 19 studies; moderate‐certainty evidence). No differences between strategies were detected by subgroup analysis (P = 0.25). Up to five years after treatment, slightly fewer cases of PTS occurred in those receiving thrombolysis; 50% compared with 53% in the standard anticoagulation (RR 0.78, 95% CI 0.66 to 0.93; 1393 participants, six studies; moderate‐certainty evidence). This was still observed at late follow‐up (beyond five years) in two studies (RR 0.56, 95% CI 0.43 to 0.73; 211 participants; moderate‐certainty evidence). We used subgroup analysis to investigate if the level of DVT (iliofemoral, femoropopliteal or non‐specified) had an effect on the incidence of PTS. No benefit of thrombolysis was seen for either iliofemoral or femoropopliteal DVT (six studies; test for subgroup differences: P = 0.29). Systemic thrombolysis and CDT had similar levels of effectiveness. Studies of CDT included four trials in femoral and iliofemoral DVT, and results from these are consistent with those from trials of systemic thrombolysis in DVT at other levels of occlusion. AUTHORS' CONCLUSIONS: Complete clot lysis occurred more frequently after thrombolysis (with or without additional clot removal strategies) and PTS incidence was slightly reduced. Bleeding complications also increased with thrombolysis, but this risk has decreased over time with the use of stricter exclusion criteria of studies. Evidence suggests that systemic administration of thrombolytics and CDT have similar effectiveness. Using GRADE, we judged the evidence to be of moderate‐certainty, due to many trials having small numbers of participants or events, or both. Future studies are needed to investigate treatment regimes in terms of agent, dose and adjunctive clot removal methods; prioritising patient‐important outcomes, including PTS and quality of life, to aid clinical decision making.

We present the final results from a high sampling rate, multi-month, spectrophotometric reverberation mapping campaign undertaken to obtain either new or improved Hbeta reverberation lag measurements for several relatively low-luminosity AGNs. We have reliably measured thetime delay between variations in the continuum and Hbeta emission line in six local Seyfert 1 galaxies. These measurements are used to calculate the mass of the supermassive black hole at the center of each of these AGNs. We place our results in context to the most current calibration of the broad-line region (BLR) R-L relationship, where our results remove outliers and reduce the scatter at the low-luminosity end of this relationship. We also present velocity-resolved Hbeta time delay measurements for our complete sample, though the clearest velocity-resolved kinematic signatures have already been published., 52 pages (AASTeX: 29 pages of text, 8 tables, 7 figures), accepted for publication in the Astrophysical Journal

Background Looked after young people (LAYP) have poorer sexual health outcomes than their peers. However, research seldom examines the health needs of, or intervenes with, this group. The aim of the current study was to identify LAYP’s perceived sexual health needs and explore sources of sexual health information, knowledge levels, concerns and service preferences. Methods Looked after young people within Fife, Scotland, were recruited through their workers and carers to participate in qualitative semistructured interviews. Those aged 12‐19 years were targeted for recruitment. National Health Services ethics approval was granted. Thematic analysis was conducted using NVivo. Results Interviews were conducted with 10 LAYP. Key themes included gaps in knowledge, and gaps between knowledge and behaviour. Being ‘looked after’ may have negative consequences on knowledge, sources of support and safer sex. A flexible, one-to-one service, aimed at several lifestyle issues, not solely sexual health, was preferred by respondents. Conclusion Looked after young people require support to bridge the gap between knowledge and behaviour and several theories relevant to the findings have been identified. Participants desired more support around a range of health issues, which may come from school, workers and carers, as well as health professionals. Further research examining effective interventions with this group is crucial to improve outcomes.

The blazar OJ 287 has produced two major optical outburst events during the years 2005-2008. These are the latest in a series of outbursts that have occurred repeatedly at 12 year intervals since early 1900s. It has been possible to explain the historical light curve fairly well by using a binary black hole model where the secondary black hole impacts the accretion disk of the primary twice during the 12 year orbital cycle. We will ask here how well does the latest light-curve fit with this model. We use a 10 million particle disk to model the accretion disk of the primary black hole. The rate of transfer of particles through the 10 Schwarzschild radius cylinder around the primary is followed. The secondary induces an inward flow through this surface. The inward flow rate is compared with the historical light curve as well as with the most recent observations reported in this paper. The observations have been carried out by using a number of small and medium size telescopes in different locations in order to ensure a dense light-curve coverage. The "inflow light curve" and the optical light curve of OJ 287 have a close resemblance to each other. It suggests that the tidally induced accretion flow is responsible for the main features of the optical light curve, with the exception of the quasi-periodic double peaks. It implies a close connection between the accretion disk and the jet where the optical synchrotron emission is presumably generated.

Objective Prevention of infection with blood-borne pathogens (BBPs) HIV and hepatitis B and C, remains a major public health challenge. The aim of this study was to assess the activity, knowledge and attitudes of community pharmacy assistants in Grampian in prevention of HIV and hepatitis B and C. Method A cross-sectional postal questionnaire survey of community pharmacy assistants. Outcome measures were practice, knowledge and barriers to practice. Setting Grampian, a mixed urban-rural health board area in North-East Scotland with a population of 532 432. Key findings Forty out of 78 (51%) assistants responded. Many were based in pharmacies that provided services for drug misusers, and/or stocked condoms. Twenty-four assistants stated that the pharmacies stocked extra-strong condoms but none was aware of dental dams being stocked. Two-thirds had leaflets relating to safer sex, HIV or hepatitis. Twenty assistants were confident that they could give advice on safer sex. Knowledge of BBPs and the infectivity of hepatitis B was relatively low. Few assistants were aware of recommendations for hepatitis B vaccination. The majority felt that in the future pharmacy assistants could have a greater role in the prevention of these infections. Principal barriers to preventive activity were described as lack of a private area, lack of training and time pressure. Conclusions Pharmacy assistants have the potential to be a focus for advice and simple information relating to prevention of HIV and hepatitis B and C. Resources are needed to address the current barriers identified.

The use of pneumococcal polysaccharide vaccine has remained controversial since licensure, especially in the elderly. Observational studies form much of the evidence base. We conducted a systematic review of observational studies and compared results with those obtained from an earlier review of randomised controlled trials (RCTs). Estimates of protection against invasive disease from observational studies were consistent, homogenous and compatible with sparse information obtained from RCTs. Studies were of moderate quality. From 13 observational studies the estimate of vaccine efficacy against invasive disease was 53% (46-59%) compared with 38% (-4 to 63%) from nine RCTs. Estimates of protection against all-cause pneumonia were based on fewer, heterogeneous studies that were not consistent with the findings from RCTs for this outcome. From five studies combined efficacy was 32% (7-50%) compared with 3% (-16 to 19%) from 13 RCTs.

Background Prevention of infection with the blood-borne pathogens (BBPs) HIV and hepatitis B and C remains a major public health challenge. The aim of this study was to assess the activity, knowledge and attitudes of community pharmacists in Grampian in prevention of HIV and hepatitis B and C. Method A questionnaire survey of community pharmacies was carried out in Grampian, a mixed urban‐rural Health Board area in NE Scotland with a population of 532 432. Results Ninety-nine out of 128 (77 per cent) community pharmacies responded. Many pharmacies were providing services for drug misusers. Nearly all pharmacies stocked condoms, 57 pharmacists stated that they stocked extrastrong condoms, and two stocked dental dams. Two-thirds had leaflets relating to safer sex, HIV or hepatitis. Less than half stated that they had lists of local agencies dealing with drug-related or sexual health problems. Knowledge of the BBPs, and confidence in giving advice, were greater for HIV than for hepatitis B and C. Few were aware of recommendations for hepatitis B vaccination. The majority felt that in the future pharmacists could have a greater role in prevention of these infections. Principal barriers to preventive activity were described as time pressure, lack of a private area and lack of training. Conclusions There is untapped potential for community pharmacists to be a focus for advice and information relating to prevention of HIV and hepatitis B and C; however, resources are needed to address the current barriers identified.

Background The recent rise in the prevalence of immune-mediated diseases has been attributed to environmental factors such as a lack of microbial challenge, or dietary change, that deviate the overall balance between mutually antagonistic subsets of T helper (Th) cells. Objective An alternative proposal is that recent environmental changes have resulted in an immune system that is more likely to produce both Th1 and Th 2 responses against benign antigens. The prediction of this hypothesis, that Th1 and Th 2-mediated diseases are not mutually exclusive, and may be positively associated, is tested here in a whole population. Methods Data from General Practices participating in the Scottish Continuous Morbidity Recording (CMR) project were used to determine the coincidence of the major Th 2-mediated atopic diseases; asthma, eczema and allergic rhinitis, with the Th1-mediated autoimmune conditions; type I diabetes, rheumatoid arthritis and psoriasis. We also identified the prescription rates of inhaled therapy for asthma in patients with Th1-mediated disease. Results There was a significant increase in the risk of presenting with a Th1-mediated autoimmune condition in patients with a history of allergic disease (standardized prevalence ratio (95% confidence interval) 1.28 (1.18–1.37)). Likewise, the standardized prevalence ratios of presenting with either eczema (1.67 (1.48–1.87)) or allergic rhinitis (1.22 (1.02–1.44)) were significantly increased in subjects with a history of Th1-mediated disease. There was a particularly strong association between current psoriasis and current eczema (standardized prevalence ratio of psoriasis in subjects with eczema 2.88, 95% confidence interval (CI) 2.38–3.45). There was also a significant increase in prescriptions for inhaled asthma therapy in patients with Th1 disease. Conclusion It is concluded that Th1- and Th 2-mediated diseases are significantly associated in a large General Practice population. This finding supports the proposal that autoimmune and atopic diseases share risk factors that increase the propensity of the immune system to generate both Th1- and Th 2-mediated inappropriate responses to non-pathological antigens.

Exercise programmes are a relatively inexpensive, low-risk option compared with other more invasive therapies for leg pain on walking (intermittent claudication (IC)).To determine the effects of exercise programmes on IC, particularly in respect of reduction of symptoms on walking and improvement in quality of life.The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last search February 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2008, Issue 1.Randomised controlled trials of exercise regimens in people with IC due to peripheral arterial disease.Two authors independently extracted data and assessed trial quality.Twenty-two trials met the inclusion criteria involving a total of 1200 participants with stable leg pain. Follow-up period was from two weeks to two years. There was some variation in the exercise regimens used, all recommended at least two sessions weekly of mostly supervised exercise. All trials used a treadmill walking test for one of the outcome measures. Quality of the included trials was good, though the majority of trials were small with 20 to 49 participants. Fourteen trials compared exercise with usual care or placebo; patients with various medical conditions or other pre-existing limitations to their exercise capacity were generally excluded.Compared with usual care or placebo, exercise significantly improved maximal walking time: mean difference (MD) 5.12 minutes (95% confidence interval (CI) 4.51 to 5.72;) with an overall improvement in walking ability of approximately 50% to 200%; exercise did not affect the ankle brachial pressure index (ABPI) (MD -0.01, 95% CI -0.05 to 0.04). Walking distances were also significantly improved: pain-free walking distance MD 82.19 metres (95% CI 71.73 to 92.65) and maximum walking distance MD 113.20 metres (95% CI 94.96 to 131.43). Improvements were seen for up to two years. The effect of exercise compared with placebo or usual care was inconclusive on mortality, amputation and peak exercise calf blood flow due to limited data.Evidence was generally limited for exercise compared with surgical intervention, angioplasty, antiplatelet therapy, pentoxifylline, iloprost and pneumatic foot and calf compression due to small numbers of trials and participants. Angioplasty may produce greater improvements than exercise in the short term but this effect may not be sustained.Exercise programmes were of significant benefit compared with placebo or usual care in improving walking time and distance in selected patients with leg pain from IC.

EDITOR—Johnston and Openshaw state that children are born with strong interleukin 4 based (type 2) immune responses and mature to interferon γ based (type 1) responses, and that this process is under genetic and environmental influence.1 They go on to …

Background Looked after young people represent a group of people under a supervision order with a local authority. They are frequently reported engaging in poorer health behaviours than are their peers. There are few reported assessments of behaviour change interventions for looked after young people, therefore the effectiveness of existing interventions and insight for the development of further interventions are unknown. Much has been made of the challenge of how to affect key health behaviours in adolescence and hence reduce future inequalities in health. The objectives were therefore to develop and assess a health behaviour change intervention for looked after young people to support healthier lifestyle choices. Methods The intervention was developed with a qualitative needs assessment, the general evidence for the effectiveness of interventions around the targeted health issues, and theory and models used in health psychology. The intervention was delivered as a service in NHS Fife, Scotland, by a health psychologist in a personally tailored way to individuals and aimed to motivate and provide looked after young people with the skills for change for sexual health, smoking, activity, healthy eating, alcohol, and drugs. Young people were guided in behaviour change techniques, including action planning to bridge intention-behaviour gaps. Several individual sessions were offered. Assessment of the effect of the intervention was undertaken before and after its delivery with behaviour questions that we developed, on the basis of questions previously used in published work—eg, "How many units do you usually have per week (on average)?" All young people engaged with the service were eligible to take part and were asked for their consent to take part in the assessment. Data were non-parametric and were analysed with the Wilcoxon signed-rank test and McNemar's test. Sessions were further assessed with a behaviour change taxonomy developed by Susan Michie and colleagues. Findings 74 young people were referred or self-referred into the service between March 3, 2009, and Aug 31, 2011, and had completed the intervention at the time of the assessment. Because of drop-outs and difficulties gaining consent for some individuals, baseline data were available for 50 young people. Some post-intervention data were available for 37 individuals and analyses undertaken in this group. Despite the small numbers, we recorded positive behaviour change in most areas targeted, including significant findings for the use of pregnancy contraceptives (before: three [21%] of 14 used them; after: ten [71%] used them; p=0·016), attending at a sexual health service (before: three [25%] of 12 had attended; after: nine [75%] had attended; p=0·031), and exercise (median before: 1·7 h/week [IQR 2·5]; median after: 2·9 h/week [2·0]; p=0·028). Drawing on the taxonomy used to audit the sessions, the intervention implemented a wide range of behaviour change techniques including motivational interviewing and action and coping planning. Interpretation The partnership between Health Psychology and Public Health has allowed the development of an innovative tailored one-to-one service for looked after young people around healthy lifestyle issues. Early assessment results show behaviour change in key risk areas; however, there are several complexities to successful research into or assessment of interventions for vulnerable groups such as looked after young people. A before and after test design without a control group is limited in its power; furthermore, in view of the difficulties engaging young people in assessment, more rigorous research is likely to encounter barriers. There are potentially wider applications for this approach, such as delivery of health behaviour change in school settings and residential care, and for selected vulnerable groups (eg, those in contact with criminal justice). Funding Fife Health and Wellbeing Alliance.