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ObjectiveTo identify demographic, premorbid and injury-related factors, or biomarkers associated with long-term (≥3 months) adverse outcomes in children after mild traumatic brain injury (mTBI).DesignScoping review of literature.PatientsChildren and adolescents with mTBI.Risk factorsAny demographic, premorbid and injury-related factors, or biomarkers were included. We excluded genetic and treatment-related factors.Main outcome measuresPostconcussion syndrome (PCS), recovery.ResultsSeventy-three publications were included, reporting 12 long-term adverse outcomes, including PCS in 12 studies and recovery in 29 studies. Additional outcomes studied were symptom scores/severity (n=22), quality of life (n=9) and cognitive function (n=9). Forty-nine risk factors were identified across studies. Risk factors most often assessed were sex (n=28), followed by age (n=23), injury mechanism = (n=22) and prior mTBI (n=18). The influence of these and other risk factors on outcomes of mTBI were inconsistent across the reviewed literature.ConclusionsThe most researched risk factors are sex, age and mechanism of injury, but their effects have been estimated inconsistently and did not show a clear pattern. The most studied outcomes are recovery patterns and symptom severity. However, these may not be the most important outcomes for clinicians and patients. Future primary studies in this area should focus on patient-important outcomes. Population-based prospective studies are needed that address prespecified hypotheses on the relationship of risk factors with given outcomes to enable reliable prediction of long-term adverse outcomes for childhood mTBI.

BackgroundVirtual wards (VWs) deliver multidisciplinary care at home to people with frailty at high risk of a crisis or in-crisis, aiming to mitigate the risk of hospital admission. Different VWs models exist and evidence of effectiveness is inconsistent.AimWe conducted a rapid realist review to identify different types of VWs, and to develop explanations for how and why VWs could deliver effective frailty management.MethodsWe searched published and grey literature to identify evidence on VWs for frailty, based in Great Britain and Ireland. Information on how and why virtual wards might ‘work’ was extracted and synthesised in two rounds with input from clinicians and patient/public contributors, generating 12 hypothesised context-mechanism-outcome configurations.ResultsWe included 17 published and 11 grey literature documents. VWs could be short-term and acute (1-21 days), or longer-term and preventative (3-7 months).Effective VW operation requires common standards agreements, information sharing processes, an appropriate multidisciplinary team that plans patient care remotely, and good co-ordination. VWs may enable delivery of frailty interventions through appropriate selection of patients, comprehensive assessment including medication review, integrated case management, and proactive care. Important components for patients and caregivers are their communication with the VW, their experience of care at home, and feeling included, safe and empowered to manage their condition.ConclusionsInsights gained from this review could inform implementation or evaluation of VWs for frailty. A combination of acute and longer-term VWs may be needed, within a whole system approach. An emphasis on proactive care is recommended.

BackgroundPaediatric abusive head trauma (AHT) occurs in young children due to violent shaking or blunt impact. Educational and behavioural programmes modifying parent/infant interactions may aid primary prevention. This systematic review aims to assess the effectiveness of such interventions to prevent AHT in infants.MethodsWe searched Embase, MEDLINE, PsycINFO, The Cochrane library, CINAHL databases and trial registries to September 2021, for studies assessing the effectiveness of educational and behavioural interventions in preventing AHT. Eligible interventions had to include messaging about avoiding or dangers of infant shaking. Randomised controlled trials (RCTs) reporting results for primary (AHT, infant shaking) or secondary outcomes (including parental responses to infant crying, mental wellbeing), and non-randomised studies (NRSs) reporting primary outcomes were included. Evidence from combinable studies was synthesised using random-effects meta-analyses. Certainty of evidence was assessed using GRADE framework. PROSPERO registration CRD42020195644.FindingsOf 25 identified studies, 16 were included in meta-analyses. Five NRSs reported results for AHT, of which four were meta-analysed (summary odds ratio [OR] 0.95, 95 % confidence intervals [CI] 0.80–1.13). Two studies assessed self-reported shaking (one cluster-RCT, OR 0.11, 95 % CI 0.02–0.53; one cohort study, OR 0.36, 95 % CI 0.20–0.64, not pooled). Meta-analyses of secondary outcomes demonstrated marginal improvements in parental response to inconsolable crying (summary mean difference 1.58, 95 % CI 0.11–3.06, on a 100-point scale) and weak evidence that interventions increased walking away from crying infants (summary incidence rate ratio 1.52, 95 % CI 0.94–2.45). No intervention effects were found in meta-analyses of parental mental wellbeing or other responses to crying.InterpretationLow certainty evidence suggests that educational programmes for AHT prevention are not effective in preventing AHT. There is low to moderate certainty evidence that educational interventions have no effect or only marginally improve some parental responses to infant crying.

Objective The overall aim of this study was to investigate how commissioning policies for accessing clinical procedures compare in the context of the English National Health Service. Our primary objective was to compare policy wording and categorise any variations identified. Our secondary objective was to explore how any points of variation relate to national guidance. Methods This study entailed documentary analysis of commissioning policies that stipulated criteria for accessing eight elective musculoskeletal procedures. For each procedure, we retrieved policies held by regions with higher and lower rates of clinical activity relative to the national average. Policies were subjected to content and thematic analysis, using constant comparison techniques . Matrices and descriptive reports were used to compare themes across policies for each procedure and derive categories of variation that arose across two or more procedures. National guidance relating to each procedure were identified and scrutinised, to explore whether these provided context for explaining the policy variations. Results Thirty-five policy documents held by 14 geographic regions were included in the analysis. Policies either focused on a single procedure/treatment or covered several procedures/treatments in an all-encompassing document. All policies stipulated criteria that needed to be fulfilled prior to accessing treatment, but there were inconsistences in the evidence cited. Policies varied in recurring ways, with respect to specification of non-surgical treatments and management, requirements around time spent using non-surgical approaches, diagnostic requirements, requirements around symptom severity and disease progression, and use of language, in the form of terms and phrases (‘threshold modifiers’) which could open up or restrict access to care. National guidance was identified for seven of the procedures, but this guidance did not specify criteria for accessing the procedures in question, making direct comparisons with regional policies difficult. Conclusions This, to our knowledge, is the first study to identify recurring ways in which policies for accessing treatment can vary within a single-payer system with universal coverage. The findings raise questions around whether formulation of commissioning policies should receive more central support to promote greater consistency – especially where evidence is uncertain, variable or lacking.

Childhood obesity is a global public health concern. While evidence from a recent comprehensive Cochrane review indicates school-based interventions can prevent obesity, we still do not know how or for whom these work best. We aimed to identify the contextual and mechanistic factors associated with obesity prevention interventions implementable in primary schools. A realist synthesis following the Realist And Meta-narrative Evidence Syntheses–Evolving Standards (RAMESES) guidance was with eligible studies from the 2019 Cochrane review on interventions in primary schools. The initial programme theory was developed through expert consensus and stakeholder input and refined with data from included studies to produce a final programme theory including all of the context-mechanism-outcome configurations. We included 24 studies (71 documents) in our synthesis. We found that baseline standardised body mass index (BMIz) affects intervention mechanisms variably as a contextual factor. Girls, older children and those with higher parental education consistently benefitted more from school-based interventions. The key mechanisms associated with beneficial effect were sufficient intervention dose, environmental modification and the intervention components working together as a whole. Education alone was not associated with favourable outcomes. Future interventions should go beyond education and incorporate a sufficient dose to trigger change in BMIz. Contextual factors deserve consideration when commissioning interventions to avoid widening health inequalities.

Background Systematic reviews of prenatal alcohol exposure effects generally only include conventional observational studies. However, estimates from such studies are prone to confounding and other biases. Objectives To systematically review the evidence on the effects of prenatal alcohol exposure from randomized controlled trials (RCTs) and observational designs using alternative analytical approaches to improve causal inference. Search strategy Medline, Embase, Web of Science, PsychINFO from inception to 21 June 2018. Manual searches of reference lists of retrieved papers. Selection criteria RCTs of interventions to stop/reduce drinking in pregnancy and observational studies using alternative analytical methods (quasi-experimental studies e.g. Mendelian randomization and natural experiments, negative control comparisons) to determine the causal effects of prenatal alcohol exposure on pregnancy and longer-term offspring outcomes in human studies. Data collection and analysis One reviewer extracted data and another checked extracted data. Risk of bias was assessed using customized risk of bias tools. A narrative synthesis of findings was carried out and a meta-analysis for one outcome. Main results Twenty-three studies were included, representing five types of study design, including 1 RCT, 9 Mendelian randomization and 7 natural experiment studies, and reporting on over 30 outcomes. One study design–outcome combination included enough independent results to meta-analyse. Based on evidence from several studies, we found a likely causal detrimental role of prenatal alcohol exposure on cognitive outcomes, and weaker evidence for a role in low birthweight. Conclusion None of the included studies was judged to be at low risk of bias in all domains, results should therefore be interpreted with caution. Systematic review registration This study is registered with PROSPERO, registration number CRD42015015941

Occupational injury rates are higher among young people when compared to older age groups. Objective: Identifying preventive occupational safety and health interventions that aim at protecting young workers from hazards at work while considering their ongoing physical and mental maturation. Methods: We ran a sensitive search strategy in twelve electronic databases to locate studies. Two review authors independently screened titles and abstracts, and later full texts for eligibility. One person extracted the details of studies and another checked for errors. Data were analyzed in an iterative process. Results: We included 39 studies. Three studies evaluated environmental interventions, 29 evaluated behavioral, one evaluated clinical and six combined more than one type of intervention. Developmental characteristics of young workers that could contribute to risk were addressed in 13 studies. Thirty-five studies were from high income countries, one was from an upper middle-income country and three were from lower middle- income countries. We found no studies from low income countries. Conclusions: There is a dearth of evidence when it comes to evaluating interventions in low and lower middle income countries and adapting interventions developed in high income countries to the needs of low and middle income ones. A higher and more integrated participation of young workers themselves, parents and other key social actors such as policy makers, employers and occupational safety and health regulators is required to optimally protect young workers. We recommend developing and evaluating interventions that specifically address the risks that youth face at work due to their ongoing developmental process. Further we need systematic reviews of the interventions identified in this review such as for young workers in the service sector.

ObjectivesTo assess the reporting quality of randomisation and allocation methods in occupational health and safety (OHS) trials in relation to Consolidated Standards of Reporting Trials (CONSORT) requirements of journals, risk of bias (RoB) and publication year.MethodsWe systematically searched for randomised controlled trials (RCTs) in PubMed between 2010 and May 2019 in 18 OHS journals. We measured reporting quality as percentage compliance with the CONSORT 2010 checklist (items 8–10) and RoB with the ROB V.2.0 tool (first domain). We tested the mean difference (MD) in % in reporting quality between CONSORT-requiring and non-requiring journals, trials with low, some concern and high RoB and publications before and after 2015.ResultsIn 135 articles reporting on 129 RCTs, average reporting quality was at 37.4% compliance (95% CI 31.9% to 43.0%), with 10% of articles reaching 100% compliance. Reporting quality was significantly better in CONSORT-requiring journals than non-requiring journals (MD 31.0% (95% CI 21.4% to 40.7%)), for studies at low RoB than high RoB (MD 33.1% (95% CI 16.1% to 50.2%)) and with RoB of some concern (MD 39.8% (95% CI 30.0% to 49.7%)). Reporting quality did not improve over time (MD −5.7% (95% CI −16.8% to 5.4%).ConclusionsArticles in CONSORT-requiring journals and of low RoB studies show better reporting quality. Low reporting quality is linked to unclear RoB judgements (some concern). Reporting quality did not improve over the last 10 years and CONSORT is insufficiently implemented. Concerted efforts by editors and authors are needed to improve CONSORT implementation.

Objectiveto identify contextual and mechanistic factors associated with outcomes of school-based obesity prevention interventions which may be implementable in UK primary schools.Designrealist synthesis following REMESES guidance. We developed an initial programme theory through expert consensus and stakeholder input and refined it with data from included studies to produce a final programme theory including all context-mechanism-outcome configurations.Settingprimary schoolsParticipantschildren aged 4-12Interventionsincluded in the 2019 Cochrane review on prevention of childhood obesityOutcomesBMIzResultsWe included 24 studies comprised of 71 documents in our synthesis. We found that contextual factors such as baseline BMIz affects intervention mechanisms variably, while girls, older children and those with higher parental education consistently benefitted more from school-based interventions. Key mechanisms associated with beneficial effect were sufficient intervention dose, environmental modification, and the intervention components working together as a whole. Education alone did not produce favourable outcomes.ConclusionsInterventions should go beyond education and incorporate a sufficient dose to trigger change in BMIz. Contextual factors deserve consideration when commissioning interventions to avoid widening health inequalities.

There is increasing interest in the influence of place on health, and the need to distinguish between environmental and individual level factors. For environmental-level factors, current evidence tends to show associations through cross-sectional and uncontrolled longitudinal analyses rather than through more robust study designs that can provide stronger causal evidence. We restricted this systematic review to randomised (or cluster) randomised controlled trials and controlled before-and-after studies of changes to the built environment. Date of search was December 2016. We identified 14 studies. No evidence was found of an effect on mental health from ‘urban regeneration’ and ‘improving green infrastructure’ studies. Beneficial effects on quality-of-life outcomes from ‘improving green infrastructure’ were found in two studies. One ‘improving green infrastructure’ study reported an improvement in social isolation. Risk-of-bias assessment indicated robust data from only four studies. Overall, evidence for the impact of built environment interventions on mental health and quality-of-life is weak. Future research requires more robust study designs and interdisciplinary research involving public health, planning and urban design experts.

BackgroundAlthough antidepressants are often a first‐line treatment for adults with moderate to severe depression, many people do not respond adequately to medication, and are said to have treatment‐resistant depression (TRD). Little evidence exists to inform the most appropriate 'next step' treatment for these people. ObjectivesTo assess the effectiveness of standard pharmacological treatments for adults with TRD. Search methodsWe searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) (March 2016), CENTRAL, MEDLINE, Embase, PsycINFO and Web of Science (31 December 2018), the World Health Organization trials portal and ClinicalTrials.gov for unpublished and ongoing studies, and screened bibliographies of included studies and relevant systematic reviews without date or language restrictions. Selection criteriaRandomised controlled trials (RCTs) with participants aged 18 to 74 years with unipolar depression (based on criteria from DSM‐IV‐TR or earlier versions, International Classification of Diseases (ICD)‐10, Feighner criteria or Research Diagnostic Criteria) who had not responded to a minimum of four weeks of antidepressant treatment at a recommended dose. Interventions were: (1) increasing the dose of antidepressant monotherapy;(2) switching to a different antidepressant monotherapy;(3) augmenting treatment with another antidepressant;(4) augmenting treatment with a non‐antidepressant.All were compared with continuing antidepressant monotherapy. We excluded studies of non‐standard pharmacological treatments (e.g. sex hormones, vitamins, herbal medicines and food supplements). Data collection and analysisTwo reviewers used standard Cochrane methods to extract data, assess risk of bias, and resolve disagreements. We analysed continuous outcomes with mean difference (MD) or standardised mean difference (SMD) and 95% confidence interval (CI). For dichotomous outcomes, we calculated a relative risk (RR) and 95% CI. Where sufficient data existed, we conducted meta‐analyses using random‐effects models. Main resultsWe included 10 RCTs (2731 participants). Nine were conducted in outpatient settings and one in both in‐ and outpatients. Mean age of participants ranged from 42 ‐ 50.2 years, and most were female. One study investigated switching to, or augmenting current antidepressant treatment with, another antidepressant (mianserin). Another augmented current antidepressant treatment with the antidepressant mirtazapine. Eight studies augmented current antidepressant treatment with a non‐antidepressant (either an anxiolytic (buspirone) or an antipsychotic (cariprazine; olanzapine; quetiapine (3 studies); or ziprasidone (2 studies)). We judged most studies to be at a low or unclear risk of bias. Only one of the included studies was not industry‐sponsored. There was no evidence of a difference in depression severity when current treatment was switched to mianserin (MD on Hamilton Rating Scale for Depression (HAM‐D) = ‐1.8, 95% CI ‐5.22 to 1.62, low‐quality evidence)) compared with continuing on antidepressant monotherapy. Nor was there evidence of a difference in numbers dropping out of treatment (RR 2.08, 95% CI 0.94 to 4.59, low‐quality evidence; dropouts 38% in the mianserin switch group; 18% in the control). Augmenting current antidepressant treatment with mianserin was associated with an improvement in depression symptoms severity scores from baseline (MD on HAM‐D ‐4.8, 95% CI ‐8.18 to ‐1.42; moderate‐quality evidence). There was no evidence of a difference in numbers dropping out (RR 1.02, 95% CI 0.38 to 2.72; low‐quality evidence; 19% dropouts in the mianserin‐augmented group; 38% in the control). When current antidepressant treatment was augmented with mirtazapine, there was little difference in depressive symptoms (MD on Beck Depression Inventory (BDI‐II) ‐1.7, 95% CI ‐4.03 to 0.63; high‐quality evidence) and no evidence of a difference in dropout numbers (RR 0.50, 95% CI 0.15 to 1.62; dropouts 2% in mirtazapine‐augmented group; 3% in the control). Augmentation with buspirone provided no evidence of a benefit in terms of a reduction in depressive symptoms (MD on Montgomery and Asberg Depression Rating Scale (MADRS) ‐0.30, 95% CI ‐9.48 to 8.88; low‐quality evidence) or numbers of drop‐outs (RR 0.60, 95% CI 0.23 to 1.53; low‐quality evidence; dropouts 11% in buspirone‐augmented group; 19% in the control). Severity of depressive symptoms reduced when current treatment was augmented with cariprazine (MD on MADRS ‐1.50, 95% CI ‐2.74 to ‐0.25; high‐quality evidence), olanzapine (MD on HAM‐D ‐7.9, 95% CI ‐16.76 to 0.96; low‐quality evidence; MD on MADRS ‐12.4, 95% CI ‐22.44 to ‐2.36; low‐quality evidence), quetiapine (SMD ‐0.32, 95% CI ‐0.46 to ‐0.18; I2 = 6%, high‐quality evidence), or ziprasidone (MD on HAM‐D ‐2.73, 95% CI ‐4.53 to ‐0.93; I2 = 0, moderate‐quality evidence) compared with continuing on antidepressant monotherapy. However, a greater number of participants dropped out when antidepressant monotherapy was augmented with an antipsychotic (cariprazine RR 1.68, 95% CI 1.16 to 2.41; quetiapine RR 1.57, 95% CI: 1.14 to 2.17; ziprasidone RR 1.60, 95% CI 1.01 to 2.55) compared with antidepressant monotherapy, although estimates for olanzapine augmentation were imprecise (RR 0.33, 95% CI 0.04 to 2.69). Dropout rates ranged from 10% to 39% in the groups augmented with an antipsychotic, and from 12% to 23% in the comparison groups. The most common reasons for dropping out were side effects or adverse events. We also summarised data about response and remission rates (based on changes in depressive symptoms) for included studies, along with data on social adjustment and social functioning, quality of life, economic outcomes and adverse events. Authors' conclusionsA small body of evidence shows that augmenting current antidepressant therapy with mianserin or with an antipsychotic (cariprazine, olanzapine, quetiapine or ziprasidone) improves depressive symptoms over the short‐term (8 to 12 weeks). However, this evidence is mostly of low or moderate quality due to imprecision of the estimates of effects. Improvements with antipsychotics need to be balanced against the increased likelihood of dropping out of treatment or experiencing an adverse event. Augmentation of current antidepressant therapy with a second antidepressant, mirtazapine, does not produce a clinically important benefit in reduction of depressive symptoms (high‐quality evidence). The evidence regarding the effects of augmenting current antidepressant therapy with buspirone or switching current antidepressant treatment to mianserin is currently insufficient. Further trials are needed to increase the certainty of these findings and to examine long‐term effects of treatment, as well as the effectiveness of other pharmacological treatment strategies.

Background Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review. Objectives To determine the effectiveness of interventions intended to prevent obesity in children, assessed by change in body-mass index (BMI) and BMI z-score (zBMI). Search methods We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers. Selection criteria Randomised controlled trials (RCTs) of diet (D) or physical activity (PA) interventions, or combined D+PA interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline. Data collection and analysis Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse event, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to12 years, and 13 to18 years afor zBMI and BMI,Main results We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that D+PA interventions, compared with control, reduced BMI (mean difference (MD) −0.07 kg/m2, 95% confidence interval (CI) −0.14 to −0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD −0.11, 95% CI −0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD −0.22 kg/m2, 95% CI −0.44 to 0.01) or zBMI (diet alone: MD −0.14, 95% CI −0.32 to 0.04; physical activity alone: MD 0.01, 95% CI −0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD −0.10 kg/m2, 95% CI −0.14 to −0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD −0.02, 95% CI −0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that D+PA compared with control, reduced zBMI (MD −0.05 kg/m2, 95% CI −0.10 to −0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD −0.03, 95% CI −0.06 to 0.01) or BMI (−0.02 kg/m2, 95% CI −0.11 to 0.06).Children aged 13 to 18 years: There is very-low certainty evidence that physical activity interventions, compared with control reduced BMI (MD −1.53 kg/m2, 95% CI −2.67 to −0.39; 4 RCTs; n = 720); and low certainty evidence for a reduction in zBMI (MD -0.2, 95% CI −0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that D+PA compared with control, had no effect on BMI (MD −0.02 kg/m2, 95% CI −0.10 to 0.05); or zBMI (MD 0.01, 95% CI −0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions:Two RCTs reported data directly comparing diet with either physical activity or D+PA interventions for children aged 6 – 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.Authors' conclusions Interventions that include D+PA can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial. However, interventions that focus only on physical activity do not appear to be effective in children of this age.In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that D+PA may be effective but we are very uncertain about this result. This review highlights a lack of evidence on, and the necessity for, RCTs to measure and report adverse effects and health inequalities.The interventions included in this update mainly focused on changing individual (personal) behaviours and were conducted in childcare centres, schools, homes and healthcare centres. About 15% of the interventions were conducted in the wider community, mainly local public community or recreation centres. If we are serious about tackling childhood obesity, this will require the implementation of these wider community-level interventions, together with upstream environmental and policy interventionsEvidence from newly identified RCTs from UMIC and LMIC countries is an important contribution for this updated review, in terms of context and external validity, particularly for policy-makers in those countries. This updated review also confirms, importantly, that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities. The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

BackgroundIn epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID‐19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.ObjectivesTo evaluate which type of full‐body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.Search methodsWe searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.Selection criteriaWe included all controlled studies that evaluated the effect of full‐body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.Data collection and analysisTwo review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random‐effects meta‐analyses were appropriate.Main resultsEarlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi‐RCT and nine had a non‐randomised design.Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups.Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias.Types of PPEThe use of a powered, air‐purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non‐compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were more difficult to doff than isolation gowns (very low‐certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) −10.28, 95% CI −14.77 to −5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI −0.15 to 3.35) compared to more water‐repellent material but may have greater user satisfaction (MD −0.46, 95% CI −0.84 to −0.08, scale of 1 to 5). According to three studies that tested more recently introduced full‐body PPE ensembles, there may be no difference in contamination.Modified PPE versus standard PPEThe following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown‐wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low‐certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31).Donning and doffingUsing Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD −5.44, 95% CI −7.43 to −3.45). One‐step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double‐gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD −0.9, 95% CI −1.4 to −0.4) and to fewer contamination spots (MD −5, 95% CI −8.08 to −1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol‐based hand rub.TrainingThe use of additional computer simulation may lead to fewer errors in doffing (MD −1.2, 95% CI −1.6 to −0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face‐to‐face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.Authors' conclusionsWe found low‐ to very low‐certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one‐step glove and gown removal, double‐gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face‐to‐face training in PPE use may reduce errors more than folder‐based training.We still need RCTs of training with long‐term follow‐up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real‐life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

Background: A large number of people are employed in sedentary occupations. Physical inactivity and excessive sitting at workplaces have been linked to increased risk of cardiovascular disease, obesity, and all-cause mortality. Objectives: To evaluate the effectiveness of workplace interventions to reduce sitting at work compared to no intervention or alternative interventions. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, OSH UPDATE, PsycINFO, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal up to 9 August 2017. We also screened reference lists of articles and contacted authors to find more studies. Selection criteria: We included randomised controlled trials (RCTs), cross-over RCTs, cluster-randomised controlled trials (cluster-RCTs), and quasi-RCTs of interventions to reduce sitting at work. For changes of workplace arrangements, we also included controlled before-and-after studies. The primary outcome was time spent sitting at work per day, either self-reported or measured using devices such as an accelerometer-inclinometer and duration and number of sitting bouts lasting 30 minutes or more. We considered energy expenditure, total time spent sitting (including sitting at and outside work), time spent standing at work, work productivity and adverse events as secondary outcomes. Data collection and analysis: Two review authors independently screened titles, abstracts and full-text articles for study eligibility. Two review authors independently extracted data and assessed risk of bias. We contacted authors for additional data where required. Main results: We found 34 studies - including two cross-over RCTs, 17 RCTs, seven cluster-RCTs, and eight controlled before-and-after studies - with a total of 3,397 participants, all from high-income countries. The studies evaluated physical workplace changes (16 studies), workplace policy changes (four studies), information and counselling (11 studies), and multi-component interventions (four studies). One study included both physical workplace changes and information and counselling components. We did not find any studies that specifically investigated the effects of standing meetings or walking meetings on sitting time. Physical workplace changes Interventions using sit-stand desks, either alone or in combination with information and counselling, reduced sitting time at work on average by 100 minutes per workday at short-term follow-up (up to three months) compared to sit-desks (95% confidence interval (CI) -116 to -84, 10 studies, low-quality evidence). The pooled effect of two studies showed sit-stand desks reduced sitting time at medium-term follow-up (3 to 12 months) by an average of 57 minutes per day (95% CI -99 to -15) compared to sit-desks. Total sitting time (including sitting at and outside work) also decreased with sit-stand desks compared to sit-desks (mean difference (MD) -82 minutes/day, 95% CI -124 to -39, two studies) as did the duration of sitting bouts lasting 30 minutes or more (MD -53 minutes/day, 95% CI -79 to -26, two studies, very low-quality evidence). We found no significant difference between the effects of standing desks and sit-stand desks on reducing sitting at work. Active workstations, such as treadmill desks or cycling desks, had unclear or inconsistent effects on sitting time. Workplace policy changes We found no significant effects for implementing walking strategies on workplace sitting time at short-term (MD -15 minutes per day, 95% CI -50 to 19, low-quality evidence, one study) and medium-term (MD -17 minutes/day, 95% CI -61 to 28, one study) follow-up. Short breaks (one to two minutes every half hour) reduced time spent sitting at work on average by 40 minutes per day (95% CI -66 to -15, one study, low-quality evidence) compared to long breaks (two 15-minute breaks per workday) at short-term follow-up. Information and counselling Providing information, feedback, counselling, or all of these resulted in no significant change in time spent sitting at work at short-term follow-up (MD -19 minutes per day, 95% CI -57 to 19, two studies, low-quality evidence). However, the reduction was significant at medium-term follow-up (MD -28 minutes per day, 95% CI -51 to -5, two studies, low-quality evidence). Computer prompts combined with information resulted in no significant change in sitting time at work at short-term follow-up (MD -10 minutes per day, 95% CI -45 to 24, two studies, low-quality evidence), but at medium-term follow-up they produced a significant reduction (MD -55 minutes per day, 95% CI -96 to -14, one study). Furthermore, computer prompting resulted in a significant decrease in the average number (MD -1.1, 95% CI -1.9 to -0.3, one study) and duration (MD -74 minutes per day, 95% CI -124 to -24, one study) of sitting bouts lasting 30 minutes or more. Computer prompts with instruction to stand reduced sitting at work on average by 14 minutes per day (95% CI 10 to 19, one study) more than computer prompts with instruction to walk at least 100 steps at short-term follow-up. We found no significant reduction in workplace sitting time at medium-term follow-up following mindfulness training (MD -23 minutes per day, 95% CI -63 to 17, one study, low-quality evidence). Similarly a single study reported no change in sitting time at work following provision of highly personalised or contextualised information and less personalised or contextualised information. One study found no significant effects of activity trackers on sitting time at work. Multi-component interventions Combining multiple interventions had significant but heterogeneous effects on sitting time at work (573 participants, three studies, very low-quality evidence) and on time spent in prolonged sitting bouts (two studies, very low-quality evidence) at short-term follow-up. Authors' conclusions: At present there is low-quality evidence that the use of sit-stand desks reduce workplace sitting at short-term and medium-term follow-ups. However, there is no evidence on their effects on sitting over longer follow-up periods. Effects of other types of interventions, including workplace policy changes, provision of information and counselling, and multi-component interventions, are mostly inconsistent. The quality of evidence is low to very low for most interventions, mainly because of limitations in study protocols and small sample sizes. There is a need for larger cluster-RCTs with longer-term follow-ups to determine the effectiveness of different types of interventions to reduce sitting time at work.

This is the protocol for a review and there is no abstract. The objectives are as follows: The overall objective of the review is to assess the effectiveness, safety and economic value of professionally applied fluoride paint-on solutions for caries control in children and adolescents, and their relative value compared to other topical fluorides. The specific objectives are. a) To determine the effectiveness and safety of professionally applied fluoride paint-on solutions in preventing and treating caries (stopping, slowing or reversing the progress of carious lesion) in children and adolescents against placebo/no treatment. b) To examine whether the effectiveness of fluoride paint-on solutions in preventing or treating caries is different with different: i. Baseline caries levels (average DMF/def scores of the sample) ii. Severity of the lesions (average size; depth, D, 2, 3, 4; or activity status etc. of lesions in sample) iii. Background exposure to fluoride in water, salt, toothpaste or any other fluoride source iv. Fluoride compounds (sodium fluoride (NaF), stannous fluoride (SnF2), silver diamine fluoride (SDF), acidulated phosphate fluoride (APF), etc.) v. Fluoride concentrations (parts per million of fluoride (ppm F)) vi. Frequency of application (times per year) vii. Duration of application (in minutes). c) To determine if there is a difference in effectiveness and safety of professionally applied fluoride paint-on solutions compared to other modalities of topical fluorides (toothpastes, mouthwashes, gels and varnishes). d) To determine if professionally applied fluoride paint-on solutions when used in addition to fluoride toothpaste are more effective than fluoride toothpaste used alone. e) To assess current evidence on the economic value associated with professionally applied fluoride paint-on solutions compared to other modalities of topical fluorides (toothpastes, mouthwashes, gels and varnishes), in terms of (incremental) resource use, costs and cost effectiveness.

Background Antidepressants continue to be a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression will not respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group.Objectives To assess the effectiveness of psychotherapies for adults with TRD.Search methods We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. We did not apply date or language restrictions.Selection criteria We included randomised controlled trials (RCTs) that enrolled participants 18 to 74 years of age who had received a diagnosis of unipolar depression that had not responded to antidepressant treatment of at least four weeks' duration at a recommended dose. We excluded studies of people with drug intolerance. Acceptable diagnoses of unipolar depression were based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions of this publication, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included studies conducted to perform either of the following comparisons in patients with TRD.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability).Data collection and analysis Review authors extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and we summarised dichotomous outcomes using risk ratios (RRs).Main results We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one study each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests favourable effects on depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and favourable results with added CBT over the long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248) versus usual care alone.Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years.Authors' conclusions Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large randomised controlled trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.

Introduction In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or SARS, healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients‘ contaminated body fluids. Personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCWs use PPE as instructed. Methods We systematically searched for and included all eligible controlled studies that compared the effect of types or components of PPE in HCWs exposed to highly infectious diseases with serious consequences, such as EVD and SARS, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or removing PPE, and the effects of various types of training in PPE use on the same outcomes. Result We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. We also found very low quality evidence that double gloving and CDC doffing guidance appear to decrease the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training. However, the data all come from single studies with high risk of bias and we are uncertain about the estimates of effects. Discussion We need simulation studies, preferably using a non-pathogenic virus, to find out which type and combination of PPE protects best, and what is the best way to remove PPE. We also need RCTs of one type of training versus another to find out long term effects. HCWs exposed to highly infectious diseases should have their use of PPE registered.

Introduction It is generally felt that randomised studies are difficult to conduct in the work-environment. Then again, nonrandomised studies (NRS) are considered to provide less reliable evidence for intervention effects. However, these are included in Cochrane reviews, despite discouragement. There has been no evaluation of when and how these designs are used. Therefore we conducted an overview of current practice. Methods We included all Cochrane reviews that considered NRS. We conducted study screening and data extraction in duplicate. Result Of the included 202 reviews, 114 (56%) did not cite a reason for including NRS. In reviews that do cite a reason, the reasons were divided into two major categories: NRS were included because randomised trials (RCTs) are wanted (n=81, 92%) but not feasible, lacking, or insufficient alone, or because RCTs are not needed (n=7, 8%). Review authors included a range of study designs with controlled before after studies being the most common. Most interventions evaluated in Cochrane reviews incorporating NRS were non-pharmaceutical and the settings non-medical. For risk of bias assessment, most review authors (38%) used Cochrane Effective Practice and Organisation of Care (EPOC) Group’s checklists while others used a variety of checklists and self-constructed tools. Discussion Most Cochrane reviews do not justify including NRS. Where they do, the majority is not in line with Cochrane recommendations. Risk of bias assessment varies across reviews and needs improvement. We provide an algorithm for when it is useful to include NRS in systematic reviews. If interventions are implemented at the group level as is often the case in occupational health studies, it is useful to also include NRS.

Medline search strategy. (DOC 66 kb)

Tables of excluded and ongoing reviews. (DOCX 64 kb)

Weight gain as reported in included reviews. (DOCX 15 kb)

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted. Objectives To evaluate the association between the quality of relationship between a person with dementia and their family carer and outcomes for the person with dementia. Design Systematic review. Eligibility criteria Cohort studies of people with clinically diagnosed dementia and their main carers. Exposures of interest were any elements of relationship quality, for example, attachment style, expressed emotion and coping style. Our primary outcome was institutionalisation, and secondary outcomes were hospitalisation, death, quality of life and behavioural and psychiatric symptoms of dementia ('challenging behaviour'). Data sources MEDLINE, Embase, Web of Science, PsycInfo, the Cochrane Library and Opengrey were searched from inception to May 2017. Study appraisal and synthesis methods The Newcastle-Ottawa Scale was used to assess risk of bias. A narrative synthesis of results was performed due to differences between studies. Results Twenty studies were included. None of the studies controlled for all prespecified confounding factors (age, gender, socioeconomic status and severity of dementia). Reporting of results was inadequate with many studies simply reporting whether associations were statistically significant' without providing effect size estimates or CIs. There was a suggestion of an association between relationship factors and global challenging behaviour. All studies evaluating global challenging behaviour provided statistical evidence of an association (most P values below 0.02). There was no consistent evidence for an association for any other outcome assessed. Conclusions There is currently no strong or consistent evidence on the effects of relationship factors on institutionalisation, hospitalisation, death or quality of life for people with dementia. There was a suggestion of an association between relationship factors and challenging behaviour, although the evidence for this was weak. To improve our ability to support those with dementia and their families, further robust studies are needed. PROSPERO registration number CRD42015020518.

Objectives: To determine the effects of low-to-moderate levels of maternal alcohol consumption in pregnancy on pregnancy and longer-term offspring outcomes.Search Strategy: Medline, Embase, Web of Science, and Psychinfo from inception to 11-07-2016. Selection Criteria: Prospective observational studies, negative control and quasi-experimental studies of pregnant women estimating effects of light drinking in pregnancy (≤32g/week) versus abstaining. Pregnancy outcomes such as birth weight, and features of fetal alcohol syndrome were examined. Data Collection and Analysis: One reviewer extracted data and another checked extracted data. Random effects meta-analyses were performed where applicable, and a narrative summary of findings was carried out otherwise. Main Results: 24 cohort and two quasi-experimental studies were included. With the exception of birth size and gestational age, there was insufficient data to meta-analyse or make robust conclusions. Odds of small-for-gestational-age (SGA) and preterm birth were higher for babies whose mothers consumed up to 32g/week versus none, but estimates for preterm birth were also compatible with no association: summary odd ratios (OR) 1·08, 95% confidence intervals (CI) (1·02 to 1·14), I2 0%, (7 studies, all estimates were adjusted) OR 1·10, 95%CI (0·95 to1·28), I2 60%, (9 studies, includes one unadjusted estimates) respectively. The earliest time points of exposure were used in the analysis.Conclusion: Evidence of the effects of drinking

List of excluded studies. (PDF 338 kb)

The Cochrane Oral Health Groups Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, the U.S. National Institutes of Health Trials Register and WHO International Clinical Trials Registry.Randomised controlled trials with an intervention and follow-up period of at least two years, comparing fluoridated milk with non-fluoridated milk.Two reviewers independently extracted data and assessed risk of bias with the Cochrane risk of bias tool.Only one unpublished trial was included. It involved 180 children aged three years at study commencement and was considered to be at high risk of bias. After three years permanent teeth had a caries reduction (mean difference (MD) -0.13, 95% CI -0.24 to -0.02) and primary teeth a caries reduction (MD -1.14, 95% CI -1.86 to -0.42). For primary teeth this is a substantial reduction, equivalent to a prevented fraction of 31%. For permanent teeth,the disease level was very low in the study, resulting in a small absolute effect size.There is low quality evidence to suggest fluoridated milk may be beneficial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. Due to the low quality of the evidence, further research is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. There was only one relatively small study, which had important methodological limitations on the data for the effectiveness in reducing caries. Furthermore, there was no information about the potential harms of the intervention. Additional RCTs of high quality are needed before we can draw definitive conclusions about the benefits of milk fluoridation.

Aims and objectives: To identify the role of dental surgical procedures in contributing to the transmission of hepatitis C. Design: Prospective observational pilot study. Setting: Shaikh Zayed Federal Postgraduate Medical Institute Lahore, Pakistan. Methods: Exposure to dental procedures, injections, tattooing, surgical intervention, blood transfusions, family history of hepatitis, diabetes mellitus and contact with jaundiced patients was evaluated in 78 consecutive adult patients of both sexes suffering from chronic hepatitis C. Main outcome measures: Distribution of risk factors for acquiring hepatitis C with emphasis on role of dentistry as a possible route of transmission. Results: Dental procedures were the major source of exposure (39.7%) followed by injections (16.6%), surgical procedures (16.6%), diabetes (12.8%), family history of hepatitis (9%), blood transfusions (7%), tattooing (5.1%) and history of contact with a jaundiced patient (2.6%). There was a statistically significant difference in distribution of risk factors, with dental procedures being the commonest factor (p < 0.001). Conclusions: The high prevalence of dental procedures in patients with chronic hepatitis C stresses the importance of ineffective infection control methods practiced by dental surgeons as a risk factor for acquiring hepatitis C and which were probably the source of infection. Large epidemiological studies are needed to elucidate the role of dentistry in transmitting hepatitis C.

The number of people working whilst seated at a desk keeps increasing worldwide. As sitting increases, occupational physical strain declines at the same time. This has contributed to increases in cardiovascular disease, obesity and diabetes. Therefore, reducing and breaking up the time that people spend sitting while at work is important for health.To evaluate the effects of workplace interventions to reduce sitting at work compared to no intervention or alternative interventions.We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, OSH UPDATE, PsycINFO, Clinical trials.gov and the World Health Organization (WHO) search trial portal up to 14 February, 2014. We also searched reference lists of articles and contacted authors.We included randomised controlled trials (RCT), cluster-randomised controlled trials (cRCTs), and quasi-randomised controlled trials of interventions to reduce sitting at work. For changes of workplace arrangements, we also included controlled before-and-after studies (CBAs) with a concurrent control group. The primary outcome was time spent sitting at work per day, either self-reported or objectively measured by means of an accelerometer coupled with an inclinometer. We considered energy expenditure, duration and number of sitting episodes lasting 30 minutes or more, work productivity and adverse events as secondary outcomes.Two review authors independently screened titles, abstracts and full-text articles for study eligibility. Two review authors independently extracted data and assessed risk of bias. We contacted authors for additional data where required.We included eight studies, four RCTs, three CBAs and one cRCT, with a total of 1125 participants. The studies evaluated physical workplace changes (three studies), policy changes (one study) and information and counselling (four studies). No studies investigated the effect of treadmill desks, stepping devices, periodic breaks or standing or walking meetings. All the studies were at high risk of bias. The quality of the evidence was very low to low. Half of the studies were from Australia and the other half from Europe, with none from low- or middle-income countries. Physical workplace changesWe found very low quality evidence that sit-stand desks with or without additional counselling reduced sitting time at work per workday at one week follow-up (MD -143 minutes (95% CI -184 to -102, one study, 31 participants) and at three months' follow-up (MD - 113 minutes, 95% CI -143 to -84, two studies, 61 participants) compared to no intervention. Total sitting time during the whole day decreased also with sit-stand desks compared to no intervention (MD -78 minutes, 95% CI -125 to -30, one study, 31 participants) as did the duration of sitting episodes lasting 30 minutes or more (MD -52 minutes, 95% CI -79 to -26, two studies, 74 participants). Sit-stand desks did not have a considerable effect on work performance and had an inconsistent effect on musculoskeletal symptoms and sick leave. Policy changesWalking strategies had no considerable effect on sitting at work (MD -16 minutes, 95% CI -54 to 23, one study, 179 participants, low quality evidence). Information and counsellingGuideline-based counselling by occupational physicians reduced sitting time at work (MD -28 minutes, 95% CI -54 to -2, one study, 396 participants, low quality evidence). There was no considerable effect on reduction in total sitting time during the whole day.Mindfulness training induced a non-significant reduction in workplace sitting time (MD -2 minutes, 95% CI -22 to 18) at six months' follow-up and at 12 months' follow-up (MD -16 minutes, 95% CI -45 to 12, one study, 257 participants, low quality evidence).There was an inconsistent effect of computer prompting on sitting time at work. One study found no considerable effect on sitting at work (MD -18 minutes, 95% CI -53 to 17, 28 participants, low quality evidence) at 10 days' follow-up, while another study reported a significant reduction in sitting at work (MD -55 minutes, 95% CI -96 to -14, 34 participants, low quality evidence) at 13 weeks' follow-up. Computer prompting software also led to a non-significant increase in energy expenditure at work (MD 278 calories/workday, 95% CI 0 to 556, one study, 34 participants, low quality evidence) at 13 weeks' follow-up.At present there is very low quality evidence that sit-stand desks can reduce sitting time at work, but the effects of policy changes and information and counselling are inconsistent. There is a need for high quality cluster-randomised trials to assess the effects of different types of interventions on objectively measured sitting time. There are many ongoing trials that might change these conclusions in the near future.

Background Healthcare workers are at risk of acquiring viral diseases such as hepatitis B, hepatitis C and HIV through exposure to contaminated blood and body fluids at work. Most often infection occurs when a healthcare worker inadvertently punctures the skin of their hand with a sharp implement that has been used in the treatment of an infected patient, thus bringing the patient's blood into contact with their own. Such occurrences are commonly known as percutaneous exposure incidents. Objectives To determine the benefits and harms of extra gloves for preventing percutaneous exposure incidents among healthcare workers versus no intervention or alternative interventions. Search methods We searched CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL, NIOSHTIC, CISDOC, PsycINFO and LILACS until 26 June 2013. Selection criteria Randomised controlled trials (RCTs) with healthcare workers as the majority of participants, extra gloves or special types of gloves as the intervention, and exposure to blood or bodily fluids as the outcome. Data collection and analysis Two authors independently assessed study eligibility and risk of bias, and extracted data. We performed meta-analyses for seven different comparisons. Main results We found 34 RCTs that included 6890 person-operations as participating units and reported on 46 intervention-control group comparisons. We grouped interventions as follows: increased layers of standard gloves, gloves manufactured with special protective materials or thicker gloves, and gloves with puncture indicator systems. Indicator gloves show a coloured spot when they are perforated. Participants were surgeons in all studies and they used at least one pair of standard gloves as the control intervention. Twenty-seven studies also included other surgical staff (e.g. nurses). All but one study used perforations in gloves as an indication of exposure. The median control group rate was 18.5 perforations per 100 person-operations. Seven studies reported blood stains on the skin and two studies reported self reported needlestick injuries. Six studies reported dexterity as visual analogue scale scores for the comparison double versus single gloves, 13 studies reported outer glove perforations. We judged the included studies to have a moderate to high risk of bias. We found moderate-quality evidence that double gloves compared to single gloves reduce the risk of glove perforation (rate ratio (RR) 0.29, 95% confidence interval (CI) 0.23 to 0.37) and the risk of blood stains on the skin (RR 0.35, 95% CI 0.17 to 0.70). Two studies with a high risk of bias also reported the effect of double compared to single gloves on needlestick injuries (RR 0.58, 95% CI 0.21 to 1.62). We found low-quality evidence in one small study that the use of three gloves compared to two gloves reduces the risk of perforation further (RR 0.03, 95% CI 0.00 to 0.52). There was similar low-quality evidence that the use of one fabric glove over one normal glove reduces perforations compared to two normal gloves (RR 0.24, 95% CI 0.06 to 0.93). There was moderate-quality evidence that this effect was similar for the use of one special material glove between two normal material gloves. Thicker gloves did not perform better than thinner gloves. There was moderate to low-quality evidence in two studies that an indicator system does not reduce the total number of perforations during an operation even though it reduces the number of perforations per glove used. There was moderate-quality evidence that double gloves have a similar number of outer glove perforations as single gloves, indicating that there is no loss of dexterity with double gloves (RR 1.10, 95% CI 0.93 to 1.31). Authors' conclusions There is moderate-quality evidence that double gloving compared to single gloving during surgery reduces perforations and blood stains on the skin, indicating a decrease in percutaneous exposure incidents. There is low-quality evidence that triple gloving and the use of special gloves can further reduce the risk of glove perforations compared to double gloving with normal material gloves. The preventive effect of double gloves on percutaneous exposure incidents in surgery does not need further research. Further studies are needed to evaluate the effectiveness and cost-effectiveness of special material gloves and triple gloves, and of gloves in other occupational groups.

We thank Dr Stevens et al (1) for their comments and interest in our work. We also thank the primary study authors who wrote this letter for their contribution and assistance during the course of our review in 2012. We would not have been able to achieve the quality in our analysis without their input. We certainly agree with their opinion on the current state of evidence being less than ideal and needing more rigor. Thus we believe that their arguments support our conclusion that, based on the low quality of exposure data and the difference in effect by study design, our findings indicate insufficient evidence for a causal relationship between night-shift work and breast cancer. We used recommended guidelines for systematic reviews employing state-of-the-art, valid methods (2–4). One of the key features is that studies of sufficient clinical and statistical homogeneity are combined (5). Clearly the studies that did not fit our predefined criteria for night-shift work based on Stevens et al (6) were not included in the meta-analysis and conclusions. Variation in exposure definition and assessment was further taken into account in risk of bias assessment and did not change results in a subsequent sensitivity analysis. Further bias in our review was avoided by ensuring all decisions on the handling of data were made in advance (a priori protocol) thus separating tested prior hypotheses from ones generated by the data (post hoc). We formulated clear hypotheses about the association between exposure to shift work and breast cancer, which we tested as far as possible given the limitations of the data in the primary studies. We agree that misclassification of exposure is possibly at work in these studies but this would not always be non-differential. Even when this is the case, it is not easy to predict the final result of this bias when the exposure is not dichotomous, as is the case with shift work (7). In the absence of real evidence, we are not convinced that recall bias can be ruled out completely from case–control studies except when the exposure was measured objectively in advance of disease occurrence. Evidence exists that systematic bias occurs in peoples’ reporting of their shift-work experience (8). Most areas of medicine today follow the hierarchy of evidence, preferring prospectively followed-up data to assert or refute causal relationships (9–11), and it should be the same here. We do not know if a long-term risk exists or not because, until Grundy et al’s (12) recently published findings, studies have not used an evidence-based ­a-priori classification of exposure time but rather a data-driven approach to analysis. Following the Grundy et al study, apparently long-term has been defined as >30 years of exposure; we recommend this be further explored. As Stevens et al (1) point out, other meta-analyses came to different conclusions. This is the result of using different inclusion criteria, different methods for combining studies, and the risk of bias assessment. Per GRADE’s (13) recommendation, we used a systematic approach in grading the quality of the evidence. As a result, we rated the evidence as being of very low quality, which means we have little confidence in the results. The authors are also correct in saying that more primary studies find a positive than a negative link. However this method of evidence synthesis, also called vote counting, is widely known to lead to incorrect conclusions. Repeating more meta-analyses and primary studies is not going to bring us closer to the truth, unless the issues in previous research are redressed by improved methods in the future, guidelines for most of which exist in the literature. To this end, a research group recently proposed the idea of conducting an individual participant data (IPD) meta-analysis using the available primary studies. We welcome this initiative as it can put to rest some doubts and save valuable resources. An alternative could be to pool/connect all databases that contain information on working hours and analyze these together as a large single study for hypotheses defined a-priori. We believe that both shift-work exposure and breast cancer are important public health issues that deserve better studies to underpin decisions on causes and solutions.

Objectives Nonrandomized studies (NRSs) are considered to provide less reliable evidence for intervention effects. However, these are included in Cochrane reviews, despite discouragement. There has been no evaluation of when and how these designs are used. Therefore, we conducted an overview of current practice. Study Design and Setting We included all Cochrane reviews that considered NRS, conducting inclusions and data extraction in duplicate. Results Of the included 202 reviews, 114 (56%) did not cite a reason for including NRS. The reasons were divided into two major categories: NRS were included because randomized controlled trials (RCTs) are wanted (N = 81, 92%) but not feasible, lacking, or insufficient alone or because RCTs are not needed (N = 7, 8%). A range of designs were included with controlled before-after studies as the most common. Most interventions were nonpharmaceutical and the settings nonmedical. For risk of bias assessment, Cochrane Effective Practice and Organisation of Care Group's checklists were used by most reviewers (38%), whereas others used a variety of checklists and self-constructed tools. Conclusion Most Cochrane reviews do not justify including NRS. When they do, most are not in line with Cochrane recommendations. Risk of bias assessment varies across reviews and needs improvement.

Background: Breast cancer is the most common cancer among women in Malaysia. Barriers for practicing breast self examination (BSE) await exploration. Objective: To assess the practice of BSE and its correlated factors and particularly barriers amongst urban women in Malaysia. Methods: This cross-sectional study was conducted with 222 Malaysian women using a self-administered questionnaire. Results: The mean (SD) age was 28.5 (±9.2) years, 59.0% were university graduates. Of the total, 81.1% were aware of breast cancer and 55% practiced BSE. Amongst 45% of respondents who did not practice BSE, 79.8% did not know how to do it, 60.6% feared being diagnosed with breast cancer, 59.6% were worried about detecting breast cancer, 22% reported that they should not touch their bodies, 44% and 28% reported BSE is embarrassing or unpleasant, 29% time consuming, 22% thought they would never have breast cancer or it is ineffective and finally 20% perceived BSE as unimportant. Logistic regression modeling showed that respondents aged ≥45 years, being Malay, married and having a high education level were more likely to practice BSE (p

Pre-term delivery of low-birth-weight (PLBW) babies is considered a major peri-natal problem in many countries and is contributing substantially to infant mortality and to childhood handicap. There is a reported incidence of pre-term delivery of low-birth-weight (PLBW) babies of 37% of all live births in Pakistan, which has a tremendous impact on health care system in this community. The prevalence of periodontal disease in Pakistan is also very high in all age groups and women of child bearing age (18-34 years) are no exception. Recent studies indicate periodontal infection as a potential independent risk factor for PLBW, and is considered to be 7 times more likely to be associated than any other risk factors. Several postulated mechanisms have been reviewed, including the virulence effects and role of asymptomatic bacteraemia, focusing on the bacterial load in periodontium facilitating its transmission from oral cavity to the uterus. The indication that periodontal disease is a potential risk factor for the delivery of PLBW; a high level of periodontal disease in women of child bearing age and similar high level of PLBW babies in country, calls for further longitudinal investigations that validate a causal relationship between periodontal infection and pre-term delivery of LBW babies in Pakistan. A review of literature and preliminary communication for a planned study is presented.