Diet and the risk of unipolar depression in adults: systematic review of cohort studies.

BACKGROUND: Nutrition may be a risk factor for unipolar depression. We aimed to review the association between dietary variables and the risk of depression. METHODS: Fifteen databases were searched up to May 2010. Only longitudinal studies for which outcomes were unipolar depression and/or depressive symptoms in adults were eligible for inclusion. Eleven studies were included and critically evaluated. Participants were in the age range 18-97 years and the study sample size was in the range 526-27 111. Follow-up ranged from 2 to 13 years. The diversity of dietary variables and nonlinear associations precluded formal meta-analysis and so a narrative analysis was undertaken. RESULTS: Variables inversely associated with depression risk were the consumption of nutrients such as folate, omega-3 fatty acids and monounsaturated fatty acids; foods such as olive oil and fish; and a diet rich in fruits, vegetables, nuts and legumes. Some of these associations varied by sex and some showed a nonlinear association. CONCLUSIONS: At the study level, weaknesses in the assessment of exposure and outcome may have introduced bias. Most studies investigated a cohort subgroup that may have resulted in selection bias. At the review level, there is a risk of publication bias and, in addition, narrative analyses are more prone to subjectivities than meta-analyses. Diet may potentially influence the risk of depression, although the evidence is not yet conclusive. Strengthening healthy-eating patterns at the public health level may have a potential benefit. Robust prospective cohort studies specially designed to study the association between diet and depression risk are needed.

Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy.

BACKGROUND: Central venous access (CVA), in which a large bore catheter is routed through a vein in the neck, upper chest or femoral area, is needed to give drugs that cannot be given by mouth or via a conventional cannula in the arm. OBJECTIVES: To establish whether either the jugular, subclavian or femoral CVA routes result in a lower incidence of venous thrombosis, venous stenosis or infection related to CVA devices.To determine whether the circumference of a long-term central venous access device influences the incidence of venous thrombosis, venous stenosis or infection related to CVA devices. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE, CINAHL, EMBASE (from inception to December 2006), reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. There were no language restrictions. SELECTION CRITERIA: We included randomized controlled trials comparing central venous catheter insertion routes. DATA COLLECTION AND ANALYSIS: Two authors assessed potentially relevant studies. We resolved disagreements by discussion. Relevant outcomes were: venous thrombosis, venous stenosis, infection related to CVA devices, mechanical complications (e.g misplaced catheter, minor bleeding, haematoma). MAIN RESULTS: We considered 83 studies for inclusion in the review. Six studies appeared eligible but five were subsequently excluded because they did not randomize participants for either site of access or catheter circumference size. One study was a high quality block randomized controlled trial. Allocation concealment was good and randomization was by a central computer. In all, 293 patients were randomized to a femoral or a subclavian CVA group. Results from this one trial were as follows. 1. CATHETER-RELATED INFECTIOUS COMPLICATIONS: Infectious complication (colonization with or without sepsis: the relative risk (RR) was 4.57 (95% confidence interval (CI) 1.95 to 10.71) favouring subclavian over femoral access. Major infectious complications (sepsis with or without bacteremia): the RR was 3.04 (95% CI 0.63 to 14.82) favouring subclavian access. Colonized catheter (greater than 103 colony-forming units/mL of gram positive microorganisms): the RR was 3.65 (95%CI 1.40 to 9.56) favouring subclavian access. Colonized catheter (greater than 103 colony-forming units/mL of gram negative microorganisms): the RR was 5.41 (95% CI 1.61 to 18.15) favouring subclavian access. 2. CATHETER-RELATED MECHANICAL COMPLICATIONS: Overall complications (arterial puncture, minor bleeding, haematoma, misplaced catheter): the RR was 0.92 (95% 0.56 to 1.51) favouring subclavian access. 3. CATHETER-RELATED THROMBOTIC COMPLICATIONS: Catheter-related thromboses (fibrin sleeves, major and complete thrombosis): the RR was 11.53 (95% CI 2.80, to 47.52) favouring subclavian access. AUTHORS' CONCLUSIONS: Subclavian CVA is preferable to femoral CVA. Further trials of subclavian versus femoral or jugular CVA are needed. Research on the impact of catheter circumference on catheter-related complications is required.

Auricular acupuncture for cocaine dependence.

BACKGROUND: Auricular acupuncture (insertion of acupuncture into a number, usually five, of specific points in the ear) is a widely-used treatment for cocaine dependence. OBJECTIVES: To determine whether auricular acupuncture is an effective treatment for cocaine dependence, and to investigate whether its effectiveness is influenced by the treatment regimen. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004); MEDLINE (January 1966 to October 2004) , EMBASE (January 1988 to October 2004); PsycInfo (1985 to October 2004); CINAHL (1982 to October 2004); SIGLE (1980 to October 2004) and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials comparing a therapeutic regimen of auricular acupuncture with sham acupuncture or no treatment for reduction of cocaine use in cocaine dependents. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data from published reports and assessed study quality using the Drug and Alcohol CRG checklist. All authors were contacted for additional information; two provided data. Separate meta-analyses were conducted for studies comparing auricular acupuncture with sham acupuncture, and with no treatment. For the main cocaine use outcomes, analyses were conducted by intention to treat, assuming that missing data were treatment failures. Available case analyses, using only individuals who provided data, were also conducted. MAIN RESULTS: Seven studies with a total of 1,433 participants were included. All were of generally low methodological quality. No differences between acupuncture and sham acupuncture were found for attition RR 1.05 (95% CI 0.89 to 1.23) or acupuncture and no acupuncture: RR 1.06 (95% CI 0.90 to 1.26) neither for any measure of cocaine or other drug use. However, the number of participants included in meta-analyses was low, and power was limited. Moderate benefit or harm is not ruled out by these results. Methodological limitations of the included studies may have also made the results open to bias. AUTHORS' CONCLUSIONS: There is currently no evidence that auricular acupuncture is effective for the treatment of cocaine dependence. The evidence is not of high quality and is inconclusive. Further randomised trials of auricular acupuncture may be justified.

Therapeutic communities for substance related disorder.

BACKGROUND: Therapeutic communities (TCs) are a popular treatment for the rehabilitation of drug users in the USA and Europe. OBJECTIVES: To determine the effectiveness of TC versus other treatments for substance dependents, and to investigate whether effectiveness is modified by client or treatment characteristics. SEARCH STRATEGY: We searched: Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2005); MEDLINE, EMBASE, Psycinfo, CINAHL, SIGLE from their inception to March 2004. Reference lists of studies were scanned. SELECTION CRITERIA: Randomised controlled trials comparing TC with other treatments, no treatment or another TC. DATA COLLECTION AND ANALYSIS: Two authors independently inspected abstracts, the methodological quality was assessed using Drug and Alcohol CRG checklist. When possible, data were summarised using relative risks and differences in means, otherwise results are presented as reported by authors. MAIN RESULTS: Seven studies were included. Differences between studies precluded any pooling of data, results are summarised for each trial individually: TC versus community residence: no significant differences for treatment completion; Residential versus day TC: attrition (first two weeks), and abstinence rates at six months significantly lower in the residential treatment group; Standard TC versus enhanced abbreviated TC: number of employed higher in standard TC RR 0.78 (95% CI 0.63, 0.96). Three months versus six months programme within modified TC, and six months versus 12 months programme within standard TC: completion rate higher in the three months programme and retention rate (40 days) significantly greater with the 12 months than 6 months programme. Two trials evaluated TCs within a prison setting: one reported significantly fewer re incarcerated 12 months after release from prison in the TC group compared with no treatment, RR 0.68 (95% CI 057, 0.81). In the other, people treated in prison with TC compared with Mental Health Treatment Programmes showed significantly fewer re incarcerations RR 0.28 (95% CI 0.13, 0.63), criminal activity 0.69 (95% CI 0.52, 0.93) and alcohol and drug offences 0.62 (95% CI 0.43, 0.90) 12 months after release from prison. AUTHORS' CONCLUSIONS: There is little evidence that TCs offer significant benefits in comparison with other residential treatment, or that one type of TC is better than another. Prison TC may be better than prison on it's own or Mental Health Treatment Programmes to prevent re-offending post-release for in-mates. However, methodological limitations of the studies may have introduced bias and firm conclusions cannot be drawn due to limitations of the existing evidence.

Interventions for prevention of drug use by young people delivered in non-school settings.

BACKGROUND: Interventions intended to prevent or reduce use of drugs by young people may be delivered in schools or in other settings. This review aims to summarise the current literature about the effectiveness of interventions delivered in non schools settings. OBJECTIVES: (1) - To summarise the current evidence about the effectiveness of interventions delivered in non-school settings intended to prevent or reduce drug use by young people under 25;(2) - To investigate whether interventions' effects are modified by the type and setting of the intervention, and the age of young people targeted;(3) - To identify areas where more research is needed. SEARCH STRATEGY: We searched Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library Issue 4, 2004), MEDLINE (1966-2004), EMBASE (1980-2004), PsycInfo (1972-2004), SIGLE (1980-2004), CINAHL (1982-2004) and ASSIA (1987-2004). We searched also reference lists of review articles and retrieved studies. SELECTION CRITERIA: Randomised trials that evaluated an intervention targeting drug use by young people under 25 years of age, delivered in a non-school setting, compared with no intervention or another intervention, that reported substantive outcomes relevant to the review. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Results were tabulated, as studies were considered too dissimilar to combine using meta-analysis. MAIN RESULTS: Seventeen studies, 9 cluster randomised studies, with 253 clusters, 8 individually randomised studies with 1230 participants, evaluating four types of intervention: motivational interviewing or brief intervention, education or skills training, family interventions and multi-component community interventions. Many studies had methodological drawbacks, especially high levels of loss to follow-up. There were too few studies for firm conclusions. One study of motivational interviewing suggested that this intervention was beneficial on cannabis use. Three family interventions (Focus on Families, Iowa Strengthening Families Program and Preparing for the Drug-Free Years), each evaluated in only one study, suggested that they may be beneficial in preventing cannabis use. The studies of multi component community interventions did not find any strong effects on drug use outcomes, and the two studies of education and skills training did not find any differences between the intervention and control groups. AUTHORS' CONCLUSIONS: There is a lack of evidence of effectiveness of the included interventions. Motivational interviewing and some family interventions may have some benefit. Cost-effectiveness has not yet been addressed in any studies, and further research is needed to determine whether any of these interventions can be recommended.

Orlistat for the treatment of obesity: cost utility model.

This study aimed to assess the cost utility of orlistat treatment based on (i) criteria from recent guidance from the National Institute for Clinical Excellence (NICE) for England and Wales (treatment discontinued if weight loss < 5% at 3 months; and < 10% at 6 months); and (ii) alternative criteria from the European Agency for the Evaluation of Medicinal Products (EMEA) licence for orlistat prescription in the European Community (treatment discontinued if weight loss < 5% at 3 months). Subjects were 1398 obese individuals who participated in three large European Phase III trials of orlistat treatment for adults (BMI: 28-47 kg m(-2)). Measures were: response to treatment in orlistat and placebo treatment groups; health benefit expressed as quality adjusted life years (QALYs) gained associated with weight loss; costs associated with orlistat treatment. In the cost utility model with multiway sensitivity analysis, the cost/QALY gained using the NICE criteria was estimated to be 24,431 pounds (sensitivity analysis range: 10,856 to 77,197 pounds). The cost/QALY gained using the alternative EMEA criteria was estimated to be 19,005 pounds (range: 8,840 to 57,798 pounds). In conclusion, NICE guidance for the continued use of orlistat was supported in this updated cost utility model, comparing favourably with a previously published estimate of 45,881 pounds per QALY gained. Moreover, the value for money of orlistat treatment is improved further if EMEA treatment criteria for continued orlistat treatment are applied. The EMEA criteria should be considered in any future changes to the NICE guidance or in guidance issued by similar agencies.

Behavioral interventions for adolescents with type 1 diabetes: how effective are they?

OBJECTIVE: To evaluate the effectiveness of behavioral interventions for adolescents with type 1 diabetes based on a systematic review of the literature. RESEARCH DESIGN AND METHODS: The literature was identified by searching 11 electronic databases, hand-searching 3 journals from their start dates, and contacting individual researchers. Only articles that reported evaluations of behavioral (including educational and psychosocial) interventions for adolescents (age range 9-21 years) with type 1 diabetes that included a control group were included in the present review. Data summarizing the key features of the interventions and their effects were extracted from each article. Where possible, effect sizes for the randomized control trials (RCTs) were calculated. RESULTS: The search process identified 64 reports of empirical studies. Of these, 35 studies included a control group, and 24 were RCTs. Effect sizes could be calculated for 18 interventions. The overall mean effect size calculated across all outcomes was 0.33 (median 0.21), indicating that these interventions have a small- to medium-sized beneficial effect on diabetes management. Interventions that were theoretically based were significantly more effective than those that were not (P<0.05, 1-tailed). CONCLUSIONS: Research to date indicates that these interventions are moderately effective. Several methodological weaknesses to be avoided in future studies are noted. It is also recommended that investigators use the reach, efficacy, adoption, implementation, and maintenance (RE-AIM) framework to guide the design of future studies, which should result in more disseminable interventions. RE-AIM assesses the intervention's reach, or percent or representativeness of patients willing to participate; efficacy across a range of outcomes; adoption, or the percent and representativeness of settings willing to implement the intervention; implementation, or the consistency of the delivery of the intervention as intended; and maintenance, or the extent to which delivery of the intervention becomes a routine part of health care in the medical setting.

Orlistat for the treatment of obesity: rapid review and cost-effectiveness model.

The aim of this study is to clarify the potential benefits, disbenefits and costs of Orlistat for the treatment of obesity. The method was a search for relevant systematic reviews and randomized controlled trials, in Medline, Pre-Medline, Embase and the Cochrane Library, using Orlistat and its synonyms. Identified trials were appraised using a standard appraisal checklist and trial data were extracted for use in cost-effectiveness modelling. Three large multicentre, randomized placebo controlled trials were included in the rapid review. On average, Orlistat results in obese people losing an additional 3-4% of their initial body weight over diet alone during a 2 year period. There was no strong evidence that this short-term weight loss would have a longer-term impact on morbidity and mortality. The cost utility of Orlistat treatment was estimated at around 46,000 Pounds per Quality Adjusted Life Year gained (extreme values sensitivity analysis 14,000 Pounds to 132,000 Pounds). This rapid review raises some important questions about the potential value of Orlistat in the treatment of obesity. Further research is needed, not only to clarify the longer-term impact of Orlistat treatment, but also to uncover the longer-term impact on mortality and morbidity from short-term weight loss.

Effects of educational and psychosocial interventions for adolescents with diabetes mellitus: a systematic review.

BACKGROUND: Insulin-dependent diabetes mellitus, also known as type 1 diabetes, is a life-threatening condition and is the third most common chronic illness among young people. As a result of minimal or non-existent insulin production, people with diabetes must take over the normally automatic task of regulation of blood glucose levels. This is achieved by a complex regimen involving multiple, daily administrations of insulin coordinated with dietary intake and energy expenditure and monitored by blood glucose testing. OBJECTIVES: To examine the effectiveness of educational and psychosocial interventions for adolescents with type 1 diabetes designed to improve their diabetes management. Specifically, it addressed the following research questions: (1) Do educational and psychosocial interventions for adolescents with type 1 diabetes have beneficial effects on biological and psychosocial outcomes? (2) Are there types or features of interventions that have been shown to be more effective than others? (3) What evidence is there of the cost-effectiveness of interventions? METHODS: A search strategy was formulated, piloted and refined. Three journals were handsearched, 11 electronic databases were searched and personal contacts, flyers, conferences and websites were used to notify the research community of the review to access further literature. This process generated 10,535 abstracts, which, after screening, resulted in 367 articles identified for retrieval. This number was augmented by hand-searching, personal contact and exploding references, and a final total of 457 articles were scrutinised. Of these, 64 reports describing 62 studies were identified as empirical papers evaluating educational or psychosocial interventions. The relevant data were extracted from the papers and summary tables for each study were prepared. Where possible, effect sizes were computed for outcomes from studies that included a randomised control group (CG) and other relevant information. RESULTS: A descriptive analysis of the 62 studies was undertaken. Most studies (67.7%) were conducted in the USA and 41% were randomised controlled trials (RCTs), none of which were UK-based. Only 48% of the reports provided an explicit theoretical rationale for the intervention. The mean number of participants was 53.8. The studies took place in various settings, evaluated a variety of interventions, involved various interventionists, addressed various components and assessed the effects by a range of outcomes, including measures of metabolic control and psychological and behavioural outcomes. Follow-up assessments were relatively rare. RESULTS - THE EFFECTIVENESS OF INTERVENTIONS: The 25 RCTs were examined in more detail and three of the most effective were described in depth. Effect sizes could be calculated for 14 studies. The mean (pooled) effect size for psychosocial outcomes was 0.37 and 0.33 for glycated haemoglobin with outliers (0.08 without outliers), indicating that these interventions have small to medium beneficial effects on diabetes management outcomes. A narrative review of the 21 pre-post studies with no CG was performed, including evaluations of interventions conducted at summer camps, interventions for poorly controlled patients and educational interventions. All studies reported beneficial effects. RESULTS - COST-EFFECTIVENESS: Few studies addressed economic considerations associated with interventions, and the lack of information on costs and the diversity of outcomes included by investigators impeded cost- effectiveness comparisons. Shorter hospitalisation at diagnosis is at least as effective in achieving control and avoiding complications in adolescence as longer stays. Home care may result in improved outcomes but may not be cheaper than hospital care at diagnosis. Targeting poorly controlled subjects may reduce adverse events and hospitalisations and may be more cost-effective than generic interventions. There is a need for rigorous cost-effectiveness studies of educational and psychosocial interventions for adolescents with type 1 diabetes that include longer-term considerations. CONCLUSIONS: The following conclusions were drawn from this review: (1) Educational and psychosocial interventions have small to medium beneficial effects on various diabetes management outcomes. (2) Well-designed trials of such interventions are needed in the UK (no completed RCTs of educational or psychosocial interventions for adolescents with type 1 diabetes conducted in the UK were found). (3) The evidence, arising primarily from studies in the USA, provides a starting point for the design of interventions in the UK. (4) Quantitative and narrative analysis of the evidence suggested that interventions are more likely to be effective if they demonstrate the inter-relatedness of the various aspects of diabetes management. (ABSTRACT TRUNCATED)

Alcohol misuse prevention for young people: a systematic review reveals methodological concerns and lack of reliable evidence of effectiveness.

In a systematic review we assessed the methodological quality of evaluations of alcohol misuse prevention programmes for young people, and recorded evidence of effectiveness. Studies were identified through systematic searches of electronic databases; hand searches of all obtained papers, existing reviews and several journals; and mailshots to key organizations, conferences and individuals. Relevant papers were checked and cross-checked by members of the review team, and only those studies with an experimental or quasi-experimental design and positive attributes on a number of other quality criteria were included in the review. After pre-screening over 500 papers which reported prevention programmes, information was systematically abstracted from 155 papers. Only 33 studies merited inclusion in the review, and most of these had some methodological shortcomings. Twenty-one studies reported some significant short- and medium-term reductions in drinking behaviour. Of two studies which carried out longer-term evaluations, only one reported a significant longer-term effect, with small effect sizes. No factors clearly distinguished partially effective from ineffective or harmful prevention programmes. In conclusion, the lack of reliable evidence means that no one type of prevention programme can be recommended. In particular there is a need to carry out well-designed scientific evaluations of the effectiveness of current or new prevention efforts which target young people's alcohol misuse.

Longer-term primary prevention for alcohol misuse in young people: a systematic review.

OBJECTIVE: To identify and summarize rigorous evaluations of psychosocial and educational interventions aimed at the primary prevention of alcohol misuse by young people aged up to 25 years, especially over the longer term (>3 years). METHODS: Cochrane Collaboration Systematic Review. DATA SOURCES: A comprehensive search of 22 databases and recursive checking of bibliographies for randomized and non-randomized controlled trials and interrupted time-series studies. MAIN OUTCOME MEASURES: Objective or self-report measures of alcohol use and misuse. RESULTS: Fifty-six studies were selected for inclusion in the systematic review. Twenty of the 56 studies showed evidence of ineffectiveness. No firm conclusions about the effectiveness of prevention interventions in the short- and medium term were possible. Over the longer term (>3 years), the Strengthening Families Programme (SFP) showed promise as an effective prevention intervention. The Number Needed to Treat (NNT) for the SFP over 4 years for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkenness) was 9 (for all three behaviours). One study also highlighted the potential value of culturally focused skills training over the longer-term (NNT = 17 over 3.5 years for 4+ drinks in the last week) CONCLUSIONS: (1) Research into important outcome variables needs to be undertaken; (2) the methodology of evaluations needs to be improved; (3) the SFP needs to be evaluated on a larger scale and in different settings; (4) culturally focused interventions require further development and rigorous evaluation; and (5) an international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention interventions in terms of safety, efficacy and effectiveness.

Organisational infrastructures to promote evidence based nursing practice.

BACKGROUND: The purpose of this systematic review is to determine to what extent organisational infrastructures are effective in promoting the implementation of high quality research evidence on the effectiveness of nursing interventions. OBJECTIVES: To identify and summarize rigorous evaluations of organisational infrastructure developments aimed at promoting evidence based nursing practice. SEARCH STRATEGY: We searched: The Cochrane Library, MEDLINE, EMBASE, CINAHL, SIGLE, HEALTHLINE, National Research Register, Nuffield Database of Health Outcomes, NIH Databases up to August 2002. We hand searched the Journal of Advanced Nursing, Applied Nursing Research and Journal of Nursing Administration (to 1999), and checked the reference lists of articles obtained. We contacted experts in the field and relevant Internet groups. SELECTION CRITERIA: Randomized controlled trials, controlled clinical trials and interrupted times series studies of an entire or identified component of an organisational infrastructure development aimed at promoting effective nursing interventions. The participants were health care organisations comprising nurses, midwives and health visitors in hospital and community settings. DATA COLLECTION AND ANALYSIS: All identified papers were screened independently for relevance, design and outcome by two reviewers. MAIN RESULTS: No studies were sufficiently rigorous to be included in this systematic review. Seven case study evaluations were identified but excluded from the review because of poor design and lack of controls. REVIEWER'S CONCLUSIONS: 1. There are no clear implications for practice.2. Several conceptual models on organisational processes to promote evidence based practice have been described in published papers, and a number of organisational infrastructural interventions have been described in published papers. None have been evaluated properly. The next step in this field should be to conduct well planned evaluations of well planned interventions. 3. Interrupted and Complex Interrupted Times Series (ITS and CITS) designs should be adopted as a useful alternative to randomized controlled trials where such trials would be impractical. The health service cost of any infrastructure developments should be assessed in any evaluation. If possible, patient outcomes should be measured directly.

Early extubation for adult cardiac surgical patients.

BACKGROUND: Over 30 studies reported that early extubation (within eight hours) appears to be safe without an increased incidence of morbidity. A benefit of the practice may be cost savings associated with shorter Intensive Care Unit and hospital length of stays. OBJECTIVES: To assess the effects of early extubation and the impact of the extubating clinician's profession on morbidity, mortality, intensive care unit and hospital length of stay, with a subgroup analysis for extubation within four hours or four to eight hours. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL)(issue 1, 2003), MEDLINE (January 1966 to June 2003), EMBASE (January 1980 to June 2003), CINAHL (January 1982 to December 2002), SIGLE(January 1980 to December 2002). We searched reference lists of articles and contacted researchers in the field. SELECTION CRITERIA: Randomized controlled trials and controlled clinical trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement, aortic aneurysm repair). DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. A meta-analysis for most outcomes was conducted. MAIN RESULTS: Six trials were included in the review. There was no evidence of a difference between early and conventionally extubated patients shown in the relative risk and 95% confidence interval for the following outcomes: mortality in intensive care was 0.8 (0.42 to 1.52); thirty day mortality was 1.2 (0.63 to 2.27); myocardial ischaemia was 0.96 (0.71 to 1.30); reintubation within 24 hours of surgery was 5.93 (0.72 to 49.14). Time spent in intensive care and in hospital were significantly shorter for patients extubated early (7.02 hours (- 7.42 to - 6.61) and 1.08 days ( - 1.35 to - 0.82) respectively). REVIEWER'S CONCLUSIONS: There is no evidence of a difference in mortality and morbidity rates between the study groups. Early extubation reduces intensive care unit and hospital length of stay. Studies were underpowered and designed to show differences between study groups rather than equivalence between the groups. Suggested future areas of investigation: establishing the safety and efficacy of immediate extubation compared with early extubation; establishing the most effective means of pain control and reducing anxiety for patients; systematic reviews of the evidence for different parts of the patients journey through a cardiac surgery episode; and the impact of the profession of the clinician making the decision to extubate.

Primary prevention for alcohol misuse in young people.

BACKGROUND: Alcohol misuse is a cause of concern for health services, policy makers, prevention workers, the criminal justice system, youth workers, teachers and parents. OBJECTIVES: 1. To identify and summarize rigorous evaluations of psychosocial and educational interventions aimed at the primary prevention of alcohol misuse by young people. 2. To assess the effectiveness of primary prevention interventions over the longer-term (> 3 years). SEARCH STRATEGY: Databases searched (no time limits): Project CORK, BIDS, PSYCLIT, ERIC, ASSIA, MEDLINE, FAMILY-RESOURCES-DATABASE, HEALTH-PERIODICALS-DATABASE, EMBASE, BIDS, Dissertation-Abstracts, SIGLE, DRUG-INFO, SOMED, Social-Work-Abstracts, National-Clearinghouse-on-Alcohol-and-Drug-Information, Mental-Health-Abstracts, DRUG-database, ETOH (all searched Feb-June 2002). SELECTION CRITERIA: 1. randomised controlled and non-randomised controlled and interrupted time series designs. 2. educational and psychosocial primary prevention interventions for young people up to 25 years old. 3. alcohol-specific or generic (drugs; lifestyle) interventions providing alcohol outcomes reported. 4. alcohol outcomes: alcohol use, age of alcohol initiation, drinking 5+ drinks on any one occasion, drunkeness, alcohol related violence, alcohol related crime, alcohol related risky behaviour. DATA COLLECTION AND ANALYSIS: Stage 1: All papers screened by one reviewer against inclusion criteria. Stage 2: For those papers that passed Stage 1, key information was extracted from each paper by 2-3 reviewers. MAIN RESULTS: 20 of the 56 studies included showed evidence of ineffectiveness. No firm conclusions about the effectiveness of prevention interventions in the short- and medium-term were possible. Over the longer-term, the Strengthening Families Program (SFP) showed promise as an effective prevention intervention. The Number Needed to Treat (NNT) for the SFP over 4 years for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkeness) was 9 (for all three behaviours). One study also highlighted the potential value of culturally focused skills training over the longer-term (NNT=17 over three-and-a-half years for 4+ drinks in the last week). REVIEWER'S CONCLUSIONS: 1. Research into important outcome variables needs to be undertaken. 2. Methodology of evaluations needs to be improved. 3. The Strengthening Families Programme needs to be evaluated on a larger scale and in different settings. 4. Culturally-focused interventions require further development and rigorous evaluation. 5. An international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention intervention in terms of safety, efficacy and effectiveness.

Measuring the outcome of paediatric intensive care.

This paper describes the background to the publication of the paediatric intensive care framework (NHS Executive 1997a) and sets out the case for outcome assessment of paediatric intensive care. Issues relating to mortality and morbidity assessment are discussed and several assessment tools are outlined. It is proposed that functional and psychological outcome assessments are important indicators of the quality of health care provision.

Career pathways in research: support and management.

This article, the third in the series on career pathways, highlights support and management careers open to nurses working in the NHS and research and development, or people working for funding bodies or charitable organisations. These roles involve ensuring that the right infrastructure is in place to support research projects, and the correct decisions are made about which research projects should be supported and commissioned.

Career pathways in research: clinical research.

This article, the second in a series on career pathways, informs readers of the knowledge they require to conduct clinical therapeutic trials to recognised standards. Many nurses start their careers in research as clinical research nurses. The skills and knowledge they develop through conducting multi-centre studies gives them an excellent grounding in the discipline, organisation and management of research.

Career pathways in research: pharmaceutical.

The pharmaceutical pathway is the final article in this series on career pathways and highlights opportunities for nurses within associated industries. This pathway shows that nurses can use their nursing qualifications, combined with their knowledge, skills and expertise, to develop a career within another sphere of employment.

Career pathways in research: academic.

The academic pathway is the fourth in this series on career pathways and might be considered the most traditional career related to research. However, as is demonstrated in this series, research is every nurse's business and not a discipline to be conducted solely through academic institutions.