Patient experiences of the Long COVID-Optimal Health Programme: a qualitative interview study in community settings.

BACKGROUND: Long COVID (LC) symptoms persist 12 weeks or more beyond the acute infection. To date, no standardised diagnostic or treatment pathways exist. However, a holistic approach has been recommended. This study explored participants' experiences of a Long COVID-Optimal Health Programme (LC-OHP); a psychoeducational self-efficacy programme. AIM: To explore perceptions and experiences of people with LC regarding the LC-OHP and identify suggestions to further improve the programme. DESIGN & SETTING: Qualitative study with patients with LC recruited through community settings. METHOD: This study is part of a wider randomised controlled trial. Eligible participants were aged ≥18 years, have LC, and attended a minimum of five LC-OHP sessions plus a booster session. We interviewed those randomised to the intervention group. Interviews were conducted by an independent researcher and thematically analysed to identify common, emerging themes. RESULTS: Eleven participants were interviewed, mostly women from a White British ethnic group (n = 10). Four main themes were identified, reflecting programme benefits and suggestions for improvement. The programme demonstrated potential for assisting patients in managing their LC, including physical health and mental wellbeing. Participants found the programme to be flexible and provided suggestions to adapting it for future users. CONCLUSION: Findings support the acceptability of the LC-OHP to people living with LC. The programme has shown several benefits in supporting physical health and mental wellbeing. Suggestions made to further adapt the programme and improve its delivery will be considered for future trials.

Interventions to support mental health in people with long COVID: a scoping review.

INTRODUCTION: Long COVID (LC) is a multisystem disease with symptoms lasting weeks or months beyond the acute COVID-19 infection. Several manifestations are reported by people with LC, including effects on mental health, with varying degrees of psychological distress and disturbances to daily activities. Research conducted to identify effective interventions to support mental health among people with LC has been limited by the breadth and scope of studies. AIM: This review aims to identify interventions being tested to support mental health of people with LC. METHODS: A scoping review was conducted by searching five databases for articles published between January 2020 and early October 2022 to identify research evaluating interventions focused on improving mental health symptoms associated with LC. Results from all sources were checked for eligibility by two reviewers, and agreements were resolved by discussion. Gray literature and reference list of included studies and relevant reviews were scrutinised to identify any additional studies. Data extraction was conducted by one reviewer and checked by another reviewer for accuracy. RESULTS: Of the 940 studies identified, 17 were included, the design of which varied but included mainly case studies (n = 6) and clinical trials (n = 5). Several interventions were described, ranging from single interventions (e.g., pharmacologic) to more holistic, comprehensive suites of services (pharmacologic and non-pharmacologic). Several mental health outcomes were measured, mostly anxiety and depression. All included studies were reported to be associated with improvements in participants' mental health outcomes. CONCLUSION: This scoping review identified studies reporting on a variety of interventions to support mental health among people with LC. Although positive changes were reported by all studies, some were case studies and thus their findings must be interpreted with caution. There is a need for more research to be conducted to identify the impact of interventions on mental health of people with LC.

Dissection-related tandem occlusion may be different from atherothrombotic tandem occlusion.

OBJECTIVES: The optimal endovascular treatment for tandem occlusion in anterior circulation ischaemic stroke remains unknown. The aim of this study was to examine how the aetiology of carotid pathology, dissection versus atherothrombosis, affects clinical outcomes. MATERIALS AND METHODS: Data was obtained from prospectively collected registries from two stroke centres between April 2016 and December 2020. Tandem cases with complete cervical internal carotid artery (ICA) occlusion or near-total occlusion (≥90% stenosis) were included. Patients were divided into two groups based on carotid pathology: dissection versus atherothrombosis. RESULTS: A total of 134 patients were included: 36 were dissection and 98 were atherothrombosis. The dissection group had better clinical outcomes compared to the atherothrombosis group, although after adjusting for age and stroke risk factors differences were non-significant. In the non-stented cohort, the dissection patients achieved a better outcome (modified Rankin scale 0-2) than atherothrombotic patients (57% vs. 34%, p=0.04) at 90-days. CONCLUSION: Dissection-related tandem occlusions appear to have different clinical features from atherothrombotic tandem occlusions which suggests different management strategies are needed.

Inhibiting amyloid beta (1-42) peptide-induced mitochondrial dysfunction prevents the degradation of synaptic proteins in the entorhinal cortex.

Increasing evidence suggests that mitochondrial dysfunction and aberrant release of mitochondrial reactive oxygen species (ROS) play crucial roles in early synaptic perturbations and neuropathology that drive memory deficits in Alzheimer's disease (AD). We recently showed that solubilized human amyloid beta peptide 1-42 (hAß1-42) causes rapid alterations at glutamatergic synapses in the entorhinal cortex (EC) through the activation of both GluN2A- and GluN2B-containing NMDA receptors. However, whether disruption of mitochondrial dynamics and increased ROS contributes to mechanisms mediating hAß1-42-induced synaptic perturbations in the EC is unknown. Here we assessed the impact of hAß1-42 on mitochondrial respiratory functions, and the expression of key mitochondrial and synaptic proteins in the EC. Measurements of mitochondrial respiratory function in wild-type EC slices exposed to 1 µM hAß1-42 revealed marked reductions in tissue oxygen consumption and energy production efficiency relative to control. hAß1-42 also markedly reduced the immunoexpression of both mitochondrial superoxide dismutase (SOD2) and mitochondrial-cytochrome c protein but had no significant impact on cytosolic-cytochrome c expression, voltage-dependent anion channel protein (a marker for mitochondrial density/integrity), and the immunoexpression of protein markers for all five mitochondrial complexes. The rapid impairments in mitochondrial functions induced by hAß1-42 were accompanied by reductions in the presynaptic marker synaptophysin, postsynaptic density protein (PSD95), and the vesicular acetylcholine transporter, with no significant changes in the degradative enzyme acetylcholinesterase. We then assessed whether reducing hAß1-42-induced increases in ROS could prevent dysregulation of entorhinal synaptic proteins, and found that synaptic impairments induced by hAß1-42 were prevented by the mitochondria-targeted antioxidant drug mitoquinone mesylate, and by the SOD and catalase mimetic EUK134. These findings indicate that hAß1-2 can rapidly disrupt mitochondrial functions and increase ROS in the entorhinal, and that this may contribute to synaptic dysfunctions that may promote early AD-related neuropathology.

Setting research priorities for management and treatment of hyperhidrosis: the results of the James Lind Alliance Priority Setting Partnership.

BACKGROUND: Hyperhidrosis is a common skin condition characterized by excessive sweating, which can negatively impact on quality of life. It is under-researched compared with other conditions of similar prevalence. AIM: To generate a Top 10 list of research priorities for the treatment and management of hyperhidrosis, with equal input from people with hyperhidrosis and healthcare professionals (HCPs). METHODS: A priority setting partnership (PSP) was established and processes from the James Lind Alliance Handbook were followed. An online survey asked participants what questions they would like research to answer. These questions were grouped into 'indicative questions', which were ranked in a second survey of 45 indicative questions. The top 23 questions were then taken to a final workshop event attended by key stakeholders, and ranked to generate the Top 10 list of research priorities. RESULTS: There were 592 questions submitted by 268 respondents for the first survey. For the second survey, 286 participants ranked the indicative questions in order of priority. At the final workshop, the Top 10 list was generated. The top three priorities were: (i) Are there any safe and effective permanent solutions for hyperhidrosis? (ii) What is the most effective and safe oral treatment (drugs taken by mouth) for hyperhidrosis? and (iii) What are the most effective and safe ways to reduce sweating in particular areas of the body? CONCLUSIONS: There are many unanswered research questions that both people with hyperhidrosis and HCPs would like to see answered. The results from this PSP will help to ensure future research funding can be directed to these areas of priority.

G protein-coupled estrogen receptor-1 enhances excitatory synaptic responses in the entorhinal cortex.

Activation of estrogen receptors is thought to modulate cognitive function in the hippocampus, prefrontal cortex, and striatum by affecting both excitatory and inhibitory synaptic transmission. The entorhinal cortex is a major source of cortical sensory and associational input to the hippocampus, but it is unclear whether either estrogens or progestogens may modulate cognitive function through effects on synaptic transmission in the entorhinal cortex. This study assessed the effects of the brief application of either 17-ß estradiol (E2) or progesterone on excitatory glutamatergic synaptic transmission in the female rat entorhinal cortex in vitro. Rats were ovariectomized on postnatal day (PD) 63 and also received subdermal E2 implants to maintain constant low levels of circulating E2 on par with estrus. Electrophysiological recordings from brain slices were obtained between PD70 and PD86, and field excitatory postsynaptic potentials (fEPSPs) reflecting the activation of the superficial layers of the entorhinal cortex were evoked by the stimulation of layer I afferents. The application of E2 (10 nM) for 20 min resulted in a small increase in the amplitude of fEPSPs that reversed during the 30-min washout period. The application of the ERα agonist propylpyrazoletriol (PPT) (100 nM) or the ß agonist DPN (1 µM) did not significantly affect synaptic responses. However, the application of the G protein-coupled estrogen receptor-1 (GPER1) agonist G1 (100 nM) induced a reversible increase in fEPSP amplitude similar to that induced by E2. Furthermore, the potentiation of responses induced by G1 was blocked by the GPER1 antagonist G15 (1 µM). Application of progesterone (100 nM) or its metabolite allopregnanolone (1 µM) did not significantly affect synaptic responses. The potentiation of synaptic transmission in the entorhinal cortex induced by the activation of GPER1 receptors may contribute to the modulation of cognitive function in female rats.

Amyloid-ß (1-42) peptide induces rapid NMDA receptor-dependent alterations at glutamatergic synapses in the entorhinal cortex.

The hippocampus and entorhinal cortex (EC) accumulate amyloid beta peptides (Aß) that promote neuropathology in Alzheimer's disease, but the early effects of Aß on excitatory synaptic transmission in the EC have not been well characterized. To assess the acute effects of Aß1-42 on glutamatergic synapses, acute brain slices from wildtype rats were exposed to Aß1-42 or control solution for 3 hours, and tissue was analyzed using protein immunoblotting and quantitative PCR. Presynaptically, Aß1-42 induced marked reductions in synaptophysin, synapsin-2a mRNA, and mGluR3 mRNA, and increased both VGluT2 protein and Ca2+-activated channel KCa2.2 mRNA levels. Postsynaptically, Aß1-42 reduced PSD95 and GluN2B protein, and also downregulated GluN2B and GluN2A mRNA, without affecting scaffolding elements SAP97 and PICK1. mGluR5 mRNA was strongly increased, while mGluR1 mRNA was unaffected. Blocking either GluN2A- or GluN2B-containing NMDA receptors did not significantly prevent synaptic changes induced by Aß1-42, but combined blockade did prevent synaptic alterations. These findings demonstrate that Aß1-42 rapidly disrupts glutamatergic transmission in the EC through mechanisms involving concurrent activation of GluN2A- and GluN2B-containing NMDA receptors.

Molecular mechanisms of neurodegeneration in the entorhinal cortex that underlie its selective vulnerability during the pathogenesis of Alzheimer's disease.

The entorhinal cortex (EC) is a vital component of the medial temporal lobe, and its contributions to cognitive processes and memory formation are supported through its extensive interconnections with the hippocampal formation. During the pathogenesis of Alzheimer's disease (AD), many of the earliest degenerative changes are seen within the EC. Neurodegeneration in the EC and hippocampus during AD has been clearly linked to impairments in memory and cognitive function, and a growing body of evidence indicates that molecular and functional neurodegeneration within the EC may play a primary role in cognitive decline in the early phases of AD. Defining the mechanisms underlying molecular neurodegeneration in the EC is crucial to determining its contributions to the pathogenesis of AD. Surprisingly few studies have focused on understanding the mechanisms of molecular neurodegeneration and selective vulnerability within the EC. However, there have been advancements indicating that early dysregulation of cellular and molecular signaling pathways in the EC involve neurodegenerative cascades including oxidative stress, neuroinflammation, glia activation, stress kinases activation, and neuronal loss. Dysfunction within the EC can impact the function of the hippocampus, which relies on entorhinal inputs, and further degeneration within the hippocampus can compound this effect, leading to severe cognitive disruption. This review assesses the molecular and cellular mechanisms underlying early degeneration in the EC during AD. These mechanisms may underlie the selective vulnerability of neuronal subpopulations in this brain region to the disease development and contribute both directly and indirectly to cognitive loss.This paper has an associated Future Leader to Watch interview with the first author of the article.

Hub-and-spoke model for thrombectomy service in UK NHS practice.

Mechanical thrombectomy is a highly effective but time dependent treatment for acute ischaemic stroke due to large vessel occlusion. In the UK, the national clinical guidelines for stroke and National Institute for Health and Care Excellence guidance endorses thrombectomy as an acute stroke treatment, and NHS England commissioned thrombectomy services. However, there are no UK 'real-world' data to verify the efficacy of the hub-and-spoke model in thrombectomy. There are currently 24 tertiary neuroscience centres in the UK that can provide thrombectomy treatment and many of these operate only within working hours. This study is the first to demonstrate that a hub-and-spoke thrombectomy service in routine UK 24/7 clinical practice is as effective and safe as in the setting of randomised controlled clinical trials. However, there are 9.3% of patients accepted for transfer to the thrombectomy centre who did not proceed to thrombectomy, mostly due to delays. Fifty-three per cent of thrombectomy cases were performed outside of standard working hours when transfer delays were increased. A 24/7 thrombectomy service is needed to maximise the benefit to all suitable patients. Measures, including improving workflow and optimising work forces, are needed to minimise the delays and continue to improve the service.

Short-term urinary catheters and their risks: an integrated systematic review.

This thematic review was part of a bigger literature review into the effects of short-term urinary catheters on patients who are discharged home from an acute hospital. This integrated review examined the risks associated with short-term urinary catheters. The MEDLINE, British Nursing Index and CINAHL databases were searched for studies published between 2013 and 2018 that researched the effects of short-term urinary catheters on patients. Twelve research studies were included, which showed the presence of short-term indwelling urinary catheters increased the risk of infection, length of hospital stay and mortality rates. Short-term urinary catheters should be strictly monitored and removed as soon as they are not required.

Examining the UK Covid-19 mortality paradox: Pandemic preparedness, healthcare expenditure, and the nursing workforce.

AIM: To examine the UK pandemic preparedness in light of health expenditure, nursing workforce, and mortality rates in and relation to nursing leadership. BACKGROUND: The Global Health Security Index categorized the preparedness of 195 countries to face a biological threat on a variety of measures, producing an overall score. The United States of America and the United Kingdom were ranked 1st and 2nd most prepared in 2019. METHOD: A cross-nation comparison of the top 36 countries ranked by Global Health Security Index score using a variety of online sources, including key data about each nation's expenditure on health and the nursing workforce, and compared these with mortality data for COVID-19. RESULTS: The extent of a country's pandemic preparedness, expenditure on healthcare and magnitude of the nursing workforce does not appear to impact mortality rates at this stage of the pandemic which is something of a paradox. CONCLUSION: It is important that arrangements for dealing with future global pandemics involve a range of agencies and experts in the field, including nurse leaders. IMPLICATIONS FOR NURSING: To achieve the best outcomes for patients, nurse leaders should be involved in policy forums at all levels of government to ensure nurses can influence health policy.

Short-term urinary catheters and their risks: an integrated systematic review.

BACKGROUND: This thematic review was part of a bigger literature review into the effects of short-term urinary catheters on patients who are discharged home from an acute hospital. AIMS: This integrated review examined the risks associated with short-term urinary catheters. METHODS: The MEDLINE, British Nursing Index and CINAHL databases were searched for studies published between 2013 and 2018 that researched the effects of short-term urinary catheters on patients. FINDINGS: Twelve research studies were included, which showed the presence of short-term indwelling urinary catheters increased the risk of infection, length of hospital stay and mortality rates. CONCLUSION: Short-term urinary catheters should be strictly monitored and removed as soon as they are not required.

Mechanical thrombectomy in patients with acute ischemic stroke: A cost-effectiveness and value of implementation analysis.

BACKGROUND: Recent clinical trials have demonstrated the efficacy of mechanical thrombectomy in acute ischemic stroke. AIMS: To determine the cost-effectiveness, value of future research, and value of implementation of mechanical thrombectomy. METHODS: Using UK clinical and cost data from the Pragmatic Ischemic Stroke Thrombectomy Evaluation (PISTE) trial, we estimated the cost-effectiveness of mechanical thrombectomy over time horizons of 90-days and lifetime, based on a decision-analytic model, using all existing evidence. We performed a meta-analysis of seven clinical trials to estimate treatment effects. We used sensitivity analysis to address uncertainty. Value of implementation analysis was used to estimate the potential value of additional implementation activities to support routine delivery of mechanical thrombectomy. RESULTS: Over the trial period (90 days), compared with best medical care alone, mechanical thrombectomy incurred an incremental cost of £5207 and 0.025 gain in QALY (incremental cost-effectiveness ratio (ICER) £205,279), which would not be considered cost-effective. However, mechanical thrombectomy was shown to be cost-effective over a lifetime horizon, with an ICER of £3466 per QALY gained. The expected value of perfect information per patient eligible for mechanical thrombectomy in the UK is estimated at £3178. The expected value of full implementation of mechanical thrombectomy is estimated at £1.3 billion over five years. CONCLUSION: Mechanical thrombectomy was cost-effective compared with best medical care alone over a patient's lifetime. On the assumption of 30% implementation being achieved throughout the UK healthcare system, we estimate that the population health benefits obtained from this treatment are greater than the cost of implementation. TRIAL REGISTRATION: NCT01745692.

Grand challenges in the science of wind energy.

Harvested by advanced technical systems honed over decades of research and development, wind energy has become a mainstream energy resource. However, continued innovation is needed to realize the potential of wind to serve the global demand for clean energy. Here, we outline three interdependent, cross-disciplinary grand challenges underpinning this research endeavor. The first is the need for a deeper understanding of the physics of atmospheric flow in the critical zone of plant operation. The second involves science and engineering of the largest dynamic, rotating machines in the world. The third encompasses optimization and control of fleets of wind plants working synergistically within the electricity grid. Addressing these challenges could enable wind power to provide as much as half of our global electricity needs and perhaps beyond.

Vertebral artery stenting to prevent recurrent stroke in symptomatic vertebral artery stenosis: the VIST RCT.

BACKGROUND: Symptomatic vertebral artery (VA) stenosis has been associated with a markedly increased early risk of recurrent stroke. VA stenosis can be treated with stenting; however, there are few data from randomised controlled trials evaluating the efficacy of this treatment, and recent studies in intracranial stenosis have suggested that stenting may be associated with increased risk. OBJECTIVE: The Vertebral artery Ischaemia Stenting Trial (VIST) was established to compare the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for recently symptomatic VA stenosis. DESIGN: VIST was a prospective, randomised, open, parallel, blinded end-point clinical trial. SETTING: The trial was performed in 14 hospitals in the UK. PARTICIPANTS: Recruitment began on 23 October 2008 and follow-up ended on 1 March 2016, by which time every patient had been followed up for at least 1 year. Participants had to have symptomatic vertebral stenosis of at least 50% resulting from presumed atheromatous disease. Both patients and clinicians were aware of treatment allocation; however, an independent adjudication committee, masked to treatment allocation, assessed all primary and secondary end points. INTERVENTIONS: Participants were randomly assigned (1 : 1) to either vertebral angioplasty/stenting plus BMT (n = 91) or BMT alone (n = 88). A total of 182 patients were initially enrolled; however, three patients (two who withdrew after randomisation and one who did not attend after the initial randomisation visit) did not contribute any follow-up data and were excluded. None of these three patients had outcome events. MAIN OUTCOMES AND MEASURES: The primary end point was the occurrence of fatal or non-fatal stroke in any arterial territory during follow-up. RESULTS: The median follow-up was 3.5 (interquartile range 2.1-4.7) years. Of the 61 patients who were stented, 48 (78.7%) had extracranial stenosis and 13 (21.3%) had intracranial stenosis. No perioperative complications occurred with extracranial stenting; two strokes occurred during intracranial stenting. The primary end point occurred in five patients (including one fatal stroke) in the stent group and in 12 patients (including two fatal strokes) in the medical group (giving a hazard ratio of 0.40, 95% confidence interval 0.14 to 1.13; p = 0.08), with an absolute risk reduction of 25 strokes per 1000 person-years. LIMITATIONS: The study was underpowered because it failed to reach target recruitment. The high rate of non-confirmation of stenosis in the stented group of the trial was a second limitation. CONCLUSIONS: The trial found no difference in risk of the primary end point between the two groups. FUTURE: Post hoc analysis suggested that stenting could be associated with a reduced recurrent stroke risk in symptomatic VA and further studies are now required to confirm these findings, particularly in extracranial VA stenosis where complication rates with stenting were confirmed to be very low. TRIAL REGISTRATION: Current Controlled Trials ISRCTN95212240. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 41. See the NIHR Journals Library website for further project information. In addition, funding for the pilot phase was provided by the Stroke Association.

About one-quarter of all strokes occur in the back of the brain, which is supplied by the vertebral and basilar arteries. An important cause of stroke is a narrowing, or stenosis, of these arteries. It is known that patients who have a minor stroke due to narrowing of a vertebral artery (VA) have a high risk of a further stroke: as much as 30% in the next year. Stenosis of the VA can be treated with stenting, in which a wire mesh is put into the narrowed artery and opens it up. Many operations to insert a vertebral stent have been carried out worldwide with good technical results; however, it is not known whether it is better to treat vertebral stenosis with stenting or only tablets. The Vertebral artery Ischaemia Stenting Trial was a randomised controlled trial comparing vertebral stenting and best medical treatment (BMT) with BMT alone in patients who had suffered a minor stroke due to vertebral stenosis. Ninety-one patients had stenting and 88 had BMT alone. Patients were followed for an average of 3.5 years. It was planned to enrol 540 patients to the trial, but recruitment was slower than expected and funding for the study was halted; therefore, recruitment was stopped at 181 patients. There was no difference in the rate of recurrent stroke between patients who had stenting and those who had BMT alone. There was some evidence that stenting might be associated with a reduced risk of recurrent stroke, but the difference was not significant. The trial was limited by the failure to recruit the anticipated sample size. The results tell us that stenting is a possible treatment for vertebral stenosis; however, further trials are required to determine whether or not it is more effective at preventing recurrent stroke than BMT alone.

Stenting for symptomatic vertebral artery stenosis: a preplanned pooled individual patient data analysis.

BACKGROUND: Symptomatic vertebral artery stenosis is associated with a high risk of recurrent stroke, with higher risks for intracranial than for extracranial stenosis. Vertebral artery stenosis can be treated with stenting with good technical results, but whether it results in improved clinical outcome is uncertain. We aimed to compare vertebral stenting with medical treatment for symptomatic vertebral stenosis. METHODS: We did a preplanned pooled individual patient data analysis of three completed randomised controlled trials comparing stenting with medical treatment in patients with symptomatic vertebral stenosis. The primary outcome was any fatal or non-fatal stroke. Analyses were performed for vertebral stenosis at any location and separately for extracranial and intracranial stenoses. Data from the intention-to-treat analysis were used for all studies. We estimated hazard ratios (HRs) with 95% CIs using Cox proportional-hazards regression models stratified by trial. FINDINGS: Data were from 354 individuals from three trials, including 179 patients from VIST (148 with extracranial stenosis and 31 with intracranial stenosis), 115 patients from VAST (96 with extracranial stenosis and 19 with intracranial stenosis), and 60 patients with intracranial stenosis from SAMMPRIS (no patients had extracranial stenosis). Across all trials, 168 participants (46 with intracranial stenosis and 122 with extracranial stenosis) were randomly assigned to medical treatment and 186 to stenting (64 with intracranial stenosis and 122 with extracranial stenosis). In the stenting group, the frequency of periprocedural stroke or death was higher for intracranial stenosis than for extracranial stenosis (ten (16%) of 64 patients vs one (1%) of 121 patients; p<0·0001). During 1036 person-years of follow-up, the hazard ratio (HR) for any stroke in the stenting group compared with the medical treatment group was 0·81% CI 0·45-1·44; p=0·47). For extracranial stenosis alone the HR was 0·63 (95% CI 0·27-1·46) and for intracranial stenosis alone it was 1·06 (0·46-2·42; pinteraction=0·395). INTERPRETATION: Stenting for vertebral stenosis has a much higher risk for intracranial, compared with extracranial, stenosis. This pooled analysis did not show evidence of a benefit for stroke prevention for either treatment. There was no evidence of benefit of stenting for intracranial stenosis. Stenting for extracranial stenosis might be beneficial, but further larger trials are required to determine the treatment effect in this subgroup. FUNDING: None.

Peer support for people with schizophrenia or other serious mental illness.

BACKGROUND: Peer support provides the opportunity for peers with experiential knowledge of a mental illness to give emotional, appraisal and informational assistance to current service users, and is becoming an important recovery-oriented approach in healthcare for people with mental illness. OBJECTIVES: To assess the effects of peer-support interventions for people with schizophrenia or other serious mental disorders, compared to standard care or other supportive or psychosocial interventions not from peers. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials on 27 July 2016 and 4 July 2017. There were no limitations regarding language, date, document type or publication status. SELECTION CRITERIA: We selected all randomised controlled clinical studies involving people diagnosed with schizophrenia or other related serious mental illness that compared peer support to standard care or other psychosocial interventions and that did not involve 'peer' individual/group(s). We included studies that met our inclusion criteria and reported useable data. Our primary outcomes were service use and global state (relapse). DATA COLLECTION AND ANALYSIS: The authors of this review complied with the Cochrane recommended standard of conduct for data screening and collection. Two review authors independently screened the studies, extracted data and assessed the risk of bias of the included studies. Any disagreement was resolved by discussion until the authors reached a consensus. We calculated the risk ratio (RR) and 95% confidence interval (CI) for binary data, and the mean difference and its 95% CI for continuous data. We used a random-effects model for analyses. We assessed the quality of evidence and created a 'Summary of findings' table using the GRADE approach. MAIN RESULTS: This review included 13 studies with 2479 participants. All included studies compared peer support in addition to standard care with standard care alone. We had significant concern regarding risk of bias of included studies as over half had an unclear risk of bias for the majority of the risk domains (i.e. random sequence generation, allocation concealment, blinding, attrition and selective reporting). Additional concerns regarding blinding of participants and outcome assessment, attrition and selective reporting were especially serious, as about a quarter of the included studies were at high risk of bias for these domains.All included studies provided useable data for analyses but only two trials provided useable data for two of our main outcomes of interest, and there were no data for one of our primary outcomes, relapse. Peer support appeared to have little or no effect on hospital admission at medium term (RR 0.44, 95% CI 0.11 to 1.75; participants = 19; studies = 1, very low-quality evidence) or all-cause death in the long term (RR 1.52, 95% CI 0.43 to 5.31; participants = 555; studies = 1, very low-quality evidence). There were no useable data for our other prespecified important outcomes: days in hospital, clinically important change in global state (improvement), clinically important change in quality of life for peer supporter and service user, or increased cost to society.One trial compared peer support with clinician-led support but did not report any useable data for the above main outcomes. AUTHORS' CONCLUSIONS: Currently, very limited data are available for the effects of peer support for people with schizophrenia. The risk of bias within trials is of concern and we were unable to use the majority of data reported in the included trials. In addition, the few that were available, were of very low quality. The current body of evidence is insufficient to either refute or support the use of peer-support interventions for people with schizophrenia and other mental illness.