Interventions from pregnancy to two years after birth for parents experiencing complex post-traumatic stress disorder and/or with childhood experience of maltreatment.

BACKGROUND: Acceptable, effective and feasible support strategies (interventions) for parents experiencing complex post-traumatic stress disorder (CPTSD) symptoms or with a history of childhood maltreatment may offer an opportunity to support parental recovery, reduce the risk of intergenerational transmission of trauma and improve life-course trajectories for children and future generations. However, evidence relating to the effect of interventions has not been synthesised to provide a comprehensive review of available support strategies. This evidence synthesis is critical to inform further research, practice and policy approaches in this emerging area. OBJECTIVES: To assess the effects of interventions provided to support parents who were experiencing CPTSD symptoms or who had experienced childhood maltreatment (or both), on parenting capacity and parental psychological or socio-emotional wellbeing. SEARCH METHODS: In October 2021 we searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers, together with checking references and contacting experts to identify additional studies. SELECTION CRITERIA: All variants of randomised controlled trials (RCTs) comparing any intervention delivered in the perinatal period designed to support parents experiencing CPTSD symptoms or with a history of childhood maltreatment (or both), to any active or inactive control. Primary outcomes were parental psychological or socio-emotional wellbeing and parenting capacity between pregnancy and up to two years postpartum. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility of trials for inclusion, extracted data using a pre-designed data extraction form, and assessed risk of bias and certainty of evidence. We contacted study authors for additional information as required. We analysed continuous data using mean difference (MD) for outcomes using a single measure, and standardised mean difference (SMD) for outcomes using multiple measures, and risk ratios (RR) for dichotomous data. All data are presented with 95% confidence intervals (CIs). We undertook meta-analyses using random-effects models. MAIN RESULTS: We included evidence from 1925 participants in 15 RCTs that investigated the effect of 17 interventions. All included studies were published after 2005. Interventions included seven parenting interventions, eight psychological interventions and two service system approaches. The studies were funded by major research councils, government departments and philanthropic/charitable organisations. All evidence was of low or very low certainty. Parenting interventions Evidence was very uncertain from a study (33 participants) assessing the effects of a parenting intervention compared to attention control on trauma-related symptoms, and psychological wellbeing symptoms (postpartum depression), in mothers who had experienced childhood maltreatment and were experiencing current parenting risk factors. Evidence suggested that parenting interventions may improve parent-child relationships slightly compared to usual service provision (SMD 0.45, 95% CI -0.06 to 0.96; I2 = 60%; 2 studies, 153 participants; low-certainty evidence). There may be little or no difference between parenting interventions and usual perinatal service in parenting skills including nurturance, supportive presence and reciprocity (SMD 0.25, 95% CI -0.07 to 0.58; I2 = 0%; 4 studies, 149 participants; low-certainty evidence). No studies assessed the effects of parenting interventions on parents' substance use, relationship quality or self-harm. Psychological interventions Psychological interventions may result in little or no difference in trauma-related symptoms compared to usual care (SMD -0.05, 95% CI -0.40 to 0.31; I2 = 39%; 4 studies, 247 participants; low-certainty evidence). Psychological interventions may make little or no difference compared to usual care to depression symptom severity (8 studies, 507 participants, low-certainty evidence, SMD -0.34, 95% CI -0.66 to -0.03; I2 = 63%). An interpersonally focused cognitive behavioural analysis system of psychotherapy may slightly increase the number of pregnant women who quit smoking compared to usual smoking cessation therapy and prenatal care (189 participants, low-certainty evidence). A psychological intervention may slightly improve parents' relationship quality compared to usual care (1 study, 67 participants, low-certainty evidence). Benefits for parent-child relationships were very uncertain (26 participants, very low-certainty evidence), while there may be a slight improvement in parenting skills compared to usual care (66 participants, low-certainty evidence). No studies assessed the effects of psychological interventions on parents' self-harm. Service system approaches One service system approach assessed the effect of a financial empowerment education programme, with and without trauma-informed peer support, compared to usual care for parents with low incomes. The interventions increased depression slightly (52 participants, low-certainty evidence). No studies assessed the effects of service system interventions on parents' trauma-related symptoms, substance use, relationship quality, self-harm, parent-child relationships or parenting skills. AUTHORS' CONCLUSIONS: There is currently a lack of high-quality evidence regarding the effectiveness of interventions to improve parenting capacity or parental psychological or socio-emotional wellbeing in parents experiencing CPTSD symptoms or who have experienced childhood maltreatment (or both). This lack of methodological rigour and high risk of bias made it difficult to interpret the findings of this review. Overall, results suggest that parenting interventions may slightly improve parent-child relationships but have a small, unimportant effect on parenting skills. Psychological interventions may help some women stop smoking in pregnancy, and may have small benefits on parents' relationships and parenting skills. A financial empowerment programme may slightly worsen depression symptoms. While potential beneficial effects were small, the importance of a positive effect in a small number of parents must be considered when making treatment and care decisions. There is a need for further high-quality research into effective strategies for this population.

Australian recommendations on perioperative use of disease-modifying anti-rheumatic drugs in people with inflammatory arthritis undergoing elective surgery.

Disease-modifying anti-rheumatic drugs (DMARDs) are effective treatments for inflammatory arthritis but carry an increased risk of infection. For patients undergoing surgery, there is a need to consider the trade-off between a theoretical increased risk of infection with continuation of DMARDs perioperatively versus an increased risk of disease flare if they are temporarily withheld. We used the Grading of Recommendations Assessment, Development and Evaluation methodology to develop recommendations for perioperative use of DMARDs for people with inflammatory arthritis undergoing elective surgery. The recommendations form part of the National Health and Medical Research Council-endorsed Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis. Conditional recommendations were made against routinely discontinuing conventional synthetic and biologic (b) DMARDs in the perioperative period but to consider temporary discontinuation of bDMARDs in individuals with a high risk of infection or where the impact of infection would be severe. A conditional recommendation was made in favour of temporary discontinuation of targeted synthetic DMARDs in the perioperative period.

Interventions to improve physical function for children and young people with cerebral palsy: international clinical practice guideline.

AIM: To provide recommendations for interventions to improve physical function for children and young people with cerebral palsy. METHOD: An expert panel prioritized questions and patient-important outcomes. Using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods, the panel assessed the certainty of evidence and made recommendations, with international expert and consumer consultation. RESULTS: The guideline comprises 13 recommendations (informed by three systematic reviews, 30 randomized trials, and five before-after studies). To achieve functional goals, it is recommended that intervention includes client-chosen goals, whole-task practice within real-life settings, support to empower families, and a team approach. Age, ability, and child/family preferences need to be considered. To improve walking ability, overground walking is recommended and can be supplemented with treadmill training. Various approaches can facilitate hand use goals: bimanual therapy, constraint-induced movement therapy, goal-directed training, and cognitive approaches. For self-care, whole-task practice combined with assistive devices can increase independence and reduce caregiver burden. Participation in leisure goals can combine whole-task practice with strategies to address environmental, personal, and social barriers. INTERPRETATION: Intervention to improve function for children and young people with cerebral palsy needs to include client-chosen goals and whole-task practice of goals. Clinicians should consider child/family preferences, age, and ability when selecting specific interventions.

Australian recommendations on tapering of biologic and targeted synthetic disease-modifying anti-rheumatic drugs in inflammatory arthritis.

Biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARD) have been an important advance in the management of inflammatory arthritis, but are expensive medications, carry a risk of infection and other adverse effects, and are often perceived as a burden by patients. We used GRADE methodology to develop recommendations for dose reduction and discontinuation of b/tsDMARD in people with rheumatoid arthritis (RA), axial spondyloarthritis (AxSpA) and psoriatic arthritis (PsA) who have achieved a low disease activity state or remission. The recommendations form part of the Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis, an NHMRC-endorsed 'living' guideline, in which recommendations are updated in near real-time as new evidence emerges. Conditional recommendations were made in favour of dose reduction in RA and AxSpA but not in PsA. Abrupt discontinuation of b/tsDMARD is not recommended in any of the three diseases.

Strengthening systematic reviews in public health: guidance in the Cochrane Handbook for Systematic Reviews of Interventions, 2nd edition.

AIMS: Decision makers in public health practice and policy rely on access to trustworthy, relevant, synthesized evidence. The second edition of the Cochrane Handbook for Systematic Reviews of Interventions ('the Handbook') reflects a major revision in guidance for authors of systematic reviews, incorporating a decade of methodological development and a number of significant changes to previous recommendations. This paper aims to highlight new guidance that addresses a number of key methodological challenges for authors of systematic reviews in public health. RESULTS: The revised Handbook includes guidance on framing public health research questions for synthesis, considering equity, intervention complexity, risk of bias assessment and synthesis methods other than meta-analysis. Reviews of public health interventions frequently encounter the types of methodological complexity addressed in this new guidance. CONCLUSION: We hope that readers will find that the Cochrane Handbook includes detailed and thoughtful guidance on both conceptualizing and executing systematic reviews relevant to public health questions. Considering the available methods guidance will, we hope, provide support for authors of public health reviews to tackle the challenges they encounter, strengthen their analysis and provide useful answers to the important questions asked by stakeholders and users of public health evidence.

Australian guidelines for the prevention and treatment of posttraumatic stress disorder: Updates in the third edition.

OBJECTIVE: This paper describes the development of the third edition of the National Health and Medical Research Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, posttraumatic stress disorder and Complex posttraumatic stress disorder, highlighting key changes in scope, methodology, format and treatment recommendations from the previous 2013 edition of the Guidelines. METHOD: Systematic review of the international research was undertaken, with GRADE methodology used to assess the certainty of the evidence, and evidence to decision frameworks used to generate recommendations. The Guidelines are presented in an online format using MAGICApp. RESULTS: Key changes since the publication of the 2013 Guidelines include a new conditional recommendation for Child and Family Traumatic Stress Intervention for children and adolescents with symptoms within the first 3 months of trauma, and a strong recommendation for trauma-focused cognitive behaviour therapy for the child alone or with a caregiver, for those with diagnosed posttraumatic stress disorder. For adults with posttraumatic stress disorder, strong recommendations are made for specific types of trauma-focused cognitive behaviour therapy and conditional recommendations are made for five additional psychological interventions. Where medication is indicated for adults with posttraumatic stress disorder, venlafaxine is now conditionally recommended alongside sertraline, paroxetine or fluoxetine. CONCLUSION: These Guidelines, based on systematic review of the international literature, are intended to guide decision making for practitioners, service planners, funders and those seeking treatment for trauma related mental health concerns. For an Australian Guideline, a critical limitation is the absence of research on the treatment of Australian Aboriginal and Torres Strait Islander peoples. The new online format of the Australian posttraumatic stress disorder Guidelines means that they can be updated as sufficient new evidence becomes available.

[The PRISMA 2020 statement: an updated guideline for reporting systematic reviewsDeclaración PRISMA 2020: una guía actualizada para la publicación de revisiones sistemáticas]. / A declaração PRISMA 2020: diretriz atualizada para relatar revisões sistemáticas.

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, published in 2009, was designed to help systematic reviewers transparently report why the review was done, what the authors did, and what they found. Over the past decade, advances in systematic review methodology and terminology have necessitated an update to the guideline. The PRISMA 2020 statement replaces the 2009 statement and includes new reporting guidance that reflects advances in methods to identify, select, appraise, and synthesise studies. The structure and presentation of the items have been modified to facilitate implementation. In this article, we present the PRISMA 2020 27-item checklist, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews.

La declaración PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), publicada en 2009, se diseñó para ayudar a los autores de revisiones sistemáticas a documentar de manera transparente el porqué de la revisión, qué hicieron los autores y qué encontraron. Durante la última década, ha habido muchos avances en la metodología y terminología de las revisiones sistemáticas, lo que ha requerido una actualización de esta guía. La declaración PRISMA 2020 sustituye a la declaración de 2009 e incluye una nueva guía de presentación de las publicaciones que refleja los avances en los métodos para identificar, seleccionar, evaluar y sintetizar estudios. La estructura y la presentación de los ítems ha sido modificada para facilitar su implementación. En este artículo, presentamos la lista de verificación PRISMA 2020 con 27 ítems, y una lista de verificación ampliada que detalla las recomendaciones en la publicación de cada ítem, la lista de verificación del resumen estructurado PRISMA 2020 y el diagrama de flujo revisado para revisiones sistemáticas.

The PRISMA 2020 statement: An updated guideline for reporting systematic reviews.

Matthew Page and co-authors describe PRISMA 2020, an updated reporting guideline for systematic reviews and meta-analyses.

What can we learn from interventions that aim to increase policy-makers' capacity to use research? A realist scoping review.

BACKGROUND: Health policy-making can benefit from more effective use of research. In many policy settings there is scope to increase capacity for using research individually and organisationally, but little is known about what strategies work best in which circumstances. This review addresses the question: What causal mechanisms can best explain the observed outcomes of interventions that aim to increase policy-makers' capacity to use research in their work? METHODS: Articles were identified from three available reviews and two databases (PAIS and WoS; 1999-2016). Using a realist approach, articles were reviewed for information about contexts, outcomes (including process effects) and possible causal mechanisms. Strategy + Context + Mechanism = Outcomes (SCMO) configurations were developed, drawing on theory and findings from other studies to develop tentative hypotheses that might be applicable across a range of intervention sites. RESULTS: We found 22 studies that spanned 18 countries. There were two dominant design strategies (needs-based tailoring and multi-component design) and 18 intervention strategies targeting four domains of capacity, namely access to research, skills improvement, systems improvement and interaction. Many potential mechanisms were identified as well as some enduring contextual characteristics that all interventions should consider. The evidence was variable, but the SCMO analysis suggested that tailored interactive workshops supported by goal-focused mentoring, and genuine collaboration, seem particularly promising. Systems supports and platforms for cross-sector collaboration are likely to play crucial roles. Gaps in the literature are discussed. CONCLUSION: This exploratory review tentatively posits causal mechanisms that might explain how intervention strategies work in different contexts to build capacity for using research in policy-making.

Intervenções para promover função física de crianças e jovens com paralisia cerebral: diretriz internacional de prática clínica.

OBJETIVO: Fornecer recomendações de intervenções para promoção da função física de crianças e jovens com paralisia cerebral. MÉTODO: Um painel de especialistas priorizou perguntas e desfechos importantes para o paciente. Usando o Grading of Recommendations Assessment, Development and Evaluation (GRADE), o painel avaliou a certeza das evidências e fez recomendações, com consultoria de especialistas internacionais e consumidores. RESULTADOS: A diretriz compreende 13 recomendações (informadas por três revisões sistemáticas, 30 estudos randomizados e cinco estudos pré-pós). Para alcance de objetivos funcionais, recomenda-se que a intervenção inclua objetivos escolhidos pelo cliente, prática completa da tarefa em ambientes da vida real, suporte para empoderar as famílias e uma abordagem em equipe. Idade, habilidade e preferências da criança/família precisam ser consideradas. Para melhora da habilidade da marcha, recomenda-se marcha no solo, que pode ser complementada com treinamento em esteira. Várias abordagens podem facilitar os objetivos relacionados ao uso das mãos: terapia bimanual, terapia de contensão induzida, treino direcionado a objetivos e abordagens cognitivas. Para auto-cuidado, prática da tarefa completa, combinada com recursos assistivos podem aumentar a independência e reduzir a sobrecarga do cuidador. A participação em objetivos de lazer pode combinar prática da tarefa completa com estratégias direcionadas para barreiras ambientais, pessoais e sociais. INTERPRETAÇÃO: Intervenção para promoção da função de crianças e jovens com paralisia cerebral precisa incluir objetivos escolhidos pelo cliente e a prática da tarefa completa dos objetivos. Os clínicos devem considerar as preferências da criança/família, idade e habilidade ao selecionarem intervenções específicas.

Policymakers' experience of a capacity-building intervention designed to increase their use of research: a realist process evaluation.

BACKGROUND: An intervention's success depends on how participants interact with it in local settings. Process evaluation examines these interactions, indicating why an intervention was or was not effective, and how it (and similar interventions) can be improved for better contextual fit. This is particularly important for innovative trials like Supporting Policy In health with Research: an Intervention Trial (SPIRIT), where causal mechanisms are poorly understood. SPIRIT was testing a multi-component intervention designed to increase the capacity of health policymakers to use research. METHODS: Our mixed-methods process evaluation sought to explain variation in observed process effects across the six agencies that participated in SPIRIT. Data collection included observations of intervention workshops (n = 59), purposively sampled interviews (n = 76) and participant feedback forms (n = 553). Using a realist approach, data was coded for context-mechanism-process effect configurations (retroductive analysis) by two authors. RESULTS: Intervention workshops were very well received. There was greater variation of views regarding other aspects of SPIRIT such as data collection, communication and the intervention's overall value. We identified nine inter-related mechanisms that were crucial for engaging participants in these policy settings: (1) Accepting the premise (agreeing with the study's assumptions); (2) Self-determination (participative choice); (3) The Value Proposition (seeing potential gain); (4) 'Getting good stuff' (identifying useful ideas, resources or connections); (5) Self-efficacy (believing 'we can do this!'); (6) Respect (feeling that SPIRIT understands and values one's work); (7) Confidence (believing in the study's integrity and validity); (8) Persuasive leadership (authentic and compelling advocacy from leaders); and (9) Strategic insider facilitation (local translation and mediation). These findings were used to develop tentative explanatory propositions and to revise the programme theory. CONCLUSION: This paper describes how SPIRIT functioned in six policy agencies, including why strategies that worked well in one site were less effective in others. Findings indicate a complex interaction between participants' perception of the intervention, shifting contextual factors, and the form that the intervention took in each site. Our propositions provide transferable lessons about contextualised areas of strength and weakness that may be useful in the development and implementation of similar studies.

Development and validation of SEER (Seeking, Engaging with and Evaluating Research): a measure of policymakers' capacity to engage with and use research.

BACKGROUND: Capacity building strategies are widely used to increase the use of research in policy development. However, a lack of well-validated measures for policy contexts has hampered efforts to identify priorities for capacity building and to evaluate the impact of strategies. We aimed to address this gap by developing SEER (Seeking, Engaging with and Evaluating Research), a self-report measure of individual policymakers' capacity to engage with and use research. METHODS: We used the SPIRIT Action Framework to identify pertinent domains and guide development of items for measuring each domain. Scales covered (1) individual capacity to use research (confidence in using research, value placed on research, individual perceptions of the value their organisation places on research, supporting tools and systems), (2) actions taken to engage with research and researchers, and (3) use of research to inform policy (extent and type of research use). A sample of policymakers engaged in health policy development provided data to examine scale reliability (internal consistency, test-retest) and validity (relation to measures of similar concepts, relation to a measure of intention to use research, internal structure of the individual capacity scales). RESULTS: Response rates were 55% (150/272 people, 12 agencies) for the validity and internal consistency analyses, and 54% (57/105 people, 9 agencies) for test-retest reliability. The individual capacity scales demonstrated adequate internal consistency reliability (alpha coefficients > 0.7, all four scales) and test-retest reliability (intra-class correlation coefficients > 0.7 for three scales and 0.59 for fourth scale). Scores on individual capacity scales converged as predicted with measures of similar concepts (moderate correlations of > 0.4), and confirmatory factor analysis provided evidence that the scales measured related but distinct concepts. Items in each of these four scales related as predicted to concepts in the measurement model derived from the SPIRIT Action Framework. Evidence about the reliability and validity of the research engagement actions and research use scales was equivocal. CONCLUSIONS: Initial testing of SEER suggests that the four individual capacity scales may be used in policy settings to examine current capacity and identify areas for capacity building. The relation between capacity, research engagement actions and research use requires further investigation.

The development of ORACLe: a measure of an organisation's capacity to engage in evidence-informed health policy.

BACKGROUND: Evidence-informed policymaking is more likely if organisations have cultures that promote research use and invest in resources that facilitate staff engagement with research. Measures of organisations' research use culture and capacity are needed to assess current capacity, identify opportunities for improvement, and examine the impact of capacity-building interventions. The aim of the current study was to develop a comprehensive system to measure and score organisations' capacity to engage with and use research in policymaking, which we entitled ORACLe (Organisational Research Access, Culture, and Leadership). METHOD: We used a multifaceted approach to develop ORACLe. Firstly, we reviewed the available literature to identify key domains of organisational tools and systems that may facilitate research use by staff. We interviewed senior health policymakers to verify the relevance and applicability of these domains. This information was used to generate an interview schedule that focused on seven key domains of organisational capacity. The interview was pilot-tested within four Australian policy agencies. A discrete choice experiment (DCE) was then undertaken using an expert sample to establish the relative importance of these domains. This data was used to produce a scoring system for ORACLe. RESULTS: The ORACLe interview was developed, comprised of 23 questions addressing seven domains of organisational capacity and tools that support research use, including (1) documented processes for policymaking; (2) leadership training; (3) staff training; (4) research resources (e.g. database access); and systems to (5) generate new research, (6) undertake evaluations, and (7) strengthen relationships with researchers. From the DCE data, a conditional logit model was estimated to calculate total scores that took into account the relative importance of the seven domains. The model indicated that our expert sample placed the greatest importance on domains (2), (3) and (4). CONCLUSION: We utilised qualitative and quantitative methods to develop a system to assess and score organisations' capacity to engage with and apply research to policy. Our measure assesses a broad range of capacity domains and identifies the relative importance of these capacities. ORACLe data can be used by organisations keen to increase their use of evidence to identify areas for further development.

The effects of radiofrequency exposure on cognition: A systematic review and meta-analysis of human observational studies.

BACKGROUND: We aimed to assess evidence of long-term effects of exposure to radiofrequency (RF) electromagnetic fields (EMF) on indicators of cognition, including domains of learning and memory, executive function, complex attention, language, perceptual motor ability and social cognition, and of an exposure-response relationship between RF-EMF and cognition. METHODS: We searched PubMed, Embase, PsycInfo and the EMF-Portal on September 30, 2022 without limiting by date or language of publication. We included cohort or case-control studies that evaluated the effects of RF exposure on cognitive function in one or more of the cognitive domains. Studies were rated for risk of bias using the OHAT tool and synthesised using fixed effects meta-analysis. We assessed the certainty of the evidence using the GRADE approach and considered modification by OHAT for assessing evidence of exposures. RESULTS: We included 5 studies that reported analyses of data from 4 cohorts with 4639 participants consisting of 2808 adults and 1831 children across three countries (Australia, Singapore and Switzerland) conducted between 2006 and 2017. The main source of RF-EMF exposure was mobile (cell) phone use measured as calls per week or minutes per day. For mobile phone use in children, two studies (615 participants) that compared an increase in mobile phone use to a decrease or no change were included in meta-analyses. Learning and memory. There was little effect on accuracy (mean difference, MD -0.03; 95% CI -0.07 to 0.02) or response time (MD -0.01; 95% CI -0.04 to 0.02) on the one-back memory task; and accuracy (MD -0.02; 95%CI -0.04 to 0.00) or response time (MD -0.01; 95%CI -0.04 to 0.03) on the one card learning task (low certainty evidence for all outcomes). Executive function. There was little to no effect on the Stroop test for the time ratio ((B-A)/A) response (MD 0.02; 95% CI -0.01 to 0.04, very low certainty) or the time ratio ((D-C)/C) response (MD 0.00; 95% CI -0.06 to 0.05, very low certainty), with both tests measuring susceptibility to interference effects. Complex attention. There was little to no effect on detection task accuracy (MD 0.02; 95% CI -0.04 to 0.08), or response time (MD 0.02;95% CI 0.01 to 0.03), and little to no effect on identification task accuracy (MD 0.00; 95% CI -0.04 to 0.05) or response time (MD 0.00;95% CI -0.01 to 0.02) (low certainty evidence for all outcomes). No other cognitive domains were investigated in children. A single study among elderly people provided very low certainty evidence that more frequent mobile phone use may have little to no effect on the odds of a decline in global cognitive function (odds ratio, OR 0.81; 95% CI 0.42 to 1.58, 649 participants) or a decline in executive function (OR 1.07; 95% CI 0.37 to 3.05, 146 participants), and may lead to a small, probably unimportant, reduction in the odds of a decline in complex attention (OR 0.67;95%CI 0.27 to 1.68, 159 participants) and a decline in learning and memory (OR 0.75; 95% CI 0.29 to 1.99, 159 participants). An exposure-response relationship was not identified for any of the cognitive outcomes. DISCUSSION: This systematic review and meta-analysis found only a few studies that provided very low to low certainty evidence of little to no association between RF-EMF exposure and learning and memory, executive function and complex attention. None of the studies among children reported on global cognitive function or other domains of cognition. Only one study reported a lack of an effect for all domains in elderly persons but this was of very low certainty evidence. Further studies are needed to address all types of populations, exposures and cognitive outcomes, particularly studies investigating environmental and occupational exposure in adults. Future studies also need to address uncertainties in the assessment of exposure and standardise testing of specific domains of cognitive function to enable synthesis across studies and increase the certainty of the evidence. OTHER: This review was partially funded by the WHO radioprotection programme and prospectively registered on PROSPERO CRD42021257548.

Synthesis methods other than meta-analysis were commonly used but seldom specified: survey of systematic reviews.

OBJECTIVES: To examine the specification and use of summary and statistical synthesis methods, focusing on synthesis methods other than meta-analysis. STUDY DESIGN AND SETTING: We coded the specification and use of summary and synthesis methods in 100 randomly sampled systematic reviews (SRs) of public health and health systems interventions published in 2018 from the Health Evidence and Health Systems Evidence databases. RESULTS: Sixty of the 100 SRs used other synthesis methods for some (27/100) or all syntheses (33/100). Of these, 54/60 used vote counting: three based on direction of effect, 36 on statistical significance, and 15 were unclear. Eight SRs summarized effect estimates (for example, using medians). Seventeen SRs used the term 'narrative synthesis' (or equivalent) without describing methods; in practice 15 of these used vote counting. 58/100 SRs used meta-analysis. In SRs providing a rationale for not proceeding with meta-analysis, the most common reason was due to diversity in study characteristics (33/39). CONCLUSION: Statistical synthesis methods other than meta-analysis are commonly used, but few SRs describe the methods. Improved description of methods is required to allow users to appropriately interpret findings, critique methods used and verify the results. Greater awareness of the serious limitations of vote counting based on statistical significance is required.

The PRISMATIC project: protocol for a research programme on novel methods to improve reporting and peer review of systematic reviews of health evidence.

BACKGROUND: Incomplete reporting about what systematic reviewers did and what they found prevents users of the report from being able to fully interpret the findings and understand the limitations of the underlying evidence. Reporting guidelines such as the PRISMA statement and its extensions are designed to improve reporting. However, there are important inconsistencies across the various PRISMA reporting guidelines, which causes confusion and misinterpretation. Coupled with this, users might need to consult multiple guidelines to gain a full understanding of the guidance. Furthermore, the current passive strategy of implementing PRISMA has not fully brought about needed improvements in the completeness of systematic review reporting. METHODS: The PRISMATIC ('PRISMA, Technology, and Implementation to enhance reporting Completeness') project aims to use novel methods to enable more efficient and effective translation of PRISMA reporting guidelines into practice. We will establish a working group who will develop a unified PRISMA statement that harmonises content across the main PRISMA guideline and several of its extensions. We will then develop a web application that generates a reporting template and checklist customised to the characteristics and methods of a systematic review ('PRISMA-Web app') and conduct a randomised trial to evaluate its impact on authors' reporting. We will also develop a web application that helps peer reviewers appraise systematic review manuscripts ('PRISMA-Peer app') and conduct a diagnostic accuracy study to evaluate its impact on peer reviewers' detection of incomplete reporting. DISCUSSION: We anticipate the novel guidance and web-based apps developed throughout the project will substantively enhance the completeness of reporting of systematic reviews of health evidence, ultimately benefiting users who rely on systematic reviews to inform health care decision-making.

Critical elements of synthesis questions are incompletely reported: survey of systematic reviews of intervention effects.

OBJECTIVES: To examine the characteristics of population, intervention and outcome groups and the extent to which they were completely reported for each synthesis in a sample of systematic reviews (SRs) of interventions. STUDY DESIGN AND SETTING: We coded groups that were intended (or used) for comparisons in 100 randomly sampled SRs of public health and health systems interventions published in 2018 from the Health Evidence and Health Systems Evidence databases. RESULTS: Authors commonly used population, intervention and outcome groups to structure comparisons, but these groups were often incompletely reported. For example, of 41 SRs that identified and/or used intervention groups for comparisons, 29 (71%) identified the groups in their methods description before reporting of the results (e.g., in the Background or Methods), 12 (29%) defined the groups in enough detail to replicate decisions about which included studies were eligible for each synthesis, 6 (15%) provided a rationale, and 24 (59%) stated that the groups would be used for comparisons. Sixteen (39%) SRs used intervention groups in their synthesis without any mention in the methods. Reporting for population, outcome and methodological groups was similarly incomplete. CONCLUSION: Complete reporting of the groups used for synthesis would improve transparency and replicability of reviews, and help ensure that the synthesis is not driven by what is reported in the included studies. Although concerted effort is needed to improve reporting, this should lead to more focused and useful reviews for decision-makers.

Effectiveness of aromatherapy for prevention or treatment of disease, medical or preclinical conditions, and injury: protocol for a systematic review and meta-analysis.

BACKGROUND: Aromatherapy - the therapeutic use of essential oils from plants (flowers, herbs or trees) to treat ill health and promote physical, emotional and spiritual well-being - is one of the most widely used natural therapies reported by consumers in Western countries. The Australian Government Department of Health (via the National Health and Medical Research Council) has commissioned a suite of independent evidence evaluations to inform the 2019-20 Review of the Australian Government Rebate on Private Health Insurance for Natural Therapies. This protocol is for one of the evaluations: a systematic review that aims to examine the effectiveness of aromatherapy in preventing and/or treating injury, disease, medical conditions or preclinical conditions. METHODS: Eligibility criteria: randomised trials comparing (1) aromatherapy (delivered by any mode) to no aromatherapy (inactive controls), (2) aromatherapy (delivered by massage) to massage alone or (3) aromatherapy to 'gold standard' treatments. POPULATIONS: any condition, pre-condition, injury or risk factor (excluding healthy participants without clearly identified risk factors). OUTCOMES: any for which aromatherapy is indicated. Searches: Cochrane Central Register of Controlled Trials (CENTRAL), with a supplementary search of PubMed (covering a 6-month lag period for processing records in CENTRAL and records not indexed in MEDLINE), AMED and Emcare. No date, language or geographic limitations will be applied. DATA AND ANALYSIS: screening by two authors, independently (records indexed by Aromatherapy or Oils volatile or aromatherapy in title; all full text) or one author (remaining records) with second author until 80% agreement. Data extraction and risk of bias assessment (ROB 2.0) will be piloted by three authors, then completed by a single author and checked by a second. Comparisons will be based on broad outcome categories (e.g. pain, emotional functioning, sleep disruption) stratified by population subgroups (e.g. chronic pain conditions, cancer, dementia) as defined in the analytic framework for the review. Meta-analysis or other synthesis methods will be used to combine results across studies. GRADE methods will be used to assess certainty of evidence and summarise findings. DISCUSSION: Results of the systematic review will provide a comprehensive and up-to-date synthesis of evidence about the effectiveness of aromatherapy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021268244.

The effect of long-term radiofrequency exposure on cognition in human observational studies: A protocol for a systematic review.

BACKGROUND: The long term effects of exposure to radiofrequency (RF) electromagnetic fields (EMF) for frequencies from 100 kHz to 300 GHz on cognitive performance are best assessed using observational studies. In recent years, the use of mobile (cell) phones has been the main source of RF EMF exposure to the brain, although other sources of exposure may be significant. Cognitive function includes various mental and psychological abilities, which can be measured in a range of domains, such as learning, memory, reasoning, problem solving, decision making and attention. Although effects on cognitive function may be most evident later in life, in the experimental setting acute and immediate effects can only be studied. Observational studies are needed when effects are observed after months or years following short or long-term exposure. The importance of the effects of exposure on children has also been recently identified. OBJECTIVES: To assess the long-term effects of RF EMF local and whole-body exposure compared to no or a lower level of exposure on indicators of cognition, including complex attention, executive function, learning and memory, perceptual motor ability and social cognition, but excluding cognitive effects caused by neurodegenerative diseases or neurodevelopmental disorders, and to assess if there is evidence of a dose response relationship. STUDY ELIGIBILITY AND CRITERIA: We will include observational studies that have evaluated cognitive effects of RF energy including a comparator group with a different level of exposure. Studies must report at least one validated measure of cognitive function, including global or domain specific measures, or cognitive impairment, with a minimum follow-up of 6 months. Cohort or case-control studies published in the peer review literature in any language are eligible. We will exclude cross-sectional studies and any that only report brain structure or biomarkers. STUDY APPRAISAL AND SYNTHESIS METHOD: We will conduct searches of PubMed, Embase, PsycINFO and the EMF-Portal. At least two authors will independently screen the titles/abstracts of all records, with any conflicts resolved by a third reviewer. Full-text screening will also be conducted independently by two authors with conflicts resolved by consensus. Data will be extracted from the studies included, such as identifiers and characteristics of the study design, exposure and comparator groups, participants, outcomes assessed and results. Risk of bias will be assessed with the Office of Health Assessment and Translation (OHAT) tool. We will conduct a meta-analysis of similar studies with a random effects model in STATA or similar software, if two or more studies are available for a given exposure-outcome combination. Confidence in the body evidence will be judged using GRADE methods as adapted by OHAT for reviews of environmental exposures.