Evaluation of an educational website for parents of children with ADHD.

INTRODUCTION: ADHD is a relatively common neuro-developmental condition characterized by hyperactivity, impulsivity and inattention. The provision of timely and accurate information about the condition and about strategies to manage it is vital especially because of widespread misconceptions about it. AIM: To see the effect of an educational website on (i) parental perceptions (ii) knowledge levels, and to obtain feedback to optimise user-experience. METHOD: Parents whose children had ADHD (or were close to diagnosis) were recruited. Following a 30-item baseline knowledge test parents/carers were directed to an educational website on ADHD. After this they were re-contacted for follow up testing and feedback. RESULTS: n=172, 14 were lost to follow up. Ninety-one (59.4 %) participants were known to have accessed the website at follow up. The majority of carers accessed the website just once or twice (32.7%). Of those who did not access the website 65% cited a lack of time as the reason while 29% cited they were unable to access the internet at the time. The majority (74%) of those accessing the site were just browsing for general information. Parents showed increased knowledge post website use p=0.000. Of those accessing the website the majority (85.5%) felt it was relevant to them and would use it again (90.8%). Content analysis of open-ended feedback identified eight core themes including website appearance, content, functionality, perceptions, target audience, usability, usage patterns with areas for improvement noted in four areas. CONCLUSION: Websites can be used as an adjunct to information given at clinic. Although a majority of parents will access them, there are still barriers to access e.g. time. Websites do seem to improve parent/carer knowledge levels.

Developing clinical guidelines: how much rigour is required?

Clinical guidelines that are rigorously developed play a fundamental role in improving healthcare and reducing unnecessary variations in practice. National guidelines are increasingly used by healthcare professionals, patients and commissioners; however, national bodies are unable to meet the demand for guidance on all topics. There are fewer resources available for guidance produced locally or by specialty groups, and it is necessary to achieve a balance between pragmatism and rigour while conforming to the widely accepted norms of what constitutes a good guideline. This paper introduces the key concepts around this topic with suggestions for those interested in developing their own guideline. An example of challenges encountered in generating high-quality clinical guidance is given in box 1. Box 1 Challenges in guideline development Professor Johnson runs a local developmental paediatrics service with eight other colleagues. All have different ways of managing children with PAVING syndrome. This was difficult for patients and staff and has led to disagreements on how certain patients should be managed. As a result, Professor Johnson developed a Guideline Development Group to look at the management of PAVING syndrome. The group identified 12 clinical questions (including diagnosis, exclusion of comorbidities, treatment modalities), searched the PubMed database and found some useful evidence that they used to formulate key recommendations. For one question about behavioural therapy, PubMed did not suggest any evidence so they informally arrived at a consensus among themselves and wrote up their guideline. On the back of this success, they applied for the guideline to be endorsed or supported by the Royal College of Paediatrics and Child Health (RCPCH). To their frustration, it was turned down on methodological grounds. Professor Johnson wrote to the RCPCH saying that he was "pretty peeved that the PAVING syndrome guideline had been rejected" for the College endorsement given all the work that had gone into writing it and "would the College mind being a bit more explicit in their guidance," to anyone who might consider doing this in the future?

Influenza vaccination for immunocompromised patients: summary of a systematic review and meta-analysis.

Vaccination of immunocompromised patients is recommended in many national guidelines to protect against severe or complicated influenza infection. However, due to uncertainties over the evidence base, implementation is frequently patchy and dependent on individual clinical discretion. We conducted a systematic review and meta-analysis to assess the evidence for influenza vaccination in this patient group. Healthcare databases and grey literature were searched and screened for eligibility. Data extraction and assessments of risk of bias were undertaken in duplicate, and results were synthesised narratively and using meta-analysis where possible. Our data show that whilst the serological response following vaccination of immunocompromised patients is less vigorous than in healthy controls, clinical protection is still meaningful, with only mild variation in adverse events between aetiological groups. Although we encountered significant clinical and statistical heterogeneity in many of our meta-analyses, we advocate that immunocompromised patients should be targeted for influenza vaccination.

Commentary on 'Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years'.

This is a commentary on a Cochrane review, published in this issue of EBCH, first published as: Furlong M, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M. Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD008225. DoI: 10.1002/14651858.CD008225.pub2.

Influenza vaccination for immunocompromised patients: systematic review and meta-analysis from a public health policy perspective.

BACKGROUND: Immunocompromised patients are vulnerable to severe or complicated influenza infection. Vaccination is widely recommended for this group. This systematic review and meta-analysis assesses influenza vaccination for immunocompromised patients in terms of preventing influenza-like illness and laboratory confirmed influenza, serological response and adverse events. METHODOLOGY/PRINCIPAL FINDINGS: Electronic databases and grey literature were searched and records were screened against eligibility criteria. Data extraction and risk of bias assessments were performed in duplicate. Results were synthesised narratively and meta-analyses were conducted where feasible. Heterogeneity was assessed using I(2) and publication bias was assessed using Begg's funnel plot and Egger's regression test. Many of the 209 eligible studies included an unclear or high risk of bias. Meta-analyses showed a significant effect of preventing influenza-like illness (odds ratio [OR]=0.23; 95% confidence interval [CI]=0.16-0.34; p<0.001) and laboratory confirmed influenza infection (OR=0.15; 95% CI=0.03-0.63; p=0.01) through vaccinating immunocompromised patie nts compared to placebo or unvaccinated controls. We found no difference in the odds of influenza-like illness compared to vaccinated immunocompetent controls. The pooled odds of seroconversion were lower in vaccinated patients compared to immunocompetent controls for seasonal influenza A(H1N1), A(H3N2) and B. A similar trend was identified for seroprotection. Meta-analyses of seroconversion showed higher odds in vaccinated patients compared to placebo or unvaccinated controls, although this reached significance for influenza B only. Publication bias was not detected and narrative synthesis supported our findings. No consistent evidence of safety concerns was identified. CONCLUSIONS/SIGNIFICANCE: Infection prevention and control strategies should recommend vaccinating immunocompromised patients. Potential for bias and confounding and the presence of heterogeneity mean the evidence reviewed is generally weak, although the directions of effects are consistent. Areas for further research are identified.

"There is nothing like looking, if you want to find something" - asking questions and searching for answers - the evidence based approach.

Evidence based medicine (EBM) consists of four separate processes. Asking a clinical question Locating the evidence Appraising and synthesizing the evidence Applying the evidence Most people are familiar with the third step but not so familiar with the first two. Well-designed clinical questions can help clarify in a clinicians mind exactly what information is being sought and also help with the search. This clinical question can be framed around the PICO format. With a well-structured PICO information can then be located in a timely manner using the concept of Haynes's 5 S's and a range of websites including trial registers and meta-search engines.

WITHDRAWN. Surfactant therapy for bronchiolitis in critically ill infants.

BACKGROUND: Viral bronchiolitis is a common cause of respiratory failure in infants and children, and accounts for a significant portion of intensive care unit (ICU) admissions during seasonal epidemics. Currently there is no evidence to support the use of anything but supportive care for this disease. Surfactant is a potentially promising therapy; alterations in its composition have been described in bronchiolitis, and it may play a role in the host immunity for this disease. OBJECTIVES: To assess the efficacy of exogenous surfactant for the treatment of bronchiolitis in mechanically ventilated infants and children. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2006, issue 1) which contains the Acute Respiratory Infections Group's Specialized Register; MEDLINE (1966 to Week 1, February 2006); and EMBASE (1990 to September 2005). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing surfactant with placebo or surfactant with no surfactant in mechanically ventilated infants and children with viral bronchiolitis. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed trial quality. Unpublished data were requested from trial authors when necessary. MAIN RESULTS: Three trials containing a total of 79 patients met the inclusion criteria. No mortality or adverse effects associated with surfactant administration were reported in any of these trials. In the three trials, use of surfactant was associated with a decrease in duration of mechanical ventilation by 2.6 days (95% confidence interval (CI) -5.34 to 0.18 days; P value 0.07) and a decrease in ICU length of stay by 3.3 days (95% CI -6.38 to -0.23 days; P value 0.04). In two studies with 59 patients, in which duration of mechanical ventilation in the control groups was more comparable, surfactant was associated with a decrease in ventilator days by 1.21 days (95% CI 0.75 to 1.67 days) and a decrease in ICU stay by 1.81 days (95% CI 1.19 days to 2.42 days). Individually the studies reported some short term benefit of surfactant on pulmonary mechanics and gas exchange. AUTHORS' CONCLUSIONS: Available data on surfactant were not sufficient to provide reliable estimates of its effects in mechanically ventilated infants and children with bronchiolitis. Future studies should be adequately powered and will need to address unresolved questions regarding which surfactant preparation may be best suited for the treatment of bronchiolitis, the appropriate dose and administration interval, and how the choice of ventilator strategy may modify its effects.