Thrombolytic strategies versus standard anticoagulation for acute deep vein thrombosis of the lower limb.

BACKGROUND: Standard treatment for deep vein thrombosis (DVT) aims to reduce immediate complications. Use of thrombolytic clot removal strategies (i.e. thrombolysis (clot dissolving drugs), with or without additional endovascular techniques), could reduce the long-term complications of post-thrombotic syndrome (PTS) including pain, swelling, skin discolouration, or venous ulceration in the affected leg. This is the fourth update of a Cochrane Review first published in 2004. OBJECTIVES: To assess the effects of thrombolytic clot removal strategies and anticoagulation compared to anticoagulation alone for the management of people with acute deep vein thrombosis (DVT) of the lower limb. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries to 21 April 2020. We also checked the references of relevant articles to identify additional studies. SELECTION CRITERIA: We considered randomised controlled trials (RCTs) examining thrombolysis (with or without adjunctive clot removal strategies) and anticoagulation versus anticoagulation alone for acute DVT. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as recommended by Cochrane. We assessed the risk of bias in included trials with the Cochrane 'Risk of bias' tool. Certainty of the evidence was evaluated using GRADE. For dichotomous outcomes, we calculated the risk ratio (RR) with the corresponding 95% confidence interval (CI). We pooled data using a fixed-effect model, unless we identified heterogeneity, in which case we used a random-effects model. The primary outcomes of interest were clot lysis, bleeding and post thrombotic syndrome. MAIN RESULTS: Two new studies were added for this update. Therefore, the review now includes a total of 19 RCTs, with 1943 participants. These studies differed with respect to the thrombolytic agent, the doses of the agent and the techniques used to deliver the agent. Systemic, loco-regional and catheter-directed thrombolysis (CDT) strategies were all included. For this update, CDT interventions also included those involving pharmacomechanical thrombolysis. Three of the 19 included studies reported one or more domain at high risk of bias. We combined the results as any (all) thrombolysis interventions compared to standard anticoagulation. Complete clot lysis occurred more frequently in the thrombolysis group at early follow-up (RR 4.75; 95% CI 1.83 to 12.33; 592 participants; eight studies) and at intermediate follow-up (RR 2.42; 95% CI 1.42 to 4.12; 654 participants; seven studies; moderate-certainty evidence). Two studies reported on clot lysis at late follow-up with no clear benefit from thrombolysis seen at this time point (RR 3.25, 95% CI 0.17 to 62.63; two studies). No differences between strategies (e.g. systemic, loco-regional and CDT) were detected by subgroup analysis at any of these time points (tests for subgroup differences: P = 0.41, P = 0.37 and P = 0.06 respectively). Those receiving thrombolysis had increased bleeding complications (6.7% versus 2.2%) (RR 2.45, 95% CI 1.58 to 3.78; 1943 participants, 19 studies; moderate-certainty evidence). No differences between strategies were detected by subgroup analysis (P = 0.25). Up to five years after treatment, slightly fewer cases of PTS occurred in those receiving thrombolysis; 50% compared with 53% in the standard anticoagulation (RR 0.78, 95% CI 0.66 to 0.93; 1393 participants, six studies; moderate-certainty evidence). This was still observed at late follow-up (beyond five years) in two studies (RR 0.56, 95% CI 0.43 to 0.73; 211 participants; moderate-certainty evidence). We used subgroup analysis to investigate if the level of DVT (iliofemoral, femoropopliteal or non-specified) had an effect on the incidence of PTS. No benefit of thrombolysis was seen for either iliofemoral or femoropopliteal DVT (six studies; test for subgroup differences: P = 0.29). Systemic thrombolysis and CDT had similar levels of effectiveness. Studies of CDT included four trials in femoral and iliofemoral DVT, and results from these are consistent with those from trials of systemic thrombolysis in DVT at other levels of occlusion. AUTHORS' CONCLUSIONS: Complete clot lysis occurred more frequently after thrombolysis (with or without additional clot removal strategies) and PTS incidence was slightly reduced. Bleeding complications also increased with thrombolysis, but this risk has decreased over time with the use of stricter exclusion criteria of studies. Evidence suggests that systemic administration of thrombolytics and CDT have similar effectiveness. Using GRADE, we judged the evidence to be of moderate-certainty, due to many trials having small numbers of participants or events, or both. Future studies are needed to investigate treatment regimes in terms of agent, dose and adjunctive clot removal methods; prioritising patient-important outcomes, including PTS and quality of life, to aid clinical decision making.

Exercise for intermittent claudication.

BACKGROUND: Exercise programmes are a relatively inexpensive, low-risk option compared with other, more invasive therapies for treatment of leg pain on walking (intermittent claudication (IC)). This is the fourth update of a review first published in 1998. OBJECTIVES: Our goal was to determine whether an exercise programme was effective in alleviating symptoms and increasing walking treadmill distances and walking times in people with intermittent claudication. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events, and improving quality of life. SEARCH METHODS: For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (last searched 15 November 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10) via the Cochrane Register of Studies Online, along with trials registries. SELECTION CRITERIA: Randomised controlled trials of an exercise regimen versus control or versus medical therapy for people with IC due to peripheral arterial disease (PAD). We included any exercise programme or regimen used for treatment of IC, such as walking, skipping, and running. Inclusion of trials was not affected by duration, frequency, or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain-free walking distance and maximum walking time or maximum walking distance), ankle brachial index (ABI), quality of life, morbidity, or amputation; if none of these was reported, we did not include the trial in this review. DATA COLLECTION AND ANALYSIS: For this update (2017), RAL and AH selected trials and extracted data independently. We assessed study quality by using the Cochrane 'Risk of bias' tool. We analysed continuous data by determining mean differences (MDs) and 95% confidence intervals (CIs), and dichotomous data by determining risk ratios (RRs) and 95% CIs. We pooled data using a fixed-effect model unless we identified significant heterogeneity, in which case we used a random-effects model. We used the GRADE approach to assess the overall quality of evidence supporting the outcomes assessed in this review. MAIN RESULTS: We included two new studies in this update and identified additional publications for previously included studies, bringing the total number of studies meeting the inclusion criteria to 32, and involving a total of 1835 participants with stable leg pain. The follow-up period ranged from two weeks to two years. Types of exercise varied from strength training to polestriding and upper or lower limb exercises; supervised sessions were generally held at least twice a week. Most trials used a treadmill walking test for one of the primary outcome measures. The methodological quality of included trials was moderate, mainly owing to absence of relevant information. Most trials were small and included 20 to 49 participants. Twenty-seven trials compared exercise versus usual care or placebo, and the five remaining trials compared exercise versus medication (pentoxifylline, iloprost, antiplatelet agents, and vitamin E) or pneumatic calf compression; we generally excluded people with various medical conditions or other pre-existing limitations to their exercise capacity.Meta-analysis from nine studies with 391 participants showed overall improvement in pain-free walking distance in the exercise group compared with the no exercise group (MD 82.11 m, 95% CI 71.73 to 92.48, P < 0.00001, high-quality evidence). Data also showed benefit from exercise in improved maximum walking distance (MD 120.36 m, 95% CI 50.79 to 189.92, P < 0.0007, high-quality evidence), as revealed by pooling data from 10 studies with 500 participants. Improvements were seen for up to two years.Exercise did not improve the ABI (MD 0.04, 95% CI 0.00 to 0.08, 13 trials, 570 participants, moderate-quality evidence). Limited data were available for the outcomes of mortality and amputation; trials provided no evidence of an effect of exercise, when compared with placebo or usual care, on mortality (RR 0.92, 95% CI 0.39 to 2.17, 5 trials, 540 participants, moderate-quality evidence) or amputation (RR 0.20, 95% CI 0.01 to 4.15, 1 trial, 177 participants, low-quality evidence).Researchers measured quality of life using Short Form (SF)-36 at three and six months. At three months, the domains 'physical function', 'vitality', and 'role physical' improved with exercise; however this was a limited finding, as it was reported by only two trials. At six months, meta-analysis showed improvement in 'physical summary score' (MD 2.15, 95% CI 1.26 to 3.04, P = 0.02, 5 trials, 429 participants, moderate-quality evidence) and in 'mental summary score' (MD 3.76, 95% CI 2.70 to 4.82, P < 0.01, 4 trials, 343 participants, moderate-quality evidence) secondary to exercise. Two trials reported the remaining domains of the SF-36. Data showed improvements secondary to exercise in 'physical function' and 'general health'. The other domains - 'role physical', 'bodily pain', 'vitality', 'social', 'role emotional', and 'mental health' - did not show improvement at six months.Evidence was generally limited in trials comparing exercise versus antiplatelet therapy, pentoxifylline, iloprost, vitamin E, and pneumatic foot and calf compression owing to small numbers of trials and participants.Review authors used GRADE to assess the evidence presented in this review and determined that quality was moderate to high. Although results showed significant heterogeneity between trials, populations and outcomes were comparable overall, with findings relevant to the claudicant population. Results were pooled for large sample sizes - over 300 participants for most outcomes - using reproducible methods. AUTHORS' CONCLUSIONS: High-quality evidence shows that exercise programmes provided important benefit compared with placebo or usual care in improving both pain-free and maximum walking distance in people with leg pain from IC who were considered to be fit for exercise intervention. Exercise did not improve ABI, and we found no evidence of an effect of exercise on amputation or mortality. Exercise may improve quality of life when compared with placebo or usual care. As time has progressed, the trials undertaken have begun to include exercise versus exercise or other modalities; therefore we can include fewer of the new trials in this update.

Thrombolysis for acute deep vein thrombosis.

BACKGROUND: Standard treatment for deep vein thrombosis aims to reduce immediate complications. Use of thrombolysis or clot dissolving drugs could reduce the long-term complications of post-thrombotic syndrome (PTS) including pain, swelling, skin discolouration, or venous ulceration in the affected leg. This is the third update of a review first published in 2004. OBJECTIVES: To assess the effects of thrombolytic therapy and anticoagulation compared to anticoagulation alone for the management of people with acute deep vein thrombosis (DVT) of the lower limb as determined by the effects on pulmonary embolism, recurrent venous thromboembolism, major bleeding, post-thrombotic complications, venous patency and venous function. SEARCH METHODS: For this update the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (February 2016). In addition the CIS searched the Cochrane Register of Studies (CENTRAL (2016, Issue 1)). Trial registries were searched for details of ongoing or unpublished studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) examining thrombolysis and anticoagulation versus anticoagulation for acute DVT were considered. DATA COLLECTION AND ANALYSIS: For this update (2016), LW and CB selected trials, extracted data independently, and sought advice from MPA where necessary. We assessed study quality with the Cochrane risk of bias tool. For dichotomous outcomes, we calculated the risk ratio (RR) and corresponding 95% confidence interval (CI). Data were pooled using a fixed-effect model unless significant heterogeneity was identified in which case a random-effects model was used. GRADE was used to assess the overall quality of the evidence supporting the outcomes assessed in this review. MAIN RESULTS: Seventeen RCTs with 1103 participants were included. These studies differed in the both thrombolytic agent used and in the technique used to deliver it. Systemic, loco-regional and catheter-directed thrombolysis (CDT) were all included. Fourteen studies were rated as low risk of bias and three studies were rated as high risk of bias. We combined the results as any (all) thrombolysis compared to standard anticoagulation. Complete clot lysis occurred significantly more often in the treatment group at early follow-up (RR 4.91; 95% CI 1.66 to 14.53, P = 0.004) and at intermediate follow-up (RR 2.44; 95% CI 1.40 to 4.27, P = 0.002; moderate quality evidence). A similar effect was seen for any degree of improvement in venous patency. Up to five years after treatment significantly less PTS occurred in those receiving thrombolysis (RR 0.66, 95% CI 0.53 to 0.81; P < 0.0001; moderate quality evidence). This reduction in PTS was still observed at late follow-up (beyond five years), in two studies (RR 0.58, 95% CI 0.45 to 0.77; P < 0.0001; moderate quality evidence). Leg ulceration was reduced although the data were limited by small numbers (RR 0.87; 95% CI 0.16 to 4.73, P = 0.87). Those receiving thrombolysis had increased bleeding complications (RR 2.23; 95% CI 1.41 to 3.52, P = 0.0006; moderate quality evidence). Three strokes occurred in the treatment group, all in trials conducted pre-1990, and none in the control group. There was no significant effect on mortality detected at either early or intermediate follow-up. Data on the occurrence of pulmonary embolism (PE) and recurrent DVT were inconclusive. Systemic thrombolysis and CDT had similar levels of effectiveness. Studies of CDT included two trials in femoral and iliofemoral DVT, and results from these are consistent with those from trials of systemic thrombolysis in DVT at other levels of occlusion. AUTHORS' CONCLUSIONS: Thrombolysis increases the patency of veins and reduces the incidence of PTS following proximal DVT by a third. Evidence suggests that systemic administration and CDT have similar effectiveness. Strict eligibility criteria appears to improve safety in recent studies and may be necessary to reduce the risk of bleeding complications. This may limit the applicability of this treatment. In those who are treated there is a small increased risk of bleeding. Using GRADE assessment, the evidence was judged to be of moderate quality due to many trials having low numbers of participants. However, the results across studies were consistent and we have reasonable confidence in these results.

Exercise for intermittent claudication.

BACKGROUND: Exercise programmes are a relatively inexpensive, low-risk option compared with other more invasive therapies for leg pain on walking (intermittent claudication (IC)). This is an update of a review first published in 1998. OBJECTIVES: The prime objective of this review was to determine whether an exercise programme in people with intermittent claudication was effective in alleviating symptoms and increasing walking treadmill distances and walking times. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events and improving quality of life. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched September 2013) and CENTRAL (2013, Issue 8). SELECTION CRITERIA: Randomised controlled trials of an exercise regimen versus control or versus medical therapy in people with IC due to peripheral arterial disease. Any exercise programme or regimen used in the treatment of intermittent claudication was included, such as walking, skipping and running. Inclusion of trials was not affected by the duration, frequency or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain-free walking distance and maximum walking time or maximal walking distance), ankle brachial index (ABI), quality of life, morbidity or amputation; if none of these were reported the trial was not included in this review. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality. MAIN RESULTS: Eleven additional studies were included in this update making a total of 30 trials which met the inclusion criteria, involving a total of 1816 participants with stable leg pain. The follow-up period ranged from two weeks to two years. The types of exercise varied from strength training to polestriding and upper or lower limb exercises; generally supervised sessions were at least twice a week. Most trials used a treadmill walking test for one of the outcome measures. Quality of the included trials was moderate, mainly due to an absence of relevant information. The majority of trials were small with 20 to 49 participants. Twenty trials compared exercise with usual care or placebo, the remainder of the trials compared exercise to medication (pentoxifylline, iloprost, antiplatelet agents and vitamin E) or pneumatic calf compression; people with various medical conditions or other pre-existing limitations to their exercise capacity were generally excluded.Overall, when taking the first time point reported in each of the studies, exercise significantly improved maximal walking time when compared with usual care or placebo: mean difference (MD) 4.51 minutes (95% confidence interval (CI) 3.11 to 5.92) with an overall improvement in walking ability of approximately 50% to 200%. Walking distances were also significantly improved: pain-free walking distance MD 82.29 metres (95% CI 71.86 to 92.72) and maximum walking distance MD 108.99 metres (95% CI 38.20 to 179.78). Improvements were seen for up to two years, and subgroup analyses were performed at three, six and 12 months where possible. Exercise did not improve the ABI (MD 0.05, 95% CI 0.00 to 0.09). The effect of exercise, when compared with placebo or usual care, was inconclusive on mortality, amputation and peak exercise calf blood flow due to limited data. No data were given on non-fatal cardiovascular events.Quality of life measured using the Short Form (SF)-36 was reported at three and six months. At three months, physical function, vitality and role physical all significantly improved with exercise, however this was a limited finding as this measure was only reported in two trials. At six months five trials reported outcomes of a significantly improved physical summary score and mental summary score secondary to exercise. Only two trials reported improvements in other domains, physical function and general health.Evidence was generally limited for exercise compared with antiplatelet therapy, pentoxifylline, iloprost, vitamin E and pneumatic foot and calf compression due to small numbers of trials and participants. AUTHORS' CONCLUSIONS: Exercise programmes are of significant benefit compared with placebo or usual care in improving walking time and distance in people with leg pain from IC who were considered to be fit for exercise intervention.

Thrombolysis for acute deep vein thrombosis.

BACKGROUND: Standard treatment for deep vein thrombosis aims to reduce immediate complications. Use of thrombolysis or clot dissolving drugs could reduce the long-term complications of post-thrombotic syndrome (PTS) (pain, swelling, skin discolouration, or venous ulceration) in the affected leg. This is the second update of a review first published in 2004. OBJECTIVES: To assess the effects of thrombolytic therapy and anticoagulation versus anticoagulation in the management of people with acute deep vein thrombosis (DVT) of the lower limb as determined by the effects on pulmonary embolism, recurrent venous thromboembolism, major bleeding, post-thrombotic complications, venous patency and venous function. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2013) and CENTRAL (2013, Issue 4). SELECTION CRITERIA: Randomised controlled trials (RCTs) examining thrombolysis and anticoagulation versus anticoagulation for acute DVT were considered. DATA COLLECTION AND ANALYSIS: In the previous review of 2010, one review author (LW) selected trials, extracted data and assessed study quality, with checking at all stages by the other review author (MPA). If necessary, we sought additional information from trialists. For this update (2013), LW and CB selected trials, extracted data independently, and sought advice from MPA where necessary. All studies, existing and new, required full risk of bias assessment in line with current Cochrane procedures. Two of LW, CB and MA independently assessed risk of bias with discussion with the third author where necessary. MAIN RESULTS: Seventeen studies with 1103 participants were included. Complete clot lysis occurred significantly more often in the treatment group in early follow up (risk ratio (RR) 4.91; 95% confidence interval (CI) 1.66 to 14.53, P = 0.004) and at intermediate follow up (RR 2.37; 95% CI 1.48 to 3.80, P = 0.0004). A similar effect was seen for any degree of improvement in venous patency. Significantly less PTS occurred in those receiving thrombolysis, (RR 0.64; 95% CI 0.52 to 0.79, P < 0.0001). Leg ulceration was reduced although the data were limited by small numbers (RR 0.48; 95% CI 0.12 to 1.88, P = 0.29). Those receiving thrombolysis had significantly more bleeding complications (RR 2.23; 95% CI 1.41 to 3.52, P = 0.0006). Three strokes occurred in the treatment group, all in trials conducted pre-1990, and none in the control group. There was no significant effect on mortality detected at either early or intermediate follow up. Data on the occurrence of pulmonary embolism (PE) and recurrent DVT were inconclusive. Systemic thrombolysis is now not commonly used and catheter-directed thrombolysis (CDT) is the more favoured means of administration. This has been studied in iliofemoral DVT, and results from two trials are consistent with those from trials of systemic thrombolysis in DVT at other levels of occlusion. AUTHORS' CONCLUSIONS: Thrombolysis increases the patency of veins and reduces the incidence of PTS following proximal DVT by a third. Strict eligibility criteria are necessary to reduce the risk of bleeding complications and this limits the applicability of this treatment. In those who are treated there is a small increased risk of bleeding. In recent years CDT is the most studied route of administration, and results appear to be similar to systemic administration.

A new model of autism spectrum disorder assessment and diagnosis by multiagency community-based teams in primary schools.

BACKGROUND: National guidelines stress the importance of early diagnosis of autism spectrum disorder (ASD). This pilot investigated the feasibility and acceptability of assessing children in their community. METHOD: The pilot study was carried out from August 2007 to January 2009, and the roll-out of the programme started in 2010 and is currently underway. Workers undertook assessments and made a group decision about diagnosis; participant observation of these team meetings explored the decision-making process. Semistructured interviews and focus groups explored the views of parents and professionals. RESULTS: Seventeen children took part in the study: six were diagnosed with ASD; three as not ASD, and eight were referred for further assessment. The model was found acceptable to parents and workers. CONCLUSIONS: With detailed consideration of administration, information, communication and training requirements, this approach has the potential to increase early diagnosis of ASD and reduce demand for specialist assessment.

Exercise for intermittent claudication.

BACKGROUND: Exercise programmes are a relatively inexpensive, low-risk option compared with other more invasive therapies for leg pain on walking (intermittent claudication (IC)). OBJECTIVES: To determine the effects of exercise programmes on IC, particularly in respect of reduction of symptoms on walking and improvement in quality of life. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last search February 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2008, Issue 1. SELECTION CRITERIA: Randomised controlled trials of exercise regimens in people with IC due to peripheral arterial disease. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed trial quality. MAIN RESULTS: Twenty-two trials met the inclusion criteria involving a total of 1200 participants with stable leg pain. Follow-up period was from two weeks to two years. There was some variation in the exercise regimens used, all recommended at least two sessions weekly of mostly supervised exercise. All trials used a treadmill walking test for one of the outcome measures. Quality of the included trials was good, though the majority of trials were small with 20 to 49 participants. Fourteen trials compared exercise with usual care or placebo; patients with various medical conditions or other pre-existing limitations to their exercise capacity were generally excluded.Compared with usual care or placebo, exercise significantly improved maximal walking time: mean difference (MD) 5.12 minutes (95% confidence interval (CI) 4.51 to 5.72;) with an overall improvement in walking ability of approximately 50% to 200%; exercise did not affect the ankle brachial pressure index (ABPI) (MD -0.01, 95% CI -0.05 to 0.04). Walking distances were also significantly improved: pain-free walking distance MD 82.19 metres (95% CI 71.73 to 92.65) and maximum walking distance MD 113.20 metres (95% CI 94.96 to 131.43). Improvements were seen for up to two years. The effect of exercise compared with placebo or usual care was inconclusive on mortality, amputation and peak exercise calf blood flow due to limited data.Evidence was generally limited for exercise compared with surgical intervention, angioplasty, antiplatelet therapy, pentoxifylline, iloprost and pneumatic foot and calf compression due to small numbers of trials and participants. Angioplasty may produce greater improvements than exercise in the short term but this effect may not be sustained. AUTHORS' CONCLUSIONS: Exercise programmes were of significant benefit compared with placebo or usual care in improving walking time and distance in selected patients with leg pain from IC.

The effectiveness of pneumococcal polysaccharide vaccines in adults: a systematic review of observational studies and comparison with results from randomised controlled trials.

The use of pneumococcal polysaccharide vaccine has remained controversial since licensure, especially in the elderly. Observational studies form much of the evidence base. We conducted a systematic review of observational studies and compared results with those obtained from an earlier review of randomised controlled trials (RCTs). Estimates of protection against invasive disease from observational studies were consistent, homogenous and compatible with sparse information obtained from RCTs. Studies were of moderate quality. From 13 observational studies the estimate of vaccine efficacy against invasive disease was 53% (46-59%) compared with 38% (-4 to 63%) from nine RCTs. Estimates of protection against all-cause pneumonia were based on fewer, heterogeneous studies that were not consistent with the findings from RCTs for this outcome. From five studies combined efficacy was 32% (7-50%) compared with 3% (-16 to 19%) from 13 RCTs.

A survey of community pharmacists on prevention of HIV and hepatitis B and C: current practice and attitudes in Grampian.

BACKGROUND: Prevention of infection with the blood-borne pathogens (BBPs) HIV and hepatitis B and C remains a major public health challenge. The aim of this study was to assess the activity, knowledge and attitudes of community pharmacists in Grampian in prevention of HIV and hepatitis B and C. METHOD: A questionnaire survey of community pharmacies was carried out in Grampian, a mixed urban-rural Health Board area in NE Scotland with a population of 532,432. RESULTS: Ninety-nine out of 128 (77 per cent) community pharmacies responded. Many pharmacies were providing services for drug misusers. Nearly all pharmacies stocked condoms, 57 pharmacists stated that they stocked extra-strong condoms, and two stocked dental dams. Two-thirds had leaflets relating to safer sex, HIV or hepatitis. Less than half stated that they had lists of local agencies dealing with drug-related or sexual health problems. Knowledge of the BBPs, and confidence in giving advice, were greater for HIV than for hepatitis B and C. Few were aware of recommendatons for hepatitis B vaccination. The majority felt that in the future pharmacists could have a greater role in prevention of these infections. Principal barriers to preventive activity were described as time pressure, lack of a private area and lack of training. CONCLUSIONS: There is untapped potential for community pharmacists to be a focus for advice and information relating to prevention of HIV and hepatitis B and C; however, resources are needed to address the current barriers identified field.

Pneumococcal polysaccharide vaccine: a systematic review of clinical effectiveness in adults.

UNLABELLED: Pneumococcal polysaccharide vaccine is recommended in western countries for individuals at high risk of pneumococcal illness. We undertook a systematic review of randomised controlled trials of pneumococcal vaccine in adults, to determine the effects on clinical outcomes. RESULTS: In industrialised populations, no benefit was detected for outcomes other than pneumococcal bacteraemia, and this did not reach statistical significance. In non-industrial populations, clear benefit was demonstrated for mortality and all-cause pneumonia. CONCLUSION: Benefit from pneumococcal vaccination depends on the baseline risk of infection and characteristics of a given population. Evidence from randomised trials for widespread adult vaccination in industrial countries is lacking.