Hospital-based alternatives to acute paediatric admission: a systematic review

Objective: To synthesise published evidence of the impacts of introducing hospital-based alternatives to acute paediatric admission. Design: Systematic review of studies of interventions published in English. Patients: Children with acute medical problems referred to hospitals. Interventions: Services provided in a hospital as an alternative to inpatient admission. Main outcome measures: Admission or discharge, unscheduled returns to hospital, satisfaction of parents and general practitioners, effects on health service activity and costs. Results: 25 studies were included: one randomised controlled trial, 23 observational or cross-sectional studies and one qualitative study. Many studies were of uncertain quality or were open to significant potential bias. About 40% of children attending acute assessment units in paediatric departments, and over 60% of those attending acute assessment units in A & E departments, do not require inpatient admission. There is little evidence of serious clinical consequences in children discharged from these units, although up to 7% may subsequently return to hospital. There is some evidence that users are satisfied with these services and that they are associated with reductions in inpatient activity levels and certain hospital costs. Evidence about the impact of urgent outpatient clinics is very limited. Conclusions: Current evidence supports a view that acute paediatric assessment services are a safe, efficient and acceptable alternative to inpatient admission, but this evidence is of limited quantity and quality. Further research is required to confirm that this type of service reorganisation does not disadvantage children and their families, particularly where inpatient services are withdrawn from a hospital

Early discharge of low-risk women from cervical screening

Background: The Scottish Cervical Screening Programme currently offers three-yearly screening to all women between the ages of 20 and 60. However, previous studies have indicated that well-screened women over the age of 50 are likely to be at low risk of cervical neoplasia. This study aimed to explore the implications of discharging these women from screening in a typical area of Scotland. Methods: A case–control study of the screening histories of women with and without screen-detected cervical neoplasia between ages 50 and 59 in Lanarkshire was carried out, as well as a cross-sectional study of the prevalence of adequate screening histories among women currently aged 50 in Lanarkshire. Routine screening programme statistics were used to estimate the effects of introducing an early discharge policy. Results: Women reaching the age of 50 with two recent, consecutive, negative smears had reduced odds of screen-detected neoplasia in the subsequent decade. The estimated odds ratio for all screen-detected neoplasia (CIN 1–3, adenocarcinoma in situ and invasive carcinoma) was 4.4 [95 per cent confidence interval (CI) 1.6–13.2, p = 0.002]. The estimated odds ratio for screen-detected high-grade CIN and invasive squamous carcinoma was 17.0 (95 per cent CI 2.4–243.0, þ = 0.0004). A total of 54.0 per cent (95 per cent CI 47.9–59.9 per cent) of screening participants currently aged 50 fulfilled the definition of adequate screening. Discharging these women might be expected to reduce screening workload by approximately 10 per cent, but those discharged would be at increased risk of neoplasia. Conclusion: Now that full screening histories are available in all health board areas since 1990, the identification of a low-risk group within the screened population could be the first step towards a screening programme targeted more closely on those with the greatest capacity to benefit

Obesity: the elephant in the corner

To date, our approach to obesity has largely been based on a simple individualistic prescription to balance energy intake against energy expenditure. This approach works for some of the people, some of the time, but is clearly not working at population level. Recognising the importance of the obesogenic environment was a crucial step forward in understanding the causes of, and potential solutions to, the emerging obesity epidemic. However, our current “environmental” responses to obesity amount to little more than marginal changes, and ignore the fact that the obesogenic environment is itself the product of the way we have chosen to organise our society. The only realistic prospect of reversing the growth in obesity lies in a decision to adopt a different set of societal priorities

Reducing social inequalities in smoking: can evidence inform policy? A pilot study

Objective: To assess the potential contribution of evidence from existing systematic reviews of effectiveness to answering the question: what works in reducing social inequalities in smoking? Data source: The Cochrane Library (2002/4). Study selection: Systematic reviews of the effectiveness of community based tobacco control interventions, and all the primary studies included in one of these reviews. Data extraction: Reviews and primary studies were assessed for intent to assess the social distribution of intervention effects, information about the social inclusiveness or targeting of interventions, baseline sociodemographic data collected on participants, and estimates of effect size stratified by sociodemographic variables. Data synthesis: Only one review aimed to examine outcomes stratified by sex, age or socioeconomic status, and these aims were only achieved with respect to sex. Sociodemographic data about participants were frequently collected in primary studies, but not used to compare intervention effects between social groups. Conclusions: There may be scope for using existing research more effectively to contribute to evidence based policy to reduce social inequalities in smoking—by explicitly seeking stratified outcome data in new systematic reviews, by re-analysing original datasets, and/or by meta-analysis of individual participant data

Multiaxial analyzer detects low-energy electrons

Three curved plate energy analyzers coupled with three electron multiplier tubes detect and measure low energy electron flux in several directions simultaneously

First results from the six-axis electron spectrometer on ISEE-1

A survey, using results from the first 25 orbits of ISEE-1, was made of some aspects of electrons in the dawn magnetosheath. There are indications that the flow of plasma is not uniformly turbulent over this region. The electron heat flux is observed to be directed away from the shock and to have an average value of about twice the interplanetary heat flux. Many magnetopause crossings were observed and usually resemble abrupt transitions from one well-defined plasma state to another. The ejection of plasma from flux tubes convected up against the magnetopause is observed for about half the time, and its thickness and dependance on the solar wind Mach number agrees with theoretical predictions. A full traversal of the whole forward hemisphere of the magnetosheath is required to fully confirm these deductions

Systematic reviews of health effects of social interventions: 1. Finding the evidence: how far should you go?

Study objective: There is little guidance on how to identify useful evidence about the health effects of social interventions. The aim of this study was to assess the value of different ways of finding this type of information. Design: Retrospective analysis of the sources of studies for one systematic review. Setting: Case study of a systematic review of the effectiveness of interventions in promoting a population shift from using cars towards walking and cycling. Main results: Only four of the 69 relevant studies were found in a "first-line" health database such as Medline. About half of all relevant studies were found through the specialist Transport database. Nine relevant studies were found through purposive internet searches and seven relevant studies were found by chance. The unique contribution of experts was not to identify additional studies, but to provide more information about those already found in the literature. Conclusions: Most of the evidence needed for this review was not found in studies indexed in familiar literature databases. Applying a sensitive search strategy across multiple databases and interfaces is very labour intensive. Retrospective analysis suggests that a more efficient method might have been to search a few key resources, then to ask authors and experts directly for the most robust reports of studies identified. However, internet publications and serendipitous discoveries did make a significant contribution to the total set of relevant evidence. Undertaking a comprehensive search may provide unique evidence and insights that would not be obtained using a more focused search

Promoting walking and cycling as an alternative to using cars: systematic review

Objectives: To assess what interventions are effective in promoting a population shift from using cars towards walking and cycling, and to assess the health and distributional effects of such interventions. Data sources: Published and unpublished reports in any language identified from electronic databases, bibliographies, websites and reference lists. Review methods: Systematic search and appraisal to identify experimental or observational studies with a prospective or controlled retrospective design that evaluated any intervention applied to an urban population or area by measuring outcomes in members of the local population. Results: 22 studies met the inclusion criteria. We found some evidence that targeted behaviour change programmes can change the behaviour of motivated subgroups, resulting (in the largest study) in a modal shift of around 5% of all trips at a population level. Single studies of commuter subsidies and a new railwy station have also shown modest effects. The balance of best available evidence about publicity campaigns, engineering measures and other interventions suggests that they have not been effective. Participants in trials of active commuting experienced short-term improvements in certain health and fitness measures, but we found no good evidence about the health effects of any effective population-level intervention. Conclusions: The best available evidence of effectiveness is for targeted behaviour change programmes, but the social distribution of their effects is unclear and some other types of intervention remain to be rigorously evaluated. We need a stronger evidence base for the health impacts of transport policies, preferably based on properly conducted prospective studies