Local anesthetic wound infusion versus standard analgesia in paediatric post-operative pain control

INTRODUCTION

Local anesthetic wound infusion has shown promising results in adults. Its use in children is limited to some centers and there are only a few prospective trials in this group of patients.

METHODS

Sub-fascial continuous local anaesthetic wound infusion (CLAWI) (0.2% Bupivacaine) plus intravenous paracetamol and rescue intravenous morphine was compared to: (a) Epidural bupivacaine (EPI) plus paracetamol and rescue intravenous morphine for patients undergoing laparotomy. (b) Intravenous morphine and paracetamol (standard post-operative analgesia-SAPA) in children undergoing Lanz incision laparotomy for complicated appendicitis. 'InfiltralLong', PANJUNK(®) catheters were placed sub-fascially after peritoneal closure for post-operative bupivacaine infusion. Pain scores were recorded regularly by the same blinded pain specialist. The primary outcomes were pain control and total morphine. The secondary outcomes were time to full feeds, mobilization requirement for urinary catheter and complications.

RESULTS

Sixty patients (18 laparotomy-CLAWI, 17 laparotomy-EPI and 12 appendectomy-CLAWI, and 13 appendectomy-SAPA) were analyzed. The average pain score was 2.5 (1-4) in the CLAWI groups, 3.0 (1-5) in the EPI group and 3.5 (2-5) in the SAPA group. Morphine requirements were markedly less for CLAWI. SAPA and EPI groups required urinary catheters for longer and took longer to mobilize (average 4 days compared to 2 days for CLAWI). There were no wound or bupivacaine complications in the CLAWI group.

CONCLUSION

Continuous subfascial bupivacaine infusion is reliable, safe and effective in paediatric post-operative pain control with considerably reduced opiate requirements.

POEMS syndrome associated with plasmacytoma of the clivus: "Time discovers the truth"

Polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes (POEMS) syndrome is characterized by the presence of a monoclonal plasma cell disorder, peripheral neuropathy, and one or more of the following features: Osteosclerotic myeloma, Castleman's disease (angiofollicular lymph node hyperplasia), increased levels of serum vascular endothelial growth factor (VEGF), organomegaly, endocrinopathy, edema, typical skin changes, and papilledema. [1] Solitary plasmacytomas most frequently occur in the bone but can also be found in soft tissues (extramedullary plasmacytoma). [2] We report a case that showed a rare association of POEMS syndrome with a plasmacytoma of the clivus.

Safety and efficacy of kunzea oil-containing formulations for the management of psoriasis: a randomized, controlled trial

WHAT IS KNOWN AND OBJECTIVE

Anecdotally, topical kunzea oil has been used to treat various skin conditions, including psoriasis and eczema, with good results. This study compared the clinical efficacy of kunzea oil (20%)-containing formulations in mild to moderate psoriasis.

METHODS

A randomized, comparative, double-blind, 8-week study was undertaken. Thirty patients (age range: 25-74 years and mean ± SD: 52·8 ± 13·6 years) with mild to moderate psoriasis (affecting at least 10% of one or more body regions: arms, head, legs and trunk) randomly received ointment and/or scalp lotion containing 20% kunzea oil (test group) or control medications not containing kunzea oil (control group). Formulations in both treatment arms also contained 5% liquor carbonis detergens (LCD) and 3% salicylic acid. The clinical responses to the test and control formulations were evaluated using the Psoriasis Area and Severity Index (PASI).

RESULTS AND DISCUSSION

After 8 weeks of treatment, both test and control groups demonstrated a significant (P < 0·05) improvement in PASI scores. Subjects in the test group had a decrease in mean±SD PASI score from 12·7 ± 7·9 to 6·7 ± 7·2, whereas the control group showed a decrease in PASI score from 8·1 ± 4·6 to 3·5 ± 4·7. Comparative efficacy analysis between the test and control groups did not reveal any significant difference (P > 0·05).

WHAT IS NEW AND CONCLUSIONS

The inclusion of kunzea oil made no difference to the efficacy of topical formulations containing LCD and salicylic acid for the treatment of psoriasis.

Dissecting susceptibility from exogenous triggers: the model of alopecia areata and associated inflammatory skin diseases

BACKGROUND

Alopecia areata (AA) is a T-cell-driven autoimmune disease of the hair follicle and frequently reported to be associated with inflammatory skin diseases (ISD) such as atopic eczema (AE) or psoriasis. Interestingly, AA on the one hand and both AE and psoriasis on the other hand are believed to be driven by mutually antagonistic T-cell subsets.

OBJECTIVE

To characterize AA-specific T-cell profiles and inflammatory pattern by intra-individual comparison of AA and coexistent ISD.

METHODS

112 patients with AA were recruited and investigated for coexisting ISD. In-depth analyses were performed in patients with AA and AE (n = 2), AA and psoriasis (n = 1), AA and psoriasis and AE (n = 1) and AA and lichen planus (n = 1), using histology, immunohistochemistry and cytokine staining of T cells isolated from lesional skin.

RESULTS

Of 112 AA patients investigated, 23 suffered from an ISD. The prevalence of AE, vitiligo, psoriasis and lichen planus was higher in the investigated AA cohort than in the normal population. The clinical as well as histological phenotype of AA the coexistent ISD were unequivocal. In line with this, T-cell infiltrates were found to be disease-characteristics with AA and lichen planus dominated by CD8+ and IFN-γ+ TNF-α+ producing T cells while psoriasis lesions in the same patients were dominated by IL-17+ and AE by IL-4+ T cells.

CONCLUSION

AA patients have a higher incidence of various T-cell-driven inflammatory skin diseases than the normal population, a phenomenon which might relate to over-activation of skin-homing T cells and to specific immune triggers as the primary cause of inflammation. More importantly, we showed that by using AA as a model disease, our approach of intra-individual comparison of distinct inflammatory responses in the same patient is feasible and offers the unique possibility to gain insights into disease pathogenesis independent from genetic susceptibilities.

Flexible Lifestyles for Youth (FL3X) behavioural intervention for at-risk adolescents with Type 1 diabetes: a randomized pilot and feasibility trial

AIM

To determine the potential effect sizes for the Flexible Lifestyle for Youth (FL3X) behavioural intervention to improve glycaemic control (HbA(1c)) and quality of life for at-risk adolescents with Type 1 diabetes.

METHODS

Participants [n = 61; age 12-16 years, HbA(1c) 64-119 mmol/mol (8-13%)] were randomized to FL3X (minimum three sessions) or usual care. Effect sizes (Cohen's d), comparing the mean difference between the groups, were calculated.

RESULTS

Study retention (95%), attendance at intervention sessions (87% attended all three sessions) and acceptability were high (100% of the adolescents and 91% of parents would recommend the programme to others). Overall, 41% of participants in the intervention group and 24% of participants in the control group were 'responders' [HbA(1c) decreased by > 6 mmol/mol (0.5%); d = 0.37]. HbA(1c) levels decreased (d = -0.18), diabetes-specific quality of life increased (d = 0.29), but generic quality of life decreased (d = -0.23) in the intervention compared with the control group.

CONCLUSIONS

The FL3X programme merits further study for improving HbA(1c) and diabetes-specific quality of life in adolescents with Type 1 diabetes. (Clinical trials registry no.: NCT01286350).

REpeated AutoLogous Infusions of STem cells In Cirrhosis (REALISTIC): a multicentre, phase II, open-label, randomised controlled trial of repeated autologous infusions of granulocyte colony-stimulating factor (GCSF) mobilised CD133+ bone marrow stem cells in patients with cirrhosis. A study protocol for a randomised controlled trial

INTRODUCTION

Liver disease mortality and morbidity are rapidly rising and liver transplantation is limited by organ availability. Small scale human studies have shown that stem cell therapy is safe and feasible and has suggested clinical benefit. No published studies have yet examined the effect of stem cell therapy in a randomised controlled trial and evaluated the effect of repeated therapy.

METHODS AND ANALYSIS

Patients with liver cirrhosis will be randomised to one of three trial groups: group 1: Control group, Standard conservative management; group 2 treatment: granulocyte colony-stimulating factor (G-CSF; lenograstim) 15 µg/kg body weight daily on days 1-5; group 3 treatment: G-CSF 15 µg/kg body weight daily on days 1-5 followed by leukapheresis, isolation and aliquoting of CD133+ cells. Patients will receive an infusion of freshly isolated CD133+ cells immediately and frozen doses at days 30 and 60 via peripheral vein (0.2×10(6) cells/kg for each of the three doses). Primary objective is to demonstrate an improvement in the severity of liver disease over 3 months using either G-CSF alone or G-CSF followed by repeated infusions of haematopoietic stem cells compared with standard conservative management. The trial is powered to answer two hypotheses of each treatment compared to control but not powered to detect smaller expected differences between the two treatment groups. As such, the overall α=0.05 for the trial is split equally between the two hypotheses. Conventionally, to detect a relevant standardised effect size of 0.8 point reduction in Model for End-stage Liver Disease score using two-sided α=0.05(overall α=0.1 split equally between the two hypotheses) and 80% power requires 27 participants to be randomised per group (81 participants in total).

ETHICS AND DISSEMINATION

The trial is registered at Current Controlled Trials on 18 November 2009 (ISRCTN number 91288089, EuDRACT number 2009-010335-41). The findings of this trial will be disseminated to patients and through peer-reviewed publications and international presentations.

Field-reversed bubble in deep plasma channels for high-quality electron acceleration

We study hollow plasma channels with smooth boundaries for laser-driven electron acceleration in the bubble regime. Contrary to the uniform plasma case, the laser forms no optical shock and no etching at the front. This increases the effective bubble phase velocity and energy gain. The longitudinal field has a plateau that allows for monoenergetic acceleration. We observe as low as 10⁻³ rms relative witness beam energy uncertainty in each cross section and 0.3% total energy spread. By varying the plasma density profile inside a deep channel, the bubble fields can be adjusted to balance the laser depletion and dephasing lengths. Bubble scaling laws for the deep channel are derived. Ultrashort pancakelike laser pulses lead to the highest energies of accelerated electrons per Joule of laser pulse energy.

Acidic environment activates inflammatory programs in fibroblasts via a cAMP-MAPK pathway

The tissue micromilieu in disorders (inflammation, ischemia, tumor) often shows pronounced metabolic acidosis that may alter signaling and transcriptional activity in resident cells which can be of special importance for omnipresent fibroblasts. In the present study we investigated the impact of metabolic acidosis on rat fibroblasts with special emphasis on their role in inflammation by regulation of TNF-α, MCP-1, COX-2 and iNOS expression and the signaling pathways involved. Extracellular acidosis led to an enhanced expression of TNF-α, COX-2 and iNOS in parallel to an activation of p38 and ERK1/2 kinases that was not observed by sole intracellular acidosis. Accordingly, the protein amounts of TNF-α and COX-2 as well as the production of nitrate and nitrite were elevated. Acidosis-induced expression of COX-2 and iNOS depended on p38 kinase, but not on ERK1/2. In contrast acidosis-induced TNF-α expression was independent of both kinases. Although GPR4, GPR68 and GPR132 are expressed in fibroblasts, the involvement of these potential candidate pH sensors could be ruled out since no acidosis-induced elevation in intracellular cAMP or free calcium content was observed. Furthermore our data show that MAPK activation by an acidic micromilieu depends on Ser/Thr phosphatase activity, but not on the production of reactive oxygen species and is sensitive to cAMP antagonism by Rp-cAMPS. In conclusion, our results show that an acidic microenvironment induces a differential transcriptional program of pathological relevant genes in fibroblasts via the cAMP-phosphatase-MAPK pathway and thereby generates a parainflammatory situation that can result in tissue remodeling.

An analysis of response to neo-adjuvant chemotherapy in patients with locally advanced breast cancer with emphasis on pathological complete response

CONTEXT

In India, most breast cancer women present at a locally advanced stage. Routine practice in majority of the cancer centers is to administer neo-adjuvant chemotherapy (NACT) followed by loco-regional treatment. Surgery is scheduled after 3 or 4 cycles. The patients who achieve pathological complete response (pCR) are expected do well.

AIMS

The present study was conducted to analyze our results with NACT, to know pCR rate, to compare pCR rates among various subgroups and to determine the factors which predict pCR.

SETTINGS AND DESIGN

The study was conducted in a tertiary care university affiliated cancer hospital in South India.

SUBJECTS AND METHODS

All patients with non-metastatic locally advanced breast cancer and agreed by the hospital tumor board to receive NACT were included. At each visit, response was assessed according to RECIST criteria. Re-staging work up and mammography was done prior to surgery.

STATISTICAL ANALYSIS USED

Chi square test was used to analyze categorical variables and uni and multivariate analysis were performed to determine the factors predicting pCR rates.

RESULTS

A total of 84 patients received NACT. Median age was 46 years (ranged from 28 to 66), 46 patients were premenopausal. Totally 72 patients completed the full course before surgery. Clinical response was complete in 26, partial in 52 and 3 had local progression, one stable and two patient developed distant metastasis. Forty-eight patients underwent modified radical mastectomy and breast could be conserved in 34 patients, pCR rate was 36%.

CONCLUSIONS

Compared with historical controls particularly from India, we could achieve higher pCR rates.

Subcutaneous panniculitis like T cell lymphoma associated with erythromelalgia

Erythromelalgia is a rare disorder that simulates a small fiber neuropathy and patients often have painful erythematous extremities during episodes. It is of two types: A primary or inherited form that is sometimes associated with a Na channel mutation or a secondary disorder associated with an underlying systemic disorder. We present a 19-year-old boy who presented to us with erythromelalgia and a febrile illness with systemic rash. Detailed work-up revealed another unusual condition: Subcutaneous panniculitis like T cell lymphoma (SPTCL). This is the first report of an association of erythromelalgia with SPTCL.

Diurnal and seasonal variability of outdoor radon concentration in the area of the NRPI Prague

In autumn 2010, an outdoor measuring station for measurement of atmospheric radon, gamma equivalent dose rate in the range of 100 nSv h(-1)-1 Sv h(-1) and proper meteorological parameters such as thermal air gradient, relative air humidity, wind speed and direction and solar radiation intensity was built in the area of the National Radiation Protection Institute vvi. The station was designed to be independent of an electrical network and enables on-line wireless transfer of all data. After introduction of the station, illustrations of its measurement properties and the results of measured diurnal and seasonal variability of atmospheric radon, based on annual continuous measurement using a high-volume scintillation cell at a height of 2.5 m above the ground, are presented.

International intercomparison of measuring instruments for radon/thoron gas and radon short-lived daughter products in the NRPI Prague

During the 7th European Conference on Protection Against Radon at Home and at Work held in the autumn of 2013 in Prague, the second intercomparison of measuring instruments for radon and its short-lived decay products and the first intercomparison of radon/thoron gas discriminative passive detectors in mix field of radon/thoron were organised by and held at the Natural Radiation Division of the National Radiation Protection Institute (NRPI) in Prague. In total, 14 laboratories from 11 different countries took part in the 2013 NRPI intercomparison. They submitted both continuous monitors for the measurement of radon gas and equivalent equilibrium radon concentration in a big NRPI chamber (48 m3) and sets of passive detectors including radon/thoron discriminative for the measurement of radon gas in the big chamber and thoron gas in a small thoron chamber (150 dm3).

Self-control revisited: Some factors that affect autoshaped responding

Pigeons were exposed to autoshaping procedures under which 50% of red key illuminations were followed by 9-sec food deliveries, and 50% of blue key illuminations were followed by 3-sec food deliveries. When all key illuminations were 6 sec, pigeons preferred the red stimulus. Subsequent manipulations demonstrated that preference could be shifted to the blue stimulus by either increasing the duration of the red stimulus or imposing a delay interval between the offset of that stimulus and food delivery. A final experiment demonstrated that, in two of three subjects, preference for key illuminations associated with longer, but delayed, food deliveries generally increased as the duration of all key illuminations was lengthened. These results, obtained under conditions where keypecking had no programmed consequences, are similar to those previously observed under procedures involving a positive response-food dependency.

Combined analysis of νμ disappearance and νμ→νe appearance in MINOS using accelerator and atmospheric neutrinos

We report on a new analysis of neutrino oscillations in MINOS using the complete set of accelerator and atmospheric data. The analysis combines the ν(μ) disappearance and ν(e) appearance data using the three-flavor formalism. We measure |Δm(32)(2)| = [2.28-2.46] × 10(-3) eV(2) (68% C.L.) and sin(2)θ(23) = 0.35-0.65 (90% C.L.) in the normal hierarchy, and |Δm(32)(2)| = [2.32-2.53] × 10(-3) eV(2) (68% C.L.) and sin(2)θ(23) = 0.34-0.67 (90% C.L.) in the inverted hierarchy. The data also constrain δ(CP), the θ(23} octant degeneracy and the mass hierarchy; we disfavor 36% (11%) of this three-parameter space at 68% (90%) C.L.

Exertional heat stroke, rhabdomyolysis and susceptibility to malignant hyperthermia

Unexpectedly severe exertional heat stroke and rhabdomyolysis should prompt a clinician to look for susceptibility to malignant hyperthermia. We report a case of exertional heat stroke and rhabdomyolysis in a man later determined to have the malignant hyperthermia phenotype. We review the existing literature regarding this association and suggest future research that could address areas of remaining clinical uncertainty.

The combination of a chemotherapy doublet (gemcitabine and capecitabine) with a biological doublet (bevacizumab and erlotinib) in patients with advanced pancreatic adenocarcinoma. The results of a phase I/II study

BACKGROUND

Preclinical data support the combined inhibition of vascular endothelial growth factor (VEGF) and epidermal growth factor receptor (EGFR) pathways in the treatment of pancreatic cancer. Following a dose finding phase I study the efficacy and toxicity of a four-drug regimen utilising the cytotoxic doublet of gemcitabine and capecitabine (GemCap), with the biological doublet of erlotinib and bevacizumab were further assessed in patients with advanced pancreatic cancer.

PATIENTS AND METHODS

In a phase II expansion cohort, patients with chemonaive locally advanced or metastatic pancreatic cancer received gemcitabine (1000mg/m(2) D1, 8, 15), capecitabine (1400mg/m(2) D1-21), erlotinib (100mg daily) and bevacizumab (5mg/kg D1, 15) every 28days. The primary endpoint was radiological response rate by response evaluation criteria in solid tumours (RECIST). Computed tomography (CT) assessment was performed every 8weeks. Consolidation radiotherapy was considered in locally advanced patients following six cycles of treatment.

RESULTS

In total 44 patients (phases I & II) were recruited. The median cycles delivered were 6 (range 1-16). Confirmed radiological responses were seen in 23% (95% confidence interval (CI): 11-38%) of patients. The median progression-free and overall survival for the entire cohort was 8.4 and 12.6months, respectively. In patients with metastatic disease the median overall survival was 10.1months. Common grade 3/4 toxicities were; neutropenia 52%, lethargy 32%, diarrhoea 18% and hand-foot syndrome 18%.

CONCLUSION

The combination of gemcitabine, capecitabine, erlotinib and bevacizumab was feasible with a manageable toxicity profile and demonstrated encouraging efficacy data in a good performance status population.

Description of the Western Sydney and Nepean Blue Mountains local health districts' influenza prevention programme

BACKGROUND

Influenza is a major cause of morbidity and mortality. In 2011, influenza vaccination was provided free for people at greatest risk of severe disease: people aged 65 years and over, Aboriginal Australians 15 years and older, pregnant women, and individuals aged 6 months and over who suffered chronic medical conditions.

AIMS

To evaluate the Western Sydney and Nepean Blue Mountains Local Health District Influenza Prevention Program and to identify some of the enablers and barriers to vaccination in the hospital outpatient setting.

METHODS

Western Sydney and Nepean Blue Mountains local health districts' influenza prevention programme provided influenza vaccine in hospital outpatient settings between 21 March 2011 and 30 June 2011. Accredited nurse immunisers vaccinated 2824 individuals and recorded their primary reason for vaccination. Nurse immunisers were interviewed to identify barriers and enablers to influenza immunisation uptake.

RESULTS

Two thousand, eight hundred and twenty-four doses of influenza vaccine were administered to people at high risk of influenza in four hospitals in the region: two tertiary facilities and two district hospitals. The primary indication for vaccination was chronic disease in 50% and pregnancy in 37%. Estimated direct cost of the programme was $19 per dose.

CONCLUSIONS

A hospital-based influenza vaccination programme can be an effective way to improve influenza vaccination rates among specific population groups at high risk of severe disease with influenza, particularly pregnant women and those younger than 65 years with a chronic medical condition.

High average power Yb:CaF2 femtosecond amplifier with integrated simultaneous spatial and temporal focusing for laser material processing

A watt level, 10-kilohertz repetition rate chirped pulse amplification system that has an integrated simultaneous spatial and temporal focusing (SSTF) processing system is demonstrated for the first time. SSTF significantly reduces nonlinear effects normally detrimental to beam control enabling the use of a low numerical aperture focus to quickly treat optically transparent materials over a large area. The integrated SSTF system has improved efficiency compared to previously reported SSTF designs, which combined with the high repetition rate of the laser, further optimizes its capability to provide rapid, large volume processing.

Achieving enhanced gain in photorefractive polymers by eliminating electron contributions using large bias fields

Photorefractive polymers have been extensively studied for over two decades and have found applications in holographic displays and optical image processing. The complexity of these materials arises from multiple charge contributions, for example, leading to the formation of competing photorefractive gratings. It has been recently shown that in a photorefractive polymer at relatively moderate applied electric fields the primary charge carriers (holes) establish an initial grating, followed by a subsequent competing grating (electrons) resulting in a decreased two-beam coupling and diffraction efficiencies. In this paper, it is shown that with relatively large sustainable bias fields, the two-beam coupling efficiency is enhanced owing to a decreased electron contribution. These results also explain the cause of dielectric breakdown experienced under large bias fields. Our conclusions are supported by self-pumped transient two-beam coupling and photocurrent measurements as a function of applied bias fields at different wavelengths.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.