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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.

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.

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.

BackgroundImmunocompromised 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 findingsElectronic 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; pConclusions/significanceInfection 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.

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.

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.To assess the efficacy of exogenous surfactant for the treatment of bronchiolitis in mechanically ventilated infants and children.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).Randomised controlled trials (RCTs) comparing surfactant with placebo or surfactant with no surfactant in mechanically ventilated infants and children with viral bronchiolitis.Two authors independently extracted data and assessed trial quality. Unpublished data were requested from trial authors when necessary.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.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.

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.

Reason for withdrawal from publication This review was withdrawn from The Cochrane Library in Issue 1, 2010, as the authors were not able to update it. To view the published versions of this article, please click the 'Other versions' tab.

This is a commentary on a Cochrane review, published in this issue of EBCH, first published as: Dobbins M, DeCorby K, Robeson P, Husson H, Tirilis D. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6–18. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD007651. DOI: 10.1002/14651858.CD007651. Further information for this Cochrane review is available in this issue of EBCH in the accompanying Summary article. Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration

You are an intensive care registrar who has taken over the care of a 3 week old baby boy diagnosed as having clinical bronchiolitis (now found to be RSV+). He was initially admitted and ventilated because of increasing respiratory distress and apnoeas. His ventilatory requirements are increasing and gas exchange is getting worse. You have just finished your stint on neonates and recall hearing that surfactant has been used on infants with bronchiolitis in trials. You wonder if it may help this child. In an infant with severe RSV+ bronchiolitis requiring ventilation [patient], does endotracheal surfactant [intervention]; (a) improve ventilation/gas exchange parameters; and (b) shorten the duration of ventilation or intensive care stay [outcome]? A search string of (a) [bronchiolitis] and [surfactant] and (b) [respiratory syncytial virus] and [bronchiolitis] was used. Cochrane database—topic …