George Bramley

Occipital Nerve Stimulation for Chronic Migraine—A Systematic Review and Meta-Analysis

Background Chronic migraine is a debilitating headache disorder that has significant impact on quality of life. Stimulation of peripheral nerves is increasingly being used to treat chronic refractory pain including headache disorders. This systematic review examines the effectiveness and adverse effects of occipital nerve stimulation (ONS) for chronic migraine. Methods Databases, including the Cochrane Library, MEDLINE, EMBASE, CINAHL and clinical trial registers were searched to September 2014. Randomized controlled trials (RCTs), other controlled and uncontrolled observational studies and case series (n≥ 10) were eligible. RCTs were assessed using the Cochrane risk of bias tool. Meta-analysis was carried out using a random-effects model. Findings are presented in summary tables and forest plots. Results Five RCTs (total n=402) and seven case series (total n=115) met the inclusion criteria. Pooled results from three multicenter RCTs show that ONS was associated with a mean reduction of 2.59 days (95% CI 0.91 to 4.27, I2=0%) of prolonged, moderate to severe headache per month at 3 months compared with a sham control. Results for other outcomes generally favour ONS over sham controls but quantitative analysis was hampered by incomplete publication and reporting of trial data. Lead migration and infections are common and often require revision surgery. Open-label follow-up of RCTs and case series suggest long-term effectiveness can be maintained in some patients but evidence is limited. Conclusions While the effectiveness of ONS compared to sham control has been shown in multiple RCTs, the average effect size is modest and may be exaggerated by bias as achieving effective blinding remains a methodological challenge. Further measures to reduce the risk of adverse events and revision surgery are needed. Systematic Review Registration this systematic review is an update and expanded work of part of a broader review registered with PROSPERO. Registration No. CRD42012002633.

Young People’s Community Engagement: What Does Research-Based and Other Literature Tell us About Young People’s Perspectives and the Impact of Schools’ Contributions?

Abstract This narrative synthesis based on a literature review undertaken for the project ‘Creating Citizenship Communities’ (funded by the Esmée Fairbairn Foundation) includes discussion, principally, about what research evidence tells us about young people’s definitions of community, of types of engagement by different groups of young people, actions by schools and what they might do in the future to promote engagement. Community is seen as a highly significant and contested area. Young people are viewed negatively by adults but are in some contexts already positively engaged in communities. There seem to be gaps in the literature about what young people understand about community. There is, broadly, some consensus about how to promote engagement.

Teachers' Views on Students' Experiences of Community Involvement and Citizenship Education.

Based upon the findings of a national survey of school coordinators and leaders on citizenship and community cohesion, this research indicates that teachers perceive their students to feel a sense of belonging to multiple communities, each with their own required actions for effective participation. There appears to be wide variation in the characteristics of students’ engagement in community activities depending on their individual needs and circumstances. While there is convincing evidence of schools successfully implementing strategies to equip students with a conceptual understanding of their roles as citizens, the research also identifies a need to develop students’ practical skills and self-efficacy to interact with their immediate and wider communities. In order to support students to participate most effectively in their communities, there is a need for schools to provide tailored support to those groups of students who may otherwise be least likely to participate in community activities.

Transcatheter aortic valve implantation for aortic stenosis in high surgical risk patients: A systematic review and meta-analysis

Background Symptomatic aortic stenosis has a poor prognosis. Many patients are considered inoperable or at high surgical risk for surgical aortic valve replacement (SAVR), reflecting their age, comorbidities and frailty. The clinical effectiveness and safety of TAVI have not been reviewed systematically for these high levels of surgical risk. This systematic review compares mortality and other important clinical outcomes up to 5 years post treatment following TAVI or other treatment in these risk groups. Methods A systematic review protocol was registered on the PROSPERO database (CRD42016048396). The Cochrane Library, Centre for Reviews and Dissemination Databases, MEDLINE, EMBASE, and ZETOC were searched from January 2002 to August 2016. Clinical trials or matched studies comparing TAVI with other treatments for AS in patients surgically inoperable or operable at a high risk were included. Data extraction and quality assessment were conducted by two reviewers. Data were pooled using random-effects meta-analysis. The main outcomes were all-cause mortality, efficacy and major complications. Results Three good quality randomised controlled trials (RCTs) were included. Patients’ mean age ranged from 83–85 years, around half were female and New York Heart Association (NYHA) functional class III or IV ranged from 83.8% to 94.2% with frequent comorbidities. In 358 surgically inoperable patients from one RCT, TAVI was superior to medical therapy for all-cause mortality at 1 year (hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.36−0.92), 2 years (HR 0.50, 95% CI 0.39−0.65), 3 years (HR 0.53, 95% CI 0.41to 0.68) and 5 years (HR 0.50, 95% CI 0.39−0.65), and NYHA class III or IV at 2 years (TAVI 16.8% (16/95), medical therapy 57.5% (23/40), p<0.001), quality of life and re-hospitalisation. TAVI had higher risks of major bleeding up to 1 year, of stroke up to 3 years (at one year 11.2% versus 5.5%, p = .06; HR at 2 years 2.79, 95% CI 1.25−6.22; HR at 3 years 2.81; 95% CI 1.26−6.26) and of major vascular complication at 3 years (HR 8.27, 95% CI 2.92−23.44). Using the GRADE tool, this evidence was considered to be of moderate quality. In a meta-analysis including 1,494 high risk surgically operable patients from two non-inferiority RCTs TAVI showed no significant differences from SAVR in all-cause mortality at two years (HR 1.03, 95% CI 0.82−1.29) and up to 5 years (HR 0.83, 95% CI 0.83−1.12). There were no statistically significant differences in major vascular complications and myocardial infarction at any time point, discrepant results for major bleeding on variable definitions and no differences in stroke rate at any time point. Using the GRADE tool, this evidence was considered of low quality. Conclusions Symptomatic aortic stenosis can be lethal without intervention but surgical resection is contraindicated for some patients and high risk for others. We found that all-cause mortality up to 5 years of follow-up did not differ significantly between TAVI and SAVR in patients surgically operable at a high risk, but favoured TAVI over medical therapy in patients surgically inoperable. TAVI is a viable life-extending treatment option in these surgical high risk groups.

Adverse effects of extracorporeal carbon dioxide removal (ECCO2R) for acute respiratory failure: a systematic review protocol

BackgroundThe extracorporeal membrane carbon dioxide removal (ECCO2R) system is primarily designed for the purpose of removing CO2 from the body for patients with potentially reversible severe acute hypercapnic respiratory failure or being considered for lung transplantation. Systematic reviews have focused on the effectiveness of ECCO2R. To the author’s best knowledge, this is the first systematic review to focus on the adverse effects of this procedure.MethodsWe will conduct a systematic review of procedure-related adverse effects of ECCO2R systems. A high sensitivity search strategy will be employed in Cochrane Library, MEDLINE, EMBASE, Web of Science and product regulatory databases and ongoing trial registers to identify citations. Reference lists of relevant studies and grey literature will also be searched. Screening of the results will be performed by two reviewers independently using pre-defined inclusion and exclusion criteria. Clinical trials and observational studies will be included. Data will be extracted using a purposefully developed extraction form. Appropriateness for statistical pooling of the results will be determined and carried out if heterogeneity is low to moderate. The GRADE framework will be employed to grade the overall quality of the evidence.DiscussionIn the UK, the current access to the use of ECCO2R is possible only with special arrangements for clinical governance, consent and for audit or research. Current evidence on ECCO2R suggests that there are a number of well-recognised complications which vary greatly across studies. This systematic review will consolidate the existing knowledge on adverse effects resulting from the use of ECCO2R.Systematic review registrationPROSPERO CRD42015023503.

Exploring Citizenship and Community in Education in England

‘Community’ and ‘citizenship’ are centrally important means by which we characterise society and establish mechanisms for societal improvement. Whereas the previous chapter was deliberately broad-brush in its efforts to identify key issues that apply across countries, this chapter synthesises what empirical data principally (but not exclusively) from England suggest about young people’ sense of, involvement in, and barriers to, community with reference to what schools can do to promote understanding and participation.

Creating Citizenship Communities through Teaching and Learning

To restate, the project ‘Creating Citizenship Communities’ had three major aims: to identify current thinking and practice in schools about citizenship education and community cohesion, to explore young people’ perceptions and practice of these areas, and to develop a strategy that would encourage partnerships, both within and outside schools, that might enhance learning.

Findings from the Focus Groups

This chapter will present and discuss the findings from the qualitative component of the Creating Citizenship Communities (CCC) project. The data presented here derive from focus group discussions conducted in eight schools across the United Kingdom, with young people aged 14–16 years of age. A central objective of the CCC project was to explore what young people’ conceptualisations of ‘community’ are, and crucially, how they feel that schools (as institutions) and the school curriculum teach them about community and citizenship. The focus group discussions provided vital insight into youth perspectives, suggesting that schools do a great deal of valuable work to develop feelings of community and civic identity among young people, but that key areas for further work and enhancement exist. The focus group data thus provided fundamental understanding of young people’ views on and experiences of community and citizenship, while also helping to contextualise findings from the survey component of the CCC project.

Why Is the Attempt to Promote Youth Engagement a Major International Issue

In this chapter, we provide an international overview of some of the issues that are important in the consideration of citizenship and community and forms of education that are intended to help young people and others understand and become more engaged in contemporary society. This chapter is deliberately international and global in its outlook and provides a wide-angled lens on developments about citizenship and community before we explore in detail, in Chapters 2–6, the specific research and development project that took place within England, and prior to broadening our focus back to overarching themes in Chapter 7. It is probably sensible for us to re-state the note of caution that we offered at the beginning of the book. We are not suggesting that in this chapter and towards the end of the book we would include all the themes and perspectives that are significant in all parts of the world. Derek Heater was right to emphasise the scale of the task when he declared: What is needed, though it would be a formidable undertaking, is a comparable study of world citizenship education.

Issues Arising from a National Survey of Schools

In this chapter, we describe what citizenship and community mean from the perspective of teachers and schools, based on the responses to our national survey of secondary schools in England completed in spring 2011.