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Driving up the quality and relevance of research through the use of agreed core outcomes There is a growing recognition that insufficient attention has been paid to the selection of the outcomes to measure in clinical trials and clinical audit. Outcomes need to be relevant to patients, clinicians, purchasers and policy-makers if the findings of research are to influence practice and future research. In addition, standardization of outcomes is needed to combine data from different studies to allow evidence synthesis and to compare data sets. Inconsistent choice of outcome measures means that many meta-analyses are unable to include data from all the relevant studies. For example, the five most accessed Cochrane reviews in 2009, together with the top cited review in that year, all described inconsistencies in the outcomes reported in eligible trials. 1 A call for the standardization of outcomes is a regular conclusion of systematic reviews. Furthermore, outcome reporting bias, defined as the bias arising from selecting outcomes for publication based on the results, affects many randomized trials 2 and 'is an under-recognized problem that affects the conclusions in a substantial proportion of Cochrane reviews'. 3 That bias is likely to affect systematic reviews more widely as well as affecting individual studies when considered on their own. Similar problems occur with clinical audit, highlighting the importance of establishing national audits that use and report the same outcomes for all participants. All these issues could be addressed with the development and application of agreed standardized sets of outcomes that have been termed 'core outcome sets'. These should be measured and reported, as a minimum, in all relevant clinical trials and national clinical audits for a specific condition. 4 Adopting a core outcome set does not imply that a particular study, review or audit should be restricted to only those outcomes. Rather, the expectation is that, as a minimum, core outcomes will always be collected and reported to allow the results of trials to be compared, contrasted and combined as appropriate. The adoption of core outcomes would have implications across all areas of research in health and health care, reduce heterogeneity between trials, and lead to research that is more likely to have measured relevant outcomes. Importantly, they would enhance the value of evidence synthesis by reducing the risk of outcome reporting bias and ensuring that all trials contribute usable information. In addition, they will increase the efficiency and value of research. An important rationale for core outcome sets is that outcomes currently reported for trials do not tinue, surely cannot be justified.

Abstract. Middleware has emerged as an important architectural component in modern distributed systems. Most recently, industry has witnessed the emergence of component-based middleware platforms, such as Enterprise JavaBeans and the CORBA Component Model, aimed at supporting third party development, configuration and subsequent deployment of software. The goal of our research is to extend this work in order to exploit the benefits of componentbased approaches within the middleware platform as well as on top of the platform, the result being more configurable and reconfigurable middleware technologies. This is achieved through a marriage of components with reflection, the latter providing the necessary levels of openness to access the underlying component infrastructure. More specifically, the paper describes in detail the OpenCOM component model, a lightweight and efficient component model based on COM. The paper also describes how OpenCOM can be used to construct a full middleware platform, and also investigates the performance of both OpenCOM and this resultant platform. The main overall contribution of the paper is to demonstrate that flexible middleware technologies can be developed without an adverse effect on the performance of resultant systems.

2. Jadad AR, Haynes RB. The Cochrane Collaboration: advances and challenges in improving evidence-based decision making. Med Decis Making. 1998;279:611-614. 3. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629-634. 4. Jadad AR, McQuay HJ. Meta-analyses to evaluate analgesic interventions: a systematic qualita-tive review of their methodology. J Clin Epidemiol. 1996;49:235-243. 5. Assendelft WJJ, Koes BW, Knipschild PG, Bouter LM. The relationship between methodological quality and conclusions in reviews of spinal manipulation.

Developing peer relationships in school is an essential part of growing up. Many children who have little or no functional speech are provided with augmentative and alternative communication (AAC) systems such as speech synthesizers and books and charts of symbols/pictures/words. Such children face many barriers to communication and to developing peer relationships. To date there exists little understanding of the characteristics of interaction between children using AAC and their speaking peers. This paper reports findings from an analysis of interactions between 12 children with physical disabilities using AAC systems and their speaking peers in school. Analysis identifies the primary structures, functions, and modes of communication used by both partners in one-to-one conversation.