Evidence-Based Medicine applied to the control of communicable disease incidents when evidence is scarce and the time is limited

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Pharmacokinetics of the combination raltegravir/atazanavir in HIV-1-infected patients

OBJECTIVES

To evaluate the use of raltegravir with unboosted atazanavir in combination with one nucleoside reverse transcriptase inhibitor (NRTI) (lamivudine or emtricitabine) as a potentially well-tolerated once-daily (qd) maintenance regimen.

METHODS

We compared the pharmacokinetics of raltegravir 400 mg twice daily (bid) with raltegravir 800 mg qd in HIV-infected patients (n=17) on unboosted atazanavir (600 mg qd) in combination with lamivudine or emtricitabine.

RESULTS

The area under the plasma concentration vs. time curve for a dose interval t (AUC0 -t ) of 800 mg qd divided by 2 was not significantly different from the AUC0 -t of 400 mg bid (P=0.664) but the minimum concentration (C min ) was 72% lower with the qd regimen (P=0.002). The regimen was well tolerated and the viral load remained undetectable in all patients during the 6 weeks of the study follow-up.

CONCLUSIONS

A qd regimen of raltegravir 800 mg, atazanavir 600 mg and lamivudine or emtricitabine resulted in favourable pharmacokinetic profiles and good short-term safety and efficacy data. Larger phase IIb studies are needed to explore this novel regimen.

Capacities, practices and perceptions of evidence-based public health in Europe

Evidence-based methodologies are used to synthesise systematic high-quality evidence and were first applied in clinical practice. Evidence-based public health, however, is still in its early stages. The European Centre for Disease Prevention and Control sought the insight of European organisations working and providing services in the field of public health on current practices, capacities, perceptions and predictions of evidence-based public health. A survey was sent to 76 organisations. A response rate of 36% was achieved, representing 27 organisations from 16 countries. Systematic reviews were the most commonly offered service, followed by health technology assessments and rapid assessments. Of 25 respondents, 13 believed that evidence-based methodologies were poorly integrated into public health. The main perceived barriers to the further development of evidence-based public health included 'lack of formalised structure or system', 'resource constraints' 'lack of understanding of evidence-based methodologies by policy makers' and 'lack of data'. Nevertheless, 22 of 27 respondents believed that evidence-based methodologies will play an increasingly important role in public health in future. However, several barriers need to be overcome. Consistent frameworks and consensus on best practices were identified as the most pressing requirements. Steps should be taken to address these barriers and facilitate integration and ultimately public health policies.

Unstable microsatellite repeats facilitate rapid evolution of coding and regulatory sequences

Tandem repeats are intrinsically highly variable sequences since repeat units are often lost or gained during replication or following unequal recombination events. Because of their low complexity and their instability, these repeats, which are also called satellite repeats, are often considered to be useless 'junk' DNA. However, recent findings show that tandem repeats are frequently found within promoters of stress-induced genes and within the coding regions of genes encoding cell-surface and regulatory proteins. Interestingly, frequent changes in these repeats often confer phenotypic variability. Examples include variation in the microbial cell surface, rapid tuning of internal molecular clocks in flies, and enhanced morphological plasticity in mammals. This suggests that instead of being useless junk DNA, some variable tandem repeats are useful functional elements that confer 'evolvability', facilitating swift evolution and rapid adaptation to changing environments. Since changes in repeats are frequent and reversible, repeats provide a unique type of mutation that bridges the gap between rare genetic mutations, such as single nucleotide polymorphisms, and highly unstable but reversible epigenetic inheritance.

Applicability of evidence-based practice in public health: risk assessment on Q fever under an ongoing outbreak

With reference to the Q fever outbreak in the Netherlands in 2009-10, we tested if an evidence-based approach, comparable to the methodology used in clinical medicine, was appropriate for giving public health advice under time constrains. According to the principles of evidence-based methodologies, articles were retrieved from bibliographic databases and categorised by type and size, outcome, strengths and limitations. The risk assessment was conducted in two months and involved six staff members. We retrieved and read 559 abstracts and selected approximately 150 full text articles. The most striking finding was the lack of sound scientific evidence behind standard treatment regimes for Q fever in pregnancy. Difficulties in applying existing evidence rating systems and in expressing uncertainties were identified as problems during the process. By systematically assessing the evidence on several questions about Q fever, we were able to draw new conclusions and specify earlier statements. We found it difficult to grade the mostly observational studies with the known evidence-based grading systems. There is need to develop new methods for grading evidence from different sources in the field of public health. We conclude that an evidence-based approach is feasible for providing a risk assessment within two to three months.

Applicability of evidence-based practice in public health: risk assessment on Q fever under an ongoing outbreak

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[Multi-dose packaging of drugs as the causative vehicle for multidrug-resistant Enterobacter cloacae: new results from a case-control study]

Hospital hygiene faces cross-cutting and methodological challenges that are time consuming and require specialised knowledge. In outbreak situations German federal states can request assistance from infectious disease epidemiologists at the Robert Koch Institute (RKI). The presented study describes the successful collaboration of local hygienists, microbiologists, clinicians, health authorities and the epidemiologists of the RKI in the investigation of an outbreak of multidrug-resistant Enterobacter (E.) cloacae in 2009 in a children's hospital. The outbreak was discovered in July 2009 when E. cloacae was detected in 12 patients in the neonatal and paediatric intensive care unit (NICU). Hygiene measures were intensified for infection control, and the RKI was invited by the responsible regional health authorities in October 2009 to assist in the outbreak investigation. We conducted a retrospective matched case-control study to identify risk factors for E. cloacae colonisation and infection. We identified a case as any child in the NICU from 1st May to 5th October 2009 with laboratory confirmation of the outbreak clone. Controls were patients staying in the NICU (> 72 h before the case's diagnosis) and swab-negative for the outbreak clone. We used standardised questionnaires to collect demographic and medical information. Matched odds ratios (mOR) were calculated by bivariate and multivariable conditional logistic regression. Environmental investigations were conducted. We identified 28 colonised and 3 bacteraemic cases. 29 matched case-control pairs were included in the study. Multivariable analysis revealed an association between E. cloacae diagnosis and the receipt of oral drugs at the bed-side from multidose packaging (mOR=1.8/drug; p=0.006). No specific drug was identified; microbiological investigation of drugs was negative. This multiresistant E. cloacae outbreak was most likely distributed by oral application using contaminated multidose drug packaging extrinsically contaminated via hands of personnel. No further cases occurred for 6 weeks after protocols for handling oral drugs were changed (smaller packaging, patient-based storage, and limited circulation time). Special attention and thorough hygiene protocols are needed for the distribution of oral medication. In NICUs the use of multi-dose medications should be avoided. The cooperation between locally available expertise and infectious disease epidemiologists enabled the discovery of a previously unidentified risk factor.

Highlights from the clinical symposium on Shiga toxin-producing Escherichia coli / haemolytic uremic syndrome, Berlin, September 2011

On 9 September 2011, the Estrel Convention Center in Berlin was the venue for a first clinical symposium on Shiga toxin-producing Escherichia coli / haemolytic uremic syndrome (STEC/HUS) reflecting on the large STEC outbreak in Germany earlier this year. The German Society of Nephrology (DGfN) invited internationally renowned clinical experts and microbiologists to discuss the basic science and diagnostics of STEC infections and the different options for treating an EHEC-associated HUS, including plasmapheresis, antibody therapy with Eculizumab, and extracorporeal immune adsorption.

Effects of a CACNA1C genotype on attention networks in healthy individuals

BACKGROUND

Recent genetic studies found the A allele of the variant rs1006737 in the alpha 1C subunit of the L-type voltage-gated calcium channel (CACNA1C) gene to be over-represented in patients with psychosis, including schizophrenia, bipolar disorder and major depressive disorder. In these disorders, attention deficits are among the main cognitive symptoms and have been related to altered neural activity in cerebral attention networks. The particular effect of CACNA1C on neural function, such as attention networks, remains to be elucidated.

METHOD

The current event-related functional magnetic resonance imaging (fMRI) study investigated the effect of the CACNA1C gene on brain activity in 80 subjects while performing a scanner-adapted version of the Attention Network Test (ANT). Three domains of attention were probed simultaneously: alerting, orienting and executive control of attention.

RESULTS

Risk allele carriers showed impaired performance in alerting and orienting in addition to reduced neural activity in the right inferior parietal lobule [Brodmann area (BA) 40] during orienting and in the medial frontal gyrus (BA 8) during executive control of attention. These areas belong to networks that have been related to impaired orienting and executive control mechanisms in neuropsychiatric disorders.

CONCLUSIONS

Our results suggest that CACNA1C plays a role in the development of specific attention deficits in psychiatric disorders by modulation of neural attention networks.

One-year follow-up effects of two obesity treatments on psychological well-being and weight

OBJECTIVES

The effectiveness of a cognitive and a behavioural treatment for obese binge eaters and obese non-binge eaters was evaluated at 1-year follow-up. Furthermore, we examined the role of weight changes on psychological well-being at 1-year follow-up.

DESIGN AND METHOD

Participants were reassessed 6 months and 1 year after they had finished a group cognitive treatment or a group behavioural treatment. The outcome measures were; psychological well-being (concerns about shape, weight and eating, self-esteem and depression), binge eating, and weight.

RESULTS AND CONCLUSIONS

Analyses on the completers' sample revealed that both treatments had a markedly positive and lasting impact on shape concern, weight concern and eating concern, binge eating, self-esteem, and depression at 1-year follow-up. Cognitive treatment was not superior to behavioural treatment on most outcome measures. This might be due to selective drop-out. Analyses including non-responders showed that the cognitive treatment was superior on shape, weight and eating concern, and binge eating. The 1-year follow-up results for weight-loss were disappointing. Between pre-treatment and 1-year follow-up participants in the behaviour treatment lost 3.0 kg, while participants in the cognitive treatment lost 0.3 kg. However, participants who gained weight were as successful on changes in psychological well-being changes as participants who lost weight.