Identification of the Minimal Replicon of Lactococcus lactis subsp. lactis UC317 Plasmid pCI305

Replication functions of the stable, cryptic 8.7-kilobase (kb) plasmid pCI305 from multi-plasmid-containing Lactococcus lactis subsp. lactis UC317 were studied. Analysis of this replicon was facilitated by the construction of replication probe vectors that consisted of the pBR322 replication region, a pUC18-derived multiple cloning site, and either the cat gene of pC194 (pCI341; 3.1 kb) or the erm gene of pAMbeta1 (pCI3330; 4.0 kb). Plasmid pCI305 was introduced into plasmid-free L. lactis subsp. lactis MG1363Sm, a streptomycin-resistant derivative of MG1363, by a transformation procedure with the 75-kb lactose-proteinase plasmid pCI301 of UC317 as a marker plasmid. A combination of transposon Tn5 mutagenesis and subcloning in pCI341 and pCI3330 with individual Tn5 insertions around the replication region facilitated the identification of a 1.6-kb minimal replicon on pCI305. This region was separable into two domains: (i) a 1.3-kb region (repB) encoding a trans-acting function (in vitro transcription-translation studies suggested the involvement of a 48-kilodalton protein); and (ii) a 0.3-kb region (repA) sufficient to direct replication when provided with repB in trans and thus probably containing the origin of replication. Lactococcus-Escherichia coli shuttle vectors based on the pCI305 replication region were constructed.

Detailed characterization and comparison of four lactic streptococcal bacteriophages based on morphology, restriction mapping, DNA homology, and structural protein analysis

Bacteriophages uc1001 and uc1002, which are lytic for Streptococcus cremoris UC501 and UC502, respectively, were characterized in detail. Comparisons were made with a previously characterized phage, P008, which is lytic for Streptococcus lactis subsp. diacetylactis F7/2, and uc3001, which is a lytic phage for S. cremoris UC503. Phages uc1001 and uc1002 had small isometric heads (diameters, 52 and 50 nm, respectively) and noncontractile tails (lengths, 152 and 136 nm, respectively), and uc1002 also had a collar. Both had 30.1 +/- 0.6 kilobase pairs (kbp) of DNA with cross-complementary cohesive ends. Restriction endonuclease maps made with seven endonucleases showed no common fragments. Despite this there was a very high level of homology between uc1001 and uc1002, and results of cross-hybridization experiments showed that the organization of both phage genomes was similar. Heteroduplex analysis confirmed this and quantified the level of homology at 83%. The regions of nonhomology comprised 2.1-, 1.1-, and 1.0-kbp deletion loops and 13 smaller loops and bubbles. The sodium dodecyl sulfate-polyacrylamide gel electrophoretic structural protein profiles were related, with a major band of about 40,000 molecular weight and minor bands of 35,000 and 34,000 molecular weight in common. There were also differences, however, in that uc1001 had a second major band of 68,000 molecular weight and two extra minor bands. Except for the restriction maps, which were strain specific, phages uc1001, uc1002, and P008 were closely related by all the criteria listed above. Their DNAs also showed a very significant bias against the cleavage sites of 9 of 11 restriction endonucleases. Phage uc3001 was unrelated to uc1001, uc1002, or P008 in that it had a prolate head (53 by 39 nm) and a shorter tail (105 nm), contained approximately 22 kbp of DNA, had unrelated cohesive ends, showed no DNA homology with the isometric-headed phages, and displayed a very different structural protein profile.

Controlled Integration into the Lactococcus Chromosome of the pCI829-Encoded Abortive Infection Gene from Lactococcus lactis subsp. lactis UC811

The phage insensitivity gene of lactococcal plasmid pCI829 which encodes an abortive infection defense mechanism (Abi) was inserted into the Lactococcus lactis subsp. lactis CH919 chromosome by utilizing the integration plasmid pCI194, which contains 4.2 kb of homology with the conjugative transposon Tn919. Chloramphenicol-resistant transformants expressed phage insensitivity to the prolate-headed phage c2 and the small isometric-headed phage 712, and hybridization analysis indicated that transformants contained pCI194 integrated in single copy. The level of phage insensitivity expressed by the transformants was reduced from that observed when the abi gene was located on a replicating plasmid, as determined by plaque assay and burst size analysis. Amplification of the integrated structure after growth in increased concentrations of chloramphenicol resulted in an increase in the expression of phage insensitivity. Hybridization analysis revealed that while pCI194 was stably maintained in an integrated state over 100 generations in the absence of selective pressure, the ability to express phage insensitivity was lost. Hybridization analysis also revealed that DNA flanking the abi gene contains homology to the CH919 chromosome.

Development of High-Frequency Delivery System for Transposon Tn919 in Lactic Streptococci: Random Insertion in Streptococcus lactis subsp. diacetylactis 18-16

The conjugative transposon Tn919, originally isolated in Streptococcus sanguis FC1, is capable of low-frequency transfer (10 and 10 per recipient) on membrane filters to a wide number of streptococcal recipients including the industrially important lactic streptococci. The introduction of pMG600 (Lac Lax; a lactose plasmid capable of conjugative transfer at high frequencies and which, in certain hosts, confers an unusual clumping phenotype) into a Streptococcus lactis CH919 donor, generating S. lactis CH001, resulted in a significant improvement in the transfer frequency of Tn919 to S. lactis CK50 (1.25 x 10 per recipient). In addition, these matings could be performed on agar surfaces, allowing the recovery of a greater number of recipients than with filter matings. Tn919 also transferred at high frequency to S. lactis subsp. diacetylactis 18-16S but not to Streptococcus cremoris strains. Insertion in 18-16S transconjugants generated from filter matings with an S. lactis CH919 donor was random, occurring at different sites on the chromosome and also in plasmid DNA. Thus, the conditions necessary for the practical exploitation of Tn919 in the targeting and cloning of genes from a member of the lactic streptococci, namely, high-frequency delivery and random insertion in host DNA, were achieved.

Personality disorder and drug use: a review

The concept of personality disorder (PD) is more relevant in the clinical management of drug users than other approaches to personality assessment. A problem in diagnosis is separating behaviours inherent in the activity of drug misuse from true evidence of PD, especially the anti-social type (ASPD), and rating instruments vary in their ability to do this. Nevertheless, the available evidence suggests that approximately two-thirds of drug users in treatment have PD, with ASPD the most common. Studies have mainly been in opiate users, while the prevalence of PD may be lower across the range of drugs, and in non-treatment settings. PD has been found to be associated with a range of complications and adverse outcomes in drug use, including psychiatric problems, poor social functioning, dropout from treatment, and increased HIV risk behaviours and infection rates. Outcomes for ASPD individuals in methadone maintenance treatment appear reasonable, however, and it may be that early recourse to such treatment is the most practical option for many PD opiate users, a potential criticism being that this does not directly address the PD problems.

Gender-related differences in quality of life domains of persons living with HIV/AIDS in South India in the era prior to greater access to antiretroviral therapy

This study sought to examine gender-based differences in the quality of life of men and women living with HIV in South India in the era prior to greater access to antiretroviral therapy. The participants in this prospective longitudinal study consisted of 215 men and 141 women who were administered a quality of life (QOL) instrument comprising five scales: physical well-being, psychosocial well-being, sexual well-being, satisfaction with health care, and strength of partner relationship. Interviews were conducted at enrollment and at 6 months in clinical care. Men and women reported similar scores in physical well-being, satisfaction with health care, and relationship with partner from the period prior to care, at enrollment, and at 6 months. Women scored significantly lower than men in psychosocial well-being from the period prior to care, at enrollment, and at 6 months (p < 0.05); women reported significantly higher levels of partner satisfaction at 6 months (p < 0.05). In light of the increasing feminization of the HIV epidemic in India, greater emphasis should be placed on examining the long-term experiences of Indian women living with HIV/AIDS, particularly their psychosocial well-being.

Understanding and measuring AIDS-related stigma in health care settings: a developing country perspective

AIDS-related stigma and discrimination remain pervasive problems in health care institutions worldwide. This paper reports on stigma-related baseline findings from a study in New Delhi, India to evaluate the impact of a stigma-reduction intervention in three large hospitals. Data were collected via in-depth interviews with hospital staff and HIV-infected patients, surveys with hospital workers (884 doctors, nurses and ward staff) and observations of hospital practices. Interview findings highlighted drivers and manifestations of stigma that are important to address, and that are likely to have wider relevance for other developing country health care settings. These clustered around attitudes towards hospital practices, such as informing family members of a patient's HIV status without his/her consent, burning the linen of HIV-infected patients, charging HIV-infected patients for the cost of infection control supplies, and the use of gloves only with HIV-infected patients. These findings informed the development and evaluation of a culturally appropriate index to measure stigma in this setting. Baseline findings indicate that the stigma index is sufficiently reliable (alpha = 0.74). Higher scores on the stigma index--which focuses on attitudes towards HIV-infected persons--were associated with incorrect knowledge about HIV transmission and discriminatory practices. Stigma scores also varied by type of health care providers--physicians reported the least stigmatising attitudes as compared to nursing and ward staff in the hospitals. The study findings highlight issues particular to the health care sector in limited-resource settings. To be successful, stigma-reduction interventions, and the measures used to assess changes, need to take into account the sociocultural and economic context within which stigma occurs.

Continuous ambulatory peritoneal dialysis versus automated peritoneal dialysis for end-stage renal disease

BACKGROUND

Peritoneal dialysis (PD) can be performed either manually as in continuous ambulatory peritoneal dialysis (CAPD) or using mechanical devices as in automated PD (APD). APD has been considered to have several advantages over CAPD such as reduced incidence of peritonitis, mechanical complications and greater psychosocial acceptability.

OBJECTIVES

To assess the comparative efficacy of CAPD and APD in patients who are dialysed for end-stage renal disease (ESRD).

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Renal Group's specialised register and CINAHL. Authors of included studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened. Date of most recent search: May 2006

SELECTION CRITERIA

RCTs comparing CAPD with APD in patients with ESRD.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently by two authors onto a standard form. Relative risk (RR) for dichotomous data and a mean difference (MD) for continuous data were calculated with 95% confidence intervals (CI).

MAIN RESULTS

Three trials (139 patients) were included. APD did not differ from CAPD with respect to mortality (RR 1.49, 95% CI 0.51 to 4.37), risk of peritonitis (RR 0.75, 95% CI 0.50 to 1.11), switching from original PD modality to a different dialysis modality (RR 0.50, 95% CI 0.25 to 1.02), hernias (RR 1.26, 95% interval 0.32 to 5.01), PD fluid leaks (RR 1.06, 95% CI 0.11 to 9.83), PD catheter removal (RR 0.64, 95% CI 0.27 to 1.48) or hospital admissions (RR 0.96, 95% CI 0.43 to 2.17). There was no difference between either PD modality with respect to residual renal function (MD -0.17, 95% CI -1.66 to 1.32). One study found that peritonitis rates and hospitalisation were significantly less in patients on APD when results were expressed as episodes/patient-year. Another study found that patients on APD had significantly more time for work, family and social activities.

AUTHORS' CONCLUSIONS

APD has not been shown to have significant advantages over CAPD in terms of important clinical outcomes. APD may however be considered advantageous in select group of patients such as in the younger PD population and those in employment or education due to its psychosocial advantages. There is a need for a RCT comparing CAPD with APD with sufficiently large patient numbers looking at important clinical outcomes including residual renal function, accompanied by an economic evaluation to clarify the relative clinical and cost-effectiveness of both modalities.

Pursuing scale and quality in STI interventions with sex workers: initial results from Avahan India AIDS Initiative

BACKGROUND

Migration, population mobility, and sex work continue to drive sexually transmitted epidemics in India. Yet interventions targeting high incidence networks are rarely implemented at sufficient scale to have impact. India AIDS Initiative (Avahan), funded by the Bill and Melinda Gates Foundation, is scaling up interventions with sex workers (SWs) and other high risk populations in India's six highest HIV prevalence states.

METHODS

Avahan resources are channelled through state level partners (SLPs) to local level non-governmental organisations (NGOs) who organise outreach, community mobilisation, and dedicated clinics for SWs. These clinics provide services for sexually transmitted infections (STIs) including Condom Promotion, syndromic case management, regular check-ups, and treatment of asymptomatic infections. SWs take an active role in service delivery. STI capacity building support functions on three levels. A central capacity building team developed guidelines and standards, trains state level STI coordinators, monitors outcomes, and conducts operations research. Standards are documented in an Avahan-wide manual. State level STI coordinators train NGO clinic staff and conduct supervision of clinics based on these standards and related quality monitoring tools. Clinic and outreach staff report on indicators that guide additional capacity building inputs.

RESULTS

In 2 years, clinics with community outreach for SWs have been established in 274 settings covering 77 districts. Mapping and size estimation have identified 187,000 SWs. In a subset of four large states covered by six SLPs (183,000 estimated SWs, 65 districts), 128,326 (70%) of the SWs have been contacted through peer outreach and 74,265 (41%) have attended the clinic at least once. A total of 127,630 clinic visits have been reported, an increasing proportion for recommended routine check ups. Supervision and monitoring facilitate standardisation of services across sites.

CONCLUSION

Targeted HIV/STI interventions can be brought to scale and standardised given adequate capacity building support. Intervention coverage, service utilisation, and quality are key parameters that should be monitored and progressively improved with active involvement of SWs themselves.

Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease

BACKGROUND

Renal replacement therapy (RRT) for end-stage kidney disease (ESKD) can be achieved by several interventions including haemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation. HD, haemofiltration (HF), haemodiafiltration (HDF) and acetate-free biofiltration (AFB) are extracorporeal RRT methods. It has been suggested that HF and HDF may reduce the frequency and severity of intradialytic and post-dialytic adverse symptoms and may be more effective than HD in the removal of high molecular weight molecules.

OBJECTIVES

To compare convective modes of extracorporeal RRT (HF, HDF or AFB) with HD and to establish if any of these techniques is superior to each other in patients with ESKD.

SEARCH STRATEGY

We searched MEDLINE (1966-2006), EMBASE (1980-2006), Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library issue 2, 2006) and CINAHL (1872-2006). Authors of included studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened.

SELECTION CRITERIA

RCTs comparing HF, HDF, AFB and HD for ESKD were included. Trials enrolling any patient undergoing RRT for ESKD were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes or weighted mean difference (MD) for continuous data with 95% confidence intervals (CI). Heterogeneity was measured using the Chi-square (chi(2)) and I(2) statistic.

MAIN RESULTS

Twenty studies (657 patients) were included. Seventeen studies compared HF, HDF or AFB with HD, two compared HDF with AFB and one compared HF with HDF. The studies were generally small with suboptimal quality. Convective modalities (HF, HDF, AFB) did not differ significantly from HD for mortality (RR 1.68, 95% CI 0.23 to 12.13; chi(2)= 2.58, P = 0.11, I(2) = 61.2%), number of hospital admissions/year (MD 0.20, 95% CI -0.07 to 0.47) and dialysis adequacy (Kt/V: MD 0.09, 95% CI 0.02 to 0.17; chi(2) = 3.73, P = 0.29, I(2) = 19.6%). No study assessed number of dialysis treatments associated with "any adverse symptoms", sessions that were stopped early, change of dialysis modality or dialysis-related amyloidosis.

AUTHORS' CONCLUSIONS

We were unable to demonstrate whether convective modalities (either HF, HDF or AFB) have significant advantages over HD with regard to clinically important outcomes of mortality, dialysis-related hypotension and hospitalisation. More adequately-powered good quality RCTs assessing clinically important outcomes (mortality, hospitalisation, quality of life) are needed.

Association of molecular markers with toxicity outcomes in a randomized trial of chemotherapy for advanced colorectal cancer (FOCUS)

2022

Background: We present data on putative markers of chemotherapy toxicity from patients randomized to receive fluorouracil alone (FU), or FU+irinotecan (Ir), or FU+oxaliplatin (Ox). Methods: 1188 patients randomized to the FOCUS trial (ASCO 05 #3518) were analyzed. First-line therapy was FU in two thirds of patients, and FU+ either Ir or Ox in one third. Second-line Ir and Ox were administered to 29% and 14% of patients respectively. DNA was extracted from formalin-fixed, paraffin embedded (FFPE) blocks. Assessed DNA polymorphisms included TSER, TS1494, DPD IVS14 + 1G>A, MTHFR C667T, MLH1 -93, UGT1A1*28, ABCB1 C3435T, GSTP1 105Val, XRCC1 Q399R and ERCC2 K751Q. The primary endpoint was chemotherapy delay or dose-reduction due to toxicity during the first 12 weeks of treatment. The secondary endpoint was incidence of CTC toxicity. The Chi-squared test was used to assess for associations. Results: In this exploratory analysis no molecular factors were observed to be associated with the primary endpoint (all p values >0.1). Furthermore, no polymorphism predicted severe CTC toxicity in patients receiving FU alone (all p values >0.1). XRCC1 variant allele carriers were at increased risk of severe CTC toxicity from Ir. Combined analysis of patients treated with first and second-line Ir appeared to show a significant association between toxicity and the presence of the variant XRCC1 allele across genotypes (57% versus 52% versus 38%; p=0.006). The UGT1A1*28 was not associated with Ir toxicity. No oxaliplatin markers predicted CTC toxicity. Conclusions: None of the assessed polymorphisms were significantly associated with the primary endpoint. Our results do not support the use of pharmacogenomics in routine clinical practice. In contrast to other studies the UGT1A1*28 VNTR was not associated with irinotecan toxicity . However, the XRCC1 Q399R polymorphism was associated with increased toxicity in patients receiving irinotecan, and these data may warrant further investigation, and independent confirmation.

No significant financial relationships to disclose.

Association of topoisomerase-1 (Topo1) with the efficacy of chemotherapy in a randomized trial for advanced colorectal cancer patients (FOCUS)

10009

Background: We have assessed potential predictive markers of the efficacy of irinotecan and oxaliplatin in advanced CRC patients randomized to fluorouracil (FU), FU+irinotecan (Ir) or FU+oxaliplatin (Ox). Methods: Pathology specimens were retrieved from 1281 patient in the FOCUS trial (ASCO 05 #3518). Normal and tumor DNA were extracted and tissue microarrays were made for immunohistochemistry (IHC). The following factors were assessed for effect on failure-free survival (FFS) with first-line therapy: IHC for MLH1, MSH2, P53, Topo1, ERCC1, MGMT, and COX2; DNA polymorphisms in GSTP1 (105Val), ABCB1 (C3435T), XRCC1 (Q399R), ERCC2 (K751Q), and UGT1A1*28. Results: Among 823 patients assessable for Topo1 IHC, we observed highly significant heterogeneity (interaction) of treatment effect in relation to Topo1 staining intensity (p=0.008, see table). 489 patients (59%) had moderate or high Topo1 expression; these patients derived highly significant benefit from 1st-line chemotherapy with either Ir or Ox. In contrast, the 334 (41%) patients with low Topo1 IHC expression showed no evidence of benefit from the addition of either Ir or Ox compared with FU alone (HR 1 and 0.9 respectively). When patients receiving FU alone are considered separately, low Topo1 expression was associated with significantly better FFS (HR 0.7 (0.6–0.9)). The other 11 molecular markers showed no significant interactions with treatment received (p values for interaction all > 0.1). Conclusions: We have identified a subgroup of 41% patients (with low Topo1 expression) for whom treatment outcome with FU alone is superior, but who appear to gain no benefit from the addition of Ir or Ox. We believe this to be the first demonstration in a large randomized trial of a genuinely predictive molecular marker. If verified in an independent dataset, this information could be used to select patients who can be safely treated with FU alone, or together with alternative additional agents.

[Table: see text]

No significant financial relationships to disclose.

Prognostic value of thymidylate synthase (TS) expression on failure-free survival of fluorouracil-treated metastatic colorectal cancer patients

10011

Background: We previously presented (ASCO 04 #9506) an exploratory analysis of 13 molecular markers in relation to clinical outcomes in 846 patients treated with fluorouracil (FU), or FU+irinotecan, or FU+oxaliplatin in a large UK-based randomized controlled trial (FOCUS - ASCO ’05 #3518). High TS IHC expression and tumor grade were highly significantly associated with reduced failure-free survival (FFS) in a multivariable model. We now present data from an independent validation set of 449 FOCUS patients and on the combined test and validation sets. Methods: Formalin-fixed, paraffin embedded blocks were retrieved from consenting patients and tissue microarrays made for IHC assessment. Factors assessed for the effect on FFS of first-line therapy were: liver metastases; ALP; grade; mucoid status; age; and IHC for dUTPase and TS. Log-rank univariate analyses and Cox Model multivariable analysis was performed. Results: Univariate analysis of the validation set failed to confirm evidence of the previously observed association between high TS expression and FFS (p=0.2); however high dUTPase IHC (p=0.01), ALP (p<0.0001) and grade (p=0.001) showed significant associations. Table 1 illustrates the results of univariate and multivariable analysis of the combined test and validation sets. In the Cox Model, high TS IHC expression, tumor grade and baseline serum ALP were highly significant predictors of reduced FFS. Conclusions: We failed to confirm a significant association between high TS expression and reduced FFS in an independent validation set. However, in an exploratory analysis of the combined validation and test sets (n>1000), TS IHC expression remained a highly significant predictor of FFS. Overall, our results cannot be taken to demonstrate a powerful and clinically useful influence of TS on treatment efficacy, but are consistent with a moderate effect.

[Table: see text]

No significant financial relationships to disclose.

Validation of the small-punch test as a technique for characterizing the mechanical properties of acrylic bone cement

This paper examines the validity of using the small-punch test technique as a means of quantifying the mechanical properties of acrylic bone cement under different test conditions. The elastic moduli calculated using the small-punch test method were compared with data measured using the international standard for acrylic bone resin, ISO 5833. Conclusions from the study indicate that the small-punch test is a reproducible miniature specimen test method that can be used to characterize the mechanical properties of retrieved acrylic bone cement as used in total joint replacement surgery. Moreover, the test conditions were found to influence the elastic modulus of acrylic bone cement. The test temperature had a greater effect on the elastic behaviour of the bone cement than the test medium.

Frequency of administration of recombinant human erythropoietin for anaemia of end-stage renal disease in dialysis patients

BACKGROUND

The benefits of recombinant human erythropoietin (rHuEPO) administration in dialysis patients have been demonstrated, however the optimal frequency regimen have yet to be established.

OBJECTIVES

To assess the effects of different frequency regimens of rHuEPO administration in dialysis patients on anaemia correction, quality of life and optimal use.

SEARCH STRATEGY

We searched 13 electronic databases (1980 to May 2001) the internet (August 1997), handsearched Kidney International (1983 to May 1997), contacted known investigators, biomedical companies, and screened reference lists of relevant articles. Most recent search: The Cochrane Renal Group's specialised register (June 2004) and The Cochrane Library (Issue 3, 2004).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing different frequencies of rHuEPO administration in dialysis patients. We compared haemodialysis and CAPD patients and subcutaneous and intravenous administration.

DATA COLLECTION AND ANALYSIS

Quality assessment was performed by two assessors. Data were abstracted by a single author onto a standard form, and a sample was checked by another author. Results were expressed as relative risk (RR) or weighted mean difference (WMD) with 95% confidence intervals (CI).

MAIN RESULTS

Eleven studies (719 patients) were included. There was no significant difference in maintaining target haemoglobin for once versus twice weekly administration (one study, 20 patients: RR 1.00, 95% CI 0.42 to 2.40) or mean haemoglobin after 12 weeks of therapy between haemodialysis and CAPD patients (two studies: WMD -0.21 g/dL, 95% CI -0.98 to 0.56) At the end of study for once versus thrice weekly administration (three studies: SMD -0.31, 95% CI -0.67 to 0.06) and at the end of maintenance phase (one study: WMD -0.2 g/dL, 95% CI -0.65 to 0.25) there was no significant difference. More rHuEPO was required by haemodialysis patients receiving once weekly versus twice weekly doses (WMD 12.0 U/kg, 95% CI 0.24 to 23.76). No difference was found for CAPD patients alone or combined (WMD 4.38 U/kg, 95% CI -11.28 to 20.04). Once versus thrice weekly administration was not significant (WMD 10.00 U/kg, 95% CI -80.87 to 100.87). There was no difference in the frequency of adverse events.

AUTHORS' CONCLUSIONS

There is no significant difference between once weekly versus thrice weekly subcutaneous administration of rHuEPO. Once weekly administration would require an additional 12 U/kg/wk for patients on haemodialysis, however this is based on one very small study. Cost of additional rHuEPO needs to assessed with regard to patient preference and compliance.

Psychosocial interventions for depression in dialysis patients

BACKGROUND

Depression is the most common psychological problem in the dialysis population. The diagnosis of depression in dialysis patients is confounded by the fact that several symptoms of uraemia mimic the somatic components of depression. It affects the physical, psychological and social well being of the dialysis population in several ways.

OBJECTIVES

The aim of this systematic review was to assess the effectiveness of psychosocial interventions in the treatment of depression in patients who are dialysed for end-stage renal disease.

SEARCH STRATEGY

A comprehensive search strategy was employed to identify all randomised controlled trials (RCTs) relevant to the treatment of depression in dialysis patients. The following databases were searched - MEDLINE (1966 - October 2003), EMBASE (1980 - October 2003), PsycINFO (1872 - October 2003) and The Cochrane Library (issue 3, 2003). Authors of potential studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened.

SELECTION CRITERIA

RCTs comparing any psychosocial intervention with control intervention or no intervention in depressed dialysis patients.

DATA COLLECTION AND ANALYSIS

Data were to be abstracted by two investigators independently onto a standard form and entered into Review Manager 4.2. Relative risk (RR) for dichotomous data and a (weighted) mean difference (MD) for continuous data were to be calculated with 95% confidence intervals (CI).

MAIN RESULTS

Despite extensive searching, no RCTs were identified.

AUTHORS' CONCLUSIONS

Data were not available to draw conclusions about the effectiveness of psychosocial interventions in the treatment of depression in the chronic dialysis population, as we did not find any RCTs of psychosocial interventions to treat depression in dialysis patients. This review highlights the need for commencing and completing adequately powered RCTs to address the issue of psychosocial interventions for depression in dialysis patients.