Evaluating vaccination strategies to control foot-and-mouth disease: a country comparison study

Vaccination is increasingly being recognised as a potential tool to supplement 'stamping out' for controlling foot-and-mouth disease (FMD) outbreaks in non-endemic countries. Infectious disease simulation models provide the opportunity to determine how vaccination might be used in the face of an FMD outbreak. Previously, consistent relative benefits of specific vaccination strategies across different FMD simulation modelling platforms have been demonstrated, using a UK FMD outbreak scenario. We extended this work to assess the relative effectiveness of selected vaccination strategies in five countries: Australia, New Zealand, the USA, the UK and Canada. A comparable, but not identical, FMD outbreak scenario was developed for each country with initial seeding of Pan Asia type O FMD virus into an area with a relatively high density of livestock farms. A series of vaccination strategies (in addition to stamping out (SO)) were selected to evaluate key areas of interest from a disease response perspective, including timing of vaccination, species considerations (e.g. vaccination of only those farms with cattle), risk area vaccination and resources available for vaccination. The study found that vaccination used with SO was effective in reducing epidemic size and duration in a severe outbreak situation. Early vaccination and unconstrained resources for vaccination consistently outperformed other strategies. Vaccination of only those farms with cattle produced comparable results, with some countries demonstrating that this could be as effective as all species vaccination. Restriction of vaccination to higher risk areas was less effective than other strategies. This study demonstrates consistency in the relative effectiveness of selected vaccination strategies under different outbreak start up conditions conditional on the assumption that each of the simulation models provide a realistic estimation of FMD virus spread. Preferred outbreak management approaches must however balance the principles identified in this study, working to clearly defined outbreak management objectives, while having a good understanding of logistic requirements and the socio-economic implications of different control measures.

Adherence to reporting guidelines and clinical trial registration policies in oncology journals: a cross-sectional review

Reporting guidelines (RG) aim to improve research transparency and ensure high-quality study reporting. Similarly, clinical trial registration policies aim to reduce bias in results reporting by ensuring prospective registration of all trial outcomes. Failure to adhere to quality standards documented in RGs may result in low-quality and irreproducible research. Herein, we investigate the adherence to common RGs and trial registration policies in 21 oncology journals. We surveyed the Instructions for Authors page for each of the included oncology journals for adherence to common reporting guidelines and trial registration policies. We corresponded with editors to determine accepted study types and cross-referenced this information with a journal's RGs and trial registration policies to calculate the per cent of journals that adhere to a specific guideline or policy. 76.2% (16/21) of oncology journals surveyed adhere to Consolidated Standards of Reporting Trials guidelines for clinical trials while only 33.3% (7/21) adhere to Strengthening the Reporting of Observational Studies in Epidemiology for observational studies. Similarly, 76.2% (16/21) of oncology journals adhere to clinical trial registration policies. We further demonstrate that journal adherence to RGs positively affects author reporting, despite adherence to trial registration policies showing no such benefit. Our results show that oncology journals adhere to RGs and trial registration policies at a higher rate than other specialties, but nonetheless show room for improvement. We conclude that oncology journal adherence to RGs and trial registration policies is encouraging, but nonetheless suboptimal. We recommend the adoption of RGs and trial registration policies by all oncology journals.

Effectiveness of informational decision aids and a live donor financial assistance program on pursuit of live kidney transplants in African American hemodialysis patients

BACKGROUND

African Americans have persistently poor access to living donor kidney transplants (LDKT). We conducted a small randomized trial to provide preliminary evidence of the effect of informational decision support and donor financial assistance interventions on African American hemodialysis patients' pursuit of LDKT.

METHODS

Study participants were randomly assigned to receive (1) Usual Care; (2) the Providing Resources to Enhance African American Patients' Readiness to Make Decisions about Kidney Disease (PREPARED); or (3) PREPARED plus a living kidney donor financial assistance program. Our primary outcome was patients' actions to pursue LDKT (discussions with family, friends, or doctor; initiation or completion of the recipient LDKT medical evaluation; or identification of a donor). We also measured participants' attitudes, concerns, and perceptions of interventions' usefulness.

RESULTS

Of 329 screened, 92 patients were eligible and randomized to Usual Care (n = 31), PREPARED (n = 30), or PREPARED plus financial assistance (n = 31). Most participants reported interventions helped their decision making about renal replacement treatments (62%). However there were no statistically significant improvements in LDKT actions among groups over 6 months. Further, no participants utilized the living donor financial assistance benefit.

CONCLUSIONS

Findings suggest these interventions may need to be paired with personal support or navigation services to overcome key communication, logistical, and financial barriers to LDKT.

TRIAL REGISTRATION

ClinicalTrials.gov [ NCT01439516 ] [August 31, 2011].

Assessing quality of randomized trials supporting guidelines for laparoscopic and endoscopic surgery

BACKGROUND

Recent studies have highlighted the risk of bias and the fragility of results in randomized controlled trials (RCTs). The aim of our study was to evaluate the clinical practice guidelines created by the Society for Gastrointestinal and Endoscopic Surgeons (SAGES) for fragility, statistical power, and risk of bias.

MATERIALS AND METHODS

We screened the SAGES clinical practice guideline references for qualifying RCTs. RCTs were assessed for risk of bias using the Cochrane Collaboration Risk of Bias tool 2.0. We used the fragility index and fragility quotient to evaluate the robustness of trial results and conducted a power analysis using G*Power to determine if trials were adequately powered.

RESULTS

Twenty-two (40.7%) of the 54 trials that we assessed were rated as having a high risk of bias, 17 (31.5%) were rated as having a low risk of bias, and 15 (27.8%) were rated as having some concerns. The median fragility index was 2.5 (interquartile range 1-7). The median fragility quotient was 0.021 (interquartile range 0.003-0.045). Mean sample size was 108, and the mean loss to follow-up was eight patients. Eight of 33 trials (24.2%) were found to be underpowered according to the sample size used in the primary outcome.

CONCLUSIONS

Guidelines created by SAGES are supported by RCTs that are frequently fragile or underpowered or have a high risk of bias. Future RCTs should utilize the Consolidated Standards of Reporting Trials statement, implement strategies to minimize loss to follow-up, and use properly powered sample sizes.

An Evaluation of Industry Relationships Among Contributors to AAOS Clinical Practice Guidelines and Appropriate Use Criteria

BACKGROUND

A long-standing relationship between orthopaedic surgeons and industry has made financial conflicts of interest a concerning issue. Research supports that financial conflicts of interest can influence both medical research and clinical practice. Financial conflicts of interest may also influence clinical practice guideline recommendations and their corresponding appropriate use criteria. Because of the influential nature of these guidelines, it is imperative that care be taken to minimize bias during guideline development.

METHODS

We retrieved clinical practice guidelines and their corresponding appropriate use criteria from the American Academy of Orthopaedic Surgery that were published or revised between 2013 and 2016. We extracted industry payments received by physicians using the Centers for Medicare & Medicaid Services Open Payments database. We then evaluated the value and types of these payments. We also used these data to determine whether disclosure statements were accurate and whether guideline development was in adherence with the Institute of Medicine's (IOM's) standards.

RESULTS

Of the 106 physicians that were evaluated, 85 (80%) received at least 1 industry payment, 56 (53%) accepted >$1,000, and 35 (33%) accepted >$10,000. Financial payments amounted to a mean of $93,512 per physician. Total reimbursement for the 85 clinical practice guideline and appropriate use criteria contributors was $9,912,309. We found that disclosure statements disagreed with the Open Payments data and that the IOM standards were not completely enforced.

CONCLUSIONS

Clinical practice guideline and appropriate use criteria contributors received substantial payments from industry, many disclosure statements were inaccurate, and the IOM standards were not completely met.

CLINICAL RELEVANCE

Clinical practice guidelines and appropriate use criteria are critical for practicing evidence-based medicine. If financial conflicts of interest are present during their development, it is possible that patient care may be compromised.

A novel radiographic method to facilitate measurement of the tibial plateau angle in dogs

The tibial plateau levelling osteotomy (TPLO) is commonly performed for treatment of cranial cruciate ligament deficiency in dogs. In order to be performed as described, this procedure relies on consistent measurement of the tibial plateau angle (TPA) on radiographs. This prospective study compared two radiographic methods for subsequent TPA measurement with respect to measured angle and ease of determining landmarks for measurement as determined by four observers. One method was the accepted standard radiographic protocol outlined in the TPLO training seminars. The other method involved a novel split image radiographic protocol not yet described in the literature. Participants' subjective scores as to ease of identifying landmarks and determining TPA on radiographs for each method were evaluated. Inter-observer TPA measurement variability was also assessed for each method. The novel radiographic method was judged to be significantly better in terms of ease of measuring TPA. Inter-observer measurement variability was considered appropriate for recommending use of this novel method for radiographing patients for TPA measurements.

Addressing the dual health epidemics of HIV and sexual abuse among children and adolescents in Kenya: uptake of HIV counseling and post-exposure prophylaxis

Purpose

Child sexual abuse and HIV are key health challenges in Kenya. In 2015, LVCT Health conducted a study aimed at assessing the quality of HIV-related services offered to child survivors of sexual violence in public health facilities.

Materials and methods

A qualitative data collection approach was utilized. Qualitative data were collected through in-depth interviews with 31 providers. Quantitative methods included a retrospective review of 164 records of child survivors of rape who had accessed services 6 months prior to the commencement of the study. SPSS Version 22 was used in the descriptive analysis of the medical records. Client exit interviews and observation data were analyzed using MS Excel. In-depth interviews were analyzed using a thematic analytical approach.

Results

Twenty-seven percent (n=164) survivors were documented to have received the first dose of postexposure prophylaxis (PEP). Providers did not conduct HIV pre- and posttest counseling for the survivors. There were no longitudinal follow-up mechanisms to ensure child survivors initiated on PEP adhered to the treatment plan. Less than 30% of survivors returned to the facility for PEP adherence counseling and follow-up HIV testing. Twenty providers cited capacity gaps in undertaking HIV risk assessment for child survivors. Limited availability of PEP is a barrier to HIV prevention, as most departments only offer services between 8 am and 5 pm. HIV tests were only available on weekdays before 5 pm. PEP being out of stock remains a barrier to HIV prevention.

Conclusion

Existing post-rape care services are not adequately structured to facilitate delivery of quality HIV-related services to child survivors. Health provider capacity in the management of children remains weak due to lack of skill-based training on the dynamics of responding to the needs of child survivors. There is a need for standard operating procedures and training modules on the prevention of HIV in the context of child sexual abuse.

Randomised controlled trial of prophylactic antibiotic treatment for the prevention of endophthalmitis after open globe injury at Groote Schuur Hospital

BACKGROUND/AIMS

Most post-traumatic acute infectious endophthalmitis occur within a week of open globe trauma, necessitating early antibiotic prophylaxis. There are few randomised studies that demonstrate the benefits of prophylactic antibiotics. This randomised controlled non-inferiority trial was aimed at determining the incidence of post-traumatic endophthalmitis using established intravenous/oral prophylaxis and comparing this to the incidence using oral antibiotics only.

METHODS

All adult patients admitted with open globe injury were included. Those with proven endophthalmitis, high-risk features, who underwent primary evisceration and those allergic to the trial antibiotics were excluded. Patients were randomised to receive either intravenous cefazolin and oral ciprofloxacin or oral ciprofloxacin and oral cefuroxime for 3 days from admission. Acute endophthalmitis was the primary outcome. Patients completed the study if they were followed up for 6 weeks post injury.

RESULTS

Three hundred patients were enrolled, with 150 in each arm. There were 99 exclusions. Seven patients developed endophthalmitis despite prophylaxis-2.0% (three cases) in the intravenous and oral arm, compared with 2.7% (four cases) in the oral-only arm-this difference was not statistically significant (p=0.703).

CONCLUSIONS

The incidence of endophthalmitis with prophylaxis was 2-3%. Selected patients with open globe injuries (without high-risk features) may receive either intravenous cefazolin and oral ciprofloxacin, or oral cefuroxime and oral ciprofloxacin as prophylaxis against acute endophthalmitis-the latter regimen has the advantage of shortening patients' hospital stays and reducing costs. Non-inferiority study-design limitations should be taken into account, however.

Acute appendicitis in South Africa: a systematic review

BACKGROUND

Acute appendicitis is one of the most common surgical emergencies in the West. A large body of research is investigating the risk factors for disease and perforation. As South Africa has a social environment, health system structure, and population demography unique from developed nations, the findings may not be generalisable to this setting. A systematic review has not been performed for appendicitis research in South Africa. The objective of this review was to systematically examine the literature on appendicitis in South Africa.

METHOD

Published articles discussing appendicitis in South Africa up to March 2014 were identified using MEDLINE and EBMReviews. Research themes were analysed in the literature. Perforation rates, mortality, negative appendicectomy rates and gender differences were analysed from audits of patients undergoing appendicectomy for acute appendicitis.

RESULTS

Ten audits were included in the quantitative analysis. Some were excluded in the subgroup analyses. Negative appendicectomies occurred at a rate of 17% (580/3 354). Women were more likely to have a negative appendicectomy than men (28% vs. 9%, p < 0.01). The perforation rate for appendicectomy patients was 36% (970/2 688), and mortality rate was 1% (36/2 946). Research efforts focused on investigating differential incidence and outcomes between racial groups within the country.

CONCLUSION

Appendicitis trends in South Africa are consistent with those in developing regions. However, there is lack of research from the private sector. Further research is needed to investigate specific factors which delay care, outcomes and cost analyses for laparoscopic surgery, and the system strengthening of surgical services at district hospitals.

Neighborhood socioeconomic status, race, and mortality in young adult dialysis patients

Young blacks receiving dialysis have an increased risk of death compared with whites in the United States. Factors influencing this disparity among the young adult dialysis population have not been well explored. Our study examined the relation of neighborhood socioeconomic status (SES) and racial differences in mortality in United States young adults receiving dialysis. We merged US Renal Data System patient-level data from 11,027 black and white patients ages 18-30 years old initiating dialysis between 2006 and 2009 with US Census data to obtain neighborhood poverty information for each patient. We defined low SES neighborhoods as those neighborhoods in U.S. Census zip codes with ≥20% of residents living below the federal poverty level and quantified race differences in mortality risk by level of neighborhood SES. Among patients residing in low SES neighborhoods, blacks had greater mortality than whites after adjusting for baseline demographics, clinical characteristics, rurality, and access to care factors. This difference in mortality between blacks and whites was significantly attenuated in higher SES neighborhoods. In the United States, survival between young adult blacks and whites receiving dialysis differs by neighborhood SES. Additional studies are needed to identify modifiable factors contributing to the greater mortality among young adult black dialysis patients residing in low SES neighborhoods.

Intravenous iron exposure and mortality in patients on hemodialysis

BACKGROUND AND OBJECTIVES

Clinical trials assessing effects of larger cumulative iron exposure with outcomes are lacking, and observational studies have been limited by assessment of short-term exposure only and/or failure to assess cause-specific mortality. The associations between short- and long-term iron exposure on all-cause and cause-specific mortality were examined.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The study included 14,078 United States patients on dialysis initiating dialysis between 2003 and 2008. Intravenous iron dose accumulations over 1-, 3-, and 6-month rolling windows were related to all-cause, cardiovascular, and infection-related mortality in Cox proportional hazards models that used marginal structural modeling to control for time-dependent confounding.

RESULTS

Patients in the 1-month model cohort (n=14,078) were followed a median of 19 months, during which there were 27.6% all-cause deaths, 13.5% cardiovascular deaths, and 3% infection-related deaths. A reduced risk of all-cause mortality with receipt of >150-350 (hazard ratio, 0.78; 95% confidence interval, 0.64 to 0.95) or >350 mg (hazard ratio, 0.79; 95% confidence interval, 0.62 to 0.99) intravenous iron compared with >0-150 mg over 1 month was observed. There was no relation of 1-month intravenous iron dose with cardiovascular or infection-related mortality and no relation of 3- or 6-month cumulative intravenous iron dose with all-cause or cardiovascular mortality. There was a nonstatistically significant increase in infection-related mortality with receipt of >1050 mg intravenous iron in 3 months (hazard ratio, 1.69; 95% confidence interval, 0.87 to 3.28) and >2100 mg in 6 months (hazard ratio, 1.59; 95% confidence interval, 0.73 to 3.46).

CONCLUSIONS

Among patients on incident dialysis, receipt of ≤ 1050 mg intravenous iron in 3 months or 2100 mg in 6 months was not associated with all-cause, cardiovascular, or infection-related mortality. However, nonstatistically significant findings suggested the possibility of infection-related mortality with receipt of >1050 mg in 3 months or >2100 mg in 6 months. Randomized clinical trials are needed to assess the safety of exposure to greater cumulative intravenous iron doses.