Method for appraising model validity of randomised controlled trials of homeopathic treatment: multi-rater concordance study

BACKGROUND

A method for assessing the model validity of randomised controlled trials of homeopathy is needed. To date, only conventional standards for assessing intrinsic bias (internal validity) of trials have been invoked, with little recognition of the special characteristics of homeopathy. We aimed to identify relevant judgmental domains to use in assessing the model validity of homeopathic treatment (MVHT). We define MVHT as the extent to which a homeopathic intervention and the main measure of its outcome, as implemented in a randomised controlled trial (RCT), reflect 'state-of-the-art' homeopathic practice.

METHODS

Using an iterative process, an international group of experts developed a set of six judgmental domains, with associated descriptive criteria. The domains address: (I) the rationale for the choice of the particular homeopathic intervention; (II) the homeopathic principles reflected in the intervention; (III) the extent of homeopathic practitioner input; (IV) the nature of the main outcome measure; (V) the capability of the main outcome measure to detect change; (VI) the length of follow-up to the endpoint of the study. Six papers reporting RCTs of homeopathy of varying design were randomly selected from the literature. A standard form was used to record each assessor's independent response per domain, using the optional verdicts 'Yes', 'Unclear', 'No'. Concordance among the eight verdicts per domain, across all six papers, was evaluated using the kappa (κ) statistic.

RESULTS

The six judgmental domains enabled MVHT to be assessed with 'fair' to 'almost perfect' concordance in each case. For the six RCTs examined, the method allowed MVHT to be classified overall as 'acceptable' in three, 'unclear' in two, and 'inadequate' in one.

CONCLUSION

Future systematic reviews of RCTs in homeopathy should adopt the MVHT method as part of a complete appraisal of trial validity.

Homeopathic ear drops as an adjunct to standard therapy in children with acute otitis media

OBJECTIVE

To assess the effectiveness of a homeopathic ear drop for treatment of otalgia in children with acute otitis media (AOM).

METHODS

Children with AOM were enrolled in the study at the time of diagnosis and randomized to receive either standard therapy alone or standard therapy plus a homeopathic ear drop solution that was to be used on as needed basis for up to 5 days. Parents of children in both treatment groups rated the severity of 5 AOM symptoms twice daily for 5 days in a symptom diary. A symptom score was computed for each assessment with lower scores denoting less severe symptoms. Parents of children randomized to receive ear drops also recorded information regarding symptoms being treated and response to treatment.

RESULTS

A total of 119 eligible children were enrolled in the study; symptom diaries were received from 94 (79%). Symptom scores tended to be lower in the group of children receiving ear drops than in those receiving standard therapy alone; these differences were significant at the second and third assessments (P = 0.04 and P = 0.003, respectively). In addition, the rate of symptom improvement was faster in children in the ear drop group compared with children in standard therapy alone group (P = 0.002). The most common reason for administration of ear drops was ear pain, recorded for 93 doses; improvement was noted after 78.4% of doses for this indication. There were no significant side effects related to use of the ear drops.

CONCLUSIONS

This study suggests that homeopathic ear drops were moderately effective in treating otalgia in children with AOM and may be most effective in the early period after a diagnosis of AOM. Pediatricians and other primary health care providers should consider homeopathic ear drops a useful adjunct to standard therapy.

Alert but less alarmed: a pooled analysis of terrorism threat perception in Australia

Background

Previous Australian research has highlighted disparities in community perceptions of the threat posed by terrorism. A study with a large sample size is needed to examine reported concerns and anticipated responses of community sub-groups and to determine their consistency with existing Australian and international findings.

Methods

Representative samples of New South Wales (NSW) adults completed terrorism perception questions as part of computer assisted telephone interviews (CATI) in 2007 (N = 2081) and 2010 (N = 2038). Responses were weighted against the NSW population. Data sets from the two surveys were pooled and multivariate multilevel analyses conducted to identify health and socio-demographic factors associated with higher perceived risk of terrorism and evacuation response intentions, and to examine changes over time.

Results

In comparison with 2007, Australians in 2010 were significantly more likely to believe that a terrorist attack would occur in Australia (Adjusted Odd Ratios (AOR) = 1.24, 95%CI:1.06-1.45) but felt less concerned that they would be directly affected by such an incident (AOR = 0.65, 95%CI:0.55-0.75). Higher perceived risk of terrorism and related changes in living were associated with middle age, female gender, lower education and higher reported psychological distress. Australians of migrant background reported significantly lower likelihood of terrorism (AOR = 0.52, 95%CI:0.39-0.70) but significantly higher concern that they would be personally affected by such an incident (AOR = 1.57, 95%CI:1.21-2.04) and having made changes in the way they live due to this threat (AOR = 2.47, 95%CI:1.88-3.25). Willingness to evacuate homes and public places in response to potential incidents increased significantly between 2007 and 2010 (AOR = 1.53, 95%CI:1.33-1.76).

Conclusion

While an increased proportion of Australians believe that the national threat of terrorism remains high, concern about being personally affected has moderated and may reflect habituation to this threat. Key sub-groups remain disproportionately concerned, notably those with lower education and migrant groups. The dissonance observed in findings relating to Australians of migrant background appears to reflect wider socio-cultural concerns associated with this issue. Disparities in community concerns regarding terrorism-related threat require active policy consideration and specific initiatives to reduce the vulnerabilities of known risk groups, particularly in the aftermath of future incidents.

Epidemiology and outcome of Shigella, Salmonella and Campylobacter infections in travellers returning from the tropics with fever and diarrhoea

INTRODUCTION

During a study on fever after a stay in the tropics, we aimed at investigating the epidemiology and outcome of invasive bacterial enteritis due to Shigella, Salmonella or Campylobacter spp. in patients diagnosed with febrile traveller's diarrhoea.

METHODS

From April 2000 to September 2006, we evaluated prospectively 594 travellers presenting with fever and diarrhoea within a month after a stay in the tropics. Patients not found with a systemic infection were assumed to have febrile traveller's diarrhoea (TD). Invasive bacterial enteritis was confirmed by isolation of Shigella, Campylobacter or nontyphoidal Salmonella in stool cultures.

RESULTS

Systemic infections (mainly malaria) were diagnosed in 259 (44%) evaluated travellers. Invasive bacterial enteritis, either alone or with another infection, was confirmed in 114 (34%) of the 335 remaining patients with febrile TD. Aetiologies were distributed between Campylobacter jejuni (47, 41%), Shigella spp. (43, 38%), Salmonella spp. (22, 19%) and mixed Campylobacter-Salmonella infection (2, 2%). Invasive bacterial enteritis accounted for about a third of febrile TD cases occurring after a stay in sub-Saharan Africa, North Africa/Middle East or Latin America, and for half of those occurring after a travel to southern Asia (including 33% only due to C. jejuni). Resistance to fluoroquinolones was exclusively observed in C. jejuni isolates, but at an overall rate of 53%. Clinical failure occurred in 33% of the patients with C. jejuni infection empirically treated with a fluoroquinolone.

CONCLUSION

Invasive bacterial enteritis was a frequent aetiology of febrile TD. C. jejuni was the leading pathogen after a travel to southern Asia, and was associated with high rate of resistance to fluoroquinolones and of clinical failure.

Preventing behavior problems among elementary schoolchildren: impact of a universal school-based program in China

BACKGROUND

To evaluate the effect on problem behaviors of a universal school-based prevention curriculum of third grade students.

METHODS

Six regular classes in 1 elementary school were randomly assigned to an intervention (n = 208) or control (n = 209) group. A 13-session program was offered to students in the intervention group. The Achenbach Child Behavior Checklist (CBCL), parent report, was used to assess problem behaviors at baseline, at the conclusion of the curriculum, and again at 6-month follow up.

RESULTS

The unadjusted mean estimates of behavioral problems were significantly lower in the intervention group posttest (at the conclusion of the curriculum), -3.53 (95% confidence interval [CI] = -6.59 to -0.48; p = .023) and at the 6-month follow up, -5.22 (95% CI: -8.27 to -2.16; p = .001). After adjusting for potential confounders, gender (female), father's educational status (high school), family relationships (good and average), and child's age in months, intervention groups (intervention posttest and intervention after 6-month follow up) showed significantly lower total behavioral scores.

CONCLUSIONS

A universal school-based prevention program for Chinese elementary school-age children resulted in a significant positive change in behavioral problems. This is an important finding in the context of the Chinese 1-child policy that places great value on the achievement of the child.

Automatic detector of high frequency oscillations for human recordings with macroelectrodes

High Frequency Oscillations (HFOs) in the EEG are a promising biomarker of epileptogenic tissue. Given that the visual marking of HFOs is highly time-consuming and subjective, automatic detectors are necessary. In this study, we present a novel automatic detector that detects HFOs by incorporating information of previously detected baselines. The detector was trained on 72 channels and tested on 278, achieving a mean sensitivity of 96.8% with a mean false positive rate of 4.86%. This low rate is reasonable since only visually marked baseline segments were considered as the true negatives. This detector could be useful for the systematic study of HFOs and for their eventual clinical application.

Validation of a four-primer real-time PCR as a diagnostic tool for single and mixed Plasmodium infections

Although microscopy remains the reference standard for malaria diagnosis, molecular tools are attracting increasing interest. To improve the detection of mixed infections, we developed a four-primer real-time PCR with four Plasmodium species-specific forward primers, based on the pan-primer design with universal Plasmodium primers as described previously. After validation for analytical sensitivity, specificity and reproducibility, the four-primer PCR was evaluated on 351 blood samples from patients presenting at the outpatient clinic of the Institute of Tropical Medicine (Belgium). With the four-primer PCR, we identified 188 Plasmodium falciparum (Pf), 54 Plasmodium vivax (Pv), 52 Plasmodium ovale (Po) and 13 Plasmodium malariae (Pm) single infections, 27 mixed infections (14 Pf + Pm; 12 Pf + Po; one Pv + Pm) and 17 negative specimens. We found lower cycle threshold values than with the pan-primer PCR, with a mean difference of 2.23, a higher analytical sensitivity (in asexual parasites/μL: Pf/Pv, 0.02; Po, 0.004; Pm, 0.006) and 15 extra mixed infections. As compared with microscopy, 17 extra mixed infections were detected and Plasmodium species were identified in four microscopy-positive samples in which species identification was not possible. Additionally, the PCR corrected 13 species mismatches between Po and Pv, and in 11 cases detected Pf as a second species that was not identified by microscopy and in five of them was not detected by rapid diagnostic tests (RDTs). PCR confirmed the presence of Pf in 30/46 histidine-rich protein-2-positive samples that were microscopy-negative. We conclude that the presently developed four-primer real-time PCR is complementary to standard malaria diagnostic tests in clinical laboratories, with an added value for simultaneous identification of the four Plasmodium species and the detection of mixed infections.

Psychosocial stress and strategies for managing adversity: measuring population resilience in New South Wales, Australia

BACKGROUND

Populations around the world are facing an increasing number of adversities such as the global financial crisis, terrorism, conflict, and climate change. The aim of this paper was to investigate self-reported strategies and sources of support used to get through "tough times" in an Australian context and to identify patterns of response in the general population and differences in potentially vulnerable subgroups.

METHODS

Data were collected through a cross-sectional survey of the New South Wales population in Australia. The final sample consisted of 3,995 New South Wales residents aged 16 years and above who responded to the question: "What are the things that get you through tough times?"

RESULTS

Respondents provided brief comments that were coded into 14 main subject-area categories. The most frequently reported responses were family and self (52%); friends and neighbors (21%); use of positive emotional and philosophical strategies (17%), such as sense of humor, determination, and the belief that things would get better; and religious beliefs (11%). The responses of four population subgroups were compared, based on gender, household income, level of psychological distress, and whether a language other than English was spoken at home. Women reported greater use of friends and neighbors and religious or spiritual beliefs for support, whereas men reported greater use of drinking/smoking and financial supports. Those with lower incomes reported greater reliance on positive emotional and philosophical strategies and on religious or spiritual beliefs. Those with high levels of psychological distress reported greater use of leisure interests and hobbies, drinking/smoking, and less use of positive lifestyle strategies, such as adequate sleep, relaxation, or work/life balance. Those who spoke a language other than English at home were less likely to report relying on self or others (family/friends) or positive emotional and philosophical strategies to get through tough times.

CONCLUSIONS

Understanding strategies and sources of support used by the population to get through adversity is the first step toward identifying the best approaches to build and support strengths and reduce vulnerabilities. It is also possible to reflect on how large-scale threats such as pandemics, disasters, conflict, bereavement, and loss could impact individual and population resilience.

ON THE USE OF ADSORBENTS IN IMMUNIZATIONS WITH HAPTENS

Experiments are described which confirm the observation of Gonzalez and Armangué that heterogenetic extracts can be made antigenic by adsorption to inorganic materials. With fractions of the original extracts from which a part of inactive material had been removed no such enhancement was observed, whereas with foreign protein an activation was still possible. Carbohydrate preparations behaved similarly in that purification, perhaps loss of protein, was accompanied by a distinct decrease in antigenicity after adsorption. The activity of a but slightly antigenic heteroalbumose preparation was markedly increased after adsorption to charcoal and alum. The most reasonable explanation for the effects observed by Gonzalez and Armangué, and Zozaya, seems to be that a preexisting antigenic capacity has been enhanced by the use of adsorbents. The experiments reported here support the view that these effects are influenced significantly by the presence of substances other than those of a specific nature.

STUDIES ON THE SENSITIZATION OF ANIMALS WITH SIMPLE CHEMICAL COMPOUNDS

Experiments on the sensitization of guinea pigs with simple chemical compounds are described. Positive effects were obtained by the administration of small quantities, namely fractions of milligrams, with 1:2:4 chlorodinitrobenzene, p-nitrosodimethylaniline, 1:2:4 trinitrobenzene, picryl chloride, four dichlorodinitrobenzenes, and a number of other aromatic compounds. Several substances chemically similar to those enumerated gave negative results. The first named compound is known to produce hypersensitiveness in human beings, a large number of cases having been observed in factory workers. The mechanism of these effects is discussed.

STUDIES ON THE SENSITIZATION OF ANIMALS WITH SIMPLE CHEMICAL COMPOUNDS : III. ANAPHYLAXIS INDUCED BY ARSPHENAMINE

Experiments are described which show that with a given treatment guinea pigs can be sensitized to arsphenamine, so that a considerable percentage die in anaphylactic shock on intravenous administration of the substance.

STUDIES ON THE SENSITIZATION OF ANIMALS WITH SIMPLE CHEMICAL COMPOUNDS. II

In continuation of previous work sensitization experiments have been made with various substances such as urushiol, benzyl chlorides, and acyl chlorides. In the case of a series of substituted benzenes (Cl, NO(2)) a connection between sensitizing capacity and lability of the Cl or NO(2) groups has been shown, indicating the formation of conjugated antigens in the animal. This led to the study of benzyl and acyl chlorides which, actually, were found to have sensitizing capacity. Most informative as to the relationship between reactions of the skin surface and anaphylaxis were experiments with acyl chlorides. Guinea pigs sensitized with p-chlorobenzoyl chloride showed, on the one hand, the usual surface lesions after application of the substance, and on the other typical anaphylactic shock following intravenous injection of a compound of p-chlorobenzoyl chloride and guinea pig serum; from which it may be inferred that the two types of allergic manifestation are closely related conditions.