Developing an intervention package to optimise the management of vancomycin therapy using theory informed co-design

BACKGROUND

Optimising the management of vancomycin by achieving target therapeutic concentrations early during therapy has been associated with reduced mortality and morbidity. Despite the availability of guidelines and training, the management of vancomycin remains suboptimal.

OBJECTIVES

The primary outcome was the development of interventions and associated implementation strategies to optimise the management of vancomycin therapy. This paper describes how co-design process was used to build a theory informed intervention package, which was implemented across a wide range of in-patient hospital settings in Queensland, Australia.

METHODS

This multiple methods study was conducted in four phases: 1) a baseline audit to identify the nature of the problem and associated determinants informed by stakeholder interviews 2) mapping these findings to the Theoretical Domains Framework (TDF) to identify behavioural correlates and modifiers 3) prioritising the behavioural modifiers and associated implementation strategies to inform a protype of the intervention in a series of co-design sessions and 4) implementing and evaluating the intervention package. The study was conducted across the four teaching hospitals in a large Queensland Hospital and Health Service across multiple healthcare disciplines namely nurses, doctors, and pharmacists. This intervention package was subsequently implemented across Queensland Health with the support of the local champions under the guidance of the steering group.

RESULTS

Clinicians identified that a multifaceted intervention package and training which can be tailored to the health-care professional disciplines, would be best suited to shift clinician behaviour to align with guidelines. The findings from the co-design process aligned with theory-informed intervention package. Each of the intervention strategies varied in their frequency and popularity of use.

CONCLUSIONS

The use of theory-informed and participatory approach assisted with the intervention development process and aligned the intervention content with the priorities of stakeholders. The TDF provided a structured process for developing intervention content which is both acceptable and useful to stakeholders and may improve the management of vancomycin.

Consumer Preferences for a Healthcare Appointment Reminder in Australia: A Discrete Choice Experiment

BACKGROUND

It is essential to consider the evidence of consumer preferences and their specific needs when determining which strategies to use to improve patient attendance at scheduled healthcare appointments.

OBJECTIVES

This study aimed to identify key attributes and elicit healthcare consumer preferences for a healthcare appointment reminder system.

METHODS

A discrete choice experiment was conducted in a general Australian population sample. The respondents were asked to choose between three options: their preferred reminder (A or B) or a 'neither' option. Attributes were developed through a literature review and an expert panel discussion. Reminder options were defined by four attributes: modality, timing, content and interactivity. Multinomial logit and mixed multinomial logit models were estimated to approximate individual preferences for these attributes. A scenario analysis was performed to estimate the likelihood of choosing different reminder systems.

RESULTS

Respondents (n = 361) indicated a significant preference for an appointment reminder to be delivered via a text message (β = 2.42, p < 0.001) less than 3 days before the appointment (β = 0.99, p < 0.001), with basic details including the appointment cost (β = 0.13, p < 0.10), and where there is the ability to cancel or modify the appointment (β = 1.36, p < 0.001). A scenario analysis showed that the likelihood of choosing an appointment reminder system with these characteristics would be 97%.

CONCLUSIONS

Our findings provide evidence on how healthcare consumers trade-off between different characteristics of reminder systems, which may be valuable to inform current or future systems. Future studies may focus on exploring the effectiveness of using patient-preferred reminders alongside other mitigation strategies used by providers.

Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review

OBJECTIVES

This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions.

ELIGIBILITY CRITERIA

We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings.

DATA EXTRACTION AND SYNTHESIS

Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework.

RESULTS

Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework.

CONCLUSIONS

Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.

Financial Aid in Children, Adolescents and Young Adult's Cancer Care: A Scoping Review

Background: The financial burden resulting from cancers on families is higher when it arises in young people compared with older adults. Previous research has provided insight into the financial toxicities associated with childhood cancer, but less is known about the efficacy of financial aid systems in reducing the financial burden on families. We conducted a scoping review to identify the determinants of success and failure of financial aid. Methods: Five databases were searched for articles published between January 1, 2000 and December 1, 2022. Dual processes were used to screen and select studies. Through thematic content analysis, we identified barriers and enablers of financial aid, categorised by country income level. Results: From 17 articles, which were evenly split between high-income countries and upper middle- to low-income countries, four major themes emerged: (1) accessibility of support, (2) delivery of support, (3) administration, and (4) psychosocial factors. Within these themes, the enablers identified were (1) support navigators, (2) establishing a direct contact between donors and beneficiaries, (3) implementation of digital solutions to improve outreach, and (4) using cultural and community values to encourage donor engagement. Conclusions: This scoping review identified the determinants of success and failure of financial aid in supporting families in the context of childhood, adolescent, and young adult (CAYA) cancers. By understanding the barriers and enablers identified in this review, organizations could develop pragmatic evidence-based care models and policies to ensure access to assistance is equitable and appropriate for families experiencing CAYA cancers.

Using Theories, Models, and Frameworks to Inform Implementation Cycles of Computerized Clinical Decision Support Systems in Tertiary Health Care Settings: Scoping Review

BACKGROUND

Computerized clinical decision support systems (CDSSs) are essential components of modern health system service delivery, particularly within acute care settings such as hospitals. Theories, models, and frameworks may assist in facilitating the implementation processes associated with CDSS innovation and its use within these care settings. These processes include context assessments to identify key determinants, implementation plans for adoption, promoting ongoing uptake, adherence, and long-term evaluation. However, there has been no prior review synthesizing the literature regarding the theories, models, and frameworks that have informed the implementation and adoption of CDSSs within hospitals.

OBJECTIVE

This scoping review aims to identify the theory, model, and framework approaches that have been used to facilitate the implementation and adoption of CDSSs in tertiary health care settings, including hospitals. The rationales reported for selecting these approaches, including the limitations and strengths, are described.

METHODS

A total of 5 electronic databases were searched (CINAHL via EBSCOhost, PubMed, Scopus, PsycINFO, and Embase) to identify studies that implemented or adopted a CDSS in a tertiary health care setting using an implementation theory, model, or framework. No date or language limits were applied. A narrative synthesis was conducted using full-text publications and abstracts. Implementation phases were classified according to the "Active Implementation Framework stages": exploration (feasibility and organizational readiness), installation (organizational preparation), initial implementation (initiating implementation, ie, training), full implementation (sustainment), and nontranslational effectiveness studies.

RESULTS

A total of 81 records (42 full text and 39 abstracts) were included. Full-text studies and abstracts are reported separately. For full-text studies, models (18/42, 43%), followed by determinants frameworks (14/42,33%), were most frequently used to guide adoption and evaluation strategies. Most studies (36/42, 86%) did not list the limitations associated with applying a specific theory, model, or framework.

CONCLUSIONS

Models and related quality improvement methods were most frequently used to inform CDSS adoption. Models were not typically combined with each other or with theory to inform full-cycle implementation strategies. The findings highlight a gap in the application of implementation methods including theories, models, and frameworks to facilitate full-cycle implementation strategies for hospital CDSSs.

"We're trained to trust our patients": a qualitative study on the general practitioners' trust in patients for colorectal cancer shared care

BACKGROUND

In a therapeutic partnership, physicians rely on patients to describe their health conditions, join in shared decision-making, and engage with supported self-management activities. In shared care, the patient, primary care, and specialist services partner together using agreed processes and outputs for the patient to be placed at the centre of their care. However, few empirical studies have explored physicians' trust in patients and its implications for shared care models.

AIM

To explore trust in patients amongst general practitioners (GPs), and the impacts of trust on GPs' willingness to engage in new models of care, such as colorectal cancer shared care.

METHODS

GP participants were recruited through professional networks for semi-structured interviews. Transcripts were integrity checked, coded inductively, and themes developed iteratively.

RESULTS

Twenty-five interviews were analysed. Some GPs view trust as a responsibility of the physician and have a high propensity for trusting patients. For other GPs, trust in patients is developed over successive consultations based on patient characteristics such as honesty, reliability, and proactivity in self-care. GPs were more willing to engage in colorectal cancer shared care with patients with whom they have a developed, trusting relationship.

CONCLUSIONS

Trust plays a significant role in the patient's access to shared care. The implementation of shared care should consider the relational dynamics between the patient and health care providers.

Identifying barriers and facilitators to successful implementation of computerized clinical decision support systems in hospitals: a NASSS framework-informed scoping review

BACKGROUND

Successful implementation and utilization of Computerized Clinical Decision Support Systems (CDSS) in hospitals is complex and challenging. Implementation science, and in particular the Nonadoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework, may offer a systematic approach for identifying and addressing these challenges. This review aimed to identify, categorize, and describe barriers and facilitators to CDSS implementation in hospital settings and map them to the NASSS framework. Exploring the applicability of the NASSS framework to CDSS implementation was a secondary aim.

METHODS

Electronic database searches were conducted (21 July 2020; updated 5 April 2022) in Ovid MEDLINE, Embase, Scopus, PyscInfo, and CINAHL. Original research studies reporting on measured or perceived barriers and/or facilitators to implementation and adoption of CDSS in hospital settings, or attitudes of healthcare professionals towards CDSS were included. Articles with a primary focus on CDSS development were excluded. No language or date restrictions were applied. We used qualitative content analysis to identify determinants and organize them into higher-order themes, which were then reflexively mapped to the NASSS framework.

RESULTS

Forty-four publications were included. These comprised a range of study designs, geographic locations, participants, technology types, CDSS functions, and clinical contexts of implementation. A total of 227 individual barriers and 130 individual facilitators were identified across the included studies. The most commonly reported influences on implementation were fit of CDSS with workflows (19 studies), the usefulness of the CDSS output in practice (17 studies), CDSS technical dependencies and design (16 studies), trust of users in the CDSS input data and evidence base (15 studies), and the contextual fit of the CDSS with the user's role or clinical setting (14 studies). Most determinants could be appropriately categorized into domains of the NASSS framework with barriers and facilitators in the "Technology," "Organization," and "Adopters" domains most frequently reported. No determinants were assigned to the "Embedding and Adaptation Over Time" domain.

CONCLUSIONS

This review identified the most common determinants which could be targeted for modification to either remove barriers or facilitate the adoption and use of CDSS within hospitals. Greater adoption of implementation theory should be encouraged to support CDSS implementation.

Which Test Is Best? A Cluster-Randomized Controlled Trial of a Risk Calculator and Recommendations on Colorectal Cancer Screening Behaviour in General Practice

INTRODUCTION

This cluster-randomized controlled trial aimed to assess the effect of the "Which test is best?" tool on risk-appropriate screening (RAS) and colorectal cancer (CRC) screening uptake.

METHODS

General practices in Sydney and Melbourne, Australia, and a random sub-sample of 460 patients (aged 25-74 years) per practice were invited by post. Clusters were computer randomized independently of the researchers to an online CRC risk calculator with risk-based recommendations versus usual care. Primary and secondary outcomes were RAS and screening uptake via self-reported 5-year screening behaviour after 12 months follow-up. The usual care group (UCG) also self-reported 5-year CRC screening behaviour at 12 month post-randomization.

RESULTS

Fifty-six practices were randomized (27 to the intervention and 29 to the control, 55 practices participated) with 818 intervention and 677 controls completing the primary outcome measure. The intervention significantly increased RAS in high-risk participants compared with UCG (80.0% vs. 64.0%, respectively; OR = 3.14, 95% CI: 1.25-7.96) but not in average-risk (44.9% vs. 49.5%, respectively; OR = 0.97, 95% CI: 0.99-1.12) or moderate-risk individuals (67.9% vs. 81.1%, respectively; OR = 0.40, 95% CI: 0.12-1.33). Faecal occult blood testing uptake over 12 months was increased compared with the UCG (24.9% vs. 15.1%; adjusted OR = 1.66, 95% CI: 1.24-2.22), and there was a non-significant increase in colonoscopies during the same period (16.6% vs. 12.2%; adjusted OR = 1.42, 95% CI: 0.97-2.08).

CONCLUSION

An online CRC risk calculator with risk-based screening recommendations increased RAS in high-risk participants and improved screening uptake overall within a 12-month follow-up period. Such tools may be useful for facilitating the uptake of risk-based screening guidelines.

Non-polymyxin-based combinations as potential alternatives in treatment against carbapenem-resistant Acinetobacter baumannii infections

Due to limited therapeutic options, combination therapy has been used empirically to treat carbapenem-resistant Acinetobacter baumannii (CRAB). Polymyxin-based combinations have been widely studied and used in the clinical setting. However, the use of polymyxins is often limited due to nephrotoxicity and neurotoxicity. This study aimed to evaluate the activity of non-polymyxin-based combinations relative to polymyxin-based combinations and to identify potential synergistic and bactericidal two-drug non-polymyxin-based combinations against CRAB. In vitro activity of 14 two-drug combinations against 50 A. baumannii isolates was evaluated using the checkerboard method. Subsequently, the two best-performing non-polymyxin-based combinations from the checkerboard assay were explored in static time-kill experiments. Concentrations of antibiotics corresponding to the fractional inhibitory concentrations (FIC) and the highest serum concentration achievable clinically were tested. The most synergistic combinations were fosfomycin/sulbactam (synergistic against 37/50 isolates; 74%), followed by meropenem/sulbactam (synergistic against 28/50 isolates; 56%). No antagonism was observed for any combination. Both fosfomycin/sulbactam and meropenem/sulbactam combinations exhibited bactericidal and synergistic activity against both isolates at the highest clinically achievable concentrations in the time-kill experiments. The meropenem/sulbactam combination displayed synergistic and bactericidal activity against one of two strains at concentrations equal to the FIC. Non-polymyxin-based combinations such as fosfomycin/sulbactam and meropenem/sulbactam may have a role in the treatment of CRAB. Further in vivo and clinical studies are required to scrutinise these activities further.

Continuous Ambulatory Peritoneal Dialysis in South Africa -A Four-Year Experience

This study describes our experience with continuous ambulatory peritoneal dialysis (CAPD) over a four year period, during which 88 patients were offered CAPD. It compares and contrasts the response to CAPD among four racial groups in Natal viz asiatics, blacks, coloureds and whites. Peritonitis -the major complication, occurred with an overall incidence of one episode every 4.41 patient months. CAPD remains a useful alternative therapy in developing countries where a high percentage of patients with chronic renal failure would be denied a chronic renal failure program because of lack of expertise in hemodialysis and/or renal transplantation, or limited financial resources.

Continuous ambulatory peritoneal dialysis (CAPD) was first described by Moncrief and Popovich (1) and, since its modification by Oreopoulos and his group (2), this technique has gained world wide usage. South Africa, like many developing countries has a high incidence of end-stage renal disease (ESRD) but because of lack of resources and economical problems, few patients with ESRD can be treated by dialysis or renal transplantation. CAPD affords a relatively simple and inexpensive form of therapy for these patients. At the present time about 200 patients are on CAPD in South Africa. Natal, the smallest of four provinces in South Africa, has a population of about five million, the majority being blacks. The minority groups include whites, asiatics and coloureds. There is only one chronic dialysis centre in Natal; situated in Durban, it serves the entire province including parts of the Transkei. This paper describes a four-year experience with CAPD in this mixed population and discusses problems unique to this situation.

Atherosclerotic vascular disease is more prevalent among black ESKD patients on long-term CAPD in South Africa

Background

Occurrence of cardiovascular disease (CVD) in the setting of chronic kidney disease (CKD) can be described as a “cruel alliance”, with CVD responsible for about half of all deaths among CKD patients. Chronic kidney disease patients are more likely to die from CVD than progress to end stage kidney disease (ESKD). Dyslipidaemia, a known traditional risk factor for CVD, is highly prevalent among CKD patients and with an even higher frequency among ESKD patients on dialytic therapies. Prolonged exposure of continuous ambulatory peritoneal dialysis (CAPD) patients to high glucose concentrations in CAPD fluid have been associated with increased risk of cardiovascular events. In this study, we investigated the relationship of atherosclerotic vascular disease (AsVD) to clinical and echocardiographic parameters among black South Africans with CKD (stage 3) and ESKD on CAPD and haemodialysis (HD).

Methods

This was a cross-sectional study of 40 adult (18–65 years) non-diabetic CKD patients (kidney disease outcome quality initiative [KDOQI] stage 3), 40 ESKD patients on CAPD, 40 ESKD patients on HD and 41 age and sex-matched healthy controls. An interviewer-administered questionnaire was used to obtain information on participants’ sociodemographic and cardiovascular risk factors. Anthropometric parameters were measured. Serum blood samples were analysed for creatinine, albumin and lipid profile; lipoprotein ratios, Framingham’s risk score and the 10-year risk of developing coronary heart disease (CHD) were calculated. Echocardiography was performed on all patients and carotid intima media thickness (CIMT) was measured in both right and left carotid arteries at 1 cm proximal to the carotid bulb. Spearman’s rank correlation and binary logistic regression were conducted to determine the relationship of AsVD to clinical and echocardiographic parameters.

Results

Atherosclerotic vascular disease was most prevalent among ESKD patients on CAPD (70%, n = 28/40). Chronic kidney disease and HD patients exhibited a similar prevalence (47.5%, n = 19/40), while the prevalence in controls was 17.1% (n = 7/41). Presence of AsVD was associated with significantly older age, higher waist hip ratio (WHR), left ventricular mass index (LVMI) and Framingham’s 10-year risk of developing CHD. Significant differences in clinical and echocardiographic parameters were observed when the study groups were compared. Age and LVH independently predicted AsVD.

Conclusion

Atherosclerotic vascular disease was more prevalent among CAPD patients compared to pre-dialysis CKD and HD patients. Among all lipoprotein ratios assessed, non-HDL-C showed the most consistent significant difference between the groups. Age (> 40 years) and presence of LVH were independent predictors of AsVD.

The recovery of online drug markets following law enforcement and other disruptions

INTRODUCTION

Online drug markets operating on the 'darknet' ('cryptomarkets') facilitate the trade of illicit substances at an international level. The present study assessed the longitudinal impact on cryptomarket trading of two major disruptions: a large international law enforcement operation, 'Operation Onymous'; and the closure of the largest cryptomarket, Evolution.

METHODS

Almost 1150 weekly snapshots of a total of 39 cryptomarkets were collected between October 2013 and November 2015. Data were collapsed by month and the number of unique vendor aliases operating across markets was assessed using interrupted time series regression.

RESULTS

Following both Operation Onymous and the closure of Evolution, significant drops of 627 (p=0.014) and 910 vendors (p<0.001) were observed, respectively. However, neither disruption significantly affected the rate at which vendor numbers increased overall.

CONCLUSIONS

Operation Onymous and the closure of Evolution were associated with considerable, though temporary, reductions in the number of vendors operating across cryptomarkets. Vendor numbers, however, recovered at a constant rate. While these disruptions likely impacted cryptomarket trading at the time, these markets appear resilient to disruption long-term.

Proteinuria, graft outcomes, and cardiovascular risk among kidney transplant recipients in a South African Public Hospital

Proteinuria is a marker of poor long-term graft survival and an independent risk factor for total and cardiovascular mortality in the transplant population. We investigated the prevalence of proteinuria and its relationship with graft function and cardiovascular risk factors in kidney transplant recipients (KTRs). Adult KTRs at the Charlotte Maxeke Johannesburg Academic Hospital were recruited. Patients' records were reviewed for information on their posttransplant follow-up. Echocardiography and carotid Doppler were performed for the assessment of cardiac status and carotid intima-media thickness (CIMT), respectively. Proteinuria was analyzed both as a categorical and continuous variable. Graft dysfunction was defined as estimated glomerular filtration rate of <60 mL/min/1.73 m 2 based on the modification of diet in renal disease formula. Framingham's risk score was used to categorize patients' cardiovascular risk. Inferential and modeling statistics were applied as appropriate using Statistical Package for Social Sciences, and P ≤0.05 was considered statistically significant. One hundred KTRs including 63% males were recruited. Proteinuria was present in 51%, the mean ± standard deviation 24 h urinary protein excretion per day was 1.67 ± 2.0 g/day with a range of 0.4-9.4 g/day. Graft dysfunction was found in 52% of patients and 36% had high cardiovascular disease (CVD) risk. Proteinuric KTRs had high CVD risk, P = 0.002. Proteinuria was associated with graft dysfunction, increased left ventricular mass index, increased CIMT, and anemia. Proteinuria is prevalent; it is a marker of graft dysfunction and is associated with markers of atherosclerosis.

Characterising dark net marketplace purchasers in a sample of regular psychostimulant users

BACKGROUND

The past five years has seen a proliferation in marketplaces operating on the 'dark net' selling licit and illicit substances. While monitoring systems have investigated the specific substances for sale on these marketplaces, less is known about consumer motivations for accessing these marketplaces and factors associated with their use.

METHODS

An Australian national sample (n=800) recruited on the basis of regular psychostimulant use was recruited and asked about purchasing substances from dark net marketplaces and the reasons for doing so. Respondents who had purchased any drug from a dark net marketplace in the preceding year were compared to those who had not in terms of demographic information and factors including drug use, criminal activity, and sexual and mental health.

RESULTS

Nine percent (n=68) of the sample had purchased from dark net markets in the past year. MDMA, LSD and cannabis were the three most commonly purchased substances, and the main benefits cited for purchasing online were the better quality and lower cost of drugs available. Controlling for other factors, participants who purchased from dark net marketplaces in the past year tended to be younger, more likely to be involved in recent property crime and to have used more classes of drugs in the preceding six months, specifically psychedelics and 'new psychoactive drugs'.

CONCLUSIONS

Though a small minority of participants reported having purchased drugs online in the preceding six months, these appeared to be a more 'entrenched' group of consumers, with more diverse substance use and rates of criminal activity. For consumers in the current sample reporting recent dark net usage, country borders are now less of a significant barrier to purchase and there is a wider range of substances available than ever before.

Obesity and graft dysfunction among kidney transplant recipients: Increased risk for atherosclerosis

Weight gain after kidney transplant is common, and may be related to graft dysfunction and high cardiovascular risk. We investigated the prevalence of obesity and evaluated the relationship between obesity and graft dysfunction in kidney transplant recipients (KTRs). All patients who received kidney transplant at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) between January 2005 and December 2009 were recruited. Information on demographics, clinical characteristics and post-transplant care were documented. All patients underwent transthoracic echocardiography and carotid Doppler ultrasound for the assessment of cardiac status and carotid intima-media thickness (cIMT), respectively. Inferential and modelling statistics were applied. One hundred KTRs were recruited, of which 63 were males. The mean age was 42.2 ± 12.42 years with a range of 19-70 years. The mean body mass index and waist circumference of the recipients were 26.4 ± 4.81 kg/m² and 90.73 ± 14.76 cm, respectively. Twenty-nine patients (29%) were obese; of these, 24 (82.8%) had moderate obesity, 4 (13.8%) had severe obesity, and 1 (3.4%) had morbid obesity. Graft dysfunction was present in 52%. Obese patients were older (P < 0.0001), had graft dysfunction (P = 0.03), higher mean arterial blood pressure (P = 0.022), total cholesterol (P = 0.019), triglycerides (P < 0.0001), left ventricular mass index (P = 0.035) and cIMT (P = 0.036). Logistic regression showed obesity to be independently associated with graft dysfunction (P = 0.033). Obesity after kidney transplantation is common and is associated with graft dysfunction and markers of atherosclerosis.

Smoking Cessation among Low-Socioeconomic Status and Disadvantaged Population Groups: A Systematic Review of Research Output

Background: Smoking cessation research output should move beyond descriptive research of the health problem to testing interventions that can provide causal data and effective evidence-based solutions. This review examined the number and type of published smoking cessation studies conducted in low-socioeconomic status (low-SES) and disadvantaged population groups. Methods: A systematic database search was conducted for two time periods: 2000–2004 (TP1) and 2008–2012 (TP2). Publications that examined smoking cessation in a low-SES or disadvantaged population were coded by: population of interest; study type (reviews, non-data based publications, data-based publications (descriptive, measurement and intervention research)); and country. Intervention studies were coded in accordance with the Cochrane Effective Practice and Organisation of Care data collection checklist and use of biochemical verification of self-reported abstinence was assessed. Results: 278 citations were included. Research output (i.e., all study types) had increased from TP1 27% to TP2 73% (χ² = 73.13, p < 0.001), however, the proportion of data-based research had not significantly increased from TP1 and TP2: descriptive (TP1 = 23% vs. TP2 = 33%) or intervention (TP1 = 77% vs. TP2 = 67%). The proportion of intervention studies adopting biochemical verification of self-reported abstinence had significantly decreased from TP1 to TP2 with an increased reliance on self-reported abstinence (TP1 = 12% vs. TP2 = 36%). Conclusions: The current research output is not ideal or optimal to decrease smoking rates. Research institutions, scholars and funding organisations should take heed to review findings when developing future research and policy.

Impact of socio-economic factors on quality of life in patients on continuous ambulatory peritoneal dialysis in an African setting

BACKGROUND

Quality of life (QOL) is an important outcome following the treatment of disease. It is influenced by physical, psychological, social and economic factors. We proposed to determine the effect of some socioeconomic factors on QOL of patients on CAPD.

STUDY DESIGN

A cross sectional study in which all patients on CAPD attending three clinics attached to the University of the Witwatersrand, Johannesburg were recruited excluding those with intercurrent illness. The WHO quality of life instrument, WHOQOL-Bref, was used to measure QOL. The patients were grouped according to marital status, highest level of education attained, income, employment, and QOL domain scores were compared using ANOVA and Student t test.

RESULTS

A total of 140 patients comprising 80 males and 40 females were assessed. The mean age of patients was 41.9 ± 11.5 years, 95%of patients were black, 44.3% married, 69.3% had secondary education, 22% were employed and 51.4% had a monthly income of less than five thousand Rand (500 US dollars). Single patients scored better in the social relationships domain compared to separated patients (p=0.02, CI: 5.6-32.9). The group with secondary education scored low in the psychological domain compared with those with primary education (p=0.02, CI: 1.35-15.8) and those with tertiary education (p=0.02, CI: 1.72-18.07).The highest income group had best scores in all domains except the physical domain. Those in employment had better scores in the physical domain (p=0.04, CI: 0.356-12.549).

CONCLUSION

Income had the most impact on QOL in study participants.

Environmental isotopic and hydrochemical characteristics of groundwater from the Sandspruit Catchment, Berg River Basin, South Africa

The Sandspruit catchment (a tributary of the Berg River) represents a drainage system, whereby saline groundwater with total dissolved solids (TDS) up to 10,870 mg/l, and electrical conductivity (EC) up to 2,140 mS/m has been documented. The catchment belongs to the winter rainfall region with precipitation seldom exceeding 400 mm/yr, as such, groundwater recharge occurs predominantly from May to August. Recharge estimation using the catchment water-balance method, chloride mass balance method, and qualified guesses produced recharge rates between 8 and 70 mm/yr. To understand the origin, occurrence and dynamics of the saline groundwater, a coupled analysis of major ion hydrochemistry and environmental isotopes (δ(18)O, δ(2)H and (3)H) data supported by conventional hydrogeological information has been undertaken. These spatial and multi-temporal hydrochemical and environmental isotope data provided insight into the origin, mechanisms and spatial evolution of the groundwater salinity. These data also illustrate that the saline groundwater within the catchment can be attributed to the combined effects of evaporation, salt dissolution, and groundwater mixing. The salinity of the groundwater tends to vary seasonally and evolves in the direction of groundwater flow. The stable isotope signatures further indicate two possible mechanisms of recharge; namely, (1) a slow diffuse type modern recharge through a relatively low permeability material as explained by heavy isotope signal and (2) a relatively quick recharge prior to evaporation from a distant high altitude source as explained by the relatively depleted isotopic signal and sub-modern to old tritium values.

Living kidney donor transplants over a 16-year period in South Africa: a single center experience

BACKGROUND

Kidney transplantation is the treatment of choice for end-stage renal disease (ESRD). The number of patients on the waiting list is increasing due to an imbalance between organ supply and demand. This has led to an increase in the number of living donor transplants in most parts of the world. The benefits to the recipients must, however, be weighed against the risks to the donors. Long-term follow-up of the donors is therefore imperative to ascertain the risks of living kidney donation.

MATERIALS AND METHODS

We reviewed the records of 571 potential living kidney donors (PLDs) in Johannesburg hospital over a 16-year period between 1990 and 2005.

RESULTS

There were 1030 kidney transplants during this period, with 800 cadaveric and 230 actual living donor (ALD) transplants. There were 571 PLDs; however, 341 (59.7%) withdrew or were withdrawn because of medical and non-medical reasons. Among the 230 ALDs, the mean age of the donors was 35.2 ± 8.3 years; 55% were females; 24% were Blacks. Eighty-five percent were related to the recipients while 15% were unrelated. Mean duration of follow-up was 8.6 ± 6.4 years. The pattern of post-donation follow-up was excellent in 29.7%, adequate in 34% and unacceptable/poor in 36.3%, based on the number of clinic visits post-donation. Hypertension was noted in 24% of the donors during long-term follow-up. Three of the donors also developed significant microalbuminuria.

CONCLUSION

There is a need to encourage living kidney donation, especially amongst the Black populations, and to emphasize the value and significance of post-donation follow-up visits to all potential donors.

Is there a need for early detection programs for chronic kidney disease?

The aims of this paper are to examine whether early detection programs are needed to assist in detecting and managing chronic kidney disease (CKD). It draws on existing material which indicates that CKD and its precursor risk factors or illnesses such as hypertension, diabetes mellitus and HIV infection are very clearly major challenges faced by health systems worldwide. This paper evaluates whether CKD meets the epidemiological criteria to justify early screening. More compelling evidence is becoming available which indicates that the prevalence of CKD is significant in both developing and developed countries and that CKD can be easily detected and treated with only small changes to existing practice and this may be improved through screening programs. A brief evaluation of the challenges of establishing early detection programs is provided, as well as an examination of the capacity which exists for establishing such programs. It concludes that, despite the lack of randomized studies, these programs appear to provide an opportunity to integrate CKD management with common chronic illnesses and, through this approach, provide clinical and cost-effective management of both CKD and cardiovascular disease.

Chronic stress alters the density and morphology of microglia in a subset of stress-responsive brain regions

The current study, in parallel experiments, evaluated the impact of chronic psychological stress on physiological and behavioural measures, and on the activation status of microglia in 15 stress-responsive brain regions. Rats were subjected, for 14 days, to two 30 min sessions of restraint per day, applied at random times each day. In one experiment the effects of stress on sucrose preference, weight gain, core body temperature, and struggling behaviour during restraint, were determined. In the second experiment we used immunohistochemistry to investigate stress-induced changes in ionized calcium-binding adaptor molecule-1 (Iba1), a marker constitutively expressed by microglia, and major histocompatibility complex-II (MHC-II), a marker often expressed on activated microglia, in a total of 15 stress-responsive nuclei. We also investigated cellular proliferation in these regions using Ki67 immunolabelling, to check for the possibility of microglial proliferation. Collectively, the results we obtained showed that chronic stress induced a significant increase in anhedonia, a decrease in weight gain across the entire observation period, a significant elevation in core body temperature during restraint, and a progressive decrease in struggling behaviour within and over sessions. With regard to microglial activation, chronic stress induced a significant increase in the density of Iba1 immunolabelling (nine of 15 regions) and the number of Iba1-positive cells (eight of 15 regions). Within the regions that exhibited an increased number of Iba1-positive cells after chronic stress, we found no evidence of a between group difference in the number of MHC-II or Ki67 positive cells. In summary, these results clearly demonstrate that chronic stress selectively increases the number of microglia in certain stress-sensitive brain regions, and also causes a marked transition of microglia from a ramified-resting state to a non-resting state. These findings are consistent with the view that microglial activation could play an important role in controlling and/or adapting to stress.

Neonatal lipopolysaccharide and adult stress exposure predisposes rats to anxiety-like behaviour and blunted corticosterone responses: implications for the double-hit hypothesis

The double-hit hypothesis posits that an early life genetic or environmental insult sets up a neural predisposition to psychopathology, which may emerge in the presence of a subsequent insult, or 'second hit' in later life. The current study assessed the effect of neonatal lipopolysaccharide (LPS) exposure on anxiety-like behaviours in the adult Wistar rat. Rats were administered either LPS (Salmonella enterica, serotype enteritidis, 0.05 mg/kg, i.p.) or saline (equivolume) on days 3 and 5 of life (birth=day 1). In adulthood (85 days), subjects were allocated to either "stress" or "no stress" treatment groups. For the "stress" group, subjects were exposed to a three-day stress protocol consisting of a 30 min period of restraint and isolation. The "no stress" group was left unperturbed but were handled during this period to control for handling effects between adult "stress" and "no stress" conditions. All animals then underwent behavioural testing using standardised tests of anxiety-like behaviour, including either the Hide Box/Open Field, Elevated Plus Maze (EPM) or Acoustic Startle Response (ASR). Time and event measures for restraint and isolation, the Hide Box/Open Field and EPM were recorded using automated tracking software. Startle amplitude and habituation across time was measured in the ASR test. Prior to and following behavioural test sessions, peripheral blood was collected to assess serum corticosterone and ACTH levels. Data analysis indicated that LPS-treated animals exposed to stress in adulthood exhibited increased anxiety-like behaviour across all behavioural tests compared to controls. Sexually dimorphic effects were observed with males exhibiting increased anxiety-related behaviours compared to females (p<.05). Neonatal LPS exposure induced a significant increase in corticosterone compared to controls (p<.05), whereas corticosterone responses to stress in adulthood were associated with a significantly blunted HPA axis response (p<.05). No differences in ACTH were observed. These results lend support to the double-hit hypothesis of anxiety-related behaviour, demonstrating that neonatal immune activation produces an enhanced propensity toward anxiety-related behaviour following stress in adulthood, and that this susceptibility is associated with alterations to HPA axis ontogeny.

Strain differences in coping behaviour, novelty seeking behaviour, and susceptibility to socially conditioned fear: a comparison between Wistar and Sprague Dawley rats

The aim of the current study was to generate socially conditioned fear in two different strains of rat (Wistar, W and Sprague Dawley, SD) using social conflict, in order to investigate whether the magnitude of the conditioned fear responses in each strain was related to behaviour exhibited prior to or during fear induction (i.e. social conflict). On day one of the study, all intruders were assessed for exploratory activity in a novel environment. Twenty four hours following the novel environment test the locomotor activity of the intruders was assessed, while they underwent a single familiarisation exposure to the arena in which the conflict was subsequently to occur in. Twenty-four hours following familiarisation, intruders underwent either a 10 min social conflict or sham conflict session. One day later we examined the response of the intruders when they were returned to the vacant resident's cage. Upon return to the conflict context, we examined the intruder's ultrasonic distress vocalisations and the extent to which locomotor activity was inhibited. We found that W rats displayed significantly more immobility (i.e. conditioned fear) upon return to context than did SD rats (p < 0.05). Importantly, we observed that the differences in the two strains behaviour upon return to context appeared to be related to their quite different patterns of coping behaviour. The results of the current study indicate that preclinical between-strain comparisons potentially have much to offer in regard to understanding the basis of resilience to social stress.

Chronic kidney disease in human immunodeficiency virus infection

The number of people living with human immunodeficiency virus (HIV) worldwide was estimated to be 39.5 million in 2006, 2.6 million more than in 2004. The manifestations of HIV infection in the kidney are multiple and varied, highlighting the complexity of the disease process. There is a wide spectrum of renal disease that occurs in the course of HIV infection. Biopsy studies reveal varying frequencies of histological patterns. HIV-associated nephropathy (HIVAN) is most common. A biopsy study at Chris Baragwanath Hospital in Soweto, South Africa showed that HIVAN was present in 27% and immune complex disease in 21%. Han et al. studied HIV-positive patients in Durban, South Africa and screened for proteinuria, including microalbuminuria. They found persistent proteinuria in 6%; HIVAN in 21/30 (72.4%) and the prevalence of HIVAN in patients with persistent microalbuminuria was 85.7%. Studies in black patients have shown a higher prevalence of both severe glomerular lesions (focal glomerulosclerosis) and nephrotic range proteinuria with renal dysfunction in the presence of normo-hypotension. There have been no prospective randomised controlled studies with any form of therapy for HIVAN to date. Therapy of HIVAN has included corticosteroids, cyclosporine and antiretroviral therapy (ART). ART appears to be a logical choice in the management of HIV-associated renal disease. Regimens containing protease inhibitors have been shown to be associated with significant slowing of the decline in creatinine clearance. Both peritoneal dialysis and haemodialysis are appropriate treatment modalities for HIV-infected patients with end stage renal disease. The choice of dialysis modality between haemodialysis and peritoneal dialysis is not a factor in predicting survival, if patients are stable on ART. Preliminary short-term data in case reports and small cohorts of liver, kidney, and heart transplant recipients suggest that patient survival rates may be similar to those in HIV-uninfected transplant recipients. However, high rates of acute and chronic rejection have been observed among HIV-infected kidney transplant recipients. The Infectious Diseases Society of America (IDSA) published guidelines in 2005, recommending that all individuals be assessed for kidney disease at the time of diagnosis of HIV infection with a screening urinalysis for proteinuria and a calculated estimate of renal function. Therefore any patient with persistent proteinuria, persistent haematuria or glomerular filtration rate < 60 mL/min per 1.73 m(2) should be referred to an institution where a specialist can evaluate this patient for further investigations. An integrated plan to reduce the progression to kidney failure together with lifestyle measures, focusing also on high risk groups with effective management at all levels of chronic kidney disease remains essential.

A cross-sectional study of HIV-seropositive patients with varying degrees of proteinuria in South Africa

Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is the most common finding on renal biopsy in HIV-infected black patients and is also the commonest cause of end-stage renal disease in these patients. Early detection of HIVAN may be beneficial in evaluating early treatment. This study examined the pattern of renal diseases in HIV-infected South Africans and also attempted to diagnose HIVAN at an early stage. In this single-center cross-sectional study, 615 HIV-infected patients were screened for proteinuria. Thirty patients with varying degrees of proteinuria underwent renal biopsy. Patients with diabetes mellitus, uncontrolled hypertension, known causes of chronic kidney disease, and serum creatinine above 250 mumol/l were excluded. Patients in this study were not on antiretroviral therapy. HIVAN was found in 25 (83%) patients. Six of them (24%) had microalbuminuria. Altogether, seven patients with persistent microalbuminuria were biopsied and six (86%) showed HIVAN. Other biopsy findings included membranoproliferative nephropathy in two (7%) and interstitial nephritis in three (10%). Four patients with HIVAN had associated membranous nephropathy. HIVAN is the commonest biopsy finding among our study patients with HIV infection who present with varying degrees of proteinuria. Microalbuminuria is a manifestation of HIVAN in our study patients. Therefore, microalbuminuria may be an early marker of HIVAN, and screening for its presence may be beneficial. Renal biopsy may be considered in seropositive patients who present with persistent microalbuminuria, especially with low CD4 counts irrespective of good renal function. This will allow diagnosis and treatment of HIVAN at an early stage and may prevent further disease progression.

The pathogenesis of membranoproliferative glomerulonephritis in KwaZulu-Natal, South Africa is unrelated to hepatitis C virus infection

Idiopathic membranoproliferative glomerulonephritis (MPGN) is a well-defined clinicopathological entity with a poor prognosis, with 50% of patients progressing to end stage renal disease (ESRD) within 10 years. It was reported in about 36% of adult Black patients with nephrotic syndrome in our center previously [Seedat et al. 1988]. Hepatitis C virus (HCV) infection has been shown to be associated with cryoglobulinemic as well as non-cryoglobulinemic (or idiopathic glomerulonephritis). The aim of this study was to determine whether an association exists between HCV infection and idiopathic MPGN in a population with a relatively high prevalence of MPGN. We studied adult patients referred with glomerular disease over a two-year period, 104 patients had primary glomerulonephritis. All 23 (22%) patients with idiopathic MPGN were enrolled, as well as 32 age-matched patients presenting with other primary glomerular diseases. We examined serum from all 55 patients for evidence of HCV antibodies and HCV RNA. None of the 55 patients showed evidence of HCV infection. Chronic renal failure was present in 82.6% of the patients with idiopathic MPGN and it was advanced in 52,2%, who either were dialysis-requiring at presentation or progressed to ESRD soon thereafter; 30.4% had moderate chronic renal failure, while only 17.4% had normal renal function. HCV infection is not associated with idiopathic MPGN in our patients. Idiopathic MPGN remains an idiopathic disease, possibly with a poor prognosis in our population.

Endothelins: vasoactive modulators of renal function in health and disease

Vasoactive autocoids with directly opposing actions on the renal vasculature, glomerular function, and in salt and water homeostasis have been demonstrated in the kidney. In the renal cortex, endothelin (ET)-1 and angiotensin-II cause vasoconstriction, decreasing renal blood flow, and glomerular filtration rate, whereas bradykinin and atrial natriuretic peptide cause vasodilation and increase glomerular capillary permeability. ET-1 causes vasoconstriction of the afferent and efferent arteries and outer medullary descending vasa recta, thereby decreasing vasa recta and papillary blood flow, while bradykinin has the opposite effect. ET-1 stimulates cell proliferation, increasing the expression of several genes, including collagenase, prostaglandin endoperoxidase synthase, and platelet-derived growth factor. ET-1 promotes natriuresis via the ET-B receptor, causing down-regulation of the epithelial Na(+) channel in the renal tubule. Thus, ETs affect three major aspects of renal physiology: vascular and mesangial tone, Na(+) and water excretion, and cell proliferation and matrix formation.

Kallikrein and kinin receptor expression in inflammation and cancer

The kallikrein family of serine proteases has been investigated in many inflammatory disorders as molecular mapping, gene characterisation and cloning of kinin receptor genes have unfolded experimentally. In the molecular events of the inflammatory response the kallikrein cascade plays a significant role, since it is considered to initiate and maintain systemic inflammatory responses and immune-modulated disorders. A primary event is the chemotactic attraction of neutrophils which deliver the kallikrein-kinin cascade to sites of cellular injury and carcinogenic transformation of cells. The present study establishes the casual involvement of the kallikrein cascade in infection, inflammatory joint disease, acute transplant rejection, renal glomerular diseases, angiogenesis and carcinoma. We provide strong evidence for new or enhanced expression of kinin B1 receptors in inflammation, and additionally the induction of kallikrein genes in angiogenesis and carcinoma. The results provide insights into possible roles of kallikrein inhibitors and kinin receptor antagonists.

GB virus C/hepatitis G virus infection in KwaZulu Natal, South Africa

Sera from 70 patients on maintenance haemodialysis, 98 patients with chronic liver disease, and 232 volunteer blood donors in the province of KwaZulu Natal, South Africa, were screened for GB virus/hepatitis G virus (GBV-C/HGV) RNA and anti-E2 by reverse transcription-polymerase chain reaction (RT-PCR) and by an enzyme-linked immunosorbent assay (ELISA), respectively. GBV-C/HGV RNA was detected in 17/70 (24.3%) haemodialysis patients, 12/98 (12.2%) patients with chronic liver disease, and 44/232 (18.9%) blood donors (Africans [29/76; 38.2%]; Asians [2/52; 3.8%]; Whites [11/49; 22.4%], and "Coloureds" [persons of mixed origin; 2/55; 3.6%]). Overall (anti-E2 and/or RNA) 43.9% (43/98) of patients with chronic liver disease, 47.1% (33/70) of haemodialysis patients, and 31.9% (74/232) of blood donors (Africans [44/76; 5.9%]; Asians [5/52; 9.6%]; Whites [15/49; 30.6%], and Coloureds [9/54; 16.6%]) were exposed to GBV-C/HGV infection. There was a significant difference in the prevalence of GBV-C/HGV infection (RNA and/or anti-E2) between African blood donors and the other racial groups (P < .001), and between blood donors and haemodialysis patients (P = .02) and patients with chronic liver disease (P = .04). Anti-E2 antibodies and GBV-C/HGV RNA were almost mutually exclusive. GBV-C/HGV-infected haemodialysis patients received more transfusions (P = .03) than noninfected patients. There was no significant difference in liver biochemistry between GBV-C/HGV-infected and noninfected patients and between blood donors in each of the four racial groups. The high prevalence of GBV-C/HGV infection in blood donors and chronic liver disease patients, and the lack of elevated liver enzymes and clinical hepatitis in blood donors and haemodialysis patients, suggest that GBV-C/HGV may not be associated with liver disease.

Endothelin-1 and endothelin receptor status in kidney transplants undergoing acute rejection

Endothelin-1 (ET-1) is a potent vasoconstrictor with vasopressor and mitogenic effects. Blood samples were collected from 21 renal transplant patients undergoing acute rejection at the time of diagnostic kidney biopsy: there were 20 men and one woman, mean age 35.6 years. All patients were on triple immunosuppressive therapy with cyclosporine A, azathioprine and methylprednisolone. Twenty living kidney donors pre-uninephrectomy (11 men and nine women, mean age 34 years) served as controls. Control kidney was obtained from fresh autopsy material and normal kidney tissue from nephrectomies for malignancy. Mean plasma ET-1 was significantly increased at 1.56 +/- 0.2 pg ml(-1) during acute rejection compared to 0.74 +/- 0.06 pg ml(-1) in donors (p = 0.0009 unpaired t-test). ET(A) receptor immunolabelling was visualised in distal tubules and collecting ducts with minimal labelling in the glomeruli and blood vessels of control kidney tissue ET(A) receptor labelling was similar in kidney biopsies with acute rejection. ET(B) receptor immunolabelling was significantly increased in glomeruli (p = 0.002) and decreased in distal tubules (p = 0.004) in kidneys with acute rejection compared to control kidney tissue. While these findings may account for the oedema and hypertension observed during acute rejection, the exact significance needs to be studied further.

Tissue kallikrein and kinins in renal disease

The renal kallikrein-kinin system is involved in sodium and water homeostasis, blood pressure regulation and inflammation. Tissue kallikrein and kinin levels were measured in the urine of patients with renal disease and in the urine of living related kidney donors prior to uninephrectomy who served as controls. Tissue kallikrein and kinin B1 and B2 receptors were immunolocalised by confocal microscopy in renal biopsy material from patients with renal disease and controls (fresh autopsy material and normal kidney tissue from nephrectomies for malignancy). Urinary tissue kallikrein excretion was significantly decreased in patients with mild renal disease (16.6 +/- 6.7 ng tissue kallikrein (TK)/ng protein; p < 0.05) and more markedly so (1.8 +/- 0.7 ng TK/microg protein; p < 0.01) in patients with severe renal failure requiring dialysis compared to normal controls (78.9 +/- 31.7 ng TK/microg protein). Basal kinin values were unchanged in patients with renal disease (14 +/- 0.8 ng/ml) compared to controls (13.3 +/- 0.56 ng/ml). In control kidney tissue kallikrein was immunolocalised in the distal connecting tubules and collecting ducts whereas decreased immunolabelling was observed with renal disease. Kinin B2 receptor labelling was present in the entire nephron in the normal control kidney but was reduced with renal disease. While kinin B1 receptor immunolabelling was not observed in the control kidneys, labelling of distal tubules and collecting ducts was noted in renal disease, suggesting an upregulation of B1 receptors in renal parenchymal disease.