Journal club articles, by date with most recent first
BBC Headline: "HIV treatment 'failing' in Africa." Do you agree?
published 17-10-2007
Views : 4911
Times marked as favorite : 204
A BBC news headline reported yesterday, "HIV treatment 'failing' in Africa". The article goes on to say, "More than a third of patients on HIV medication in sub-Saharan Africa die or discontinue their treatment within two years of starting it, a survey shows."
I have not yet read the article, published in PLoS Medicine, but will soon. Meanwhile, here are two questions for you to think about and, if you want, comment below.
Is it a "failure" that 61% of patients are alive and continuing treatment after two years in an ART program?
The study includes reports published between 2000 and 2007. Do the results take into account any changes in during that time? That is, are programs more or less effective now than they were 10 years ago? Is there enough information to know? Again, I haven't read it yet but it's a good question to consider as you read.
Strategies for prevention of Group B Strep infection in newborns
published 15-10-2007
Views : 3511
Times marked as favorite : 121
This study uses a mathematical model to predict the value of different strategies for preventing newborn group B streptococcal (GBS) infections. The values needed for the model, such as the incidence of GBS colonization and infection, were drawn from existing studies.
The conclusion was that the most cost effective policy (in the UK) would be to add
culture testing for low risk term women, while treating all preterm and high risk term women, with a total of 21% of all women being treated.
"Syndromic management" may be, well, useless (?) for chlamydia and N. gonorrhea in Batswana women
published 15-10-2007
Views : 356
Times marked as favorite : 45
This study examined the prevalence of C. trachomatis and N. gonorrhoeae among 703 antenatal care patients in Botswana. The important finding was that most of these women would not have been properly treated if the syndromic approach to STDs were followed, because signs and symptoms of vaginal discharge were not predictive of the infections. In fact, the signs and symptoms were no more useful than simply knowing the socio-demographic factors (such as age and education) alone.
The authors conclude that (1) rapid diagnostic tests are urgently needed if these STIs are to be found and treated and (2) without such tests, resources could be better used elsewhere than in a [futile] attempt to manage these disease by the syndromic approach.
Note that among the 703 women 51 were infected with C. trachomatis and 21 with N gonorrhoea, so the study was not very large. Also, the results in Botswana may not be the same as those in other areas of Africa. Still, the results merit careful examination since the syndromic approach is widely used: perhaps it needs more justification in the case of these two STIs.
"Unfortunately, risk scores do not appear to improve the management of cervical infections in pregnancy substantially. To diagnose and treat asymptomatic cervical infections, and to reduce the massive overtreatment in the syndromic management, specific diagnostic tests are necessary. Screening for cervical infections in pregnant women is an essential public health measure, and rapid tests will hopefully be available in developing countries within a few years. In the temporary absence of such tests, health authorities in sub-Saharan Africa should consider reallocating their resources to other STI measures rather than diagnosing and treating gonorrhoea and chlamydia inadequately in antenatal care."
This descriptive study looked at patients admitted to the Medical Research Council hospital in the Gambia with a possible diagnosis of sepsis/bacteremia. About 10% of 871 patients had a positive blood culture considered to be "a genuine pathogen." The median age of all patients was 2 years, range 2 months - 80 years. S. pneumococcus was the most frequently-isolated pathogen.
Click the read-more arrow to see the abstract or follow the link below to the full article (free).
This editorial review looks at the evidence that zinc reduces child mortality, including two recent articles in The Lancet. Both studies showed a reduction in mortality, at least in children older than one year, but the reductions were "statistically non-significant." The article makes the extremely important, often-overlooked point, though, that "In studies with results that do not reach statistical significance, if the upper boundary of the confidence interval includes an important benefit, the possibility that the treatment still might be worthwhile has not been ruled out." In plain English, the failure to find a "statistically significant effect" does not necessarily rule out a real, clinically important effect.
For example, in the Zanzibar study quoted, there was an 18% reduction in child mortality in the zinc supplemented group. This was labeled a "marginally significant" reduction (relative risk 0·82, 95% CI 0·68–1·00) because its statistical p value was 0.05 or, in confidence interval terms, the 95% confidence interval includes the ratio 1.0, i.e. no effect. However, the confidence interval includes the whole range from 0.68 through 1.0. This means that even if the true effect of zinc in this study were a 32% reduction of mortality, we could expect to get the observed results in at least 5% of similar studies. We have not ruled out an effect even as large as a one-third reduction in mortality, let alone a reduction of smaller magnitude.
The article continues to discuss the difficulties of finding more precise answers, mainly (1) the large number of subjects needed in a study looking at a moderate effect on an uncommon event (death) and (2) the ethical issues in doing more placebo-controlled trials of zinc.
The dangers of attacking disease programmes for developing countries.
published 06-10-2007
Views : 553
Times marked as favorite : 59
"Roger England has launched yet another broadside attack on programmesfor priority diseases in poor countries (BMJ 2007;335:565 doi:10.1136/bmj.39335.520463.94 and 2007;334:344 doi: 10.1136/bmj.39113.402361.94).In his latest Personal View, he claims that "disease specificglobal programmes [are] not the way to help Africa," insteadthat they cause "big problems for recipients," and that moneyfor HIV/AIDS is "the worst." He claims that off-budget moneyleads to distortions; that there are duplications of plans,operations, and monitoring; and that priority disease programmesare neither cost effective nor sustainable."
In this important contribution, the authors refute point by point the arguments claiming that "priority disease programs" such as those targeted at HIV, malaria, and tuberculosis, are counterproductive in the developing world.
