Non‐specific effects of diphtheria‐tetanus‐pertussis and measles vaccinations? An analysis of surveillance data from Navrongo,Ghana

Objectives Studies from low‐income countries have suggested that routine vaccinations may have non‐specific effects on child mortality; measles vaccine (MV) is associated with lower mortality and diphtheria‐tetanus‐pertussis (DTP) with relatively higher mortality. We used data from Navrongo, Ghana, to examine the impact of vaccinations on child mortality. Methods Vaccination status was assessed at the initiation of a trial of vitamin A supplementation and after 12 and 24 months of follow‐up. Within the placebo group, we compared the mortality over the first 4 months and the full 2 years of follow‐up for different vaccination status groups with different likelihoods of additional vaccinations during follow‐up. The frequency of additional vaccinations was assessed among children whose vaccination card was seen at 12 and 24 months of follow‐up. Results Among children with a vaccination card, more than 75% received missing DTP or MV during the first 12 months of follow‐up, whereas only 25% received these vaccines among children with no vaccination card at enrolment. Children without a card at enrolment had a significant threefold higher mortality over the 2‐year follow‐up period than those fully vaccinated. The small group of children with DTP3‐4 but no MV at enrolment had lower mortality than children without a card and had the same mortality as fully vaccinated children. In contrast, children with 1–2 DTP doses but no MV had a higher mortality during the first 4 months than children without a card [MRR = 1.65 (0.95, 2.87)]; compared with the fully vaccinated children, they had significantly higher mortality after 4 months [MRR = 2.38 (1.07, 5.30)] and after 2 years [MRR = 2.41 (1.41, 4.15)]. Children with 0–2 DTP doses at enrolment had higher mortality after 4 months (MRR = 1.67 (0.82, 3.43) and after 2 years [MRR = 1.85 (1.16, 2.95)] than children who had all three doses of DTP at enrolment. Conclusions As hypothesised, DTP vaccination was associated with higher child mortality than measles vaccination. To optimise vaccination policies, routine vaccinations need to be evaluated in randomised trials measuring the impact on survival.     

Long‐term follow‐up of patients with bone metastases from differentiated thyroid carcinoma – surgery or conventional therapy?

OBJECTIVE: Surgery of bone metastases from differentiated thyroid carcinoma seems indicated in individual patients. This study was performed (1) to analyse retrospectively patients with bone metastases from differentiated thyroid carcinoma and (2) to evaluate the impact of surgery of bone metastases on survival. PATIENTS AND DESIGN: We analysed 41 consecutive patients with bone metastases from differentiated thyroid carcinoma who had undergone thyroid surgery at Vienna University Hospital since 1966. The median follow-up time was 12 years. There were 24 females and 17 males with a mean age of 60 +/- 12 years. Primary tumour histology was follicular in 35 and papillary in six patients. Radioiodine treatment was performed in 32 with a mean administered activity of 27 +/- 24 GBq 131I. Metastases restricted to the skeleton were found in 22 whereas in 19 individuals additional extraskeletal distant metastases were seen. Twenty-seven patients had multiple bone metastases. In 21 individuals, up to five bone metastases were surgically removed with the intention of cure. RESULTS: Univariate analysis identified total thyroidectomy (P = 0.003), lymph node surgery (P = 0.001), radioiodine therapy (P = 0.036), and the absence of extraskeletal distant metastases (P = 0.017) as significant predictors of survival. Multivariate analysis failed to identify significant prognostic factors. In the subgroup of patients with distant metastases limited to the bones, univariate analysis identified, in addition to thyroid and lymph node surgery, the surgical extirpation of the bone metastases as a significant prognostic factor associated with improved survival (P = 0.025). CONCLUSIONS: These findings indicate that in patients without additional extraskeletal distant metastases, the radical surgical extirpation of bone metastases from differentiated thyroid carcinoma might be associated with improved survival.     

Are mosquitoes diverted from repellent‐using individuals to non‐users? Results of a field study in Bolivia

Outside sub-Saharan Africa, Anopheline mosquito exophagic and/or crepuscular behaviour patterns imply that insecticide-treated nets may provide incomplete protection from malaria-infective mosquito bites. Supplementary repellent treatment has been recommended in such circumstances, especially where vectors are exophilic and so are not susceptible to residual insecticide spraying. As maintaining complete usage of repellents in a community is unrealistic, the potential negative impact on non-users of repellent usage by 'neighbours' in the same community needs to be addressed in the context of health policy promoting equity. This study quantifies diversion of host-seeking mosquitoes, from repellent wearing to unprotected individuals, 1 m apart under field conditions in Bolivia. Each of the six volunteer-pairs sat >20 m apart from other pairs. Volunteers were allocated di-ethyl toluamide (DEET) or mineral oil in ethanol control. Treatments were rotated, so that during the trial, both pair-members wore repellent on 72 occasions; both pair-members wore control on 72 occasions; and on 36 occasions, one pair-member wore repellent and the other control. Unprotected (control) pair-members received 36.4% [95% confidence interval (CI): 8.1-72.0%] more Anopheles darlingi landings (P = 0.0096) and 20.4% (95% CI: 0.6-44.0%) more mosquito landings (P = 0.044), when their 'partner' wore repellent than when their partner also wore control. A second, smaller Latin-square trial using 30% lemongrass (Cymbopogon citratus) repellent, with control, obtained 26.0% (95% CI: 5.2-51.0%) more mosquito landings when controls sat with repellent-wearers rather than other controls (P = 0.0159). With incomplete community repellent usage, non-users could be put at an increased risk of malaria. The results also have implications for repellent-efficacy assay design, as protection will appear magnified when mosquitoes are given a choice between repellent-users and non-users.     

What If They Do Not Want Treatment?: Lessons Learned from Intervention Studies of Non‐Treatment‐Seeking,Drug‐Using Pregnant Women

Despite specialized drug treatment, many pregnant drug-using women do not seek admission to such programs. This study examined two types of brief drug use intervention models for attracting and retaining pregnant women in drug abuse treatment. Both models offered motivational interviewing (MI) + behavioral incentives (BI) for drug abstinence. One model had an additional case management (CM) component. The addition of CM resulted in less drug use and fewer psychosocial needs, but similar levels of poor participation in the intervention was observed with both models. The intensity of effort expended to retain participants is discussed.     

What is multi‐impulsive bulimia and can multi‐impulsive patients benefit from supervised self‐help?

Definitions of multi‐impulsivity and sample characteristics between studies of impulsivity vary widely leading to inconsistent results. Outcome data was examined to assess the comparative response of multi‐impulsive and non multi‐impulsive bulimic patients to a supervised self‐help CBT programme. Multi‐impulsivity was defined as the presence of two or more impulsive behaviours in the last 2 months in addition to bulimia nervosa as reported with the Multi‐Impulsivity Scale. Multi‐impulsive patients reported similar levels of bulimic behaviours but higher levels of depression at pre‐treatment. They achieved similar levels of change by the end of treatment. However, despite improvements, their levels of depressive symptoms remain high and bulimic symptoms subclinical and may be at higher risk of relapse. Copyright © 2002 John Wiley & Sons, Ltd and Eating Disorders Association.     

Is Non‐suicidal Self‐injury Related to Impulsivity in Anorexia Nervosa? Results from Self‐report and Performance‐based Tasks

The present study investigates the association between non‐suicidal self‐injury (NSSI) and impulsivity in anorexia nervosa (AN) patients by means of self‐report and behavioural tasks. In total, 60 female AN patients were included in the study, filled out the Barratt Impulsiveness Scale‐11 (BIS‐11) and performed three performance‐based tasks to assess different facets of impulsivity. Overall, 30% of the AN patients engaged in at least one form of NSSI during their lifetime. AN patients with and without NSSI did not significantly differ on the BIS‐11 impulsiveness scale. On the performance‐based measures, few differences emerged between AN patients with and without NSSI. Patients with NSSI showed more perseverations and perseveration errors (p < .05). The associations between self‐report and performance‐based measures were rather low, except for the association between the BIS‐11 and Wisconsin Card Sorting Task perseveration responses and errors (correlations |r| range between .32 and .42). The implications for theory and treatment of AN patients with and without NSSI will be discussed. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.     

Therapeutic potential of Takeda‐G‐protein‐receptor‐5 (TGR5) agonists. Hope or hype?

The gastrointestinal tract regulates glucose and energy metabolism, and there is increasing recognition that bile acids function as key signalling molecules in these processes. For example, bile acid changes that occur after bariatric surgery have been implicated in the effects on satiety, lipid and cholesterol regulation, glucose and energy metabolism, and the gut microbiome. In recent years, Takeda‐G‐protein‐receptor‐5 (TGR5), a bile acid receptor found in widely dispersed tissues, has been the target of significant drug discovery efforts in the hope of identifying effective treatments for metabolic diseases including type 2 diabetes, obesity, atherosclerosis, fatty liver disease and cancer. Although the benefits of targeting the TGR5 receptor are potentially great, drug development work to date has identified risks that include histopathological changes, tumorigenesis, gender differences, and questions about the translation of animal data to humans. The present article reviews the noteworthy challenges that must be addressed along the path of development of a safe and effective TGR5 agonist therapy.     

Why have meta‐analyses of randomized controlled trials of the association between non‐white‐blood‐cell‐reduced allogeneic blood transfusion and postoperative infection produced discordant results?

Intention-to-treat analyses of randomized controlled trials (RCTs) of the association between non-white-blood-cell (WBC)-reduced allogeneic blood transfusion (ABT) and postoperative infection were reported as the reason why meta-analyses of RCTs of this association have produced discordant results. We examined three possible reasons for disagreements between meta-analyses: (i) sources of medical heterogeneity and integration of RCTs despite extreme heterogeneity; (ii) reliance on as-treated (vs. intention-to-treat) comparisons; and (iii) inclusion (or not) of the three most recent RCTs. When nine RCTs reported up to 2002 were combined despite extreme heterogeneity, both intention-to-treat and as-treated comparisons found an association between non-WBC-reduced ABT and postoperative infection [summary odds ratio (OR) = 1.38, 95% confidence interval (CI) 1.03-1.85, P < 0.05; and summary OR = 1.56, 95% CI 1.06-2.31, P < 0.05, respectively]. When 12 RCTs reported up to 2005 were integrated despite extreme heterogeneity, both intention-to-treat and as-treated comparisons found no association of non-WBC-reduced ABT with postoperative infection (summary OR = 1.24, 95% CI 0.98-1.56, P > 0.05; and summary OR = 1.31, 95% CI 0.98-1.75, P > 0.05, respectively). In both analyses, the separate integration of four RCTs transfusing red blood cells (RBCs) or whole blood filtered after storage showed an association between non-WBC-reduced ABT and postoperative infection, whereas the separate integration of six (or nine) RCTs, reported through 2002 or 2005, and transfusing prestorage-filtered RBCs showed no association, whether intention-to-treat or as-treated comparisons were used. Thus, the published meta-analyses have produced discordant results because they did (or did not) investigate medical sources of heterogeneity and did (or did not) include the most recent RCTs. Intention-to-treat and as-treated comparisons produced concordant results.     

Does Nonresponse Bias the Results of Retrospective Surveys of End‐of‐Life Care?

OBJECTIVES: To evaluate the effect of nonresponse bias on reports of the quality of end‐of‐life care that older adults receive. DESIGN: Nationwide retrospective survey of end‐of‐life care. SETTING: Sixty‐two Veterans Affairs Medical Centers. PARTICIPANTS: Patients were eligible if they died in a participating facility. One family member per patient was selected from medical records and invited to participate. MEASUREMENTS: The telephone survey included 14 items describing important aspects of the patient's care in the last month of life. Scores (0–100) reflect the percentage of items for which the family member reported that the patient received the best possible care, and a global item defined the proportion of families who said the patient received “excellent” care. To examine the effect of nonresponse bias, a model was created to predict the likelihood of response based on patient and family characteristics; then this model was used to apply weights that were equivalent to the inverse of the probability of response for that individual. RESULTS: Interviews were completed with family members of 3,897 of 7,110 patients (55%). Once results were weighted to account for nonresponse bias, the change in mean individual scores was 2% of families reporting “excellent” care. Of the 62 facilities in the sample, the scores of only 19 facilities (31%) changed more than 1% in either direction, and only 10 (16%) changed more than 2%. CONCLUSION: Although nonresponse bias is a theoretical concern, it does not appear to have a significant effect on the facility‐level results of this retrospective family survey.     

The “Short‐Coupled” Variant of Right Ventricular Outflow Ventricular Tachycardia: A Not‐So‐Benign Form of Benign Ventricular Tachycardia?

Idiopathic ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT-VT) and idiopathic RVOT-extrasystoles are generally considered benign arrhythmias. We described three cases who originally presented with typical "benign looking" RVOT-extrasystoles or RVOT-VT but developed malignant polymorphic VT during follow-up. The unusual aspect of their RVOT-extrasystoles was their coupling interval, which appears to be intermediate between the ultra-short coupling interval of idiopathic VF and the long coupling interval seen in the truly benign RVOT-VT.