Effect of a simple educational intervention on the hospital management of community-acquired pneumonia

BACKGROUND AND OBJECTIVES: Both the speed of commencement and the appropriateness of i.v. antibiotic administration influence outcomes in patients hospitalized with community-acquired pneumonia (CAP). While quality improvement projects have been linked to better CAP management and outcomes, there are limited data evaluating simple and achievable interventions. METHODS: A simple educational programme targeting rapid and appropriate antibiotic administration for the inpatient treatment of CAP was evaluated using a retrospective chart review of all patients admitted through the emergency department with CAP during 'pre-intervention' and 'post-intervention' periods. RESULTS: There were 108 pre-intervention patients (56 women, median age 63 years) and 88 post-intervention patients (43 women, median age 61 years) included in the evaluation. Comparison of indicators of care in the post-intervention period with those in the pre-intervention period showed there were significant changes in: median time to antibiotic administration (2.5 h vs 3.5 h, 95% CI: 0-1.25, P = 0.01); subjects not prescribed macrolide antibiotics (2.3% vs 10.2%, 95% CI for OR 1.02-46.19, P = 0.04); hospital length of stay (3.5 vs 6 days, 95% CI: 1-3, P < 0.001) and mortality (0% vs 6.5%, 95% CI for OR 1.13 to infinity, P = 0.02). CONCLUSION: A simple, inexpensive educational intervention was associated with significant improvements in the hospital management of CAP. The widespread introduction of similar programmes has the potential to effect substantial improvements in management, and possibly patient outcomes, and requires prospective confirmation in a larger, randomized sample.     

Can source reduction of mosquito larval habitat reduce malaria transmission in Tigray,Ethiopia?

The development of irrigation schemes by dam construction has led to an increased risk of malaria in Tigray, Ethiopia. We carried out a pilot study near a microdam to assess whether environmental management could reduce malaria transmission by Anopheles arabiensis, the main vector in Ethiopia. The study took place in Deba village, close to a dam; Maisheru village, situated 3-4 km away from the dam, acted as a control. Baseline entomological and clinical data were collected in both villages during the first 12 months. Source reduction, involving filling, draining and shading of potential mosquito-breeding habitats was carried out by the community of Deba in the second year and routine surveillance continued in both villages during the second year. Anopheles arabiensis was highly anthropophilic (Human Blood Index=0.73), biting early in the night before people went to bed. The major breeding habitats associated with the dam were areas of seepage at the dam base (28%), leaking irrigation canals (16%), pools that formed along the bed of streams from the dam (13%), and man-made pools (12%). In the pre-intervention year, 5.9-7.2 times more adult vectors were found in the dam village compared with the control village. There was a 3.1% higher prevalence of an enlarged spleen in children under 10 years in the dam village than in the control village during the pre-intervention period, but no statistically significant difference was found in the incidence of falciparum malaria between the two villages during the same period. Source reduction was associated with a 49% (95% CI=46.6-50.0) relative reduction in An. arabiensis adults in the dam village compared with the pre-intervention period. There were very few cases of malaria during the intervention period in both villages making it impossible to judge whether malaria incidence had been reduced. These preliminary findings suggest that in areas of low intensity transmission community-led larval control may be a cheap and effective method of controlling malaria. Further, large-scale studies are needed to confirm these findings.     

Epidemiology of malaria in an area of low transmission in central India

A longitudinal study on malaria was carried out from 2003 to 2005 in an area of unstable malaria in the Panna district in central India. Both Plasmodium vivax and P. falciparum were prevalent; however, the risk of P. falciparum malaria was 31.6% (95% confidence interval [CI] = 29.6-33.6%), which is four times higher compared with that of P. vivax malaria (7.8%, 95% CI = 6.7-9%). An increasing trend was recorded in malaria prevalence from 30.2% in 2003 to 46.6% in 2004 (odds ratio [OR] = 2.0, 95% CI = 1.6-2.5) that increased to 58.6% in 2005 (OR = 1.6, 95% CI = 1.2-2.1). This increase was statistically significant (chi(2) = 120.5, degrees of freedom = 2, P < 0.0001). Anopheles culicifacies was the dominant vector of malaria and showed partial (< 50%) resistance to DDT, which indicated that DDT can still be used. Improved access to treatment facilities, combination therapy, and vector control appears to be the most promising method for controlling malaria in this region.     

A randomized, double-blind, placebo-controlled, clinical trial of the impact of malaria prevention on the educational attainment of school children

A double-blind, placebo-controlled trial of nine months duration was carried out to investigate the impact of malaria and its prevention on the educational attainment of school children in a malaria-endemic area in southern Sri Lanka where both Plasmodium falciparum and P. vivax infections are prevalent. A total of 587 children attending grades 1-5 in four schools and resident in the area were randomly allocated to chloroquine (n = 295) and placebo (n = 292) arms. Language and mathematics scores of end-of-term school examinations for 1998 and 1999 and number of days absent and reasons for absenteeism during seven months pre-intervention and nine months of the intervention were recorded. The results indicate that there were no differences in language (95% confidence interval [CI] = 48.44-53.78 in chloroquine group and 50.43-55.81 in placebo group) and mathematics (95% CI = 49.24-54.38 in chloroquine group and 51.12-56.38 in placebo group) scores between the two groups prior to the intervention. During the intervention, the malaria incidence rate decreased by 55% (95% CI = 49-61%) and school absenteeism due to malaria was reduced by 62.5% (95% CI = 57-68%) in children who received chloroquine compared with the placebo group. Post-intervention, children who received chloroquine scored approximately 26% higher in both language (95% CI = 21-31%) and mathematics (95% CI = 23-33%) than children who received placebo. In a multivariate model, educational attainment was significantly associated with taking chloroquine prophylaxis and absenteeism due to malaria (P < 0.001 for both) but not due to health causes other than malaria or non-health causes. Language scores were associated with number of malaria attacks (P < 0.022). Educational attainment was significantly better among children whose compliance to chloroquine prophylaxis was higher (P < 0.001). The data suggest that malarial attacks have an adverse impact on the educational attainment of the school child and prevention of these attacks significantly improves educational attainment of children living in malaria-endemic areas.     

An electronic medical record intervention increased nursing home advance directive orders and documentation

OBJECTIVES: To develop an electronic medical record intervention to improve documentation of patient preferences about life-sustaining care, detail of resuscitation and treatment-limiting orders, and concordance between these orders and patient preferences. DESIGN: Prospective before-after intervention trial. SETTING: Veterans Affairs nursing home with an electronic medical record for all clinical information, including clinician orders. PARTICIPANTS: All 224 nursing home admissions from May 1 to October 31, 2004. MEASUREMENTS: Completion of an advance directive discussion note by the primary clinician, clinician orders about resuscitation and other life-sustaining treatments, and concordance between these orders and documented patient preferences. INTERVENTION: The electronic medical record was modified so that an admission order would specify resuscitation status. Additionally, the intervention alerted the primary clinician to complete a templated advance directive discussion note for documentation of life-sustaining treatment preferences. RESULTS: Primary clinicians completed an advance directive discussion note for five of 117 (4%) admissions pre-intervention and 67 of 107 (63%) admissions post-intervention (P<.001). In multivariate analysis, the intervention was independently associated with advance directive discussion note completion (odds ratio=42, 95% confidence interval=15-120). Of patients who preferred do-not-resuscitate (DNR) status, a DNR order was written for 86% pre-intervention versus 98% post-intervention (P=.07); orders to limit other life-sustaining treatments were written for 16% and 40%, respectively (P=.01). CONCLUSIONS: A targeted electronic medical record intervention increased completion of advance directive discussion notes in seriously ill patients. For patients who preferred DNR status, the intervention also increased the frequency of DNR orders and of orders to limit other life-sustaining treatments.     

The effects of introducing artemether-lumefantrine malaria treatment and insecticide-impregnated bed nets to an elective surgical hospital

Malaria and anaemia in patients admitted for elective orthopaedic operations commonly cause delays to surgery. Our hospital has introduced artemether-lumefantrine as the standard treatment for malaria in accordance with the national policy, replacing sulphadoxine-pyrimethamine. Insecticide-impregnated bed nets were also introduced throughout our wards. A retrospective audit of all new elective surgical admissions over a 12-month period was performed in order to assess the effect of these changes. The study was designed to follow an identical audit performed before their introduction. Of the 435 patients admitted, 75 (17.2%) had malaria parasites present on blood film. In these patients, surgery was significantly delayed, by a mean of 9.9 days more than the group without malaria (P < 0.001). Before the changes to malaria treatment, the mean delay was 2.2 days (P < 0.05). Six patients (1.7%) developed malaria during admission, significantly fewer than the 16 (4.3%) before the introduction of bed nets (P = 0.036). The average haemoglobin level on admission in patients with malaria parasites was 11.8 g/dL (95% confidence interval [CI] 11.4-12.2) and in those without 13.1 g/dL (95% CI: 12.9-13.3). Seventeen patients (3.9%) were admitted with a haemoglobin concentration of <10 g/dL and two (0.5%) of <8 g/dL. There were no significant delays to surgery in these patients compared to those without anaemia. The adoption of artemether-lumefantrine by our hospital significantly increased delays to surgery. The introduction of insecticide-impregnated bed nets significantly reduced the number of patients developing malaria during their hospital stay.     

Deploying artemether‐lumefantrine with rapid testing in Ethiopian communities: impact on malaria morbidity,mortality and healthcare resources

Objective To assess the impact and feasibility of artemether‐lumefantrine deployment at community level, combined with phased introduction of rapid diagnostic tests (RDTs), on malaria transmission, morbidity, and mortality and health service use in a remote area of Ethiopia. Methods Two‐year pilot study in two districts: artemether‐lumefantrine was prescribed after parasitological confirmation of malaria in health facilities in both districts. In the intervention district, artemether‐lumefantrine was also made available through 33 community health workers (CHWs); of these, 50% were equipped with RDTs in the second year. Results At health facilities; 54 774 patients in the intervention and 100 535 patients in the control district were treated for malaria. In the intervention district, 75 654 patients were treated for malaria by community health workers. Use of RDTs in Year 2 excluded non‐Plasmodium falciparumin 89.7% of suspected cases. During the peak of malaria transmission in 2005, the crude parasite prevalence was 7.4% (95% CI: 6.1–8.9%) in the intervention district and 20.8% (95% CI: 18.7–23.0%) in the control district. Multivariate modelling indicated no significant difference in risk of all‐cause mortality between the intervention and the control districts [adjusted incidence rate ratio (aIRR) 1.03, 95%CI 0.87–1.21, P = 0.751], but risk of malaria‐specific mortality was lower in the intervention district (aIRR 0.60, 95%CI 0.40–0.90, P = 0.013). Conclusions Artemether‐lumefantrine deployment through a community‐based service in a remote rural population reduced malaria transmission, lowered the malaria case burden for health facilities and reduced malaria morbidity and mortality during a 2‐year period which included a major malaria epidemic.     

Suppression of exposure to malaria vectors by an order of magnitude using microbial larvicides in rural Kenya

OBJECTIVE: To determine the contribution larviciding could make to reduce the burden of malaria, by conducting a trial of microbial larvicides in a 4.5 km2 area in and around a large village in rural western Kenya. METHOD: The abundance of immature and adult mosquitoes was monitored for 12 months under baseline conditions. Then microbial larval control was implemented for 28 months. After the intervention, the abundance of immature and adult mosquitoes was monitored for a further 12 months. RESULTS: Of the 419 mosquito larval habitats identified, 336 (80%) originated from human activities. Application of Bacillus thuringiensis var. israelensis and Bacillus sphaericus larvicides reduced the proportion of aquatic habitats containing Anopheles larvae from 51% during non-intervention periods to 7% during the intervention. The occurrence of late instar Anopheles in habitats was reduced from 39% and 33% in pre-intervention and post-intervention periods to 0.6% during intervention. Overall, larviciding reduced Anopheles larval density by 95% and human exposure to bites from adults by 92%. The estimated cost of providing this protection to the human population in the study area was less than US$ 0.90/person/year. CONCLUSION: Appropriately applied microbial larvicides can substantially and cost-effectively reduce human exposure to malaria in rural sub-Saharan Africa.     

The impact of antiretroviral treatment on mortality trends of HIV‐positive adults in rural Uganda: a longitudinal population‐based study, 1999–2009

Objective To investigate trends in all‐cause adult mortality after the roll‐out of an antiretroviral therapy (ART) programme in rural Uganda. Methods Longitudinal population‐based cohort study of approximately 20 000 residents in rural Uganda. Mortality in adults aged 15–59 years was determined for the 5‐year period (1999–2003) before introduction of ART in January 2004 and for the 5‐year period afterwards. Poisson regression was used to estimate mortality rate ratios (RRs) for the period before ART, 1 year after ART introduction (from January 2004 to January 2005) and more than 1 year after ART introduction. Trends in mortality were analysed by HIV status, age and sex. Results Before ART became available, the mortality rate (deaths per 1000 person‐years) was 4.0 (95% CI = 3.3–4.8) among HIV‐negative individuals and 116.4 (95% CI = 101.9–133.0) among HIV‐positive individuals. During the period January 2004–end November 2009, 279 individuals accessed ART. In the year after ART was introduced, the mortality rate (deaths per 1000 person‐years) among HIV‐negative individuals did not change significantly (adjusted RR = 0.95, 95% CI = 0.61–1.47), but among HIV‐positive individuals dropped by 25% to 87.4 (adjusted RR = 0.75, 95% CI = 0.53–1.06). In the period 2005–2009, the mortality rate (deaths per 1000 person‐years) among HIV‐positive individuals fell further to 39.9 (adjusted RR = 0.33, 95% CI = 0.26–0.43). The effect was greatest among individuals aged 30–44 years, and trends were similar in men and women. Conclusion The substantially reduced mortality rate among HIV‐positive individuals after ART roll‐out lends further support to the intensification of efforts to ensure universal access to ART.     

Smoking cessation after acute myocardial infarction: effects of a nurse-managed intervention

STUDY OBJECTIVE: To determine the effect of a nurse-managed intervention for smoking cessation in patients who have had a myocardial infarction. DESIGN: Randomized, with a 6-month treatment period and a 6-month follow-up. SETTING: Kaiser Foundation hospitals in Redwood City, Santa Clara, Hayward, and San Jose, California. PATIENTS: Sequential sample of 173 patients, 70 years of age or younger, who were smoking before hospitalization for acute myocardial infarction. Eighty-six patients were randomly assigned to the intervention and 87 to usual care; 130 patients (75%) completed the study and were available for follow-up. INTERVENTION: Nurse-managed and focused on preventing relapse to smoking, the intervention was initiated in the hospital and maintained thereafter primarily through telephone contact. Patients were given an 18-page manual that emphasized how to identify and cope with high-risk situations for smoking relapse. MEASUREMENTS AND MAIN RESULTS: One year after myocardial infarction, the smoking cessation rate, verified biochemically, was 71% in the intervention group compared with 45% in the usual care group, a 26% difference (95% CI, 9.5% to 42.6%). Assuming that all surviving patients lost to follow-up were smoking, the 12-month smoking cessation rate was 61% in the intervention group compared with 32% in the usual care group, a 29% difference (95% CI, 14.5% to 43.5%). Patients who either resumed smoking within 3 weeks after infarction or expressed little intention of stopping in the hospital were unlikely to have stopped by 12 months. CONCLUSIONS: A nurse-managed smoking cessation intervention largely conducted by telephone, initiated in the hospital, and focused on relapse prevention can significantly reduce smoking rates at 12 months in patients who have had a myocardial infarction.     

A test-and-treat policy does not save endoscopy workload in a non-referral hospital

AIM : To assess the impact that a test-and-treat policy with open-access urea breath testing (UBT) has had on the referral rates for endoscopy in a district hospital. Additionally, we examined for any change in the proportion of serious pathology detected endoscopically after adopting the policy. METHODS : Analysis of data on all open-access endoscopy referrals in a 12-month period before (October 1994 to September 1995) and 2 years after (October 1997 to September 1998) the introduction of the UBT service. This was compared with the same service in our sister hospital, which had not provided a UBT service. Results of patients attending the UBT service during the period of study were also examined. RESULTS : A total of 798 patients attended for endoscopy (18% aged < 40 years, 82% aged > 40 years) in the pre-UBT year compared with 1905 patients (16% aged < 40 years, 84% aged > 40 years) in the post-UBT year. The standardized referral ratios were significantly higher for both age groups in the post-UBT year: 210 in the < 40 years group (95% CI 187 to 235) and 244 in the > 40 years group (95% CI 233 to 257). Six per cent of the < 40 years group in the post-UBT year had serious pathology compared with 7% pre-UBT (P < 0.1). However, the proportion of serious pathology decreased from 37 to 27% in the > 40 years group (P < 0.01). The total number of open-access endoscopies had increased steadily over the 3 years, despite the introduction of the UBT service. This trend was mirrored in our sister hospital. A total of 457 patients attended the UBT service during the 12 months. Of these, 24.5% were Helicobacter pylori positive, with a 66.3% eradication rate. CONCLUSIONS : A test-and-treat policy has not saved endoscopy workload in this non-referral hospital. We feel that results from centres with an H. pylori interest cannot be generalized for the vast majority.     

Clinical features of children hospitalized with malaria--a study from Bikaner, northwest India

Severe Plasmodium vivax malaria in adults has been reported from Bikaner (northwestern India) but the reports on children are scanty. This prospective study was done on 303 admitted children of malaria. The diagnosis was done by peripheral blood smear and rapid diagnostic test. Further confirmation of severe P. vivax monoinfection was done by polymerase chain reaction (PCR). The proportion of P. falciparum, P. vivax, and mixed (P. falciparum and P. vivax) infection was 61.01%, 33.99%, and 4.95%, respectively. Severe disease was present in 49.5% (150/303) children with malaria, with the risk greatest among P. vivax monoinfection (63.1% [65/103]) compared with P. falciparum, either alone (42.7% [79/185]; odds ratio [OR] = 2.3 [95% confidence interval (CI) = 1.40-3.76], P = 0.001) or mixed infections (40% [6/15]; OR = 2.57 [95% CI = 0.88-7.48]). In children < 5 years of age, the proportion of severe malaria attributable to P. vivax rose to 67.4% (31/46) compared with 30.4% (14/46) of P. falciparum (OR = 4.7 [95% CI = 2.6-8.6], P < 0.0001) and 2.2% (1/46) of mixed infection (OR = 92 [95% CI = 24.6-339.9], P < 0.0001). The proportion of patients having severe manifestations, which included severe anemia, thrombocytopenia, cerebral malaria, acute respiratory distress syndrome, hepatic dysfunction, renal dysfunction, abnormal bleeding was significantly high in association with P. vivax monoinfection in 0-5 year age group, while the same was significantly high in association with P. falciparum monoinfection in 5-10 year age group. Similarly P. vivax monoinfection had greatest propensity to cause multiorgan dysfunction in 0-5 year age group (34.1% [17/41], P < 0.0001) in comparison to P. falciparum monoinfection, which had similar propensity in 5-10 year age group (36.8% [35/95], P = 0.039). Plasmodium vivax monoinfection was almost equally serious to cause significant mortality in comparison to P. falciparum (case fatality rate of severe P. vivax was 3.9% versus 3.2% of severe P. falciparum malaria; P = 1.0). This study reaffirms the evidence of severe P. vivax malaria in children in Bikaner.     

A gender-specific HIV/STD risk reduction intervention for women in a health care setting: short- and long-term results of a randomized clinical trial

This study assessed the short- and long-term effect of a gender-specific group intervention for women on unsafe sexual encounters and strategies for protection against HIV/STD infection. Family planning clients (N = 360) from a high HIV seroprevalence area in New York City were randomized to an eight-session, a four-session or a control condition and followed at one, six and 12 months post-intervention. Using an intention-to-treat analysis, women who were assigned to the eight-session group had about twice the odds of reporting decreased or no unprotected vaginal and anal intercourse compared to controls at one month (OR = 1.93, 95% confidence interval [CI] = 1.07, 3.48, p = 0.03) and at 12-month follow-up (OR = 1.65, 95% CI = 0.94, 2.90, p = 0.08). Relative to controls, women assigned to the eight-session condition reported during the previous month approximately three-and-a-half (p = 0.09) and five (p < 0.01) fewer unprotected sex occasions at one- and 12-month follow-up, respectively. Women in the eight-session group also reduced the number of sex occasions at both follow-ups, and had a greater odds of first time use of an alternative protective strategy (refusal, outercourse, mutual testing) at one-month follow-up. Results for the four-session group were in the expected direction but overall were inconclusive. Thus, gender-specific interventions of sufficient intensity can promote short- and long-term sexual risk reduction among women in a family planning setting.     

Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial

BACKGROUND: falls and related injuries are known to be a significant problem for older people. There is evidence that identifying and addressing individual risk factors can reduce the incidence of falls in the community but no evidence of the effectiveness of targeted risk factor reduction methods applied to hospital in-patients. OBJECTIVE: to test the efficacy of a targeted risk factor reduction core care plan in reducing risk of falling while in hospital. DESIGN: a group (ward) randomised trial. SETTING: elderly care wards and associated community units of a district general hospital in the North of England. SUBJECTS: all elderly patients who received care in eight wards and community units during a 12-month study period. METHODS: matched pairs of wards were randomly allocated to intervention or control groups. In the intervention wards, staff used a pre-printed care plan for patients identified as at risk of falling and introduced appropriate remedial measures. Numbers of falls in each group were then compared. RESULTS: after introduction of the care plan there was a significant reduction in the relative risk of recorded falls on intervention wards (relative risk 0.79, 95% CI 0.65-0.95) but not on control wards (RR 1.12, 95% CI 0.96-1.31). The difference in change between the intervention wards and control wards was highly significant (RR 0.71, 95% CI 0.55-0.90, P = 0.006). There was no significant reduction in the incidence of falls-related injuries. CONCLUSION: the use of a core care plan targeting risk factor reduction in older hospital in-patients was associated with a reduction in the relative risk of recorded falls.     

School nurse asthma program reduces healthcare utilization in children with persistent asthma

Objective: We examined the impact of a novel, school nurse-supervised asthma therapy program on healthcare utilization. Methods: We retrospectively reviewed charts of 84 children enrolled in this program in central Massachusetts between 2012 and 2015. Physicians identified children with persistent asthma and poor medication adherence. These children were enrolled in the program to receive daily-inhaled corticosteroid at school, supervised by their school nurse, with ongoing communication between physician's office and school nurse through the school year. This program relied on established family, provider and school resources rather than research staff. The primary outcome was change in the number of emergency department (ED) visits in the year before and after enrollment. Secondary outcomes were hospital admissions, school absences, and rescue medication use. Results: The study population was on average 10.5 years old, 63% male, 67% Hispanic, 19% black, 14% white with 95% using Medicaid insurance. Asthma-related ED visits over a 1-year period decreased 37.5%, from a pre-intervention mean of 0.8 visits to a post-intervention mean of 0.3 visits (p < 0.001). Asthma-related hospital admissions decreased from a pre-intervention mean of 0.3 admissions to post-intervention mean of 0 admissions (p < 0.001). Asthma rescue medication refills decreased by 46.3% from the pre- to post-intervention period (p = <.001). There were also non-significant declines in school absences and oral steroid use for children enrolled. Conclusions: We demonstrate a significant reduction in healthcare utilization for children enrolled in this unique school nurse-supervised asthma program, which utilizes a clinical-school partnership to deliver preventative asthma medication to school-aged children under sustainable conditions.     

Long-term outcomes of patients with acute myocardial infarction presenting to hospitals without catheterization laboratory and randomized to immediate thrombolysis or interhospital transport for primary percutaneous coronary intervention. Five years' follow-up of the PRAGUE-2 Trial.

AIM: Randomized trials in ST-elevation myocardial infarction (STEMI) showed improved early outcomes after primary percutaneous coronary intervention (p-PCI) compared with thrombolysis (TL). It is less known whether the early benefit is sustained during the long-term follow-up. METHODS AND RESULTS: The PRAGUE-2 trial enrolled 850 STEMI patients presenting to community hospitals without cath-labs within 12 h of symptom onset. Patients were randomized into the groups 'TL in community hospital' (n = 421) and 'interhospital transfer for p-PCI' (n = 429). Follow-up data were available in 416 (98.8%) patients in the TL group and 428 (99.8%) in the p-PCI group. At 5 year follow-up, the cumulative incidence of composite endpoint (death from any cause or recurrent infarction or stroke or revascularization) was 53% in TL patients compared with 40% in p-PCI patients (HR 1.8; 95% CI 1.38-2.33; P < 0.001). The respective cumulative incidence of death from any cause was 23 and 19% (HR 1.34; 95% CI 0.99-1.82; P = 0.06), recurrent infarction 19 vs. 12% (HR 1.72; 95% CI 1.15-2.58; P = 0.009), stroke 8 vs. 8% (HR 1.65; 95% CI 0.84-2.23; P = 0.18), revascularization 51 vs. 34% (HR 1.81; 95% CI 1.21-2.35; P < 0.001). CONCLUSION: The early benefit from the p-PCI strategy (over TL) is sustained during the 5 years' follow-up. It can be almost exclusively derived from differences in event rate during the first month.     

Population-Wide Malaria Testing and Treatment with Rapid Diagnostic Tests and Artemether-Lumefantrine in Southern Zambia: A community Randomized Step-Wedge Control Trial Design

Reducing the human reservoir of malaria parasites is critical for elimination. We conducted a community randomized controlled trial in Southern Province, Zambia to assess the impact of three rounds of a mass test and treatment (MTAT) intervention on malaria prevalence and health facility outpatient case incidence using random effects logistic regression and negative binomial regression, respectively. Following the intervention, children in the intervention group had lower odds of a malaria infection than individuals in the control group (adjusted odds ratio = 0.47, 95% confidence interval [CI] = 0.24–0.90). Malaria outpatient case incidence decreased 17% in the intervention group relative to the control group (incidence rate ratio = 0.83, 95% CI = 0.68–1.01). Although a single year of MTAT reduced malaria prevalence and incidence, the impact of the intervention was insufficient to reduce transmission to a level approaching elimination where a strategy of aggressive case investigations could be used. Mass drug administration, more sensitive diagnostics, and gametocidal drugs may potentially improve interventions targeting the human reservoir of malaria parasites.     

Cetuximab efficacy in patients treated routinely in university hospitals

INTRODUCTION: The aim of this study was to evaluate the efficacy and tolerance of cetuximab (Cx) in patients with irinotecan-refractory metastatic colorectal cancer (IRMCRC) treated routinely at five university hospitals. PATIENTS AND METHODS: Data from all patients treated with Cx (N=105) during the study period (between January 2004 and September 2005) were included in the analysis. RESULTS: Median number of Cx infusions was 12 (range: 1 to 62). Objective response rate was 24.8%; stable disease in 23.8%; progression in 34.3%; 17.1% of the patients were not evaluable. Digestive and hematological adverse events were grade III in 20% and 12%, respectively, and grade IV in 12% and 11%, respectively. Response rates were higher in patients with acne-like rashes than in patients without (P=0.005). Median time to tumor progression (TTP; intention-to-treat) was 3.9 months (95% CI: 2.6-4.8). Median overall survival after Cx initiation was 8.3 months (95% CI: 6.310.7). Four prognostic factors were significantly associated with a shorter TTP: center (Center 4: HR=2.25, 95% CI: 1.16-4.35, P=0.017); absence of hepatic metastases (HR=2.5, 95% CI: 1.434.37, P=0.001); WHO performance status (HR=1.47, 95% CI: 1.10-1.96, P=0.008); and number of metastatic sites (HR=1.30, 95% CI: 1.05-1.60, P=0.014). CONCLUSION: This analysis of a random population of IRMCRC patients supports Cx efficacy and feasibility, and is in agreement with the results of the BOND study.