Riviste scientifiche

Single-dose oral ciprofloxacin prophylaxis as a response to a meningococcal meningitis epidemic in the African meningitis belt: A 3-arm, open-label, cluster-randomized trial

PLoS Medicine - Ma, 26/06/2018 - 23:00

by Matthew E. Coldiron, Bachir Assao, Anne-Laure Page, Matt D. T. Hitchings, Gabriel Alcoba, Iza Ciglenecki, Céline Langendorf, Christopher Mambula, Eric Adehossi, Fati Sidikou, Elhadji Ibrahim Tassiou, Victoire De Lastours, Rebecca F. Grais

Background

Antibiotic prophylaxis for contacts of meningitis cases is not recommended during outbreaks in the African meningitis belt. We assessed the effectiveness of single-dose oral ciprofloxacin administered to household contacts and in village-wide distributions on the overall attack rate (AR) in an outbreak of meningococcal meningitis.

Methods and findings

In this 3-arm, open-label, cluster-randomized trial during a meningococcal meningitis outbreak in Madarounfa District, Niger, villages notifying a suspected case were randomly assigned (1:1:1) to standard care (the control arm), single-dose oral ciprofloxacin for household contacts within 24 hours of case notification, or village-wide distribution of ciprofloxacin within 72 hours of first case notification. The primary outcome was the overall AR of suspected meningitis after inclusion. A random sample of 20 participating villages was enrolled to document any changes in fecal carriage prevalence of ciprofloxacin-resistant and extended-spectrum beta-lactamase (ESBL)–producing Enterobacteriaceae before and after the intervention. Between April 22 and May 18, 2017, 49 villages were included: 17 to the control arm, 17 to household prophylaxis, and 15 to village-wide prophylaxis. A total of 248 cases were notified in the study after the index cases. The AR was 451 per 100,000 persons in the control arm, 386 per 100,000 persons in the household prophylaxis arm (t test versus control p = 0.68), and 190 per 100,000 persons in the village-wide prophylaxis arm (t test versus control p = 0.032). The adjusted AR ratio between the household prophylaxis arm and the control arm was 0.94 (95% CI 0.52–1.73, p = 0.85), and the adjusted AR ratio between the village-wide prophylaxis arm and the control arm was 0.40 (95% CI 0.19‒0.87, p = 0.022). No adverse events were notified. Baseline carriage prevalence of ciprofloxacin-resistant Enterobacteriaceae was 95% and of ESBL-producing Enterobacteriaceae was >90%, and did not change post-intervention. One limitation of the study was the small number of cerebrospinal fluid samples sent for confirmatory testing.

Conclusions

Village-wide distribution of single-dose oral ciprofloxacin within 72 hours of case notification reduced overall meningitis AR. Distributions of ciprofloxacin could be an effective tool in future meningitis outbreak responses, but further studies investigating length of protection, effectiveness in urban settings, and potential impact on antimicrobial resistance patterns should be carried out.

Trial registration

ClinicalTrials.gov NCT02724046

Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data

PLoS Medicine - Ma, 26/06/2018 - 23:00

by Amit Kumar, Momotazur Rahman, Amal N. Trivedi, Linda Resnik, Pedro Gozalo, Vincent Mor

Background

Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees.

Methods and findings

This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation.

Conclusions

Compared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs.

Trade challenges at the World Trade Organization to national noncommunicable disease prevention policies: A thematic document analysis of trade and health policy space

PLoS Medicine - Ma, 26/06/2018 - 23:00

by Pepita Barlow, Ronald Labonte, Martin McKee, David Stuckler

Background

It has long been contested that trade rules and agreements are used to dispute regulations aimed at preventing noncommunicable diseases (NCDs). Yet most analyses of trade rules and agreements focus on trade disputes, potentially overlooking how a challenge to a regulation’s consistency with trade rules may lead to ‘policy or regulatory chill’ effects whereby countries delay, alter, or repeal regulations in order to avoid the costs of a dispute. Systematic empirical analysis of this pathway to impact was previously prevented by a dearth of systematically coded data.

Methods and findings

Here, we analyse a newly created dataset of trade challenges about food, beverage, and tobacco regulations among 122 World Trade Organization (WTO) members from January 1, 1995 to December 31, 2016. We thematically describe the scope and frequency of trade challenges, analyse economic asymmetries between countries raising and defending them, and summarise 4 cases of their possible influence. Between 1995 and 2016, 93 food, beverage, and tobacco regulations were challenged at the WTO. ‘Unnecessary’ trade costs were the focus of 16.4% of the challenges. Only one (1.1%) challenge remained unresolved and escalated to a trade dispute. Thirty-nine (41.9%) challenges focussed on labelling regulations, and 18 (19.4%) focussed on quality standards and restrictions on certain products like processed meats and cigarette flavourings. High-income countries raised 77.4% (n = 72) of all challenges raised against low- and lower-middle–income countries. We further identified 4 cases in Indonesia, Chile, Colombia, and Saudi Arabia in which challenges were associated with changes to food and beverage regulations. Data limitations precluded a comprehensive evaluation of policy impact and challenge validity.

Conclusions

Policy makers appear to face significant pressure to design food, beverage, and tobacco regulations that other countries will deem consistent with trade rules. Trade-related influence on public health policy is likely to be understated by analyses limited to formal trade disputes.

Are we alone in the universe? Science says it’s a definite maybe

New Scientist - Ma, 26/06/2018 - 19:20
Research looking at the number of civilisations in the universe has prompted headlines saying we are the only one, but the reality is more nuanced

First cannabis-based drug approved in the US to treat epilepsy

New Scientist - Ma, 26/06/2018 - 18:32
Epidiolex has become the first drug derived from marijuana to win FDA approval in the US, and will be used to treat two forms of childhood epilepsy

Illegal Chinese refrigerator factories are selling banned CFCs

New Scientist - Ma, 26/06/2018 - 15:00
Last month it was revealed that someone somewhere was still manufacturing banned CFCs. Now it appears that illegal factories in China are the source

Here’s what alien astronomers would see if they looked at Earth

New Scientist - Ma, 26/06/2018 - 14:49
Astronomers have used a spacecraft called DSCOVR to figure out what the inner solar system would look like to distant telescopes

The case of Billy Caldwell shows UK drug laws are out of date

New Scientist - Ma, 26/06/2018 - 11:00
The announcement of an urgent review into the legal status of medicinal cannabis is to be welcomed, but the UK government should go further

[Correspondence] Preventing rural to urban spread of Ebola: lessons from Liberia

The Lancet - Ma, 26/06/2018 - 00:30
There has been an eerie mirroring of events between the ongoing outbreak of Ebola virus disease in the Democratic Republic of the Congo (DRC) and the 2014–15 outbreak in Liberia. The DRC has vast historical experience from containing eight prior outbreaks, but the country has not previously had to respond to urban Ebola spread.

Calling men by their surname gives them an unfair career boost

New Scientist - Lu, 25/06/2018 - 21:00
We are more likely to refer to professional men by their surname than women in the same jobs - making them sound more famous, eminent and worthy of awards

AI trained on 3500 years of games finally beats humans at Dota 2

New Scientist - Lu, 25/06/2018 - 18:54
AI finally beats the world’s best amateurs at the video game Dota 2, after playing 180-years’ worth of games every day for 19 days

There are two types of worrier – which you are depends on genes

New Scientist - Lu, 25/06/2018 - 18:38
The genomes of half a million people reveal that there are two kinds of worrier, providing new clues about how genes help form our personalities

An entire Arctic ecosystem could vanish within the next decade

New Scientist - Lu, 25/06/2018 - 18:00
The Barents Sea, home to a diverse array of wildlife, could be completely gone in just a few years – perhaps the most dramatic impact of climate change yet seen

Crewed missions to the moon and Mars need dreamers and doers

New Scientist - Lu, 25/06/2018 - 12:00
Since the moon landings, we have come crashing back down to Earth. Getting back into space will take wild ambition and serious amounts of hard work

[Comment] Agonism of receptors in the gut–pancreas axis in type 2 diabetes: are two better than one?

The Lancet - Sa, 23/06/2018 - 06:00
Pharmacotherapy for type 2 diabetes has become complex with the advent of a large number of treatment options. Major goals of therapy include achieving glycaemic targets (glycated haemoglobin [HbA1c] ≤7%) to minimise the development and progression of microvascular and, to a lesser extent, macrovascular complications, while avoiding hypoglycaemia.1 Obesity is a key risk factor of type 2 diabetes—hence, the terminology diabesity.2 Weight loss, even when modest, might improve not only glycaemic control and cardiovascular risk but also hepatic steatosis—the non-alcoholic fatty liver disease that is now the most common cause of chronic liver disease globally.

[Articles] MEDI0382, a GLP-1 and glucagon receptor dual agonist, in obese or overweight patients with type 2 diabetes: a randomised, controlled, double-blind, ascending dose and phase 2a study

The Lancet - Sa, 23/06/2018 - 06:00
MEDI0382 has the potential to deliver clinically meaningful reductions in blood glucose and bodyweight in obese or overweight individuals with type 2 diabetes.

[Editorial] Health systems for prosperity and solidarity: Tallinn 2018

The Lancet - Sa, 23/06/2018 - 00:00
Last week, ministers of health, policy makers in health and finance, patient organisations, and academic advisers met in Tallinn, Estonia, to discuss the future of European health systems. Under the stewardship of WHO's Regional Office for Europe (WHO EURO), and hosted by Estonia's President, Kersti Kaljulaid, and Minister of Health and Labour, Riina Sikkut, 250 or so representatives of WHO EURO member states celebrated the tenth anniversary of the Tallinn Charter and agreed on principles for building sustainable people-centred health systems.

[Editorial] Turning Brexit uncertainties into public health advancement

The Lancet - Sa, 23/06/2018 - 00:00
This June 23 issue of The Lancet falls on the second anniversary since the UK European Union (EU) membership referendum altered the course of European history: throwing prospects for health, medicine, and scientific research into uncertainty against a backdrop of heightened feelings. 2 years later, few bodies have clear plans for their post-Brexit strategies. The European Medicine Agency's building relocation from London to Amsterdam is on track for completion by March, 2019, but the agency has made no progress towards redefining its relationship with the UK.

[Editorial] ICD-11: a brave attempt at classifying a new world

The Lancet - Sa, 23/06/2018 - 00:00
The 11th version of the International Classification of Diseases (ICD) launched on June 18 is the latest attempt at systematically describing and categorising all human mortality and morbidity. Designed for the global digital age, it is an onscreen, multipurpose, multilingual database interconnecting with other operating systems—including electronic hospital records. It is a quantum leap forward from the ICD-10, which, although revised several times over the past two decades, was originally published in 1992, when internet use was minimal, smartphones were unheard of, and patient records were paper based.

[Comment] Robot-assisted versus open cystectomy

The Lancet - Sa, 23/06/2018 - 00:00
Open radical cystectomy with pelvic lymph node dissection is an integral component of the treatment for high-risk, non-muscle-invasive, and muscle-invasive bladder cancer.1 When the surgery is done by an experienced surgeon, the approach practically guarantees patient outcomes that have remained unchanged since the 1980s.2 New surgical techniques must be compared against this standard with regard to parameters such as morbidity, quality of life, costs, and oncological outcomes. In The Lancet, Dipen J Parekh and colleagues report a multicentre, randomised controlled, phase 3, non-inferiority study3 comparing open cystectomy and robot-assisted cystectomy.
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