Developing WHO guidelines with pragmatic, structured, evidence-based processes: A case study

Many guidelines, including those produced by the World Health Organisation (WHO), have failed to adhere to rigorous methodological standards. Operational examples of guideline development processes may provide important lessons learned to improve the rigour and quality of future guidelines. To this end, this paper describes the process of developing WHO guidelines on prevention and care interventions for adults and adolescents living with HIV. Using a pragmatic, structured, evidence-based approach, we created an organising committee, identified topics, conducted systematic reviews, identified experts and distributed evidence summaries. Subsequently, 55 global HIV experts drafted and anonymously submitted guideline statements at the beginning of a conference. During the conference, participants voted on statements using scales evaluating appropriateness of the statements, strength of recommendation and level of evidence. After review of voting results, open discussion, re-voting and refinement of statements, a draft version of the guidelines was completed. A post-conference writing team refined the guidelines based on pre-determined guideline writing principles and incorporated external comments into a final document. Successes and challenges of the guideline development process were identified and are used to highlight current issues and debates in developing guidelines with a focus on implications for future guideline development at WHO.

The impact of HIV treatment on risk behaviour in developing countries: A systematic review

In developing countries, access to antiretroviral therapy (ART) is improving as HIV treatment becomes a greater priority in the global fight against AIDS. While ART has clearly beneficial clinical effects, increased access to treatment may also affect sexual behaviour. To examine the strength of evidence for the impact of medical treatment for HIV-positive individuals on behavioural outcomes in developing countries, we conducted a comprehensive search of the peer-reviewed literature. Studies were included if they provided clinical treatment to HIV-positive individuals in a developing country, compared behavioural, psychological, social, care, or biological outcomes related to HIV-prevention using a pre/post or multi-arm study design, and were published between January 1990 and January 2006. Only three studies were identified that met the inclusion criteria. All were conducted in Africa, utilized before/after or multi-arm study designs, and relied on self-reported behaviour. In all three studies, a majority of HIV-infected individuals reported being sexually abstinent, and access to ART was not associated with an increase in HIV-related risky sexual behaviours. However, one cross-sectional study found that ART patients were more likely to report STD treatment. The available evidence indicates a significant reduction in risk behaviour associated with ART in developing countries. However, there are few existing studies and the rigor of these studies is weak. More studies are needed to build an evidence base on which to make programmatic and policy decisions.

Biliary hypoplasia in Williams syndrome

Neonatal hepatitis and biliary hypoplasia are not recognised features of Williams syndrome. A case of Williams syndrome, presenting with neonatal conjugated hyperbilirubinaemia leading to an initial misdiagnosis is reported.

Frozen section diagnosis of pancreatic malignancy: a sensitive diagnostic technique

BACKGROUND

Patients with potentially resectable pancreatic masses, without evidence of metastatic disease, require surgical exploration. We assessed the reliability of frozen section diagnosis of pancreatic malignancy.

METHODS

We analysed data from 120 patients who underwent pancreatic exploration, including frozen section assessment, over a period of 41 months.

RESULTS

A total of 310 pancreatic biopsies were sent for frozen section analysis. The frozen section result concurred with the final histological diagnosis in 98.1% of biopsies. The false-negative rate was 1.9%, with the correct diagnosis being established on subsequent frozen section in half of these cases. Only 3 patients were not correctly diagnosed intra-operatively by frozen section. The majority of tumours identified were pancreatic ductal adenocarcinomas, but endocrine tumours and lymphoma were also detected. 15 (12.5%) patients required more than one set of biopsies in order to establish a diagnosis of malignancy. 19 (15.8%) patients had malignant disease outside the pancreas, making their tumours unsuitable for curative resection.

CONCLUSIONS

Frozen section diagnosis is very reliable in the assessment of pancreatic masses and accurately differentiates between benign and malignant disease. More than one biopsy is needed to make a diagnosis, and if clinically suspicious, successive sets of biopsies may be required.

The emergency department versus the computer: which is the better electrocardiographer?

Electrocardiograms (ECGs) are frequently ordered in the pediatric emergency department (ED). Pediatric cardiologists are generally not asked to interpret every ECG; thus, ED patient management is often guided by the ED physicians' ECG interpretation. The objective of this study was to analyze the accuracy of ECG interpretation by ED physicians and a computer-generated interpretation and compare the two. A 12-month prospective study was performed in a pediatric ED. All patients (<22 years) who had an ECG in the ED were included. The ED physicians and the computer interpretation were compared to a reference standard. Each electrocardiographic diagnosis, as well as the ECG as a whole, was assigned to one of the following predetermined classes: I, normal sinus rhythm; II, minimal clinical significance; III, indeterminate clinical significance; IV, those of definite clinical significance. Both groups correctly interpreted all normal (class I) ECGs. The computer correctly interpreted approximately 75% of the class II and class III ECGs, whereas the ED physicians correctly interpreted 36% of both groups. For the class IV ECGs, both the computer and the ED physicians performed poorly, correctly interpreting just 14% and 28%, respectively. The computer proved to be more accurate than the ED physicians in interpreting ECGs of less than critical significance (classes II and III), but neither group was able to correctly interpret even a simple majority of the most significant abnormalities (class IV). We speculate that distributing the computer-generated interpretation to the ED physicians and formal review of all ED ECGs by a skilled interpreter may decrease the number of missed diagnoses.

Role of the glutamate decarboxylase acid resistance system in the survival of Listeria monocytogenes LO28 in low pH foods

The glutamate decarboxylase (GAD) acid resistance system of the foodborne pathogen Listeria monocytogenes plays a major role in its survival at low pH. It was found that survival of the wild-type strain. LO28, in acidified reconstituted skim milk, diluted to reduce free glutamate levels. improves in response to supplementation with monosodium glutamate. A mutant, in which the two listerial GAD homologs have been deleted (and in which there is no discernible GAD activity), did not respond to glutamate supplementation and displayed greatly enhanced sensitivity in a number of low pH foods, even when levels of free glutamate were as low as 0.22 mM. We thus show that the GAD system plays a major role in the survival of L. monocytogenes in acidic foods even when levels of free glutamate are low.

Effectiveness of HIV prevention interventions in developing countries

OBJECTIVE

To review the effectiveness of projects and programs in developing countries that aim to reduce sexual transmission of HIV infection or transmission related to injection drug use.

DESIGN

We identified 34 published studies undertaken in 18 developing countries that met rigorous inclusion criteria. These criteria included the length of follow-up, use of statistical analysis, the inclusion of a comparison group, and type of outcomes measured.

RESULTS

We found that behavioral change interventions are effective when targeted to populations at high risk, particularly female sex workers and their clients. Few studies have evaluated harm reduction interventions in injecting drug users (IDUs). Evidence on the effectiveness of voluntary counseling and testing programs was promising, and VCT was most effective when directed at discordant couples. Treatment of sexually transmitted diseases (STD) appears highly effective in reducing HIV/STD transmission, particularly in the earlier stages of the epidemic.

CONCLUSIONS

This review demonstrates that HIV prevention interventions can be effective in changing risk behaviors and preventing transmission in low and middle-income countries. When the appropriate mix of interventions is applied, they can lead to significant reductions in the prevalence of HIV at the national level. Additional research is needed to identify effective interventions, particularly in men who have sex with men, youth, IDUs and HIV-infected persons. Structural and environmental interventions show great promise, although more evaluation is needed.

Cerebrospinal fluid abnormalities in a phase III trial of Avonex (IFNbeta-1a) for relapsing multiple sclerosis. The Multiple Sclerosis Collaborative Research Group

BACKGROUND AND OBJECTIVE

This report provides results of CSF analyses done in a subset of relapsing remitting MS patients participating in a placebo-controlled, double-blind, phase III clinical trial of IFNbeta-Studies supported by the National Multiple Sclerosis Society (grants RG2019, RG2827),a (Avonex , Biogen). The clinical trial demonstrated that IFNbeta-1a treatment resulted in significantly reduced disability progression, annual relapse rate, and new brain lesions visualized by cranial magnetic resonance imaging. The objectives of the current study were to determine: (a) whether CSF abnormalities in MS patients correlated with disease or MRI characteristics, and (b) effects of IFNbeta-1a therapy on these CSF abnormalities.

METHODS

CSF was analyzed from 262 (87%) of the 301 study subjects at entry into the clinical trial, and a second CSF sample was analyzed from 137 of these 262 subjects after 2 years of therapy. CSF cell counts, oligoclonal bands (OCB), IgG index, and free kappa light chains were measured using standard assays. Baseline CSF results were compared with demographic, disease, and MRI parameters. Differences in on-study relapse rate, gadolinium enhancement, and EDSS change according to baseline CSF status was used to determine the predictive value of CSF for subsequent clinical and MRI disease activity. Change in CSF parameters after 104 weeks were used to determine the effects of treatment.

RESULTS

(1) At study baseline, 37% of the subjects had abnormal CSF WBC counts, 61% had abnormal levels of CSF free kappa light chains, 84% had abnormal IgG index values, and 90% were positive for OCB. (2) Baseline IgG index, kappa light chains, and OCB showed weakly positive, statistically significant correlations with Gd-enhanced lesion volume and T2 lesion volume. WBC showed a statistically significant correlation with Gd-enhancing lesion volume but was uncorrelated with T2 lesion volume. (3) There was an associated between baseline CSF WBC counts and on-study clinical and MRI disease activity in placebo recipients. (4) IFNbeta-1a treatment resulted in significantly reduced CSF WBC counts, but there was no treatment-related change in CSF IgG index, kappa light chains, or OCB, which remained relatively stable over time in both patient groups.

CONCLUSIONS

The current study documents significant reductions in CSF WBC counts in patients treated with IFNbeta-1a for 104 weeks. This finding is considered relevant to the therapeutic response, since CSF WBC counts were found to be positively correlated with subsequent clinical and MRI disease activity in placebo-treated relapsing MS patients.

The ESRC review of government social classifications

In this article we first discuss the background to the ESRC Review of Government Social Classifications and the recommendations of the Review Committee's initial report to the Office for National Statistics in 1995. Second, we discuss the work of Phase 2 of the review, including the derivation of an interim version of a proposed revised government social classification schema and the criterion and construct validation work so far undertaken using this schema. Finally, we indicate the further work required to establish the schema in its ultimate recommended form for use by ONS and others. The main purpose of the paper is to introduce users of government social classifications both to the ideas underlying the review and to the revised version of the current classifications which we shall be recommending to ONS.

Prevention campaigns for hard-to-reach populations at risk for HIV infection: theory and implementation

Using applied behavioral science techniques that have been successful in other areas of health promotion, community-level campaigns were implemented in 5 cities to prevent HIV infection among hard-to-reach, at-risk populations: men who have sex with men but do not self-identify as gay; women who engage in sex for money or drugs; injecting drug users (IDUs), female sex partners of IDUs; and youth in high-risk situations. Communication materials presented positive role models for risk-reducing behaviors, and peer networks prompted and reinforced the behavior change process. This article describes the first year of intervention experience and documents the practical application of theoretical concepts of persuasion and learning. The use of theory and data to develop 188 educational messages is illustrated and training methods and experiences are reported for 150 peer leaders, 104 other community networkers, and 22 outreach workers. These activities are feasible and appear to offer an effective, general approach for diverse, special populations.

Using formative research to lay the foundation for community level HIV prevention efforts: an example from the AIDS Community Demonstration Projects

The AIDS Community Demonstration Projects provided community-level HIV prevention interventions to historically hard-to-reach groups at high risk for HIV infection. The projects operated under a common research protocol which encompassed formative research, intervention delivery, process evaluation, and outcome evaluation. A formative research process specifically focusing on intervention development was devised to assist project staff in identifying, prioritizing, accessing, and understanding the intervention target groups. This process was central to the creation of interventions that were acceptable and unique to the target populations. Intended to be rapid, the process took 6 months to complete. Drawn from the disciplines of anthropology, community psychology, sociology, and public health, the formative research process followed distinct steps which included (a) defining the populations at high-risk for HIV; (b) gathering information about these populations through interviews with persons who were outside of, but who had contact with, the target groups (such as staff from the health department and alcohol and drug treatment facilities, as well as persons who interacted in an informal manner with the target groups, such as clerks in neighborhood grocery stores and bartenders); (c) interviewing people with access to the target populations (gatekeepers), and conducting observations in areas where these high-risk groups were reported to gather (from previous interviews); (d) interviewing members of these groups at high risk for HIV infection or transmission; and (e) systematically integrating information throughout the process. Semistructured interview schedules were used for all data collection in this process. This standardized systematic method yielded valuable information about the focal groups in each demonstration project site. The method, if adopted by others, would assist community intervention specialists in developing interventions that are culturally appropriate and meaningful to their respective target populations.

Comparison of in-hospital mortality from myocardial infarction in the pre- and post-thrombolysis eras at the Royal University Hospital, Saskatoon, Saskatchewan

PURPOSE

To compare in-hospital mortality of acute myocardial infarction (AMI) in two groups of patients in the pre- (1978-79) and post- (1990-91) thrombolysis era via a retrospective study.

DATA SOURCE

Hospital files of patients discharged from the Royal University Hospital (RUH) in Saskatoon, Saskatchewan with the diagnosis of AMI.

RESULTS

The diagnosis of AMI was established in 125 patients in 1978-79 and in 164 patients in 1990-91. The two groups were comparable with exceptions noted in the recorded family history of myocardial infarction and hypercholesterolemia. The overall in-hospital mortality decreased from 21.6% (1978-79) to 11.0% (1990-91; P = 0.05). The difference was more significant for patients admitted directly to the RUH, 24.0% (1978-79) versus 7.0% (1990-91; P = 0.05), and for patients over the age of 70 years. Marked differences were observed in the treatments provided to patients between these two decades.

CONCLUSIONS

The in-hospital mortality of patients with AMI has decreased considerably in the past two decades. The use of thrombolytic agents, acetylsalicylic acid, heparin and beta-blockers may have contributed to these changes. A worse prognosis was observed with advancing age, hypotension on admission and the development of congestive heart failure, malignant arrhythmias or shock.

Racial influence in renal stone disease: a Saskatchewan story

Data was obtained from two separate governement sources in an effort to review the prevalence of kidney stone disease in the province of Saskatchewan for the years 1983-1988 inclusive. The data revealed a statistally significant difference in prevalence rate among different ethnic groups within the population. Aboriginal people were found to have a prevalence rate approximately one-third that of the nonaboriginal (non-native) population. A renal stone episode prevalence of 0.858 per 1000 population compared to 0.222 per 1000 population in aboriginal people (p.<.001). The reasons for this difference could not be retrospectively associated with geographical variation. A discussion of other possible causes in association is offered, but it is felt that, in the end, more research into this area is required.

Risking everything? Risk behavior, behavior change, and AIDS

Inquiry into the determinants of risk-related sexual behavior is important for the development of interventions to reduce the incidence of new cases of human immunodeficiency virus infection. Recent social and behavioral research has revealed much about the individual and social factors influencing risk-taking. Findings from these studies have been important in the development of new educational and community-based interventions for communities at risk in the developed and developing worlds.

Expression of inducible stress protein 70 in rat heart myogenic cells confers protection against simulated ischemia-induced injury

Myocardial ischemia markedly increases the expression of several members of the stress/heat shock protein (HSP) family, especially the inducible HSP70 isoforms. Increased expression of HSP70 has been shown to exert a protective effect against a lethal heat shock. We have examined the possibility of using this resistance to a lethal heat shock as a protective effect against an ischemic-like stress in vitro using a rat embryonic heart-derived cell line H9c2 (2-1). Myogenic cells in which the heat shock proteins have been induced by a previous heat shock are found to become resistant to a subsequent simulated ischemic stress. In addition, to address the question of how much does the presence of the HSP70 contribute to this protective effect, we have generated stably transfected cell lines overexpressing the human-inducible HSP70. Embryonal rat heart-derived H9c2(2-1) cells were used for this purpose. This stably transfected cell line was found to be significantly more resistant to an ischemic-like stress than control myogenic cells only expressing the selectable marker (neomycin) or the parental cell line H9c2(2-1). This finding implicates the inducible HSP70 protein as playing a major role in protecting cardiac cells against ischemic injury.