The effectiveness of the COVID-19 vaccines in the prevention of post-COVID conditions in children and adolescents: a systematic literature review and meta-analysis

Objective

We performed a systematic literature review and meta-analysis on the effectiveness of coronavirus disease 2019 (COVID-19) vaccination against post-COVID conditions (long COVID) in the pediatric population.

Design

Systematic literature review/meta-analysis.

Methods

We searched PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 1, 2019, to August 14, 2023, for studies evaluating the COVID-19 vaccine effectiveness against post-COVID conditions among vaccinated individuals < 21 years old who received at least 1 dose of COVID-19 vaccine. A post-COVID condition was defined as any symptom that was present 4 or more weeks after COVID-19 infection. We calculated the pooled diagnostic odds ratio (DOR) (95% CI) for post-COVID conditions between vaccinated and unvaccinated individuals.

Results

Eight studies with 23,995 individuals evaluated the effect of vaccination on post-COVID conditions, of which 5 observational studies were included in the meta-analysis. The prevalence of children who did not receive COVID-19 vaccines ranged from 65% to 97%. The pooled prevalence of post-COVID conditions was 21.3% among those unvaccinated and 20.3% among those vaccinated at least once. The pooled DOR for post-COVID conditions among individuals vaccinated with at least 1 dose and those vaccinated with 2 doses were 1.07 (95% CI, 0.77-1.49) and 0.82 (95% CI, 0.63-1.08), respectively.

Conclusions

A significant proportion of children and adolescents were unvaccinated, and the prevalence of post-COVID conditions was higher than reported in adults. While vaccination did not appear protective, conclusions were limited by the lack of randomized trials and selection bias inherent in observational studies.

Syphilis Treatment: Systematic Review and Meta-Analysis Investigating Nonpenicillin Therapeutic Strategies

Background

Penicillin's long-standing role as the reference standard in syphilis treatment has led to global reliance. However, this dependence presents challenges, prompting the need for alternative strategies. We performed a systematic literature review and meta-analysis to evaluate the efficacy of these alternative treatments against nonneurological syphilis.

Methods

We searched MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Scopus, and Web of Science from database inception to 28 August 2023, and we included studies that compared penicillin or amoxicillin monotherapy to other treatments for the management of nonneurological syphilis. Our primary outcome was serological cure rates. Random-effect models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 test.

Results

Of 6478 screened studies, 27 met the inclusion criteria, summing 6710 patients. The studies were considerably homogeneous, and stratified analyses considering each alternative treatment separately revealed that penicillin monotherapy did not outperform ceftriaxone (pooled odds ratio, 1.66 [95% confidence interval, .97-2.84]; I2 = 0%), azithromycin (0.92; [.73-1.18]; I2 = 0%), or doxycycline (0.82 [.61-1.10]; I2 = 1%) monotherapies with respect to serological conversion.

Conclusions

Alternative treatment strategies have serological cure rates equivalent to penicillin, potentially reducing global dependence on this antibiotic.

Prevalence, predictors, and patient-reported outcomes of long COVID in hospitalized and non-hospitalized patients from the city of São Paulo, Brazil

Background

Robust data comparing long COVID in hospitalized and non-hospitalized patients in middle-income countries are limited.

Methods

A retrospective cohort study was conducted in Brazil, including hospitalized and non-hospitalized patients. Long COVID was diagnosed at 90-day follow-up using WHO criteria. Demographic and clinical information, including the depression screening scale (PHQ-2) at day 30, was compared between the groups. If the PHQ-2 score is 3 or greater, major depressive disorder is likely. Logistic regression analysis identified predictors and protective factors for long COVID.

Results

A total of 291 hospitalized and 1,118 non-hospitalized patients with COVID-19 were included. The prevalence of long COVID was 47.1% and 49.5%, respectively. Multivariable logistic regression showed female sex (odds ratio [OR] = 4.50, 95% confidence interval (CI) 2.51-8.37), hypertension (OR = 2.90, 95% CI 1.52-5.69), PHQ-2 > 3 (OR = 6.50, 95% CI 1.68-33.4) and corticosteroid use during hospital stay (OR = 2.43, 95% CI 1.20-5.04) as predictors of long COVID in hospitalized patients, while female sex (OR = 2.52, 95% CI 1.95-3.27) and PHQ-2 > 3 (OR = 3.88, 95% CI 2.52-6.16) were predictors in non-hospitalized patients.

Conclusion

Long COVID was prevalent in both groups. Positive depression screening at day 30 post-infection can predict long COVID. Early screening of depression helps health staff to identify patients at a higher risk of long COVID, allowing an early diagnosis of the condition.

The effectiveness of COVID-19 vaccine in the prevention of post-COVID conditions: a systematic literature review and meta-analysis of the latest research

Objective

We performed a systematic literature review and meta-analysis on the effectiveness of coronavirus disease 2019 (COVID-19) vaccination against post-COVID conditions (long COVID) among fully vaccinated individuals.

Design

Systematic literature review/meta-analysis.

Methods

We searched PubMed, Cumulative Index to Nursing and Allied Health, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 1, 2019, to June 2, 2023, for studies evaluating the COVID-19 vaccine effectiveness (VE) against post-COVID conditions among fully vaccinated individuals who received two doses of COVID-19 vaccine. A post-COVID condition was defined as any symptom that was present four or more weeks after COVID-19 infection. We calculated the pooled diagnostic odds ratio (DOR) (95% confidence interval) for post-COVID conditions between fully vaccinated and unvaccinated individuals. Vaccine effectiveness was estimated as 100% x (1-DOR).

Results

Thirty-two studies with 775,931 individuals evaluated the effect of vaccination on post-COVID conditions, of which, twenty-four studies were included in the meta-analysis. The pooled DOR for post-COVID conditions among fully vaccinated individuals was 0.680 (95% CI: 0.523-0.885) with an estimated VE of 32.0% (11.5%-47.7%). Vaccine effectiveness was 36.9% (23.1%-48.2%) among those who received two doses of COVID-19 vaccine before COVID-19 infection and 68.7% (64.7%-72.2%) among those who received three doses before COVID-19 infection. The stratified analysis demonstrated no protection against post-COVID conditions among those who received COVID-19 vaccination after COVID-19 infection.

Conclusions

Receiving a complete COVID-19 vaccination prior to contracting the virus resulted in a significant reduction in post-COVID conditions throughout the study period, including during the Omicron era. Vaccine effectiveness demonstrated an increase when supplementary doses were administered.

Automated Detection, Segmentation, and Tracking of Brain Metastases in Repeated Courses of Stereotactic Radiosurgery Using Integrated Artificial Intelligence

PURPOSE/OBJECTIVE(S)

Salvage stereotactic radiosurgery (SRS) for distant brain metastases has been demonstrated as a safe and effective approach for intracranial recurrences after initial SRS. However, accurate tumor detection and segmentation among responding tumors within the irradiated parenchyma can be challenging. The requirement for the registration and reference to the previous course of SRS is very time-consuming and suffers significant inter and intra-reader variability. Artificial intelligence (AI)-assisted system has been proven to improve the accuracy and efficiency in the clinical flow of de-novo SRS. We hypothesize that an integrated AI system can facilitate an automated tumor contouring process for repeated SRS.

MATERIALS/METHODS

Three patients who underwent their third course of SRS to brain metastases were selected for the pioneering works. They have had two sessions of SRS with a mean lesion number of 4 and 3.7, respectively. VBrain, an FDA-approved brain tumor management AI platform, was used to co-registered serial MR scans and automatically identify, track, and contour brain metastases for each course of SRS. The AI also indicated new lesions and treated lesions for each course. Three radiation oncologists experienced in brain SRS contoured the gross tumor volumes (GTVs) of the third course of SRS in two reader modes (assisted then unassisted) with a memory washout period of one week between each section. The segmentation ground truth was established through consensus among the three experts. Lesion-wise sensitivity, contouring accuracy, and consuming time were compared between the two contouring modes.

RESULTS

In each patient, there were 15, 11, and 9 metastases, with a median diameter of 4.72 (95% CI: 4.05, 6.91) mm. The mean lesion-wise sensitivity was 96.96±2.47% with AI assistance and 76.90 ± 7.10% without assistance. There were two false-positive lesions in the assisted read, resulting in a low average false-positive rate of 0.67 per patient, while no false positive for the unassisted mode. AI assistance improved contouring accuracy. The median Dice similarity coefficient (DSC) was 0.71 (95% CI: 0.55, 0.87) for assisted contouring and 0.65 (95% CI: 0.46, 0.85) for unassisted contouring. We also use average Hausdorff distance (HD) to measure segmentation results. The mean HD was 0.72± 0.13 mm versus 0.73±0.08 mm for the two contouring modes (p = 0.02) Furthermore, the median contouring time per case was significantly shorter with AI assistance than without assistance (20.8 minutes vs. 29.8 minutes; p < 0.001), corresponding to a 43.2% time-saving.

CONCLUSION

Our results suggest that the integration of an AI-based system into repeated brain SRS can significantly improve the accuracy and efficiency of tumor detection and segmentation. This approach has the potential to streamline the treatment planning process for salvage SRS.

Design, delivery and effectiveness of health practitioner regulation systems: an integrative review

BACKGROUND

Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions.

METHODS

We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework.

FINDINGS

This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures-processes-outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners.

CONCLUSION

We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.

Diagnostic Stewardship: A Systematic Review and Meta-analysis of Blood Collection Diversion Devices Used to Reduce Blood Culture Contamination and Improve the Accuracy of Diagnosis in Clinical Settings

Background

Blood culture contamination may lead to misdiagnosis, overutilization of antibiotics, and prolonged length of stay. Blood specimen diversion devices can reduce contamination rates during blood culture collection procedures. We performed a systematic literature review and meta-analysis evaluating the influence of blood specimen diversion devices in blood culture contamination rates.

Methods

We searched Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Scopus, and Web of Science, from database inception to 1 March 2023, for studies evaluating the impact of a diversion device on blood culture contamination. Blood culture contamination was a positive blood culture with microorganisms not representative of true bacteremia, but rather introduced during collection or processing the blood sample. Random-effects models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 test.

Results

Of 1768 screened studies, 12 met inclusion criteria for this systematic literature review. Of them, 9 studies were included in the meta-analysis. Studies were substantially heterogeneous, but stratified analyses considering only high-quality studies revealed that venipuncture using a diversion device was associated with a significant reduction in blood culture contamination in comparison to the standard procedure of collection (pooled odds ratio [OR], 0.26 [95% confidence interval {CI}, .13-.54]; I2 = 19%). Furthermore, the stratified analysis showed that the adoption of a diversion device did not reduce the detection of true infection (pooled OR, 0.85 [95% CI, .65-1.11]; I2 = 0%).

Conclusions

Blood culture diversion devices was associated with decreased contamination rates and could improve quality of care, reduce costs, and avoid unnecessary antibiotic use.

Urban Governance, Multisectoral Action, and Civic Engagement for Population Health, Wellbeing, and Equity in Urban Settings: A Systematic Review

Objectives: To identify the validated and reliable indicators and tools to assess good governance for population health, wellbeing, and equity in urban settings, and assess processes of multisectoral action and civic engagement as reported by peer-reviewed articles. Methods: We conducted a systematic review searching six databases for observational studies reporting strategies of either urban health, multisectoral action or civic engagement for wellbeing, health, or equity. Results: Out of 8,154 studies initially identified we included 17. From the included studies, 14 presented information about high-income countries. The general population was the main target in most studies. Multisectoral action was the most frequently reported strategy (14 studies). Three studies used Urban Health Equity Assessment and Response Tool (Urban HEART). Health indicators were the most frequently represented (6 studies). Barriers and facilitators for the implementation of participatory health governance strategies were reported in 12 studies. Conclusion: Data on the implementation of participatory health governance strategies has been mainly reported in high-income countries. Updated and reliable data, measured repeatedly, is needed to closely monitor these processes and further develop indicators to assess their impact on population health, wellbeing, and equity.

Creating 'wellbeing societies': moving from rhetoric to action

Several global challenges have emerged and coalesced in recent times, including climate change and environmental crises; growing health and social inequalities; geopolitical conflicts; and increasing rates of both communicable and noncommunicable and mental health diseases. The urgency and need for change has never been greater. In response, governments are paying increasing attention to the notion of wellbeing as an integrating concept to drive action to address these challenges. They are beginning to take action by introducing wellbeing indexes; wellbeing budgets; joined-up 'triple bottom line' approaches to policy making, and the inclusion of civil society in the decision-making processes. To date, these steps have been sporadic and localised; yet if these multiple social, environmental and economic crises are to be averted, coherent and systematic actions at the global, national and local levels are needed. The World Health Organization (WHO) and its 194 Member States have come together to map a path forward through the Geneva Charter for Well-being and the Well-being Framework. These aim to set the foundation and direction for action. They map the pathway towards a 'wellbeing society', a concept WHO brought to attention in the Geneva Charter. The intention is to support and galvanise nations to build on their nascent efforts to adopt a welbeing agenda, and move beyond rhetoric to take concerted action. To achieve the promise of 'wellbeing societies' will require developing new governance models,bringing all sectors together to define the problems and solutions, adopting new economic levers, and reorienting financing systems to focus on what is truly important. In this paper we describe the background and context for these initiatives, the concept of wellbeing societies and how WHO is advancing this global agenda.

Allosteric Inhibitors of Zika Virus NS2B-NS3 Protease Targeting Protease in "Super-Open" Conformation

The Zika virus (ZIKV), a member of the Flaviviridae family, is considered a major health threat causing multiple cases of microcephaly in newborns and Guillain-Barré syndrome in adults. In this study, we targeted a transient, deep, and hydrophobic pocket of the "super-open" conformation of ZIKV NS2B-NS3 protease to overcome the limitations of the active site pocket. After virtual docking screening of approximately seven million compounds against the novel allosteric site, we selected the top six candidates and assessed them in enzymatic assays. Six candidates inhibited ZIKV NS2B-NS3 protease proteolytic activity at low micromolar concentrations. These six compounds, targeting the selected protease pocket conserved in ZIKV, serve as unique drug candidates and open new opportunities for possible treatment against several flavivirus infections.

Healthy cities initiative in China: Progress, challenges, and the way forward

China implemented the first phase of its National Healthy Cities pilot program from 2016-20. Along with related urban health governmental initiatives, the program has helped put health on the agenda of local governments while raising public awareness. Healthy City actions taken at the municipal scale also prepared cities to deal with the COVID-19 pandemic. However, after intermittent trials spanning the past two decades, the Healthy Cities initiative in China has reached a crucial juncture. It risks becoming inconsequential given its overlap with other health promotion efforts, changing public health priorities in response to the pandemic, and the partial adoption of the Healthy Cities approach advanced by the World Health Organization (WHO). We recommend aligning the Healthy Cities initiative in China with strategic national and global level agendas such as Healthy China 2030 and the Sustainable Development Goals (SDGs) by providing an integrative governance framework to facilitate a coherent intersectoral program to systemically improve population health. Achieving this alignment will require leveraging the full spectrum of best practices in Healthy Cities actions and expanding assessment efforts.

FUNDING

Tsinghua-Toyota Joint Research Fund "Healthy city systems for smart cities" program.

Training prediction models for individual risk assessment of postoperative complications after surgery for colorectal cancer

BACKGROUND

The occurrence of postoperative complications and anastomotic leakage are major drivers of mortality in the immediate phase after colorectal cancer surgery. We trained prediction models for calculating patients' individual risk of complications based only on preoperatively available data in a multidisciplinary team setting. Knowing prior to surgery the probability of developing a complication could aid in improving informed decision-making by surgeon and patient and individualize surgical treatment trajectories.

METHODS

All patients over 18 years of age undergoing any resection for colorectal cancer between January 1, 2014 and December 31, 2019 from the nationwide Danish Colorectal Cancer Group database were included. Data from the database were converted into Observational Medical Outcomes Partnership Common Data Model maintained by the Observation Health Data Science and Informatics initiative. Multiple machine learning models were trained to predict postoperative complications of Clavien-Dindo grade ≥ 3B and anastomotic leakage within 30 days after surgery.

RESULTS

Between 2014 and 2019, 23,907 patients underwent resection for colorectal cancer in Denmark. A Clavien-Dindo complication grade ≥ 3B occurred in 2,958 patients (12.4%). Of 17,190 patients that received an anastomosis, 929 experienced anastomotic leakage (5.4%). Among the compared machine learning models, Lasso Logistic Regression performed best. The predictive model for complications had an area under the receiver operating characteristic curve (AUROC) of 0.704 (95%CI 0.683-0.724) and an AUROC of 0.690 (95%CI 0.655-0.724) for anastomotic leakage.

CONCLUSIONS

The prediction of postoperative complications based only on preoperative variables using a national quality assurance colorectal cancer database shows promise for calculating patient's individual risk. Future work will focus on assessing the value of adding laboratory parameters and drug exposure as candidate predictors. Furthermore, we plan to assess the external validity of our proposed model.

Biopsy for molecular risk stratification in uveal melanoma: Yields and molecular characteristics in 119 patients

BACKGROUND

Prognostic cytological and molecular features of uveal melanoma have been well researched and are essential in management. Samples can be obtained in vivo through fine needle aspirate biopsy, vitrector cutter, forceps or post-enucleation for off-site testing. This study aims to examine cytological and chromosome microarray yields of these samples.

METHODS

A retrospective cohort analysis of 119 uveal melanoma biopsies submitted to our laboratory. Samples included those taken in vivo (n = 57) and post-enucleation (n = 62). Patient and tumour features were collected including age, sex, primary tumour location, basal diameter and tumour height. Prognostic outcomes measured include cell morphology, chromosomal status and immunohistochemistry.

RESULTS

Post-enucleation biopsies accounted for just over half of our samples (52%). Post-enucleation samples had a more successful genetic yield than in vivo biopsies (77% vs. 50%, p = 0.04) though there was no difference for cytological yields. There was no difference in cytological or microarray yields between instruments. The vitrector biopsy group had the smallest tumour thickness (5 mm vs. 10 mm [fine-needle aspirate biopsy], p = 0.003). There was a strong correlation between monosomy 3, BAP1 aberrancy and epithelioid cell type in post-enucleation samples (Tb  = 0.742, p = 0.005). However, epithelioid morphology was not associated with either monosomy 3 (p = 0.07) or BAP1 aberrancy (p = 0.24) for in vivo biopsies.

CONCLUSIONS

All three biopsy instruments provide similar cytological yields as post-enucleation sampling, although post-enucleation samples had a more successful chromosome microarray yield. Epithelioid cytomorphology alone is insufficient for prognostication in in vivo biopsies, immunohistochemistry would be a useful surrogate test.

Law and urban governance for health in times of rapid change

Governance is an important factor in urban health, and law is an important element of healthy governance. Law can be an intervention local government wields to influence behavior and shape environments. Law can also be an important target of health promotion efforts: Law and the enforcement and implementation behaviors it fosters can promote unhealthy behaviors and environmental conditions, and can act as a barrier to healthy interventions or practices. Finally, law is a design and construction tool for the organization of governance. Law is the means through which cities are formally established. Their powers and duties, organizational structure, boundaries and decision-making procedures are all set by law. Regardless of the form of government, cities have legal levers they can manipulate for health promotion. Cities can use tax authority to influence the price of unhealthy products, or to encourage consumption of healthy foods. Cities can use their legal powers to address incidental legal effects of policies that they themselves cannot control. Cities may also have the authority to use law to address deeper determinants of health. The overall level of income or wealth inequality in a country reflects factors well-beyond a local government’s control, but city government nonetheless has levers to directly and indirectly reduce economic and social inequality and their effects. A renewed focus on law and urban governance is the key to assuring health and well-being and closing the health equity gap.

Best case/worst case for the trauma ICU: Development and pilot testing of a communication tool for older adults with traumatic injury

BACKGROUND

"Best Case/Worst Case" (BC/WC) is a communication tool to support shared decision making in older adults with surgical illness. We aimed to adapt and test BC/WC for use with critically ill older adult trauma patients.

METHODS

We conducted focus groups with 48 trauma clinicians in Wisconsin, Texas, and Oregon. We used qualitative content analysis to characterize feedback and adapted the tool to fit this setting. Using rapid sequence iterative design, we developed an implementation tool kit. We pilot tested this intervention at two trauma centers using a pre-post study design with older trauma patients in the intensive care unit (ICU). Main outcome measures included study feasibility, intervention acceptability, quality of communication, and clinician moral distress.

RESULTS

BC/WC for trauma patients uses a graphic aid to document major events over time, illustrate plausible scenarios, and convey uncertainty. We enrolled 86 of 116 eligible patients and their surrogates (48 pre/38 postintervention). The median patient age was 72 years (51-95 years) and mean Geriatric Trauma Outcome Score was 126.1 (±30.6). We trained 43 trauma attendings and trauma fellows to use the intervention. Ninety-four percent could perform essential tool elements after training. The median end-of-life communication score (scale 0-10) improved from 4.5 to 6.6 (p = 0.006) after intervention as reported by family and from 4.1 to 6.0 (p = 0.03) as reported by nurses. Moral distress did not change. However, there was improvement (less distress) reported by physicians regarding "witnessing providers giving false hope" from 7.34 to 5.03 (p = 0.022). Surgeons reported the tool put multiple clinicians on the same page and was useful for families, but tedious to incorporate into rounds.

CONCLUSION

BC/WC trauma ICU is acceptable to clinicians and may support improved communication in the ICU. Future efficacy testing is threatened by enrollment challenges for severely injured older adults and their family members.

LEVEL OF EVIDENCE

Therapeutic, level III.

Development of new therapeutic options for the treatment of uveal melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults. Important cytogenetic and genetic risk factors for the development of UM include chromosome 3 monosomy, mutations in the guanine nucleotide-binding proteins GNAQ/GNA11, and loss of the BRACA1-associated protein 1 (BAP 1). Most primary UMs are treated conservatively with radiotherapy, but enucleation is necessary for large tumours. Despite the effectiveness of local control, up to 50% of UM patients develop metastasis for which there are no effective therapies. Attempts to utilise the targeted therapies that have been developed for the treatment of other cancers, including a range of signal transduction pathway inhibitors, have rarely produced significant outcomes in UM. Similarly, the application of immunotherapies that are effective in cutaneous melanoma to treat UM have also been disappointing. Other approaches that have been initiated involve proteasomal inhibitors and histone deacetylase inhibitors which are approved for the treatment of other cancers. Nevertheless, there have been occasional positive outcomes from these treatments in UM. Moreover, combination approaches in UM have also yielded some positive developments. It would be valuable to identify how to apply such therapies efficiently in UM, potentially via individualised tumour profiling. It would also be important to characterise UM tumours to differentiate the potential drivers of progression from those in other types of cancers. The recent identification of novel kinases and metastatic genes in UM tumours makes the development of new UM-specific treatments feasible.

Governance in health workforce: how do we improve on the concept? A network-based, stakeholder-driven approach

BACKGROUND

Health workforce governance has been proposed as key to improving health services delivery, yet few studies have examined the conceptualisation of health workforce governance in detail and exploration in literature remains limited.

METHODS

A literature review using PubMed, Google Scholar and grey literature search was conducted to map out the current conceptualisation of health workforce governance. We identified all published literature relating to governance in health workforce since 2000 and analysed them on two fronts: the broad definition of governance, and the operationalisation of broad definition into key dimensions of governance.

RESULTS

Existing literature adopts governance concepts established in health literature and does not adapt understanding to the health workforce context. Definitions are largely quoted from health literature whilst dimensions are focused around the sub-functions of governance which emphasise operationalising governance practices over further conceptualisation. Two sub-functions are identified as essential to the governance process: stakeholder participation and strategic direction.

CONCLUSIONS

Although governance in health systems has gained increasing attention, governance in health workforce remains poorly conceptualised in literature. We propose an improved conceptualisation in the form of a stakeholder-driven network governance model with the national government as a strong steward against vested stakeholder interests. Further research is needed to explore and develop on the conceptual thinking behind health workforce governance.

Foresight in the time of COVID-19

Foresight methodologies enable individuals and organizations to envision different future scenarios and plan for greater future resilience. However, foresight is an underused methodology in the Western Pacific region for health policy development that could be extremely beneficial, among other areas, in the context of public health emergency response. We present lessons learned from the application of foresight methodologies through remote, agile think tank sprints to inform the World Health Organization (WHO) Western Pacific Regional Office's (WPRO) response to the COVID-19 pandemic. Four think tanks were set up in topic areas of interest. The think tanks used a six-step foresight methodology to develop scenarios for the pandemic in an 18-month horizon. Backcasting was used to generate recommendations for WHO response and support for countries. This case study demonstrates the value of using foresight methodologies in public health, and specifically in the context of a public health emergency, and its ability to inform more context-appropriate and future-proof responses.

FUNDING

Japan.

Aurothioglucose enhances proangiogenic pathway activation in lungs from room air and hyperoxia-exposed newborn mice

Bronchopulmonary dysplasia (BPD), a long-term respiratory morbidity of prematurity, is characterized by attenuated alveolar and vascular development. Supplemental oxygen and immature antioxidant defenses contribute to BPD development. Our group identified thioredoxin reductase-1 (TXNRD1) as a therapeutic target to prevent BPD. The present studies evaluated the impact of the TXNRD1 inhibitor aurothioglucose (ATG) on pulmonary responses and gene expression in newborn C57BL/6 pups treated with saline or ATG (25 mg/kg ip) within 12 h of birth and exposed to room air (21% O₂) or hyperoxia (>95% O₂) for 72 h. Purified RNA from lung tissues was sequenced, and differential expression was evaluated. Hyperoxic exposure altered ~2,000 genes, including pathways involved in glutathione metabolism, intrinsic apoptosis signaling, and cell cycle regulation. The isolated effect of ATG treatment was limited primarily to genes that regulate angiogenesis and vascularization. In separate studies, pups were treated as described above and returned to room air until 14 days. Vascular density analyses were performed, and ANOVA indicated an independent effect of hyperoxia on vascular density and alveolar architecture at 14 days. Consistent with RNA-seq analyses, ATG significantly increased vascular density in room air, but not in hyperoxia-exposed pups. These findings provide insights into the mechanisms by which TXNRD1 inhibitors may enhance lung development.

SUN-357 Trial in Progress: A Multicenter, Dose-titration, Open-Label Phase 2b Study of Nevanimibe Hydrochloride, a Novel ACAT1 Inhibitor, for the Treatment of Classic Congenital Adrenal Hyperplasia

More than 90% of classic congenital adrenal hyperplasia (CAH) patients have defects in the cytochrome P450 enzyme steroid 21-hydroxylase, resulting in the inability to produce cortisol as well as the overproduction of androgens and androgen precursors such as 17-hydroxyprogesterone (17-OHP). Management of classic CAH can be challenging since patients are often unable to adequately balance the supraphysiologic doses of exogenous glucocorticoids required to suppress excess androgen production while avoiding the iatrogenic side effects of high dose glucocorticoids. Nevanimibe hydrochloride is a novel, orally-administered adrenal-specific acyl-CoA:cholesterol acyltransferase-1 (ACAT1) inhibitor. Nevanimibe inhibits adrenal steroidogenesis by decreasing cholesteryl esters, the substrate required for steroid synthesis. This inhibition of adrenocortical steroidogenesis at an early step results in impaired production across all pathways (i.e., mineralocorticoid, glucocorticoid and androgens). In a previous Phase 2 study in patients with classic CAH and elevated 17-OHP levels (NCT02804178), nevanimibe decreased 17-OHP levels within 2 weeks of treatment. Millendo Therapeutics is now conducting a Phase 2b study to evaluate the efficacy and safety of nevanimibe in treating patients with classic CAH over a longer period (NCT03669549). At approximately 12 sites in the EU, Israel, and Brazil, 20-24 patients with classic CAH and elevated 17-OHP will be treated with nevanimibe at doses of 1000-2000 mg twice per day for 12 weeks. During the screening period, patients who are on a high glucocorticoid dose and have suppressed 17-OHP levels may undergo a slight reduction in their supraphysiologic glucocorticoid dose in order to allow their 17-OHP levels to increase to > 4x the upper limit of normal (ULN). All eligible patients will be started on nevanimibe 1000 mg BID, and nevanimibe doses will be titrated based on 17-OHP levels. The primary efficacy endpoint is the proportion of patients who are able to achieve a reduction of 17-OHP to ≤ 2x ULN. Safety endpoints include the incidence of treatment-emergent adverse events (AEs) and serious adverse events (SAEs), as well as values and changes from baseline in clinical laboratory tests, vital signs, physical examinations, and electrocardiogram parameters. Nevanimibe, an adrenal-specific ACAT1 inhibitor, presents a novel therapeutic approach to the treatment of classic CAH that may allow patients to more easily achieve balance between replacement glucocorticoid doses and control of hyperandrogenemia.

SAT-100 Trial-in-Progress: ZEPHYR, a Pivotal Phase 2b/3 Randomized, Placebo-Controlled Study of Livoletide, a Novel Unacylated Ghrelin Analog, for the Treatment of Hyperphagia and Food-Related Behaviors in Patients with Prader-Willi Syndrome

Background: Prader-Willi syndrome (PWS) is a rare and complex endocrine disease characterized by hyperphagia and abnormal food-related behaviors that contribute to severe morbidity and early mortality and to a significant burden on patients and caregivers. There is no approved treatment for hyperphagia in PWS. Patients with PWS have increased circulating levels of the orexigenic hormone acylated ghrelin (AG) with a relative deficit of unacylated ghrelin (UAG). Livoletide (AZP-531) is a first-in-class UAG analog that was previously shown in a Phase 2 randomized placebo-controlled study in a 47-patient PWS cohort to significantly improve hyperphagia, food related behaviors, and metabolic parameters and to be well-tolerated with no serious adverse events or treatment discontinuations over a 14-day period. [Allas S et al. (2018) PLoS ONE 13(1): e0190849] Objective: ZEPHYR (EudraCT 2018-003062-13) is a pivotal Phase 2b/3 study that is designed to evaluate the long-term safety and efficacy of livoletide in patients with PWS. Methods: The ZEPHYR study will be conducted in centers in North America and Europe. In its Phase 2b portion, approximately 150 patients with PWS will be randomized in a 1:1:1 ratio to receive livoletide low exposure (8 mg/mL), livoletide high exposure (16 mg/mL), or placebo, once a day by sc injection for a three-month core period. Then, patients who received placebo will cross over to livoletide low or high exposure and be treated for 9 months. Patients who received livoletide will continue at their original dose for an additional 9 months. The Phase 3 portion will be initiated following results of the Phase 2b core period with patients randomized 1:1 to livoletide at a dose based on Phase 2b core data or to placebo for a six-month duration. Subsequently, patients who received placebo will be crossed over to livoletide for six months, while patients on livoletide initially will continue for six more months. Main entry criteria for ZEPHYR include genetic diagnosis of PWS, age 8-65 years, single primary caregiver available for the duration of the study, BMI ≤65 kg/m² for adult patients. Patients with type 2 diabetes with HbA1C ≤10% and stable therapy may be enrolled. Use of human growth hormone will be allowed if dosage is stable. Patients enrolled in Phase 2b will not be eligible for Phase 3. The primary outcome measure is the Hyperphagia Questionnaire-Clinical Trials (HQ-CT) score. The HQ-CT has been validated and is considered by regulatory authorities as a valid primary endpoint. Secondary outcome measures include fat mass as assessed by DEXA, BMI, and body weight in overweight/obese patients. Results: The study is ongoing: enrollment began in early 2019 and an updated status will be reported. Conclusion: ZEPHYR is a pivotal study that will provide data on the long-term safety and efficacy on hyperphagia and food-related behaviors of the novel UAG analog livoletide in patients with PWS.

A rapid review of treatment literacy materials for tuberculosis patients

OBJECTIVE

To assess available treatment literacy materials for patients undergoing treatment for tuberculosis (TB).

DESIGN

We conducted a rapid review by searching the US Centers for Disease Control's Find TB Resources website and the websites of health departments and TB-focused organizations. We included English-language documents intended to educate TB patients about anti-tuberculosis treatment. We evaluated the format, readability, and content of documents, and audience. We defined 12 essential content elements based on those previously identified as facilitating human immunodeficiency virus treatment literacy.

RESULTS

Of the 205 documents obtained, 45 were included in our review. The median reading grade level was 7 (IQR 5-8). The median number of essential content elements present was 6 (IQR 4-8), with the most comprehensive document containing 11 of the 12 elements. Only two documents were written for children with TB or their care givers, and two for patients with drug-resistant TB. Many documents contained paternalistic and non-patient-centered language.

CONCLUSION

We found few examples of comprehensive, patient-centered documents. Work is needed to achieve consensus as to the essential elements of TB treatment literacy and to create additional materials for children, patients with drug-resistant TB, and those with lower literacy levels.

Antimicrobial resistance and universal health coverage

The WHO launched a Global Action Plan on antimicrobial resistance (AMR) in 2015. World leaders in the G7, G20 and the UN General Assembly have declared AMR to be a global crisis. World leaders have also adopted universal health coverage (UHC) as a key target under the sustainable development goals. This paper argues that neither initiative is likely to succeed in isolation from the other and that the policy goals should be to both provide access to appropriate antimicrobial treatment and reduce the risk of the emergence and spread of resistance by taking a systems approach. It focuses on outpatient treatment of human infections and identifies a number of interventions that would be needed to achieve these policy goals. It then shows how a strategy for achieving key attributes of a health system for UHC can take into account the need to address AMR as part of a UHC strategy in any country. It concludes with a list of recommended priority actions for integrating initiatives on AMR and UHC.

More than a virus: a qualitative study of the social implications of hepatitis B infection in China

Background

China has the largest absolute number of people living with hepatitis B with up to 300,000 people estimated to die each year from hepatitis B related diseases. Despite advances in immunisation, clinical management, and health policy, there is still a lack of accessible and affordable health care for people with hepatitis B. Through in-depth interviews, this study identifies the personal, social and economic impact of living with hepatitis B and considers the role of stigma and discrimination as barriers to effective clinical management of the disease.

Methods

Semi-structured qualitative interviews were held with 41 people living with hepatitis B in five Chinese cities. Participants were recruited through clinical and non-government organisations providing services to people with hepatitis B, with most (n = 32) being under the age of 35 years.

Results

People living with hepatitis B experience the disease as a transformative intergenerational chronic infection with multiple personal and social impacts. These include education and employment choices, economic opportunities, and the development of intimate relationships. While regulations reducing access to employment and education for people with hepatitis B have been repealed, stigma and discrimination continue to marginalise people with hepatitis B.

Conclusions

Effective public policy to reduce morbidity and mortality associated with hepatitis B needs to address the lived impact of hepatitis B on families, employment and educational choices, finances, and social marginalisation.

Health promotion in Australia: twenty years on from the Ottawa Charter

Australia has a longstanding history of promoting health through programs that reflect the principles of the Ottawa Charter and recognising the importance of social determinants of health. Health promotion programs are delivered by a wide range of organisations, in a wide range of settings and sectors for, or with, multiple groups. Since the mid-1980s aspects of infrastructure and capacity for health promotion, such as human and financial resources, have been put in place including the establishment of health promotion foundations via tobacco hypothecation. Following neo-liberal reforms in the 1990s, however, government policies have increasingly focused more narrowly on specific diseases and risk factors. Chronic disease has become the new banner under which health promotion, social determinants and efforts to address health inequalities fit. While the importance of social determinants is often recognised within and outside the health sector, health promotion practitioners are seldom at the centre of policy development. ( Promotion & Education, 2007, XIV (4): pp 203-208)

Improving Health Promotion Using Quality Improvement Techniques in Australian Indigenous Primary Health Care

Although some areas of clinical health care are becoming adept at implementing continuous quality improvement (CQI) projects, there has been limited experimentation of CQI in health promotion. In this study, we examined the impact of a CQI intervention on health promotion in four Australian Indigenous primary health care centers. Our study objectives were to (a) describe the scope and quality of health promotion activities, (b) describe the status of health center system support for health promotion activities, and (c) introduce a CQI intervention and examine the impact on health promotion activities and health centers systems over 2 years. Baseline assessments showed suboptimal health center systems support for health promotion and significant evidence-practice gaps. After two annual CQI cycles, there were improvements in staff understanding of health promotion and systems for planning and documenting health promotion activities had been introduced. Actions to improve best practice health promotion, such as community engagement and intersectoral partnerships, were inhibited by the way health center systems were organized, predominately to support clinical and curative services. These findings suggest that CQI can improve the delivery of evidence-based health promotion by engaging front line health practitioners in decision-making processes about the design/redesign of health center systems to support the delivery of best practice health promotion. However, further and sustained improvements in health promotion will require broader engagement of management, senior staff, and members of the local community to address organizational and policy level barriers.

Combination therapy with cystic fibrosis transmembrane conductance regulator modulators augment the airway functional microanatomy

Recently approved therapies that modulate CFTR function have shown significant clinical benefit, but recent investigations regarding their molecular mechanism when used in combination have not been consistent with clinical results. We employed micro-optical coherence tomography as a novel means to assess the mechanism of action of CFTR modulators, focusing on the effects on mucociliary clearance. Primary human airway monolayers from patients with a G551D mutation responded to ivacaftor treatment with increased ion transport, airway surface liquid depth, ciliary beat frequency, and mucociliary transport rate, in addition to decreased effective viscosity of the mucus layer, a unique mechanism established by our findings. These endpoints are consistent with the benefit observed in G551D patients treated with ivacaftor, and identify a novel mechanism involving mucus viscosity. In monolayers derived from F508del patients, the situation is more complicated, compounded by disparate effects on CFTR expression and function. However, by combining ion transport measurements with functional imaging, we establish a crucial link between in vitro data and clinical benefit, a finding not explained by ion transport studies alone. We establish that F508del cells exhibit increased mucociliary transport and decreased mucus effective viscosity, but only when ivacaftor is added to the regimen. We further show that improvement in the functional microanatomy in vitro corresponds with lung function benefit observed in the clinical trials, whereas ion transport in vitro corresponds to changes in sweat chloride. Functional imaging reveals insights into clinical efficacy and CFTR biology that significantly impact our understanding of novel therapies.

Can learning sets help policy managers with their wicked problems?

This paper reports on an evaluation of a national action learning set for health policy managers from three Australian state/territory health authorities, conducted during 2010–2011. We collected and analysed qualitative data about the major problems the participants encountered in their work, their experiences of the learning set and their perceptions of the outcomes. The predominant concerns of participants were ‘wicked problems’ in four areas: managing the environment, managing the policy process, managing the self and managing the policy team. Participants reported that the learning set had assisted them to gain greater awareness of and ability to navigate their environment, developed their judgement, strategic and problem-solving skills, contributed to empowerment and self-efficacy, and assisted them in providing support for their staff and building capacity in their organisation. Aspects of the method that contributed to learning included engaging with problems experienced by other members and discussing one’s own problems and strategies; and gaining new insight into ways of framing, analysing and responding to problems. The findings suggest that learning sets can be a powerful method for building policy capacity amongst middle-senior policy managers.

Interface, interaction and integration: how people with chronic disease in Australia manage CAM and conventional medical services

OBJECTIVES

To understand the extent to which conventional and complementary health care are integrated for CAM users with chronic conditions.

METHODS

In-depth interviews and a self-administered questionnaire were used to collect data on care-seeking, self-management and CAM use among people with type 2 diabetes and/or cardiovascular disease living in Victoria, Australia.

RESULTS

Many participants reported regular, frequent and long-term use of CAM therapies to maintain their health or assist in the management of their chronic condition. They generally managed the interface between convention and complementary health care on their own, as the perceived or expressed negative attitudes of some doctors, or the belief that the doctor did not need to know, were barriers to the disclosure of CAM use. For a smaller group, there was interaction between conventional and CAM providers, which limited the extent of uncertainty and conflicting information being (mis)interpreted by consumers.

CONCLUSIONS

Greater interaction between CAM and medical providers would be beneficial to consumers. Structural barriers, related to financing and service organization, need to be addressed. Attitudinal shifts of some health-care practitioners also need to be addressed, in the context of workforce development.

Room for improvement: complementary therapy users and the Australian health system

CONTEXT

People with chronic conditions who are often in contact with the health-care system are well placed to reflect on how services meet their needs. Some research characterizes people who use complementary and alternative medicines (CAMs) as a distinct group who opt out of the mainstream health system. However, many CAM users are people with chronic or terminal health conditions who concurrently use mainstream health-care services. The difference in perspectives between people with chronic conditions who do or do not use CAM has received little attention by researchers.

OBJECTIVE

To explore the views of CAM users with chronic conditions and identify their perspectives on the health system.

DESIGN AND SETTING

In-depth interviews and a self-administered questionnaire were used to collect data on care-seeking, self-management and CAM use among people with type 2 diabetes and/or cardiovascular disease living in Victoria, Australia.

RESULTS

One in four CAM practitioner users was partly motivated to use CAM as a result of their dissatisfaction with the mainstream health system. In general, their dissatisfaction mirrored the concerns of the general population. This included the perceived lack of a humanistic or person-centred approach, which was central to problems relating to individuals' clinical encounters as well as to health system design.

DISCUSSION AND CONCLUSION

Participants' concerns suggest room for improvement in the Australian health system to better reflect patients' needs. A systems approach is needed to reorient health-care practitioners to modify the organization of care because of the incentives embedded in the structure of the health-care system.

Ferric pyrophosphate citrate administered via dialysate reduces erythropoiesis-stimulating agent use and maintains hemoglobin in hemodialysis patients

Ferric pyrophosphate citrate (FPC) is a water-soluble iron salt administered via dialysate to supply iron directly to transferrin. The PRIME study tested whether treatment with FPC could reduce prescribed erythropoiesis-stimulating agent (ESA) use and maintain hemoglobin in hemodialysis patients. This 9-month, randomized, placebo-controlled, double-blind, multicenter clinical study included 103 patients undergoing hemodialysis 3-4 times weekly. The FPC group received dialysate containing 2 μmol/l of iron. The placebo group received standard dialysate. A blinded central anemia management group facilitated ESA dose adjustments. Intravenous iron was administered according to the approved indication when ferritin levels fell below 200 μg/l. The primary end point was the percentage change from baseline in prescribed ESA dose at end of treatment. Secondary end points included intravenous iron use and safety. At the end of treatment, there was a significant 35% reduction in prescribed ESA dose in FPC-treated patients compared with placebo. The FPC patients used 51% less intravenous iron than placebo. Adverse and serious adverse events were similar in both groups. Thus, FPC delivered via dialysate significantly reduces the prescribed ESA dose and the amount of intravenous iron needed to maintain hemoglobin in chronic hemodialysis patients.