Implementation level of best practice policies by Italian government for healthier food environments

Background

Government actions play a critical role in shaping healthy food environments, which can improve population's diet and decrease the burden of disease. This study aims to determine and compare the level of policy implementation for healthy food environments in Italy with reference to international benchmarks and make prioritized recommendations based on the identified implementation gaps.

Methods

The Healthy Food Environment Policy Index (Food-EPI) tool from the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) was adapted for the Italian context. This tool includes two components, thirteen domains and fifty good practice indicators, which were verified with experts from National Health Institute (NHI). Evidence for implementation was gathered and summarized for all fifty indicators from data sources such as governmental websites, non-government organizations publications and websites and via direct contact with government officials. After collecting all evidence, experts from the NHI verified the completeness and accuracy of it. The evidence document will be presented to stakeholders, aiming to seek consensus on the priority actions to be implemented by the Italian Government to improve food environments.

Results

The evidence for policy implementation concerning Italy varied among domains and indicators. We found the highest level of evidence within three domains: Food Composition (2/2 indicators), Food Labelling (3/4 indicators) and Food Promotion (4/5 indicators). The domains with less identified evidence were Food Prices (1/4 indicators), Food Retail (0/4 indicators), Food Trade and Investment (0/2 indicators) and Platforms and Interaction (1/4 indicators).

Conclusions

The evidence summarization and the upcoming stakeholders' meeting to rate the level of implementation for each indicator in Italy, have the potential to improve government commitment to shape healthier food environments.

Key messages

Food environment policies, implemented by the government, play a key role in the health of the population, decreasing the burden of disease. Several food environment policies have been implemented and supported by the Italian government but there are still some priority actions to be taken towards healthier food environments.

Success of reformulation and health education in reducing sodium intakes across socioeconomic groups

Background

The UK salt reduction programme started in 2005, consisting of education campaigns and a reformulation strategy. This programme is often cited as an example of a successful public health programme, and used as a model for other programmes. This study aims at assessing how the programme succeeded in reducing sodium intakes, and whether success was even across socioeconomic (SES) groups.

Methods

Food intakes for the UK adult population were derived from food diaries in the UK National Diet and Nutrition Survey for 2008/09 (Y1) and 2016/17 (Y9). Year-specific sodium densities of foods were used to calculate the quantity-weighted average sodium density of all food and beverage consumed by the population. Using a decomposition approach (Griffith et al., Economica, 2017), changes in sodium density were attributed to either changes in food composition (change in sodium density), or changes in behaviour (type and quantity of food products consumed), stratifying by SES.

Results

The programme was linked to a 16% decrease in sodium intakes between Y1 and Y9, while sodium density decreased by 15%. This decrease was largely driven by reformulation (-12mg/100g), while changes in food choices had a smaller impact (-2mg/100g). This finding was consistent across SES groups, whether stratified by education or income, with no significant differences between SES groups in behavioural responses to the programme (changes in food choices).

Conclusions

Changing people's food environment, through reformulation to reduce the sodium density of foods, had a larger impact on sodium intakes in the UK population than efforts to change food choices, and produced consistent impacts across SES groups.

Key messages

Reformulation led to a consistent reduction of the sodium density of food consumed across SES. There was no evidence of adverse equity impact from changes in behaviour.

The STOP project

The STOP project aims at expanding and consolidating the multi-disciplinary evidence base upon which effective and sustainable policies can be built to prevent and manage childhood obesity. STOP also aims at creating the conditions for evidence to translate into policy and for policy to translate into impacts on the ground. The primary focus of STOP is on the cumulative impacts of multiple and synergistic exposures in vulnerable and socially disadvantaged children and their families, which must be a priority target for the fight against childhood obesity in Europe to reach a tipping point and succeed. STOP will identify critical stages in childhood at which interventions can be most effective and efficient.

STOP is covering the whole umbrella of different research disciplines, to be able to understand and produce useful policy recommendations for complex issues such as childhood obesity. It is providing basic clinic research insights, comprehensive epidemiological data, study and overview of different public health-oriented measurements, understanding of stakeholders networking and effective communication. It builds on the observation that many interventions deployed by governments have failed to improve health-related behaviours in a sustained way over the life cycle. Little has been done to combine and triangulate different sources of biological, socio-economic and behavioural data to look at the overall, long-term consequences of an intervention on nutrition and metabolic health. Therefore, among other things, STOP focuses on the core idea that obesity has multiple and diverse characterisations, and therefore that one-size-fits-all policy approaches to childhood obesity are bound to fail, and the scientific component of the project is designed to recognise diversity and support the development of tailored solutions.

Gut Microbiota, Immune System, and Bone

The gut microbiota (GM) is the whole of commensal, symbiotic, and pathogenic microorganisms living in our intestine. The GM-host interactions contribute to the maturation of the host immune system, modulating its systemic response. It is well documented that GM can interact with non-enteral cells such as immune cells, dendritic cells, and hepatocytes, producing molecules such as short-chain fatty acids, indole derivatives, polyamines, and secondary bile acid. The receptors for some of these molecules are expressed on immune cells, and modulate the differentiation of T effector and regulatory cells: this is the reason why dysbiosis is correlated with several autoimmune, metabolic, and neurodegenerative diseases. Due to the close interplay between immune and bone cells, GM has a central role in maintaining bone health and influences bone turnover and density. GM can improve bone health also increasing calcium absorption and modulating the production of gut serotonin, a molecule that interacts with bone cells and has been suggested to act as a bone mass regulator. Thus, GM manipulation by consumption of antibiotics, changes in dietary habits, and the use of pre- and probiotics may affect bone health. This review summarizes evidences on the influence of GM on immune system and on bone turnover and density and how GM manipulation may influence bone health.

Lenalidomide normalizes tumor vessels in colorectal cancer improving chemotherapy activity

Background

Angiogenesis inhibition is a promising approach for treating metastatic colorectal cancer (mCRC). Recent evidences support the seemingly counterintuitive ability of certain antiangiogenic drugs to promote normalization of residual tumor vessels with important clinical implications. Lenalidomide is an oral drug with immune-modulatory and anti-angiogenic activity against selected hematologic malignancies but as yet little is known regarding its effectiveness for solid tumors. The aim of this study was to determine whether lenalidomide can normalize colorectal cancer neo-vessels in vivo, thus reducing tumor hypoxia and improving the benefit of chemotherapy.

Methods

We set up a tumorgraft model with NOD/SCID mice implanted with a patient-derived colorectal cancer liver metastasis. The mice were treated with oral lenalidomide (50 mg/Kg/day for 28 days), intraperitoneal 5-fluorouracil (5FU) (20 mg/Kg twice weekly for 3 weeks), combination (combo) of lenalidomide and 5FU or irrelevant vehicle. We assessed tumor vessel density (CD146), pericyte coverage (NG2; alphaSMA), in vivo perfusion capability of residual vessels (lectin distribution essay), hypoxic areas (HP2-100 Hypoxyprobe) and antitumor activity in vivo and in vitro.

Results

Treatment with lenalidomide reduced tumor vessel density (p = 0.0001) and enhanced mature pericyte coverage of residual vessels (p = 0.002). Perfusion capability of tumor vessels was enhanced in mice treated with lenalidomide compared to controls (p = 0.004). Accordingly, lenalidomide reduced hypoxic tumor areas (p = 0.002) and enhanced the antitumor activity of 5FU in vivo. The combo treatment delayed tumor growth (p = 0.01) and significantly reduced the Ki67 index (p = 0.0002). Lenalidomide alone did not demonstrate antitumor activity compared to untreated controls in vivo or against 4 different mCRC cell lines in vitro.

Conclusions

We provide the first evidence of tumor vessel normalization and hypoxia reduction induced by lenalidomide in mCRC in vivo. This effect, seemingly counterintuitive for an antiangiogenic compound, translates into indirect antitumor activity thus enhancing the therapeutic index of chemotherapy. Our findings suggest that further research should be carried out on synergism between lenalidomide and conventional therapies for treating solid tumors that might benefit from tumor vasculature normalization.

Treatment with intermittent PTH increases Wnt10b production by T cells in osteoporotic patients

We evaluated the effect of parathyroid hormone (PTH) on Wnt10b production by immune system cells in humans. We showed that bone anabolic effect of intermittent PTH treatment may be amplified by T cells through increased production of Wnt10b. Chronic increase in PTH as in primary hyperparathyroidism does not increase Wnt10b expression.

INTRODUCTION

The aim of this study is to assess the effect of PTH on Wnt10b production by immune system cells in humans. We assessed both the effect of intermittent PTH administration (iPTH) and of chronic PTH hypersecretion in primary hyperparathyroidism (PHP).

METHODS

Eighty-two women affected by post-menopausal osteoporosis were randomly assigned to treatment with calcium and vitamin D alone (22) or plus 1-84 PTH (42), or intravenous ibandronate (18). Wnt10b production by unfractioned blood nucleated cells and by T, B cells and monocytes was assessed by real-time RT-PCR and ELISA at baseline, 3, 6, 12 and 18 months of treatment. The effect of chronic elevation of PTH was evaluated in 20 patients affected by PHP at diagnosis and after surgical removal of parathyroid adenoma. WNT10b from both osteoporotic and PHP patients was compared to healthy subjects matched for age and sex.

RESULTS

iPTH increases Wnt10b production by T cells, whereas PHP does not. After surgical restoration of normal parathyroid function, WNT10b decreases, although it is still comparable with healthy subjects' level. Thus, chronic elevation of PTH does not significantly increase WNT10b production as respect to control.

CONCLUSIONS

This is the first work showing the effect of both intermittent and chronic PTH increase on Wnt10b production by immune system cells. We suggest that, in humans, T cells amplified the anabolic effect of PTH on bone, by increasing Wnt10b production, which stimulates osteoblast activity.

Incidence of primary and second cancers in renal transplant recipients: a multicenter cohort study

Limited data exist about cancer prognosis and the development of second cancers in renal transplant recipients. In a retrospective cohort study on 3537 patients incidence rates of the first and, if any, of a second cancer, and standardized incidence ratios [SIR (95% CI)] were computed. Two hundred and sixty-three (7.5%) patients developed a NMSC, and 253 (7.2%) another type of cancer after a median follow-up of 6.5 and 9.0 years, respectively. A statistically significant excess risk, if compared to an age- and sex-matched reference general population, was observed for Kaposi sarcoma and NMSC, followed by non-Hodgkin lymphoma and carcinoma of cervix uteri; a small number of unusual cancers such as tumors of the salivary glands, small intestine and thyroid also were detected at a level worthy of additional scrutiny. Ten-year survival rate of all noncutaneous cancers was 71.3%, with lower rates for lung carcinoma and non-Hodgkin lymphoma (0% and 41.7%, respectively). Patients with NMSC had an increased risk of developing a second NMSC [SIR 8.3 (7.0-10.0)], and patients with a primary noncutaneous cancer had increased risk of developing a second noncutaneous cancer [SIR 1.8 (1.2-2.8)], if compared to the whole cohort. Our study underscore that the high risk of primary and second cancer in renal transplant recipients, including unusual cancers.

Teriparatide increases the maturation of circulating osteoblast precursors

This study shows that teriparatide promotes the circulating osteoblast (OB) precursor degree of maturation in patients affected by postmenopausal osteoporosis.

INTRODUCTION

Anabolic treatment with teriparatide has proven effective for the therapy of postmenopausal osteoporosis and significantly reduces the risk of non-vertebral fragility fractures. The aim of this study was to investigate the effect of teriparatide on circulating OB precursors.

METHODS

We evaluated by flow cytometry and real-time PCR the expression of OBs typical markers in peripheral blood mononuclear cells during treatment with teriparatide plus calcium and vitamin D, raloxifene plus calcium and vitamin D or calcium and vitamin D alone at various time points. Serum bone alkaline phosphatase and osteocalcin (OC) were measured as markers of bone turnover.

RESULTS

Our results show that circulating OB precursors are more numerous and more immature in patients affected by fragility fractures than in osteoporotic patients without fractures. We also show that teriparatide treatment increases the expression of alkaline phosphatase and of OC in OB precursors; thus, it increases their degree of maturation.

CONCLUSIONS

We suggest that teriparatide acts as anabolic agents also by promoting the maturation of OB precursors.

Bone and bone marrow pro-osteoclastogenic cytokines are up-regulated in osteoporosis fragility fractures

This study evaluates cytokines production in bone and bone marrow of patients with an osteoporotic fracture or with osteoarthritis by real time PCR, Western blot and immunohistochemistry. We demonstrate that the cytokine pattern is shifted towards osteoclast activation and osteoblast inhibition in patients with osteoporotic fractures.

INTRODUCTION

Fragility fractures are the resultant of low bone mass and poor bone architecture typical of osteoporosis. Cytokines involved in the control of bone cell maturation and function are produced by both bone itself and bone marrow cells, but the roles of these two sources in its control and the amounts they produce are not clear. This study compares their production in patients with an osteoporotic fracture and those with osteoarthritis.

METHODS

We evaluated 52 femoral heads from women subjected to hip-joint replacement surgery for femoral neck fractures due to low-energy trauma (37), or for osteoarthritis (15). Total RNA was extracted from both bone and bone marrow, and quantitative PCR was used to identify the receptor activator of nuclear factor kB Ligand (RANKL), osteoprotegerin (OPG), macrophage colony stimulating factor (M-CSF), transforming growth factor β (TGFβ), Dickoppf-1 (DKK-1) and sclerostin (SOST) expression. Immunohistochemistry and Western blot were performed in order to quantify and localize in bone and bone marrow the cytokines.

RESULTS

We found an increase of RANKL/OPG ratio, M-CSF, SOST and DKK-1 in fractured patients, whereas TGFβ was increased in osteoarthritic bone. Bone marrow produced greater amounts of RANKL, M-CSF and TGFβ compared to bone, whereas the production of DKK-1 and SOST was higher in bone.

CONCLUSIONS

We show that bone marrow cells produced the greater amount of pro-osteoclastogenic cytokines, whereas bone cells produced higher amount of osteoblast inhibitors in patients with fragility fracture, thus the cytokine pattern is shifted towards osteoclast activation and osteoblast inhibition in these patients.

Randomized controlled trial comparing the effectiveness of 308-nm excimer laser alone or in combination with topical hydrocortisone 17-butyrate cream in the treatment of vitiligo of the face and neck

BACKGROUND

Vitiligo is a pigmentary disorder which may have disfiguring consequences. Its treatment remains a challenge.

OBJECTIVES

We designed a parallel-group randomized controlled trial to compare the effectiveness of 308-nm excimer laser alone or in combination with topical hydrocortisone 17-butyrate cream in patients with vitiligo unresponsive to previous treatment with topical steroids or narrow-band ultraviolet (UV) B phototherapy.

METHODS

Consecutive patients aged 18-75 years with nonsegmental vitiligo localized on the face and/or neck lacking response to previous conventional treatment were eligible. In total, 84 patients (44 women and 40 men, mean age 44 years) were randomized to 308-nm excimer laser phototherapy twice weekly alone or in combination with topical hydrocortisone 17-butyrate cream twice daily for three periods of 3 weeks followed by a 1-week steroid-free interval. The primary outcome was a reduction of at least 75% of the overall lesional areas as judged by automatic image analysis on reflected UV photographs, conducted blind to treatment assignment, at 12 weeks compared with baseline. Secondary outcomes were clearance, and improvements on Physician's Global Assessment (PGA) and Skindex-29 scores.

RESULTS

A total of 76 (90%) patients completed the study. In an intention-to-treat analysis, seven [16.6%; 95% confidence interval (CI) 5.3-27.8%] patients in the excimer monotherapy arm and 18 (42.8%; 95% CI 27.8-57.8%) in the combination arm showed > or = 75% reduction of vitiligo lesions at 12 weeks (chi(2) test 6.89, P = 0.0087). Clearance was observed in two (4.7%; 95% CI 1.6-11.2%) and nine (21.4%; 95% CI 9.0-33.8%) patients, respectively (Fisher's exact test P = 0.04). A significant difference also emerged for PGA scores, while no difference was documented for Skindex-29.

CONCLUSIONS

Recalcitrant vitiligo of the face and neck may benefit from the combination of excimer laser phototherapy with topical hydrocortisone 17-butyrate cream.

Affirmative action: the lessons for health care

Governments are becoming more assertive about reducing ethnic inequalities

A cost-utility analysis of patients undergoing orthognathic treatment for the management of dentofacial disharmony

INTRODUCTION

Management of dentofacial discrepancies using orthognathic treatment is now a common procedure in the United Kingdom. Although the benefits of orthognathic intervention are often considered, the cost implications have not been investigated to our knowledge. This study is a cost-utility analysis of orthognathic treatment.

PATIENTS AND METHODS

Twenty-one patients were interviewed five times during treatment using the time trade-off (TTO) method to establish utility values. Quality adjusted life years (QALYs) gained as a result of treatment were calculated and discounted. The resource use was calculated for each of the 21 patients individually and the costs subjected to both a sensitivity analysis and discounting. The incremental mean cost per additional QALY was calculated (as compared with a 'no treatment' approach).

RESULTS

The incremental cost for each additional QALY was 561 pounds sterling for the groups combined, based on mean additional costs and QALYs (546 pounds sterling for the bimaxillary group and 617 pounds sterling for the single jaw group).

DISCUSSION

Orthognathic treatment seems to provide good outcomes at relatively low cost. Even allowing for the uncertainty in mean costs and QALYs, there is a high probability of treatment being cost-effective. Cost-utility analysis is still a relatively new technique in dentistry and further studies should be encouraged.

[Public health in the XXI century]

To understand what will happen in the future one must draw on the experience of those from the past who have tried to predict what is happening now. The paper develops a taxonomy of visionaries of futurologist; the advocates of historical determinism, who come from both the left, such as Marx, and the right, such as Toffler and Fukuyama; the scientist, ranging from Leonardo da Vinci to Arthur C. Clarke, and the pragmatists, who seek to learn from evidence and the experience of others. These will be examined in turn and the frequent failings of the first three will be illustrated. Drawing on experience in a variety of European countries it will be concluded that our best hope is to learn from each other and from empirical evidence. The article will conclude with a review of some of the challenges which are either predictable but being ignored or totally unpredictable.

Association between HLA-A/-B antigens and -DRB1 alleles and nasopharyngeal carcinoma in Tunisia

Using serologic and molecular methods, 45 nasopharyngeal carcinoma (NPC) patients were typed for HLA class I and class II and were compared to 100 unrelated normal Tunisians. Our results showed that the antigen frequency of HLA-B13 and allelic frequencies of DRB1*03, DRB1*15 were significantly higher in the NPC patients than in the control group (15.5 vs. 4; 26.4 vs. 11.5, and 14.4 vs. 6.5%, respectively) probably indicating a positive association with NPC. Moreover, we observed that HLA-A23 was absent in our NPC sample and was present in 18% of normal controls, and HLA-DRB1*11 was less frequent among the patients compared to the controls (5.5 vs. 14%) suggesting a protective effect of this association with NPC.

The European way to health technology assessment. Lessons from an evaluation of EUR-ASSESS

OBJECTIVES

The EUR-ASSESS project was undertaken by a large number of members of European health technology assessment (HTA) agencies and programs with the aim of improving coordination through developments in several areas of HTA. At the conclusion of the project, an independent survey was undertaken to reassess the importance of the original objectives of EUR-ASSESS and determine the impact of the project on the way HTA activities are organized and carried out in Europe.

METHODS

A postal questionnaire survey and a series of more in-depth personal interviews.

RESULTS

EUR-ASSESS was generally considered successful in achieving its aims, particularly in creating an informal network of people and organizations, improving the understanding of the work of others, improving the ability to focus the objectives of HTA, facilitating the sharing of experience and mutual learning opportunities, exchanging ideas on research agendas, and developing a common language. However, significant differences emerged in the expectations of different actors in European HTA, and in their perceptions of the impact of the project. These reflect the wide diversity of approaches existing in Europe.

CONCLUSIONS

Health technology assessment in Europe is changing its nature from a set of national or local initiatives with relatively limited impact to a truly European movement with strong links and coordination between its individual components. Important lessons can be learned from the experience of EUR-ASSESS, particularly in the light of an increasing commitment of the European Commission to play a role in the development of technology assessment.

Cost analysis of nurse telephone consultation in out of hours primary care: evidence from a randomised controlled trial

OBJECTIVE

To undertake an economic evaluation of nurse telephone consultation using decision support software in comparison with usual general practice care provided by a general practice cooperative.

DESIGN

Cost analysis from an NHS perspective using stochastic data from a randomised controlled trial.

SETTING

General practice cooperative with 55 general practitioners serving 97 000 registered patients in Wiltshire, England.

SUBJECTS

All patients contacting the service, or about whom the service was contacted during the trial year (January 1997 to January 1998).

MAIN OUTCOME MEASURES

Costs and savings to the NHS during the trial year.

RESULTS

The cost of providing nurse telephone consultation was 81 237 pound sterling per annum. This, however, determined a 94 422 pound sterling reduction of other costs for the NHS arising from reduced emergency admissions to hospital. Using point estimates for savings, the cost analysis, combined with the analysis of outcomes, showed a dominance situation for the intervention over general practice cooperative care alone. If a larger improvement in outcomes is assumed (upper 95% confidence limit) NHS savings increase to 123 824 pound sterling per annum. Savings of only 3728 pound sterling would, however, arise in a scenario where lower 95% confidence limits for outcome differences were observed. To break even, the intervention would have needed to save 138 emergency hospital admissions per year, around 90% of the effect achieved in the trial. Additional savings of 16 928 pound sterling for general practice arose from reduced travel to visit patients at home and fewer surgery appointments within three days of a call.

CONCLUSIONS

Nurse telephone consultation in out of hours primary care may reduce NHS costs in the long term by reducing demand for emergency admission to hospital. General practitioners currently bear most of the cost of nurse telephone consultation and benefit least from the savings associated with it. This indicates that the service produces benefits in terms of service quality, which are beyond the reach of this cost analysis.

Hepatitis C virus antibodies in dialysis patients in Tunisia: a single center study

Fifty-eight patients on maintenance hemodialysis in a dialysis unit at Tunis, Tunisia were tested for anti-hepatitis C virus (anti-HCV) antibodies by second generation ELISA test, and for HCV-RNA by nested reverse transcriptase polymerase chain reaction (RT-PCR) of 5' non-coding region. Specificity of the antibodies was confirmed by immunoblot test. HCV genotype was defined using INNO-LIPA test. Twenty-seven out of 58 patients (46.5%) were reactive by ELISA. Transaminase levels were assessed over a six-month period and showed normal average values. Fourteen of the 27 anti-HCV positive patients (51%) were positive by RT-PCR. Type 1b HCV genotype was the most prevalent, seen in all the dialysis patients and one patient in addition, was co-infected with genotype 4. There was a significant correlation between the duration on dialysis (over five years) and the prevalence of anti-HCV-positive patients (P< 0.005) while no correlation existed between the number of blood transfusions and the presence of anti-HCV antibodies. The present study illustrates the high prevalence of HCV infection among Tunisian dialysis patients (51%) and indicates that the spread may be nosocomial rather than transfusion-related.

Vaccines for preventing hepatitis B in health-care workers

BACKGROUND

Hepatitis B causes acute and chronic liver disease and may be prevented by vaccination.

OBJECTIVES

To assess the effectiveness and safety of plasma-derived vaccines against acute and chronic hepatitis B in health-care workers in protecting them from hepatitis B infection and its consequences.

SEARCH STRATEGY

MEDLINE and Excerpta Medica Database (EMBASE) search using standard Cochrane strategy, Cochrane Library, full text searching of the journal "Vaccine", bibliography of retrieved studies and correspondence with authors, researchers and manufacturers.

SELECTION CRITERIA

All original prospective randomised comparisons of yeast-derived vaccines and plasma-derived vaccines against no intervention, placebo, or vaccines against other disease (control vaccines). Assessment of trial quality was made according to: 1. generation of allocation schedule 2. measure(s) taken to conceal treatment allocation 3. drop-out of allocated health-care worker participants from the analysis of trial results 4. measures taken to implement double blinding Trial reports were blinded by removal of authors and their affiliation, journal reference, introduction, results, and discussion.

DATA COLLECTION AND ANALYSIS

To assess efficacy the incidence rates of acute hepatitis B were observed in the surveillance of the vaccinated and control groups of the trials included in the review. Safety was assessed from side-effect rates, classified as systemic (malaise, nausea, fever, arthralgias, rash, headache) or local (induration and soreness at the site of the inoculation).

MAIN RESULTS

Four trials fulfilling the criteria were identified and the data synthesised. All trials compared plasma-derived vaccines versus placebo. Differences in the settings (and level of incidence) between three of the trial settings and Dienstag's led us to stratify our comparison grouping the three trials performed in dialysis units together. After our stratification, the Desmyter, Smuzness and Crosnier group appears to be homogeneous (Chi-square = 0.11, degrees of freedom = 2). Our estimates of effectiveness and safety in the high risk group favour treatment, the OR for cases of HB being 0.34; 95% CI (0.21, 0.55). The analysis also revealed a non-significant trend towards benefit in the lower risk health-care workers (Dienstag trial, OR 0.26 (0.05, 1.30). Overall the evidence strongly favours vaccination (OR=0.33; 95% CI (0.21, 0.53)). There was no difference in the incidence and severity of side-effects between the two arms of the trials. We calculated that it was necessary to vaccinate between 145 (assuming a baseline rate of 10 cases/1000/year) and 7 (for a baseline rate of 200/1000/year) health-care workers with plasma-derived vaccines to avoid one case of hepatitis B. Completeness of trial reporting was not good with all four trials failing to report titre results on antibodies against hepatitis B surface antigen and hepatitis B core antigen in the placebo arms (correspondence with two of the four authors failed to shed light on the reasons for such an omission). All four trials achieved low scores in the four quality dimensions assessed (generation of allocation schedule, measure(s) taken to conceal treatment allocation, exclusion of allocated participants from the analysis of the trial and measures taken to implement and protect double blinding). Mean length of follow-up was 14.5 months.

REVIEWER'S CONCLUSIONS

Plasma-derived vaccines appear to be efficacious and safe for use in high risk health-care workers, such as staff of renal dialysis and transplant units. There is some uncertainty concerning the effectiveness of the vaccine in lower risk health-care workers, although the trend is towards benefit. We found no evidence of a long-term protective effect due to the short follow-up time of the four trials included in this review. We found relatively poor standard of trial reporting, possibly related to the age of the trials.

Economic evaluation of diagnostic technology. Methodological challenges and viable solutions

The principles of economic evaluation are increasingly accepted by clinicians and policy makers as evidence from a significant number of studies becomes available to support their decisions. However, methods of assessment still need to be improved. This paper reports a comprehensive review of methodological challenges in the economic evaluation of diagnostic technology, where such challenges are more evident. This review formed the basis for a prioritized research agenda, with four main areas: modeling techniques for dealing with complexity; measures of the opportunity cost of shared resources; techniques for eliciting decision makers' utility functions for diagnostic tests; and ways of assessing the robustness of decisions. A number of methodological solutions are proposed, aimed at capturing elements and relationships that are usually neglected and fully recognizing the presence of an inductive cognitive component in decision-making processes.