General Perceptions and Knowledge of Antibiotic Resistance and Antibiotic Use Behavior: A Cross-Sectional Survey of US Adults

This study aimed to assess understanding of antibiotic resistance and evaluate antibiotic use themes among the general public. In March 2018, respondents that were ≥21 years old and residing in the United States were recruited from ResearchMatch.org and surveyed to collect data on respondent expectations, knowledge, and opinions regarding prescribing antibiotics and antibiotic resistance. Content analysis was used to code open-ended definitions of antibiotic resistance into central themes. Chi-square tests were used to assess differences between the definitions of antibiotic resistance and antibiotic use. Among the 657 respondents, nearly all (99%) had taken an antibiotic previously. When asked to define antibiotic resistance, the definitions provided were inductively coded into six central themes: 35% bacteria adaptation, 22% misuse/overuse, 22% resistant bacteria, 10% antibiotic ineffectiveness, 7% body immunity, and 3% provided an incorrect definition with no consistent theme. Themes that were identified in respondent definitions of resistance significantly differed between those who reported having shared an antibiotic versus those who had not (p = 0.03). Public health campaigns remain a central component in the fight to combat antibiotic resistance. Future campaigns should address the public’s understanding of antibiotic resistance and modifiable behaviors that may contribute to resistance.

Major Update 2: Antibody Response and Risk for Reinfection After SARS-CoV-2 Infection-Final Update of a Living, Rapid Review

BACKGROUND

The durability of the antibody response after SARS-CoV-2 infection and the role of antibodies in protection against reinfection are unclear.

PURPOSE

To synthesize evidence on the SARS-CoV-2 antibody response and reinfection risk with a focus on gaps identified in our prior reports.

DATA SOURCES

MEDLINE (Ovid), EMBASE, CINAHL, World Health Organization Research Database, and reference lists from 16 December 2021 through 8 July 2022, with surveillance through 22 August 2022.

STUDY SELECTION

English-language, cohort studies evaluating IgG antibody duration at least 12 months after SARS-CoV-2 infection, the antibody response among immunocompromised adults, predictors of nonseroconversion, and reinfection risk.

DATA EXTRACTION

Two investigators sequentially extracted study data and rated quality.

DATA SYNTHESIS

Most adults had IgG antibodies after SARS-CoV-2 infection at time points greater than 12 months (low strength of evidence [SoE]). Although most immunocompromised adults develop antibodies, the overall proportion with antibodies is lower compared with immunocompetent adults (moderate SoE for organ transplant patients and low SoE for patients with cancer or HIV). Prior infection provided substantial, sustained protection against symptomatic reinfection with the Delta variant (high SoE) and reduced the risk for severe disease due to Omicron variants (moderate SoE). Prior infection was less protective against reinfection with Omicron overall (moderate SoE), but protection from earlier variants waned rapidly (low SoE).

LIMITATION

Single review for abstract screening and sequential review for study selection, data abstraction, and quality assessment.

CONCLUSION

Evidence for a sustained antibody response to SARS-CoV-2 infection is considerable for both Delta and Omicron variants. Prior infection protected against reinfection with both variants, but, for Omicron, protection was weaker and waned rapidly. This information may have limited clinical applicability as new variants emerge.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42020207098).

Receipt of Concurrent VA and Non-VA Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veterans With Traumatic Brain Injury

OBJECTIVE

Receipt of concurrent psychotropic prescription medications from both US Department of Veterans Affairs (VA) and non-VA healthcare providers may increase risk of adverse opioid-related outcomes among veterans with traumatic brain injury (TBI). Little is known about patterns of dual-system opioid or sedative-hypnotic prescription receipt in this population. We estimated the prevalence and patterns of, and risk factors for, VA/non-VA prescription overlap among post-9/11 veterans with TBI receiving opioids from VA providers in Oregon.

SETTING

Oregon VA and non-VA outpatient care.

PARTICIPANTS

Post-9/11 veterans in Oregon with TBI who received an opioid prescription from VA providers between the years of 2014 and 2019.

DESIGN

Historical cohort study.

MAIN MEASURES

Prescription overlap of VA opioids and non-VA opioids or sedative-hypnotics; proportions of veterans who received VA or non-VA opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were also examined by year and by veteran characteristics.

RESULTS

Among 1036 veterans with TBI receiving opioids from the VA, 210 (20.3%) received an overlapping opioid prescription from a non-VA provider; 5.3% received overlapping benzodiazepines; and none received overlapping nonbenzodiazepine sedative-hypnotics. Proportions of veterans with prescription overlap tended to decrease over time. Veterans with other than urban versus urban addresses (OR = 1.4; 95% CI, 1.0-1.8), high versus medium average annual VA visits (OR = 1.7; 95% CI, 1.1-2.6), and VA service connection of 50% or more versus none/0% to 40% (OR = 4.3; 95% CI, 1.3-14.0) were more likely to have concurrent VA/non-VA prescriptions in bivariable analyses; other than urban remained associated with overlap in multivariable models. Similarly, veterans with comorbid posttraumatic stress disorder diagnoses were more likely to have concurrent VA/non-VA prescriptions in both bivariable and multivariable (OR = 2.1; 95% CI, 1.0-4.1) models.

CONCLUSION

Among post-9/11 veterans with TBI receiving VA opioids, a considerable proportion had overlapping non-VA prescription medications. Providers and healthcare systems should consider all sources of psychotropic prescriptions, and risk factors for overlapping medications, to help mitigate potentially unsafe medication use among veterans with TBI.

Mask use in community settings in the context of COVID-19: A systematic review of ecological data

BACKGROUND

The wearing of medical and non-medical masks by the general public in community settings is one intervention that is important for the reduction of SARS-CoV-2 transmission, and has been the subject of considerable research, policy, advocacy and debate. Several observational studies have used ecological (population-level) data to assess the effect of masks on transmission, hospitalization, and mortality at the region or community level.

METHODS

We undertook this systematic review to summarize the study designs, outcomes, and key quality indicators of using ecological data to evaluate the association between mask wearing and COVID-19 outcomes. We searched the World Health Organization (WHO) COVID-19 global literature database up to 5 March 2021 for studies reporting the impact of mask use in community settings on outcomes related to SARS-CoV-2 transmission using ecological data.

FINDINGS

Twenty one articles were identified that analysed ecological data to assess the protective effect of policies mandating community mask wearing. All studies reported SARS-CoV-2 benefits in terms of reductions in either the incidence, hospitalization, or mortality, or a combination of these outcomes. Few studies assessed compliance to mask wearing policies or controlled for the possible influence of other preventive measures such as hand hygiene and physical distancing, and information about compliance to these policies was lacking.

INTERPRETATION

Ecological studies have been cited as evidence to advocate for the adoption of universal masking policies. The studies summarized by this review suggest that community mask policies may reduce the population-level burden of SARS-CoV-2. Methodological limitations, in particular controlling for the actual practice of mask wearing and other preventive policies make it difficult to determine causality. There are several important limitations to consider for improving the validity of ecological data.

162. Assessment of Beta-lactam Allergies as Rationale for Receipt of Vancomycin for Surgical Prophylaxis

Background

Beta-lactam (BL) antibiotics are first-line agents for most patients receiving antimicrobial prophylaxis in surgical procedures. Despite evidence showing low cross-reactivity between classes of BLs, patients with allergies commonly receive vancomycin as an alternative to avoid allergic reaction. The objective of this study was to identify potentially inappropriate use of vancomycin surgical prophylaxis among patients with reported BL allergies.

Methods

Adult patients (≥18 years) receiving vancomycin for surgical prophylaxis with a reported penicillin and/or cephalosporin allergy at our institution between August 2017 to July 2018 were retrospectively evaluated for potential eligibility for penicillin allergy testing and/or receipt of standard prophylaxis. Surgery type and allergy history were extracted from the electronic medical record. Per our institution’s penicillin-testing protocol, patients with IgE-mediated reactions < 10 years ago were eligible for penicillin skin testing (PST), mild reactions or IgE-mediated reaction > 10 years ago were eligible for direct oral amoxicillin challenge, and severe non-IgE mediated allergies were ineligible for penicillin allergy evaluation or BL prophylaxis.

Results

Among 830 patients who received vancomycin for surgical prophylaxis, 196 reported BL allergy and were included in the analysis (155 with penicillin allergy alone; 21 with cephalosporin allergy; 20 with both cephalosporin and penicillin allergy). Approximately 40% of surgeries were orthopedic. Six patients were ineligible for BL prophylaxis. Per institutional protocol, 73 of 155 patients (48%) may have qualified for PST; 81 of 155 (52%) patients may have received a direct oral amoxicillin challenge. Only 3 of 22 patients with history of methicillin-resistant Staphylococcus aureus appropriately received additional prophylaxis with vancomycin and a BL.

Conclusion

Patients with BL allergies often qualify for receipt of a first-line BL antibiotic. An opportunity exists for improved BL allergy assessment as an antimicrobial stewardship intervention. Future studies should evaluate outcomes associated with BL allergy evaluation and delabeling in patients receiving surgical prophylaxis.

Disclosures

All Authors: No reported disclosures

1034. Automating Assessments of Vancomycin Appropriateness

Background

Assessing appropriateness of hospital antibiotic use is typically a labor-intensive task for antimicrobial stewardship teams and relies heavily on clinician judgement rather than a systematic process. Vancomycin is a frequently used agent that is a common stewardship target. We developed an algorithm to automatically classify the appropriateness of vancomycin days of therapy (DOTs) based upon electronic health record data.

Methods

We constructed a retrospective cohort of Oregon Health and Science University (OHSU) Hospital and Doernbecher Children’s Hospital patients admitted August 1, 2017 to July 31, 2018 receiving vancomycin. Data were collected on demographic, encounter, pharmacy, microbiology, and surgery data. An electronic algorithm was applied to classify vancomycin DOTs as appropriate, inappropriate, or indeterminate. Inappropriate use was defined as any case in which there was an opportunity for de-escalation as identified using microbiology data, ICD-10 codes, and procedure codes.

Results

We included 4,231 encounters; 493 (12%) were pediatric patients. Our algorithm automatically classified 59%, 3%, and 38% of encounters as having either appropriate, inappropriate, or indeterminate DOTs, respectively. Forty-four percent of all encounters received no more than a 24-hour course of vancomycin and were considered appropriate empiric therapy; half of these were attributed to surgical prophylaxis. Nine percent of all encounters had vancomycin administered within 3 days of a blood, sputum or tissue culture in which either a methicillin-resistant Staphylococcus species or an ampicillin-resistant, vancomycin-susceptible Enterococcus species was isolated and were classified as appropriate. Six percent of all encounters had cultures in which only Gram-negatives, fungi, or yeast were isolated and were therefore considered appropriate in the empiric period (≤48 hours) but inappropriate thereafter.

Conclusion

Automated assessments of antibiotic appropriateness could facilitate more informed antimicrobial stewardship initiatives and serve as a valuable stewardship metric. Characterization of indeterminate vancomycin use may inform increased automated classification. Further effort is needed to validate these assessments.

Disclosures

All authors: No reported disclosures.

1027. Vancomycin Use in Community-Acquired Pneumonia: Assessing Inappropriate Therapy

Background

Current Infectious Disease Society of America guidelines recommend anti-methicillin-resistant Staphylococcus aureus(MRSA) agents for treatment of community-acquired pneumonia (CAP) only in specific high-risk patients. There are limited data on duration of vancomycin use that is appropriate in hospitalized patients with CAP. The objective of this study was to evaluate the use of vancomycin for CAP among inpatients.

Methods

We conducted a retrospective cohort study of inpatients at Oregon Health and Science University Hospital from August 1^st, 2017 to July 31^st, 2018 who received IV vancomycin and had a pneumonia encounter ICD-9 diagnosis code. Patients with hospital or ventilator-associated pneumonia were excluded. Appropriate therapy was defined as empiric therapy with known risk-factors, concordant therapy with no de-escalation option, or concurrent sepsis or febrile neutropenia. Vancomycin appropriateness was assessed based on medical history and microbiology for both empiric and definitive therapy. We characterized patients receiving inappropriate therapy and calculated the proportion of inappropriate days of therapy (DOT).

Results

We identified 52 patients with CAP who were treated with vancomycin for a median of 2 DOT (Interquartile Range (IQR): 1–3). Approximately 21% (11/52) of patients had risk factors warranting vancomycin empiric therapy and 42% (22/52) had concurrent sepsis. Nine CAP patients received inappropriate courses of vancomycin, median of 1 day (IQR: 1–2.25) of inappropriate therapy. The most common reason for classifying use as inappropriate was a positive culture for organisms other than MRSA. Patients receiving inappropriate therapy were more frequently transferred from another hospital (44% vs. 30%, P = 0.22). Overall, 16% (20/125) of vancomycin DOT were inappropriate.

Conclusion

In our study,CAP patients accounted for a small number of pneumonia patients who received vancomycin. The median inappropriate DOT was relatively short, possibly indicating that identification and de-escalation was performed quickly. Further work is required to determine the impact of these findings on patients.

Disclosures

All authors: No reported disclosures.

1873. Next Steps in Predicting Anti-MRSA Antibiotic Prescribing

Background

Antibiotic use metrics are utilized by antimicrobial stewardship programs to benchmark performance against peer institutions and inform stewardship efforts. Benchmarking requires risk adjustment for patient- and facility-level factors so that remaining differences are attributable only to prescribing practices. Antibiotics for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) are one of the most frequently used drug classes. Our objective was to identify predictors of anti-MRSA antibiotic use in a nationwide network of hospitals.

Methods

We used data from inpatient encounters at facilities participating in the Vizient data repository between January 1, 2016 and December 31, 2016. The outcome, anti-MRSA antibiotic use, was calculated as days of therapy per patient-days present for each encounter. We constructed a multivariable negative binomial regression model and assessed the following predictors for inclusion: age, sex, race, ethnicity, diagnosis related groups (DRGs), ICU days, admit month, facility bed size, facility teaching status, and region. A clinical framework was used to categorize DRGs based on risk of anti-MRSA antibiotic use. A backwards stepwise approach was used to identify the final model. We evaluated predictor effect size and significance, and assessed model fit using a deviance-based pseudo-R².

Results

One hundred forty-five facilities representing 3,608,711 encounters met inclusion criteria. All predictors considered in our model were significant. Predictors with the greatest magnitude of association included DRG categories and patient age. The DRG categories with the strongest associations were DRGs for infections likely due to Staphylococcus aureus (RR = 1.66, P < 0.0001) or for diagnoses likely to receive long-term MRSA coverage (RR = 1.49, P < 0.0001). The age group with the strongest association was age 2–10 years (RR = 1.64; P < 0.001). The deviance-based pseudo-R² of the final model was 0.19, indicating good model fit.

Conclusion

DRGs and patient-level characteristics can be utilized to account for variability in anti-MRSA antibiotic use beyond what is explained through facility-level characteristics. Incorporation of the significant predictors identified in this study may aid in more meaningful interhospital comparisons of anti-MRSA antibiotic use in both adults and pediatrics.

Disclosures

J. C. McGregor, Merck: Grant Investigator, Research grant.

Timing of Decompression in Patients With Acute Spinal Cord Injury: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To conduct a systematic review and synthesis of the literature to assess the comparative effectiveness, safety, and cost-effectiveness of early (≤24 hours) versus late decompression (>24 hours) in adults with acute spinal cord injury (SCI).

METHODS

A systematic search was conducted of Medline, EMBASE, the Cochrane Collaboration Library, and Google Scholar to identify studies published through November 6, 2014. Studies published in any language, in humans, and with an abstract were considered for inclusion. Included studies were critically appraised and the overall strength of evidence was determined using methods proposed by the Grading of Recommendation Assessment, Development and Evaluation working group.

RESULTS

The search yielded 449 potentially relevant citations. Sixteen additional primary studies were identified through other sources. Six studies met inclusion criteria. All but 2 studies were considered to have moderately high risk of bias. Across studies and injury levels, the impact of early surgical decompression (≤24 hours) on clinically important improvement in neurological status was variable. Isolated studies reported statistically significant and clinically important improvements at 6 months (cervical injury, low strength of evidence) and following discharge from inpatient rehabilitation (all levels, very low strength of evidence) but not at other time points; another study observed a statistically significant 6 point improvement in ASIA Impairment Scale (AIS) among patients with AIS B, C, or D, but not for those with AIS A (very low strength of evidence). In one study of acute central cord syndrome without instability, a clinically and statistically meaningful improvement in total motor scores was reported at 6 and 12 months in patients treated early (versus late). There were, however, no significant differences in AIS improvement between early and late surgical groups at 6- or 12-months (very low strength of evidence). One of 3 studies found a shorter length of hospital stay associated with early surgical decompression. Of 3 studies reporting on safety, no significant differences in rates of complications (including mortality, neurologic deterioration, pneumonia or pressure ulcers) were noted between early and late decompression groups.

CONCLUSIONS

Results surrounding the efficacy of early versus late decompressive surgery, as well as the quality of evidence available, were variable depending on the level of SCI, timing of follow-up, and specific outcome considered. Existing evidence supports improved neurological recovery among cervical SCI patients undergoing early surgery; however, evidence regarding remaining SCI populations and clinical outcomes was inconsistent.

Efficacy, Safety, and Timing of Anticoagulant Thromboprophylaxis for the Prevention of Venous Thromboembolism in Patients With Acute Spinal Cord Injury: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The objective of this study was to answer 5 key questions: What is the comparative effectiveness and safety of (1a) anticoagulant thromboprophylaxis compared to no prophylaxis, placebo, or another anticoagulant strategy for preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) after acute spinal cord injury (SCI)? (1b) Mechanical prophylaxis strategies alone or in combination with other strategies for preventing DVT and PE after acute SCI? (1c) Prophylactic inferior vena cava filter insertion alone or in combination with other strategies for preventing DVT and PE after acute SCI? (2) What is the optimal timing to initiate and/or discontinue anticoagulant, mechanical, and/or prophylactic inferior vena cava filter following acute SCI? (3) What is the cost-effectiveness of these treatment options?

METHODS

A systematic literature search was conducted to identify studies published through February 28, 2015. We sought randomized controlled trials evaluating efficacy and safety of antithrombotic strategies. Strength of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Nine studies satisfied inclusion criteria. We found a trend toward lower risk of DVT in patients treated with enoxaparin. There were no significant differences in rates of DVT, PE, bleeding, and mortality between patients treated with different types of low-molecular-weight heparin or between low-molecular-weight heparin and unfractionated heparin. Combined anticoagulant and mechanical prophylaxis initiated within 72 hours of SCI resulted in lower risk of DVT than treatment commenced after 72 hours of injury.

CONCLUSION

Prophylactic treatments can be used to lower the risk of venous thromboembolic events in patients with acute SCI, without significant increase in risk of bleeding and mortality and should be initiated within 72 hours.

Limitations of A Measurement Tool to Assess Systematic Reviews (AMSTAR) and suggestions for improvement

A Measurement Tool to Assess Systematic Reviews (AMSTAR) is a commonly used tool to assess the quality of systematic reviews; however, modifications are needed to improve its usability, reliability, and validity. In this commentary, we summarize our experience and the experiences of others who have used AMSTAR and provide suggestions for its improvement. We propose that AMSTAR should modify a number of individual items and their instructions and responses to make them more congruent with an assessment of the methodologic quality of systematic reviews. We recommend adding new items and modifying existing items to assess the quality of the body of evidence and to address subgroup and sensitivity analyses. More detailed instructions are needed for scoring individual items across multiple reviewers, and we recommend that a total score should not be calculated. These suggestions need to be empirically tested prior to implementation.

Clinical trial registries are of minimal use for identifying selective outcome and analysis reporting

OBJECTIVE

This study aimed to examine selective outcome reporting (SOR) and selective analysis reporting (SAR) in randomized controlled trials (RCTs) and to explore the usefulness of trial registries for identifying SOR and SAR.

STUDY DESIGN AND SETTING

We selected one "index outcome" for each of three comparative effectiveness reviews (CERs) of pharmacotherapy and extracted data on this outcome from trial registries and from study publications.

RESULTS

Among 50 RCTs published since 2005 and reporting the index outcome, only 50% were listed in registries; 90% of RCTs were assessed as having SOR or SAR. The index outcome in the registry was different from that in the publication in 75% of trials in two CERs, and not specified at all in the third. Reported outcomes and analyses were not consistent between the publication's methods section and the results section in 33% and 46% of the two CERs where the index outcome was a benefit. There were no statistically significant predictors of SOR and SAR in our small sample where some predictors lacked variability.

CONCLUSION

The SOR and SAR were frequent in this pilot study, and the most common type of SOR was the publication of outcomes that were not pre-specified. Trial registries were of little use in identifying SOR and of no use in identifying SAR.

Conflicts of interest among authors of clinical practice guidelines for glycemic control in type 2 diabetes mellitus

BACKGROUND

Conflict of interest (COI) is an important potential source of bias in the development of clinical practice guidelines (CPGs).

OBJECTIVES

To examine rates of disclosure of COI, including financial interests in companies that manufacture drugs that are recommended in CPGs on glycemic control in type 2 diabetes mellitus, and to explore the relationship between recommendations for specific drugs in a guideline and author COI.

METHODS

We identified a cohort of relevant guidelines from the National Guideline Clearinghouse (NGC) and abstracted COI disclosures from all guideline authors for this observational, cross-sectional study. We determined which hypoglycemic drugs were recommended in each guideline, and explored the relationship between specific disclosures and whether a drug was recommended.

RESULTS

Among 13 included guidelines, the percentage of authors with one or more financial disclosures varied from 0 to 94% (mean 44.2%), and was particularly high for two US-based guidelines (91% and 94%). Three guidelines disclosed no author financial COI. The percentage of authors with disclosures of financial interests in manufacturers of recommended drugs was also high (mean 30%). On average, 56% of manufacturers of patented drugs recommended in each guideline had one or more authors with a financial interest in their company. We did not find a significant relationship between financial interests and whether a drug was recommended in our sample; US-based guidelines were more likely to make recommendations for a specific drug compared to non-US based guidelines.

DISCUSSION

Authors of this cohort of guidelines have financial interests directly related to the drugs that they are recommending. Although we did not find an association between author COI and drugs recommended in these guidelines and we cannot draw conclusions about the validity of the recommendations, the credibility of many of these guidelines is in doubt.

Quality of clinical practice guidelines for glycemic control in type 2 diabetes mellitus

Background

Several studies have reported that clinical practice guidelines (CPGs) in a variety of clinical areas are of modest or variable quality. The objective of this study was to evaluate the quality of an international cohort of CPGs that provide recommendations on pharmaceutical management of glycemic control in patients with type 2 diabetes mellitus (DM2).

Methods and Findings

We searched the National Guideline Clearinghouse (NGC) on February 15th and June 4th, 2012 for CPGs meeting inclusion criteria. Two independent assessors rated the quality of each CPG using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. Twenty-four guidelines were evaluated, and most had high scores for clarity and presentation. However, scope and purpose, stakeholder involvement, rigor of development, and applicability domains varied considerably. The majority of guidelines scored low on editorial independence, and only seven CPGs were based on an underlying systematic review of the evidence.

Conclusions

The overall quality of CPGs for glycemic control in DM2 is moderate, but there is substantial variability among quality domains within and across guidelines. Guideline users need to be aware of this variability and carefully appraise and select the guidelines that they apply to patient care.

Conflict of interest disclosures for clinical practice guidelines in the national guideline clearinghouse

BACKGROUND

Conflict of interest (COI) is an important potential source of bias in the development of clinical practice guidelines (CPGs) and high rates of COI among guideline authors have been reported in the past. Our objective was to report current rates of disclosure and specific author COI across a broad range of CPGs and to examine whether CPG characteristics were associated with the presence of disclosures and of conflicts.

METHODS AND FINDINGS

We selected a random sample of 250 CPGs listed in the National Guideline Clearinghouse on November 22, 2010, representing approximately a 10% sample of guidelines listed in the NGC on that date. We abstracted information on author COI from each CPG and examined predictors of the disclosures and COI using a logistic generalized estimating equation regression model. 87% of organizations developing guidelines had a CPG-specific policy, however, 40% of CPGs did not indicate that they had collected disclosures from guideline authors. In addition, 42% of organizations that did collect author disclosures did not have those disclosures available in the public domain. Of CPGs where we had disclosures for all authors, 60% had one or more authors with a conflict. On average, 28% of the authors of CPGs with available disclosures had a COI. Guidelines that were published in journals with an impact factor greater than 5.0 were more likely to have one or more authors with a COI than guidelines not published in journals.

CONCLUSIONS

Rates of disclosure of author COI and the public availability of that information are unacceptably low, however rates of COI among guideline authors may have decreased in recent years. Continued efforts are needed to establish and enforce optimal COI policies in clinical practice guideline development in order to minimize the risk of bias associated with those conflicts.

Characteristics of physicians receiving large payments from pharmaceutical companies and the accuracy of their disclosures in publications: an observational study

Background

Financial relationships between physicians and industry are extensive and public reporting of industry payments to physicians is now occurring. Our objectives were to describe physician recipients of large total payments from these seven companies, and to examine discrepancies between these payments and conflict of interest (COI) disclosures in authors’ concurrent publications.

Methods

The investigative journalism organization, ProPublica, compiled the Dollars for Docs database of payments to individuals from publically available data from seven US pharmaceutical companies during the period 2009 to 2010. We examined the cohort of 373 physicians in this database who each received USD $100,000 or more in the reporting period 2009 to 2010.

Results

These physicians received a total of $52,600,624 during this period (mean payment per physician $141,020). The predominant specialties were internal medicine and psychiatry. 147 of these physicians authored a total of 134 publications in the first quarter of 2011 and 77% (103) of these publications provided a COI disclosure. 69% of the 103 publications did not contain disclosures of the payment listed in the Dollars for Docs database.

Conclusions

With increased public reporting of industry payments to physicians, it is apparent that large sums are being paid for services such as consulting and peer education. In over two-thirds of publications where COI disclosures were provided, the disclosures by physician authors did not include industry payments that were documented in the Dollars for Docs database.

Conflict of interest policies for organizations producing a large number of clinical practice guidelines

BACKGROUND

Conflict of interest (COI) of clinical practice guideline (CPG) sponsors and authors is an important potential source of bias in CPG development. The objectives of this study were to describe the COI policies for organizations currently producing a significant number of CPGs, and to determine if these policies meet 2011 Institute of Medicine (IOM) standards.

METHODOLOGY/PRINCIPAL FINDINGS

We identified organizations with five or more guidelines listed in the National Guideline Clearinghouse between January 1, 2009 and November 5, 2010. We obtained the COI policy for each organization from publicly accessible sources, most often the organization's website, and compared those polices to IOM standards related to COI. 37 organizations fulfilled our inclusion criteria, of which 17 (46%) had a COI policy directly related to CPGs. These COI policies varied widely with respect to types of COI addressed, from whom disclosures were collected, monetary thresholds for disclosure, approaches to management, and updating requirements. Not one organization's policy adhered to all seven of the IOM standards that were examined, and nine organizations did not meet a single one of the standards.

CONCLUSIONS/SIGNIFICANCE

COI policies among organizations producing a large number of CPGs currently do not measure up to IOM standards related to COI disclosure and management. CPG developers need to make significant improvements in these policies and their implementation in order to optimize the quality and credibility of their guidelines.

Conflict of interest in clinical practice guideline development: a systematic review

BACKGROUND

There is an emerging literature on the existence and effect of industry relationships on physician and researcher behavior. Much less is known, however, about the effects of these relationships and other conflicts of interest (COI) on clinical practice guideline (CPG) development and recommendations. We performed a systematic review of the prevalence of COI and its effect on CPG recommendations.

METHODOLOGY/PRINCIPAL FINDINGS

We searched Medline (1980 to March, 2011) for studies that examined the effect of COI on CPG development and/or recommendations. Data synthesis was qualitative. Twelve studies fulfilled inclusion criteria; 9 were conducted in the US. All studies reported on financial relationships of CPG authors with the pharmaceutical industry; 1 study also examined relationships with diagnostic testing and insurance companies. The majority of guidelines had authors with industry affiliations, including consultancies (authors with relationship, range 6-80%); research support (4-78%); equity/stock ownership (2-17%); or any COI (56-87%). Four studies reported multiple types of financial interactions for individual authors (number of types per author: range 2 to 10 or more). Data on the effect of COI on CPG recommendations were confined to case studies wherein authors with specific financial ties appeared to benefit from the related CPG recommendations. In a single study, few authors believed that their relationships influenced their recommendations. No studies reported on intellectual COI in CPGs.

CONCLUSIONS/SIGNIFICANCE

There are limited data describing the high prevalence of COI among CPG authors, and only case studies of the effect of COI on CPG recommendations. Further research is needed to explore this potential source of bias.

l-dopa-induced reversal in striatal glutamate following partial depletion of nigrostriatal dopamine with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine

We have reported that 1 month following acute (20mg/kg x 4) or subchronic (30 mg/kg/day x 7d) administration of the neurotoxin, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine, there is an increase or decrease, respectively, in the extracellular level of striatal glutamate as determined by in vivo microdialysis [Robinson S, Freeman P, Moore C, Touchon JC, Krentz L, Meshul CK (2003) Acute and subchronic MPTP administration differentially affects striatal glutamate synaptic function. Exp Neurol 180:73-86]. The goal of this study was to determine the effects of treatment with l-dopa (15 mg/kg) for 21 days on striatal glutamate starting on day 8 after the first dose of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine was administered to mice. Following acute administration of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine, the increase in extracellular striatal glutamate due to lesion of the nigrostriatal pathway was completely reversed to a level below that found in the vehicle-treated group after l-dopa treatment. Subchronic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine treatment resulted in a decrease in striatal extracellular glutamate that was reversed to the level close to that observed in the vehicle-treated group. There was no change in the density of nerve terminal glutamate immunolabeling associated with the synaptic vesicle pool, suggesting that the alterations in extracellular glutamate most likely originated from the calcium-independent pool. There was a similar decrease in the relative density of tyrosine hydroxylase immunolabeling, a marker for dopamine terminals, within the dorsolateral striatum in both the acute and subchronic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated groups that had been administered l-dopa. There was a decrease in the relative density of immunolabeling within the dorsolateral striatum for the glutamate transporter, GLT-1, following acute 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine treatment in the groups administered either vehicle or l-dopa. There was no change in GLT-1 immunolabeling following subchronic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. The results demonstrate that the reversal in the extracellular level of striatal glutamate following l-dopa treatment in both the acute and subchronic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated groups is not due to changes in either striatal dopamine nerve terminals or in the density of the glutamate transporter, GLT-1.

Apomorphine-induced alterations in striatal and substantia nigra pars reticulata glutamate following unilateral loss of striatal dopamine

We have reported time-dependent changes in extracellular glutamate within the striatum at 1 and 3 months following a unilateral lesion of the nigrostriatal pathway using the neurotoxin, 6-hydroxydopamine (6-OHDA) (Meshul, C.K., Emre, N., Nakamura, C.M., Allen, C., Donohue, M.K., Buckman, J.F., 1999. Time-dependent changes in striatal glutamate synapses following a 6-hydroxydopamine lesion. Neurosci. 88, 1-16.). The aim of the present study was to determine the effects of such a lesion on glutamate within the substantia nigra pars reticulata (SN-PR) and the effect of subchronic administration of the dopamine D-1/D-2 agonist, apomorphine, on extracellular glutamate within both the striatum and the SN-PR using in vivo microdialysis. One month after the lesion, there is an increase in extracellular glutamate within the striatum and apomorphine treatment leads to a further increase. Within the SN-PR, a loss of striatal dopamine leads to a decrease in extracellular glutamate, while apomorphine treatment leads to a further decrease in nigral glutamate. Three months after a 6-OHDA lesion, there is a decrease in extracellular striatal glutamate, with apomorphine administration leading to essentially no further change in glutamate. The loss of striatal dopamine increased extracellular glutamate within the SN-PR while apomorphine administration resulted in a decrease in extracellular glutamate back to the value observed in the control group. The data suggests that the increase in striatal glutamate 1 month following a 6-OHDA lesion alone or following subchronic apomorphine is consistent with the hypothesis that a decrease in glutamate within the SN-PR leads to activation of the thalamo-cortico-striatal pathway. The decrease in striatal glutamate 3 months after a nigrostriatal lesion is also consistent with the observed increase in extracellular glutamate within the SN-PR, thus leading to a decrease in output of the thalamo-cortico-striatal pathway.

High and low responders to novelty show differential effects in striatal glutamate

The goal of this study was to determine whether there was a difference in glutamate within the dorsolateral striatum in mice exhibiting either a high (HR) or low (LR) locomotor response to a novel environment. The number of line crossings over a 30-min-period when the mice were placed in a novel environment was determined, and those mice for which the values were above the mean were in the HR group and those with the values below the mean were in the LR group. In vivo microdialysis was carried out to determine the basal extracellular level of striatal glutamate, and the contralateral striatum was taken to measure the density of glutamate immunolabeling within nerve terminals making an asymmetrical (excitatory) synaptic contact using quantitative immuno-gold electron microscopy. There was a statistically significant difference (35%) in the basal extracellular level of striatal glutamate between the HR and LR groups, with the HR group having a lower level, compared with that of the LR group. There was a 25% difference in the density of nerve terminal glutamate immuno-gold labeling associated with the synaptic vesicle pool in the HR, compared with that in the LR group, but this difference was not statistically significant. There was no change in the basal extracellular level of striatal dopamine between the two groups, but there was a statistically significant difference (73%) in the basal turnover ratio of striatal dopamine and its metabolites in the HR, compared with that in the LR group. The data suggests that the difference in extracellular striatal glutamate between the HR and LR groups is not due to an alteration in basal extracellular dopamine but could be due to an increase in dopamine turnover.

Dietary restriction affects striatal glutamate in the MPTP-induced mouse model of nigrostriatal degeneration

One month following subchronic treatment with the neurotoxin, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) (30 mg/kg/d x 7 days), there is a decrease in the extracellular level of striatal glutamate. It has been reported that following dietary restriction (DR) (fed on alternate days) of C57BL/6 mice, MPTP administration resulted in a reduction in the loss of tyrosine hydroxylase-positive neurons within the substantia nigra pars compacta (SN-PC) compared to the ad libitum (AL)-fed MPTP-treated mice. However, there have been no reports of whether the MPTP-induced alterations in brain neurochemistry or morphology can be similarly attenuated by DR if initiated after administration of the toxin. In the MPTP/AL group there is a decrease in the extracellular level of striatal glutamate compared to the Vehicle/AL group. However, 21 days of DR starting 1 day after the last subchronic dose of MPTP results in a reversal in the extracellular level of striatal glutamate compared to the MPTP/AL group. DR alone resulted in a decrease in extracellular striatal glutamate. There was no change in the relative density of the glutamate transporter, GLT-1, within the striatum or SN-PC between any of the groups, suggesting that the alterations in striatal extracellular glutamate were not due to a change in this specific transporter. There was an increase in the density of nerve terminal glutamate immunolabeling in the MPTP/AL and MPTP/DR groups compared to the Vehicle/AL group. There was a similar decrease in the relative density of tyrosine hydroxylase immunolabeling within the striatum and the SN-PC in both the MPTP/AL and MPTP/DR groups compared to the Vehicle/AL group. Since a decrease in the activity of the corticostriatal glutamate pathway has been reported in both Parkinson's disease and in animal models of nigrostriatal loss, these data suggest that DR initiated after the partial loss of striatal dopamine appears to reverse the decrease in striatal glutamate.

Differential effects of chronic escapable versus inescapable stress on male syrian hamster (Mesocricetus auratus) reproductive behavior

Stress decreases sexual activity, but it is uncertain which aspects of stress are detrimental to reproduction. This study used an escapable/inescapable stress paradigm to attempt to dissociate physical from psychological components of stress, and assess each component's impact on reproductive behavior in the male Syrian hamster (Mesocricetus auratus). Two experiments were completed using this protocol where two animals receive the same physical stressor (an electric footshock) but differ in the psychological aspect of control. One group (executive) could terminate the shock for themselves as well as a second group (yoked) by pressing a bar. Experiment 1 demonstrated a significant increase in plasma glucocorticoids at the end of a single 90-min stress session with no difference in glucocorticoid levels between the executive and yoked groups at any time point. Experiment 2 quantified male reproductive behavior prior to and immediately following 12 days of escapable or inescapable stress in executive, yoked, and no-stress control hamsters (n = 12/group). Repeated-measures analysis of variance revealed a number of significant changes in reproductive behavior before and after stress in the three treatment groups. The most striking difference was a decrease in hit rate observed only in the animals that could not control their stress (yoked group). Hit rate in the executive males that received the exact same physical stressor but could terminate the shock by pressing a bar was nearly identical to control animals that never received any foot shock. Therefore, we conclude that coping or control can ameliorate the negative effects of stress on male reproductive behavior.