Changes in Use of Hepatitis C Direct-Acting Antivirals After Access Restrictions Were Eased by State Medicaid Programs

Importance

Direct-acting antivirals (DAAs) are safe and highly effective for curing hepatitis C virus (HCV) infection, but their high cost led certain state Medicaid programs to impose coverage restrictions. Since 2015, many of these restrictions have been lifted voluntarily in response to advocacy or because of litigation.

Objective

To estimate how the prescribing of DAAs to Medicaid patients changed after states eased access restrictions.

Design, Setting, and Participants

This modified difference-in-differences analysis of 39 state Medicaid programs included Medicaid beneficiaries who were prescribed a DAA from January 1, 2015, to December 31, 2019. DAA coverage restrictions were measured based on a series of cross-sectional assessments performed from 2014 through 2022 by the US National Viral Hepatitis Roundtable and the Center for Health Law and Policy Innovation.

Exposure

Calendar quarter when states eased or eliminated 3 types of DAA coverage restrictions: limiting treatment to patients with severe liver disease, restricting use among patients with active substance use, and requiring prescriptions to be written by or in consultation with specialists. States with none of these restrictions at baseline were excluded.

Main Outcomes and Measures

Quarterly number of HCV DAA treatment courses per 100 000 Medicaid beneficiaries.

Results

Of 39 states, 7 (18%) eliminated coverage restrictions, 25 (64%) eased restrictions, and 7 (18%) maintained the same restrictions from 2015 to 2019. During this period, the average quarterly use of DAAs increased from 669 to 3601 treatment courses per 100 000 Medicaid beneficiaries. After states eased or eliminated restrictions, the use of DAAs increased by 966 (95% CI, 409-1523) treatment courses per 100 000 Medicaid beneficiaries each quarter compared with states that did not ease or eliminate restrictions.

Conclusions and Relevance

The results of this study suggest that there was greater use of DAAs after states relaxed coverage restrictions related to liver disease severity, sobriety, or prescriber specialty. Further reductions or elimination of these rules may improve access to a highly effective public health intervention for patients with HCV.

Benchmarking of the Cervical Cancer Care Cascade and Survival Outcomes After Radiation Treatment in a Low- and Middle-Income Country Setting

PURPOSE

Timely radiation treatment (RT) is critical in cervical cancer treatment, but patients in low- and middle-income countries (LMICs) in sub-Saharan Africa often face barriers that delay care. Time to care was benchmarked in a multidisciplinary team (MDT) setting in Botswana.

METHODS

Time intervals between steps in care were recorded for 230 patients reviewed at MDT between January 2016 and July 2018. Associations between RT delay and overall survival (OS) were evaluated using Kaplan-Meier curves and multivariable Cox proportional hazards models.

RESULTS

For patients who received RT (n = 187; 81.3%), the median biopsy to pathology reporting interval was 25 (IQR, 19-36) days and was 57 (IQR, 28-68) days for patients who did not (P = .003). Intervals in care did not differ between patients who did and did not receive RT. Among treated patients, the uppermost quartile interval from pathology reporting to RT initiation was ≥111 days and that from RT simulation to initiation was ≥12 days. Among patients receiving a RT dose of ≥65 Gy (n = 100), the delay from RT simulation to initiation of >12 days was associated with worse median OS (2.0 v 4.6 years; P = .048); this association trended toward, although did not meet, statistical significance on multivariable analysis (hazard ratio, 2.35; 95% CI, 0.95 to 5.85; P = .07).

CONCLUSION

The MDT-coordinated care model allows for systematic benchmarking of the patient treatment cascade. Barriers to timely treatment exist for this cohort in Botswana, and RT delay may be associated with OS of patients receiving curative treatment. Interventions to accelerate the timing of the radiation oncology care cascade may improve clinical outcomes in this LMIC setting.

SARS-CoV-2 Vaccine-Induced Immune Responses Among Hematopoietic Stem Cell Transplant Recipients

Background

Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination reduces the risk and severity of coronavirus disease 2019 (COVID-19), several variables may impact the humoral response among patients undergoing hematopoietic stem cell transplantation (HSCT).

Methods

A retrospective chart review was conducted among SARS-CoV-2-vaccinated HSCT recipients between 2020 and 2022 at a single center in Boston, Massachusetts. Patients age ≥18 years who received doses of Pfizer, Moderna, or J&J vaccines were included. Anti-spike (S) immunoglobulin G (IgG) titer levels were measured using the Roche assay. Responders (≥0.8 U/mL) and nonresponders (<0.8 U/mL) were categorized and analyzed. Multivariable linear and logistic regression were used to estimate the correlation coefficient and odds ratio of response magnitude and status.

Results

Of 152 HSCT recipients, 141 (92.8%) were responders, with a median (interquartile range [IQR]) anti-S IgG titer of 2500 (107.9-2500) U/mL at a median (IQR) of 80.5 (36-153.5) days from last dose, regardless of the number of doses received. Higher quantitative titers were associated with receipt of more vaccine doses (coeff, 205.79; 95% CI, 30.10 to 381.47; P = .022), being female (coeff, 343.5; 95% CI, -682.6 to -4.4; P = .047), being younger (<65 years; coeff, 365.2; 95% CI, -711.3 to 19.1; P = .039), and not being on anti-CD20 therapy (coeff, -1163.7; 95% CI, -1717.7 to -609.7; P = .001). Being male (odds ratio [OR], 0.11; 95% CI, 0.01 to 0.93; P = .04) and being on anti-CD20 therapy (OR, 0.16; 95% CI, 0.03 to 0.70; P = .016) were associated with nonresponse.

Conclusions

Overall, most HSCT recipients had high SARS-CoV-2 antibody responses. More vaccine doses improved the magnitude of immune responses. Anti-S IgG monitoring may be useful for identifying attenuated vaccine-induced responses.

Severe Acute Respiratory Syndrome Coronavirus 2 Vaccine Immunogenicity among Chimeric Antigen Receptor T Cell Therapy Recipients

Patients receiving chimeric antigen receptor T cell (CAR-T) therapy may have impaired humoral responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccinations owing to their underlying hematologic malignancy, prior lines of therapy, and CAR-T-associated hypogammaglobulinemia. Comprehensive data on vaccine immunogenicity in this patient population are limited. A single-center retrospective study of adults receiving CD19 or BCMA-directed CAR-T therapy for B cell non-Hodgkin lymphoma or multiple myeloma was conducted. Patients received at least 2 doses of SARS-CoV-2 vaccination with BNT162b2 or mRNA-1273 or 1 dose of Ad26.COV2.S and had SARS-CoV-2 anti-spike antibody (anti-S IgG) levels measured at least 1 month after the last vaccine dose. Patients were excluded if they received SARS-CoV-2 monoclonal antibody therapy or immunoglobulin within 3 months of the index anti-S titer. The seropositivity rate (assessed by an anti-S assay cutoff of ≥.8 U/mL in the Roche assay) and median anti-S IgG titers were analyzed. Fifty patients were included in the study. The median age was 65 years (interquartile range [IQR], 58 to 70 years), and the majority were male (68%). Thirty-two participants (64%) had a positive antibody response, with a median titer of 138.5 U/mL (IQR, 11.61 to 2541 U/mL). Receipt of ≥3 vaccines was associated with a significantly higher anti-S IgG level. Our study supports current guidelines for SARS-CoV-2 vaccination among recipients of CAR-T therapy and demonstrates that a 3-dose primary series followed by a fourth booster increases antibody levels. However, the relatively low magnitude of titers and low percentage of nonresponders demonstrates that further studies are needed to optimize vaccination timing and determine predictors of vaccine response in this population.

1939. COVID-19 vaccine immunogenicity among CD19 receptor T-cell (CAR-T) therapy

Background

Patients receiving CAR-T therapy may have impaired humoral responses to SARS-CoV-2 vaccinations due to their high net state of immunosuppression associated with the underlying disease, prior lines of therapy and CAR-T treatment associated hypogammaglobinemia. Comprehensive data on vaccine immunogenicity in this patient population are currently lacking.

Methods

A single-center retrospective study of adults receiving CD19 CAR-T therapy for non-Hodgkin’s lymphoma was conducted between 3/27/2018 – 8/31/2021. Patients received at least two doses of COVID-19 vaccinations with BNT162b2 (Pfizer, BioNTech), mRNA-1273 (Moderna), or 1 dose of Ad26.COV2.S (Janssen) and had SARS-CoV-2 anti-spike (S) levels measured at least one month after the last vaccine dose. We excluded patients who received COVID-19 monoclonal antibody therapy or immunoglobulin within 3 months of the index anti-S titer. Patients were followed from the time of the first COVID-19 vaccines through their index anti-S antibody result. Patients were censored on the first day of any additional antineoplastic therapy after disease relapse. Our primary endpoint was the percentage of patients who develop a positive anti-S response (assessed by anti-S assay cutoff of &gt;0.8 U/mL, Roche assay).

Results

Twenty-five patients met eligibility. Median age was 65 years (range 41 – 78), and majority of patients were male (72%). The number of patients with a positive antibody response was 12 (48%). Median number of vaccines received was 3. 18 patients (72%) received Pfizer vaccines, 4 patients (16%) received Moderna, 2 patients (8%) received Moderna and Pfizer, and 1 patient (4%) received Janssen and Pfizer. Median anti-S titers among patients with a positive response was 111 U/mL (range 2.44 – 12500). Two patients (8%) had COVID-19, both with negative anti-S responses.

Conclusion

Our analysis shows that only 48% of patients who received CAR-T therapy developed a positive antibody response after at least two COVID-19 vaccine doses, with a low median titer among responders. This patient population is at higher risk for developing severe COVID-19 disease and likely remains vulnerable even after vaccination. Alternative approaches are needed to prevent COVID-19 and mitigate disease severity in patients undergoing CAR-T.

Disclosures

Nicolas C. Issa, MD, AiCuris: Grant/Research Support|Merck: Grant/Research Support Sarah P. Hammond, MD, F2G: Advisor/Consultant|F2G: Grant/Research Support|GSK: Grant/Research Support|Scynexis: Grant/Research Support Caron Jacobson, MD, MMSc, Abintus Bio: Advisor/Consultant|Bluebird Bio: Advisor/Consultant|BMS/Celgene: Advisor/Consultant|Daiichi-Sankyo: Advisor/Consultant|Epizyme: Advisor/Consultant|ImmPACT Bio: Advisor/Consultant|Instill Bio: Advisor/Consultant|Ipsen: Advisor/Consultant|Kite/Gilead: Advisor/Consultant|Kite/Gilead: Grant/Research Support|Lonza: Advisor/Consultant|Novartis: Advisor/Consultant|Pfizer: Grant/Research Support.

Prevalence and outcomes of twin pregnancies in Botswana: a national birth outcomes surveillance study

OBJECTIVES

This study aims to evaluate the prevalence and outcome of twin pregnancies in Botswana.

SETTING

The Tsepamo Study conducted birth outcomes surveillance at 8 government-run hospitals (~45% of all births in Botswana) from August 2014 to June 2018 and expanded to 18 hospitals (~70% of all births in Botswana) from July 2018 to March 2019.

PARTICIPANTS

Data were collected for all live-born and stillborn in-hospital deliveries with a gestational age (GA) greater than 24 weeks. This analysis included 117 593 singleton and 3718 twin infants (1859 sets (1.6%)) born to 119 477 women between August 2014 and March 2019 and excluded 73 higher order multiples (23 sets of triplets and 1 set of quadruplets).

OUTCOMES MEASURED

Our primary outcomes were preterm delivery (<37 weeks GA), very preterm delivery (<32 weeks GA) and stillbirth (APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score of 0, 0, 0).

RESULTS

Women with twin pregnancies had a similar median number of antenatal care visits (9 vs 10), but were more likely to deliver in a tertiary centre (54.8% vs 45.1%, p<0.001) and more likely to have a cesarean-section (54.6% vs 22.0%, p<0.001) than women with singletons. Compared with singletons, twin pregnancies had a higher risk of preterm delivery (<37 weeks GA) (47.6% vs 16.7%, adjusted risk ratio (aRR) 2.8, 95% CI 2.7 to 2.9) and very preterm delivery (<32 weeks) (11.8% vs 4.0%, aRR 3.0 95% CI 2.6 to 3.4). Among all twin pregnancies, 128 (6.9%) had at least one stillborn infant compared with 2845 (2.4%) stillbirths among singletons (aRR 2.8, 95% CI 2.3 to 3.3).

CONCLUSION

Adverse birth outcomes are common among twins in Botswana, and are often severe. Interventions that allow for earlier identification of twin gestation and improved antenatal management of twin pregnancies may improve infant and child survival.

Disparities in SARS-CoV-2 Vaccination-to-Infection Risk During the COVID-19 Pandemic in Massachusetts

This cohort study examines the alignment of vaccination and SARS-CoV-2 risk in Massachusetts by creating and applying a vaccination-to-infection risk ratio.

Retrospective cohort analysis of prescription patterns of cancer medications during periods of drug stockouts in Botswana

OBJECTIVE

Cancer drug stockouts occur at high frequencies globally, however, their effects on treatment are understudied in sub-Saharan Africa (SSA). We aimed to determine whether causes of suboptimal cancer treatment prescriptions differed between periods of stockout and full treatment supply.

DESIGN

A retrospective cohort study of systemic therapy prescriptions for patients diagnosed with the twelve most common solid tumour cancers treated in 2016.

SETTING

Princess Marina Hospital in Gaborone, Botswana.

PARTICIPANTS

Patients in the retrospective cohort who experienced any suboptimal treatment events, defined as ≥7 days delay or switch from guideline-concordant initiated therapy.

PRIMARY AND SECONDARY OUTCOME MEASURES

Frequency of delays and patterns of prescription changes for specific regimens and cancer types.

RESULTS

167/378 patients contributed to 320 suboptimal events (115 therapy switches, 167 delays and 38 events with both), over 1452 total chemotherapy cycles received. Events during stockout were 43% delays, 43% switches and 14% both during stockout periods and 67.2% delays, 24.4% switches and 8.4% both during non-stockout periods (p<0.001). Majority of switches involved de-escalation of initially prescribed guideline-recommended regimens in patients with breast cancer, Kaposi sarcoma and patients with colorectal cancer, which occurred more frequently during periods of drug stockouts. Among patients with breast cancer, substitution of docetaxel for paclitaxel event occurred exclusively during paclitaxel drug stockout. Delays of ≥7 days events were most frequent in breast cancer patients receiving paclitaxel during stockout, and combination doxorubicin and cyclophosphamide even during periods of non-stockout.

CONCLUSIONS

The aetiology of suboptimal events differed during stockout and non-stockout periods. Prescription patterns that involved de-escalation of initiated therapy and substitution of paclitaxel with docetaxel occurred frequently during periods of drug stockout. Further research needs to be conducted to understand the impact of stockout on survival and barriers to maintaining essential cancer medicines supplies in SSA, and the factors driving frequent delays in therapy delivery.

The Impact of Syndromic Management of Vaginal Discharge Syndrome on Adverse Birth Outcomes in Botswana

Background

Vaginal discharge syndrome (VDS) is a common clinical diagnosis during pregnancy in Botswana; it is treated with broad-spectrum antibiotics using a syndromic approach. We evaluated associations between the syndromic management of VDS and adverse birth outcomes.

Methods

The Tsepamo Study performs birth outcomes surveillance at government hospitals throughout Botswana. Obstetric record data collected from August 2014 to March 2019 were analyzed. Chi-square tests were conducted to compare proportions of maternal characteristics and infant outcomes. To avoid immortal time bias, all analyses were conducted among women who presented to care before 24 weeks gestation, with VDS categorized as present or absent by 24 weeks gestation. Log-binomial regression models were generated to determine associations between treated VDS and infant outcomes.

Results

VDS was diagnosed in 36 731 (30.7%) pregnant women, of whom 33 328 (90.7%) received antibiotics. Adjusted analyses yielded a harmful association between treated VDS and very preterm delivery (adjusted risk ratio, 1.11; 95% CI, 1.02-1.21). This association remained when restricting to women with VDS who received the recommended antibiotic treatment regimen. Sensitivity analyses produced nonsignificant associations when women with treated VDS were compared with women without VDS who received antibiotics for other indications.

Conclusions

A clinical diagnosis of VDS is common among pregnant women in Botswana, and the majority receive antibiotics in pregnancy. Although analyses of VDS occurring later in pregnancy are precluded by immortal time bias, a modest association between treated VDS and very preterm delivery was observed among women diagnosed with VDS by 24 weeks gestation.

Disparities in SARS-CoV-2 Testing in Massachusetts During the COVID-19 Pandemic

This cohort study examines disparities in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing during the coronavirus disease 2019 (COVID-19) pandemic in Massachusetts.

Weight gain during pregnancy among women initiating dolutegravir in Botswana

BACKGROUND

Recent data suggests clinically significant weight gain among non-pregnant HIV-positive adults after starting dolutegravir-based ART (DTG). Excess or insufficient weight gain in pregnancy could adversely impact pregnancy outcomes, but data for pregnant women receiving DTG are limited.

METHODS

The Tsepamo Study captured data at delivery sites in Botswana from 2014 to 2019. HIV testing, HIV treatment information, and weight measurements during antenatal care were abstracted from the maternity obstetric record at delivery. HIV-positive women initiating DTG or efavirenz-based ART (EFV) between conception and 17 weeks gestation and HIV-uninfected women first presenting for antenatal care before 17 weeks gestation were included. We evaluated weekly weight gain, total 18-week weight gain, excess weight gain (>0.59 kg/week), insufficient weight gain (<0.18 kg/week), and weight loss between 18±2 and 36±2 weeks gestation, adjusting for demographic and clinical variables.

FINDINGS

Baseline characteristics were similar by exposure group, including pre-pregnancy and early pregnancy weight. Compared with EFV, mean weekly weight gain between 18 and 36 weeks gestation was 0.05 (95% CI 0.03, 0.07) kg/week higher for women initiating DTG and 0.12 (0.10, 0.14) kg/week higher for HIV-uninfected women. Mean 18-week weight gain was 1.05 (95% CI 0.61, 1.49) kg higher for women initiating DTG and 2.31 (1.85, 2.77) kg higher for HIV-uninfected women, compared with EFV. Women initiating DTG were more likely to gain excess weight but less likely to gain insufficient weight or lose weight than women initiating EFV.

INTERPRETATION

Women initiating DTG compared with EFV during pregnancy gained more weight between 18 and 36 weeks gestation. Neither group gained as much weight as HIV-uninfected women. Initiating DTG compared with EFV during pregnancy could increase the risk of excess weight gain but decrease the risk of insufficient weight gain and weight loss, which could have positive and negative consequences in pregnancy. Our findings are consistent with prior studies in non-pregnant adults.

SARS-CoV-2 Testing Disparities in Massachusetts

OBJECTIVE

Early deficiencies in testing capacity contributed to poor control of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the context of marked improvement in SARS-CoV-2 testing infrastructure, we sought to examine the alignment of testing with epidemic intensity to mitigate subsequent waves of COVID-19 in Massachusetts.

METHODS

We compiled publicly available weekly SARS-CoV-2 molecular testing data for period (May 27 to October 14, 2020) following the initial COVID-19 wave. We defined testing intensity as weekly SARS-CoV-2 tests performed per 100,000 population and used weekly test positivity (percent of tests positive) as a measure of epidemic intensity. We considered optimal alignment of testing resources to be matching community ranks of testing and positivity. In communities with a lower rank of testing than positivity in a given week, the testing gap was calculated as the additional tests required to achieve matching ranks. Multivariable Poisson modeling was utilized to assess for trends and association with community characteristics.

RESULTS

During the observation period, 4,262,000 tests were reported in Massachusetts and the misalignment of testing with epidemic intensity increased. The weekly testing gap increased 9.0% per week (adjusted rate ratio [aRR]: 1.090, 95% confidence interval [CI]: 1.08-1.10). Increasing levels of community socioeconomic vulnerability (aRR: 1.35 per quartile increase, 95% CI: 1.23-1.50) and the highest quartile of minority and language vulnerability (aRR: 1.46, 95% CI 0.96-1.49) were associated with increased testing gaps, but the latter association was not statistically significant. Presence of large university student population (>10% of population) was associated with a marked decrease in testing gap (aRR 0.21, 95% CI: 0.12-0.38).

CONCLUSION

These analyses indicate that despite objectives to promote equity and enhance epidemic control in vulnerable communities, testing resources across Massachusetts have been disproportionally allocated to more affluent communities. Worsening structural inequities in access to SARS-CoV-2 testing increase the risk for another intense wave of COVID-19 in Massachusetts, particularly among vulnerable communities.

Incisional hernia formation in hepatobiliary surgery using transverse and hybrid incisions: a systematic review and meta-analysis

INTRODUCTION

Evidence suggests that midline incisions should be closed with the small-bite technique to reduce IH formation. No recommendations exist for the closure of transverse incisions used in hepatobiliary surgery. This work systematically summarises rates of IH formation and associated technical factors for these transverse incisions.

METHODS

A systematic search was undertaken. Studies describing the incidence of IH were included. Incisions were classified as transverse (two incision types) or hybrid (transverse with midline extension, comprising five incision types). The primary outcome measure was the pooled proportion of IH. Subgroup analysis based on minimum follow-up of two years and a priori definition of IH with clinical and radiological diagnosis was undertaken.

FINDINGS

Thirteen studies were identified and included 5,427 patients; 1,427 patients (26.3%) underwent surgery for benign conditions, 3,465 (63.8%) for malignancy and 535 (9.9%) for conditions that were not stated or classified as 'other'. The pooled incidence of IH was 6.0% (2.0-10.0%) at a weighted mean follow-up of 17.5 months in the transverse group, compared with 15.0% (11.0-19.0%) at a weighted mean follow-up of 42.0 months in the hybrid group (p = 0.045). Subgroup analysis did not demonstrate a statistical difference in IH formation between the hybrid versus transverse groups.

CONCLUSION

Owing to the limitations in study design and heterogeneity, there is limited evidence to guide incision choice and methods of closure in hepatopancreatobiliary surgery. There is an urgent need for a high-quality prospective cohort study to understand the techniques used and their outcomes, to inform future research.

Neural-Tube Defects and Antiretroviral Treatment Regimens in Botswana

BACKGROUND

A preliminary safety signal for neural-tube defects was previously reported in association with dolutegravir exposure from the time of conception, which has affected choices of antiretroviral treatment (ART) for human immunodeficiency virus (HIV)-infected women of reproductive potential. The signal can now be evaluated with data from follow-up of additional pregnancies.

METHODS

We conducted birth-outcomes surveillance at hospitals throughout Botswana, expanding from 8 to 18 sites in 2018. Trained midwives performed surface examinations of all live-born and stillborn infants. Research assistants photographed abnormalities after maternal consent was obtained. The prevalence of neural-tube defects and major external structural defects according to maternal HIV infection and ART exposure status was determined. In the primary analyses, we used the Newcombe method to evaluate differences in prevalence with 95% confidence intervals.

RESULTS

From August 2014 through March 2019, surveillance captured 119,477 deliveries; 119,033 (99.6%) had an infant surface examination that could be evaluated, and 98 neural-tube defects were identified (0.08% of deliveries). Among 1683 deliveries in which the mother was taking dolutegravir at conception, 5 neural-tube defects were found (0.30% of deliveries); the defects included two instances of myelomeningocele, one of anencephaly, one of encephalocele, and one of iniencephaly. In comparison, 15 neural-tube defects were found among 14,792 deliveries (0.10%) in which the mother was taking any non-dolutegravir ART at conception, 3 among 7959 (0.04%) in which the mother was taking efavirenz at conception, 1 among 3840 (0.03%) in which the mother started dolutegravir treatment during pregnancy, and 70 among 89,372 (0.08%) in HIV-uninfected mothers. The prevalence of neural-tube defects was higher in association with dolutegravir treatment at conception than with non-dolutegravir ART at conception (difference, 0.20 percentage points; 95% confidence interval [CI], 0.01 to 0.59) or with other types of ART exposure. Major external structural defects were found in 0.95% of deliveries among women exposed to dolutegravir at conception and 0.68% of those among women exposed to non-dolutegravir ART at conception (difference, 0.27 percentage points; 95% CI, -0.13 to 0.87).

CONCLUSIONS

The prevalence of neural-tube defects was slightly higher in association with dolutegravir exposure at conception than with other types of ART exposure at conception (3 per 1000 deliveries vs. 1 per 1000 deliveries). (Funded by the National Institutes of Health.).

Prescription patterns and associated cost during periods of cancer drug stockouts in a resource-limited setting

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Background: Cancer drug stockouts occur at high frequencies globally, however their clinical effects are understudied in sub-Saharan Africa (SSA). We aim to describe prescription patterns and cost of systemic chemotherapy in cancer patients in Botswana during periods of stockout. Methods: Using a retrospective cohort study of the ten most common solid tumor malignancies treated with systemic chemotherapy at Princess Marina Hospital (PMH), Gaborone in 2016, we conducted a subset analysis of suboptimal events, defined as a cycle with ≥ 7 days delay or therapy switch from initiated guideline regimen, that occurred during drug stockout vs non-stockout periods. We estimated financial cost of therapy per cycle using Management Sciences for Health International Price Indicator Guide. Chi-squared and Wilcoxon rank sum were used for comparisons. Results: 167/378 patients contributed to 320 suboptimal events. 63% (201/320) of events occurred during a drug stockout, of which 43%, 43% and 14% were delays, switches, or both, respectively. There were significantly more delays (56% vs 44%, p < .0001) and switches (75% vs 26%, p < .0001) during stockout periods vs no stockout. The majority of switches during drug stockouts occurred in breast cancer patients receiving curative therapy: 48% (20/42) were “paclitaxel + trastuzumab” ($4673) to “paclitaxel alone” ($35) in HER2 positive patients resulting in a 99% cost decrease; and 29% (12/42) were paclitaxel ($35) to docetaxel ($108) resulting in a 209% cost increase per cycle switched. Colon cancer patients receiving palliative-intent therapy were the second most frequent patients with therapy switches during stockout periods: 42% (8/19) were “capecitabine + oxaliplatin” ($259) to “capecitabine alone” ($105) resulting in a 59% cost decrease. Conclusions: Breast cancer patients form the majority of patients treated with systemic chemotherapy at PMH and experienced the most delays and switches in therapy during drug stockout periods. Changes in drug prescription patterns during stockout periods may be associated with switches leading to inferior but less costly regimens, and in some cases costly regimens with higher toxicity. Interventions that minimize cancer drug stockouts are imperative and further studies to understand impact of stockout on survival are needed in SSA.

Patient Characteristics, Early Outcomes, and Implementation Lessons of Cervical Cancer Treatment Services in Rural Rwanda

PURPOSE

Low- and middle-income countries account for 86% of all cervical cancer cases and 88% of cervical cancer mortality globally. Successful management of cervical cancer requires resources that are scarce in sub-Saharan Africa, especially in rural settings. Here, we describe the early clinical outcomes and implementation lessons learned from the Rwanda Ministry of Health's first national cancer referral center, the Butaro Cancer Center of Excellence (BCCOE). We hypothesize that those patients presenting at earlier stage and receiving treatment will have higher rates of being alive.

METHODS

The implementation of cervical cancer services included developing partnerships, clinical protocols, pathology services, and tools for monitoring and evaluation. We conducted a retrospective study of patients with cervical cancer who presented at BCCOE between July 1, 2012, and June 30, 2015. Data were collected from the electronic medical record system and by manually reviewing medical records. Descriptive, bivariable and multivariable statistical analyses were conducted to describe patient demographics, disease profiles, treatment, and clinical outcomes.

RESULTS

In all, 373 patients met the study inclusion criteria. The median age was 53 years (interquartile rage, 45 to 60 years), and 98% were residents of Rwanda. Eighty-nine percent of patients had a documented disease stage: 3% were stage I, 48% were stage II, 29% were stage III, and 8% were stage IV at presentation. Fifty percent of patients were planned to be treated with a curative intent, and 54% were referred to chemoradiotherapy in Uganda. Forty percent of patients who received chemoradiotherapy were in remission. Overall, 25% were lost to follow-up.

CONCLUSION

BCCOE illustrates the feasibility and challenges of implementing effective cervical cancer treatment services in a rural setting in a low-income country.

Hip fracture pattern at a major Tanzanian referral hospital: focus on fragility hip fractures

This study examined hip fractures during a 5-year period at Kilimanjaro Christian Medical Center (KCMC). There was a general increase in proportions of fragility hip fractures during this period.

PURPOSE

Fragility hip fractures are expected to increase in low-resource countries. This study examined hip fractures in the osteoporotic age group during a 5-year period at the Kilimanjaro Christian Medical Center (KCMC), which is located in Moshi, Tanzania.

METHODS

We conducted a retrospective study of all hip fracture patients above the age of 50 who were admitted to KCMC between January 1, 2011 and December 31, 2015. Objective measures including patient demographics, mechanism of injury, and X-ray evaluation were used to differentiate high- and low-energy fractures. Low-energy hip fractures with no other suspected pathological processes on X-ray were labelled as fragility fractures.

RESULTS

Three hundred forty patients were admitted in the study period and 222 patients met the inclusion criteria. Males contributed to 59.5% of hip fractures. Falls from standing height constituted the majority of fractures (76%) followed by injury from road traffic crashes (14%). Regardless of high- or low-energy aetiology, intertrochanteric fracture dominated representing 54.5% of all hip fractures. 75.6% (n = 168) of the analysed patients had fragility fractures. The fragility fractures were 55.8% (n = 96) intertrochanteric, 28.5% (n = 49) cervical, 9.9% (n = 17) subtrochanteric, and 5.8% (n = 10) mixed subtrochanteric with intertrochanteric. We noted a 2.34% per year increase in the proportions of fragility fractures among all included hip fractures over 5 years.

CONCLUSION

We concluded that men and women contributed almost equally to the fragility hip fracture burden. The dominant cause of hip fractures overall was low-energy injuries. There was an increase in proportions of fragility hip fractures in the period of January 2011 to December 2015.

Reduction in membranous immunohistochemical staining for the intracellular domain of epithelial cell adhesion molecule correlates with poor patient outcome in primary colorectal adenocarcinoma

BACKGROUND

Epithelial cell adhesion molecule (epcam) is a multifunctional transmembrane glycoprotein expressed on both normal epithelium and epithelial neoplasms such as gastric, breast, and renal carcinomas. Recent studies have proposed that the proteolytic cleavage of the intracellular domain of epcam (epcam-icd) can trigger signalling cascades leading to aggressive tumour behavior. The expression profile of epcam-icd has not been elucidated for primary colorectal carcinoma. In the present study, we examined epcam-icd immunohistochemical staining in a large cohort of patients with primary colorectal adenocarcinoma and assessed its performance as a potential prognostic marker.

METHODS

Immunohistochemical staining for epcam-icd was assessed on tissue microarrays consisting of 137 primary colorectal adenocarcinoma samples. Intensity of staining for each core was scored by 3 independent pathologists. The membranous epcam-icd staining score was calculated as a weighted average from 3 core samples per tumour. Univariate analysis of the average scores and clinical outcome measures was performed.

RESULTS

The level of membranous epcam-icd staining was positively associated with well-differentiated tumours (p = 0.01); low preoperative carcinoembryonic antigen (p = 0.001); and several measures of survival, including 2-year (p = 0.02) and 5-year survival (p = 0.05), and length of time post-diagnosis (p = 0.03). A number of other variables-including stage, grade, and lymph node status-showed correlations with epcam staining and markers of poor outcome, but did not reach statistical significance.

CONCLUSIONS

Low membranous epcam-icd staining might be a useful marker to identify tumours with aggressive clinical behavior and potential poor prognosis and might help to select candidates who could potentially benefit from treatment targeting epcam.

Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery

Introduction In 2010 a care bundle was introduced by the Department of Health (DH) to reduce surgical site infections (SSIs) in England. To date, use of the care bundle has not been evaluated despite incorporating interventions with resource implications. The aim of this study was to evaluate the DH SSI care bundle in open colorectal surgery. Methods A prospective cohort design was used at two teaching hospitals in England. The baseline group consisted of 127 consecutive patients having colorectal surgery during a 6-month period while the intervention group comprised 166 patients in the subsequent 6 months. SSI and care bundle compliance data were collected using dedicated surveillance staff. Results Just under a quarter (24%) of the patients in the baseline group developed a SSI compared with just over a quarter (28%) in the care bundle group (p>0.05). However, compliance rates with individual interventions, both before and after the implementation of the bundle, were similar. Interestingly, in only 19% of cases was there compliance with the total care bundle. The single intervention that showed an associated reduction in SSI was preoperative warming (p=0.032). Conclusions The DH care bundle did not reduce SSIs after open colorectal surgery. Despite this, it is not possible to state that the bundle is ineffective as compliance rates before and after bundle implementation were similar. All studies evaluating the effectiveness of care bundles must include data for compliance with interventions both before and after implementation of the care bundle; poor compliance may be one of the reasons for the lower than expected reduction of SSIs.

Interfacing of Science, Medicine and Law: The Stem Cell Patent Controversy in the United States and the European Union

The patent eligibility of stem cells–particularly those derived from human embryos–has long been under debate in both the scientific and legal communities. On the basis of moral grounds, the European Patent Office (EPO) has refrained from granting patents for stem cells obtained through the destruction of human embryos. On the contrary, the United States Patent and Trademark Office (USPTO) has historically granted patents regarding the isolation and use of human embryonic and other stem cells. To date, these US patents remain valid despite an increasing onslaught of challenges in court. However, recent precedents established in US courts significantly narrow the scope of patent eligibility within biotechnology. This article compares the implications of recent legal changes on stem cell patent eligibility between the EU and US.

Tissue dielectric constant (TDC) measurements as a means of characterizing localized tissue water in arms of women with and without breast cancer treatment related lymphedema

Quantitative measurements to detect lymphedema early in persons at-risk for breast cancer (BC) treatment-related lymphedema (BCRL) can aid clinical evaluations. Since BCRL may be initially manifest in skin and subcutis, the earliest changes might best be detected via local tissue water (LTW) measurements that are specifically sensitive to such changes. Tissue dielectric constant (TDC) measurements, which are sensitive to skin-to-fat tissue water, may be useful for this purpose. TDC differences between lymphedematous and non-lymphedematous tissue has not been fully characterized. Thus we measured TDC values (2.5 mm depth) in forearms of three groups of women (N = 80/group): 1) healthy with no BC (NOBC), 2) with BC but prior to surgery, and 3) with unilateral lymphedema (LE). TDC values for all arms except LE affected arms were not significantly different ranging between 24.8 ± 3.3 to 26.8 ± 4.9 and were significantly less (p < 0.001) as compared to 42.9 ± 8.2 for LE affected arms. Arm TDC ratios, dominant/non-dominant for NOBC, were 1.001 ± 0.050 and at-risk/ contralateral for BC were 0.998 ± 0.082 with both significantly less (p < 0.001) than LE group affected/control arm ratios (1.663 ± 0.321). These results show that BC per se does not significantly change arm LTW and that the presence of BCRL does not significantly change LTW of non-affected arms. Further, based on 3 standard deviations of measured arm ratios, our data demonstrates that an at-risk arm/contralateral arm TDC ratio of 1.2 and above could be a possible threshold to detect pre-clinical lymphedema. Further prospective measurement trial are needed to confirm this value.

Deletion of ubiquitin fold modifier protein Ufm1 processing peptidase Ufsp in L. donovani abolishes Ufm1 processing and alters pathogenesis

Previously, we showed Leishmania donovani Ufm1 has a Gly residue conserved at the C-terminal region with a unique 17 amino acid residue extension that must be processed prior to conjugation to target proteins. In this report, we describe for the first time the isolation and characterization of the Leishmania Ufm1-specific protease Ufsp. Biochemical analysis of L. donovani Ufsp showed that this protein possesses the Ufm1 processing activity using sensitive FRET based activity probes. The Ufm1 cleavage activity was absent in a mutant Ufsp in which the active site cysteine is altered to a serine. To examine the effects of abolition of Ufm1 processing activity, we generated a L. donovani null mutant of Ufsp (LdUfsp^−/−). Ufm1 processing activity was abolished in LdUfsp^−/− mutant, and the processing defect was reversed by re-expression of wild type but not the cys>ser mutant in the LdUfsp^−/− parasites. Further LdUfsp^−/− mutants showed reduced survival as amastigotes in infected human macrophages but not as promastigotes. This growth defect in the amastigotes was reversed by re-expression of wild type but not the cys>ser mutant in the Ufsp^−/− indicating the essential nature of this protease for Leishmania pathogenesis. Further, mouse infection experiments showed deletion of Ufsp results in reduced virulence of the parasites. Additionally, Ufsp activity was inhibited by an anti-leishmanial drug Amphotericin B. These studies provide an opportunity to test LdUfsp^−/− parasites as drug and vaccine targets.

Ubiquitin and ubiquitin like proteins (Ubls) and the enzymes that mediate the conjugation/deconjugation reactions have not been well studied in protozoan parasites despite their widely recognized importance in a broad range of cellular functions in eukaryotes. We have previously reported that Ufm1 has distinct protein targets and cellular localization in the human parasite Leishmania donovani and deletion of Ufm1 in L. donovani adversely impacts the pathogenesis suggesting that Ufm1 associated enzymes could be exploited as drug targets. Using sensitive FRET based activity probes we identified the Ufm1 processing peptidase Ufsp in L. donovani. In addition, we show that deletion of Ufsp specifically reduces the survival of amastigotes, the parasite stage that is present in the humans thus altering the pathogenesis. Studies showing inhibition of Ufsp activity by anti-leishmanial drug further suggests that Leishmania Ufsp can serve as a novel target for pharmacological intervention for this parasite that causes deadly disease.

Unintended consequences of regulating traditional medicine

The World Health Organization (WHO) has the noble goals of advancing traditional medicine and simultaneously promoting the regulation and professionalization of traditional healers. However, such regulation has the unintended consequence of withholding power from traditional practitioners. This review explores this concept through a historical analysis of traditional medicine in both India and Zimbabwe. During the post-colonial period in both countries, traditional medicine contributed to the creation of national identity. In the process of nationalizing traditional medicine, regulations were set in place that led to a rise in the university-style teaching of traditional healing. This period of professionalization of traditional healers resulted in certain types of traditional medicine being marginalized, as they were neither included in regulation nor taught at university. Since then, the current era of globalization has commoditizedtraditional healing. Private industries like ZEPL and Dabur have rapidly and vastly altered the role of traditional healers. Consumers can now buy traditional medication directly from companies without visiting a healer. Additionally, disputes over patents and other intellectual property rights have led to important questions regarding ownership of certain plants traditionally known for healing properties. Through regulation and commercialization of traditional medicine, healers have lost some of their independence to practise.

Changes in tissue water and indentation resistance of lymphedematous limbs accompanying low level laser therapy (LLLT) of fibrotic skin

Our goal was to determine effects of low-level-laser-therapy (LLLT) on skin water and tissue indentation resistance (TIR) in patients with arm (N = 38) or leg (N = 38) lymphedema. Skin water was determined from tissue dielectric constant (TDC) measurements and TIR determined from measurements of force resulting from tissue indentations of 3-4 mm. A limb-location with fibrosis was identified by palpation and treated with an LLLT device for one minute at each of five points within a 3 cm2 area. TDC and TIR at these sites and corresponding sites on the contralateral limb were measured prior to LLLT (pre-LLLT), immediately after LLLT (post-LLLT) and after a manual lymphatic drainage (MLD) session (post-MLD). Results, from arms and legs, showed that post-LLLT values of TIR and TDC were significantly less than pre-LLLT. TIR values remained significantly reduced at post-MLD whereas TDC values were not significantly different from pre-LLLT values. On follow-up visit, 17 previously LLLT treated legs were sham treated with an inactive LLLT unit and measurements replicated. A TIR and TDC change-pattern similar to that obtained with the active LLLT was obtained, but sham-related reductions in TIR and TDC immediately post sham-treatment were significantly less than achieved with the prior active LLLT treatment.

A delayed presentation of cardiac tamponade after blunt trauma

Cardiac tamponade is a recognised complication of blunt trauma to the chest. It usually presents at the time of the acute event but there are rare cases of delayed presentations. We present such a case where the tamponade occurred six weeks following the trauma to the chest wall.

Local tissue water changes assessed by tissue dielectric constant: single measurements versus averaging of multiple measurements

Previous reports describe the use of average tissue dielectric constant (TDC) measurements to assess local tissue water and its change. Our goal was to determine if a single TDC measurement could be used in place of the average of multiple measurements. The comparison criteria used to test this was the extent to which single and averaged measurements yielded similar TDC values in both normal and lymphedematous tissue. Measurements were made on both ventral forearms to a depth of 2.5 mm in 10 women with unilateral arm lymphedema. The main results showed that the 95% confidence interval for differences between single and averaged TDC values was less than +/- 1 TDC unit for both normal and lymphedematous arms. This finding strongly suggests that for most, if not all, clinical evaluations, suitable assessments can be made using a single TDC measurement.

Perception regarding quality of services in urban ICDS blocks in Delhi

The good quality of the services is an important determinant for acceptance of a programme in a community. It not only enhances the credibility of a worker at the ground level but also generate the demand for the services. In this paper perception for the quality of the services was assessed through the exit interview of the beneficiaries at the Anganwadi centres (AWCs). 200 beneficiaries were included from 20 AWCs in a period of one and half month. 52.5% respondents were dissatisfied for the services provided from the AWC for one or more reason. The most common reason mentioned was the not easy accessibility of the AWC and less space available at the AWC (68.6%), followed by the poor quality of the food distributed (66.7%) and irregular pre school education (57.1%) from AWCs.

Localized tissue water changes accompanying one manual lymphatic drainage (MLD) therapy session assessed by changes in tissue dielectric constant inpatients with lower extremity lymphedema

Previous reports described the utility of assessing local tissue water via tissue dielectric constant (TDC) measurements. Our goal was to determine the suitability of this method to evaluate lymphedema changes. For this purpose, we measured changes in TDC produced by one MLD treatment in 27 legs of 18 patients with lower extremity lymphedema. TDC values were measured to a depth of 2.5 mm at the greatest leg swelling site before and after one MLD treatment. Girth at the target site was measured with a calibrated tape measure. TDC values, which range from 1 for zero water to 78.5 for all water within the sampled volume, were measured four times and the average used to estimate local changes. Results showed that in every case the posttreatment TDC was reduced from its pretreatment value with percentage reductions (mean SD) of -9.8 +/- 5.64% (p < 0.0001). Girth changes were smaller being -1.5 +/- 1.93% (p < 0.01). We conclude that since TDC measurements reflect changes to a depth of about 2.5 mm whereas girth measurements reflect conditions of the entire cross-section, TDC assessment may be more sensitive to localized lymphedema changes. This finding suggests that TDC measurements are useful as complementary and perhaps as independent assessment methods of edema/lymphedema and treatment-related changes.

GEISHA: an in situ hybridization gene expression resource for the chicken embryo

An important and ongoing focus of biomedical and agricultural avian research is to understand gene function, which for a significant fraction of genes remains unknown. A first step is to determine when and where genes are expressed during development and in the adult. Whole mount in situ hybridization gives precise spatial and temporal resolution of gene expression throughout an embryo, and a comprehensive analysis and centralized repository of in situ hybridization information would provide a valuable research tool. The GEISHA project (gallus expression in situ hybridization analysis) was initiated to explore the utility of using high-throughput in situ hybridization as a means for gene discovery and annotation in chicken embryos, and to provide a unified repository for in situ hybridization information. This report describes the design and implementation of a new GEISHA database and user interface (www.geisha.arizona.edu), and illustrates its utility for researchers in the biomedical and poultry science communities. Results obtained from a high throughput screen of microRNA expression in chicken embryos are also presented.

Gallus Expression In Situ Hybridization Analysis: A Chicken Embryo Gene Expression Database

With sequencing of the chicken genome largely completed, significant effort is focusing on gene annotation, including acquiring information about the patterns of gene expression. The chicken embryo is ideally suited to provide detailed temporal and spatial expression information through in situ hybridization gene expression analysis in vivo. We have developed the Gallus expression in situ hybridization analysis (GEISHA) database and user interface (http://geisha.arizona.edu) to serve as a centralized repository of in situ hybridization photos and metadata from chicken embryos. This report describes the design and implementation the GEISHA database and Web site and illustrates its usefulness for researchers in the biomedical and poultry science communities. Results from a recent comprehensive expression analysis of microRNA expression in chicken embryos are also presented.

A new HLA-A Allele, HLA-A*6824, identified in three unrelated individuals*

A novel allele, human leukocyte antigen (HLA)-A*6824, has been identified in three unrelated individuals of northwestern European origin in a period of less than 4 months, implying that this allele may be quite common in this population. HLA-A*6824 differs from A*680102 by a single nucleotide change at position 275 in exon 2, which results in a conservative amino acid substitution from lysine to arginine in the peptide-binding groove at codon 68.

Genetic susceptibility to fibrocalculous pancreatic diabetes in Bangladeshi subjects: a family study

Fibrocalculous pancreatic diabetes (FCPD) is an uncommon cause of diabetes, seen mainly in developing countries. A family-based study was carried out in 67 Bangladeshi families, consisting of a proband with FCPD and both parents, to determine whether an association exists between FCPD susceptibility and either the major histocompatiblity complex (MHC) or insulin gene (INS) loci. HLA-DQB1 typing was done using allele-specific primers, and INS was typed using the restriction enzyme HphI. Three microsatellites (TNFa, TNFc and TNFd), from within and flanking the TNF-LT locus, were used for MHC Class IV typing and a PCR-RFLP assay was used to define the -308G/A TNF promoter polymorphism. The extended transmission disequilibrium test (ETDT) was used for statistical analysis. An overall association was observed between FCPD and HLA-DQB1 (P = 0.003), that was largely due to a positive association with HLA-DQB1*0302 and a negative association with HLA-DQB1*0202. Although no association was found between FCPD and TNF-LT microsatellite markers a trend was observed for TNFc (P = 0.037, Pc = 0.15). No association was found between FCPD and INS (P = 0.26). This study confirms an association between FCPD and the MHC using a family-based study design and the stringent ETDT analysis; a novel protective association was found with HLA-DQB1*0202 in Bangladeshi FCPD subjects. The genetic susceptibility to FCPD has features both similar and dissimilar to T1DM.

DNA damage-dependent and -independent phosphorylation of the hRad9 checkpoint protein

Cell cycle checkpoints are regulatory mechanisms that maintain genomic integrity by preventing cell cycle progression when genetic anomalies are present. The hRad9 protein is the human homologue of Schizosaccharomyces pombe Rad9, a checkpoint protein required for preventing the onset of mitosis if DNA damage is present or if DNA replication is incomplete. Genetic and biochemical analyses indicate that hRad9 is a component of the checkpoint response in humans and has possible roles in regulating the cell cycle, apoptosis, and DNA repair. Previous studies indicate that hRad9 is modified by phosphorylation, both in the absence of exogenous stress and in response to various genotoxins. In this study, we report the mapping of several sites of constitutive phosphorylation of hRad9 to (S/T)PX(R/P) sequences near the C terminus of the protein. We also demonstrate that a serine to alanine mutation at residue 272 abrogates an ionizing radiation (IR)-induced phosphorylation of hRad9 and further show that phosphorylation at (S/T)P sites is not a prerequisite for IR-induced phosphorylation of serine 272. Finally, we report that hRad9 undergoes cell cycle-regulated hyper-phosphorylation in G(2)/M that is enhanced by IR but distinct from that on serine 272. Unlike the IR-induced phosphorylation at serine 272, this event is dependent on serine 277 and threonine 292, two C-terminal (S/T)P sites in hRad9.

Reduced or modified dietary fat for preventing cardiovascular disease

BACKGROUND

Reduction or modification of dietary fat can improve total cholesterol levels, but may also have a variety of effects, both positive and negative, on other cardiovascular risk factors.

OBJECTIVES

The aim of this systematic review was to assess the effect of reduction or modification of dietary fats on total and cardiovascular mortality and cardiovascular morbidity over at least 6 months, using all available randomized clinical trials.

SEARCH STRATEGY

The Cochrane Library, MEDLINE, EMBASE, CAB Abstracts, CVRCT registry and related Cochrane Groups' trial registers were searched through spring 1998, SIGLE to January 1999. Trials known to experts in the field and biographies were included through May 1999.

SELECTION CRITERIA

Trials fulfilled the following criteria: 1) randomized with appropriate control group, 2) intention to reduce or modify fat or cholesterol intake (excluding exclusively omega-3 fat interventions), 3) not multi factorial, 4) healthy adult humans, 5) intervention at least six months, 6) mortality or cardiovascular morbidity data available. Inclusion decisions were duplicated, disagreement resolved by discussion or a third party.

DATA COLLECTION AND ANALYSIS

Rate data were extracted by two independent reviewers and meta-analysis performed using random effects methodology. Meta-regression and funnel plots were used.

MAIN RESULTS

Twenty seven studies were included (40 intervention arms, 30,901 person-years). There was no significant effect on total mortality (rate ratio 0.98, 95% CI 0.86 to 1.12), a trend towards protection form cardiovascular mortality (rate ratio 0.91, 95% CI 0.77 to 1.07), and significant protection from cardiovascular events (rate ratio 0.84, 95% CI 0.72 to 0.99). The latter became non-significant on sensitivity analysis. Trials where participants were involved for more than 2 years showed significant reductions in the rate of cardiovascular events and a suggestion of protection from total mortality. The degree of protection from cardiovascular events appeared similar in high and low risk groups, but was statistically significant only in the former.

REVIEWER'S CONCLUSIONS

The findings are suggestive of a small but potentially important reduction in cardiovascular risk in trials longer than two years. Lifestyle advice to all those at high risk of cardiovascular disease (especially where statins are unavailable or rationed), and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates.