Transtheoretical model-based dietary interventions in primary care: a review of the evidence in diabetes

The objective of this study was to review the evidence concerning stage-based dietary interventions in primary care among persons with diabetes or an elevated diabetes risk. Search strategies were electronic databases and manual search. Selection criteria were randomized controlled studies with stage-based dietary intervention, conducted in primary care with at least 6 months of follow-up, and participants with either type 2 diabetes or with an elevated risk. The researchers evaluated trials for inclusion, extracted data and assessed study quality. Seven articles, based on five data sets, were included. These studies concentrated on cardiovascular diseases and being overweight, not diabetes. The quality of the studies was moderate to weak. Inadequacies in the reporting often involved unspecific information on the training of health care providers. Long-term positive outcomes (compared with controls) were found in total and monounsaturated fat intake, diastolic blood pressure, health status and well-being. The existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model. More high-quality studies focusing on diabetes are needed, with greater attention to the training of providers and process evaluation. There is a need for a standardized appraisal tool for study evaluation, focusing separately on education interventions for patients and providers

Export-Oriented International Joint Venture: Endogenous Set-Up Costs and Information Gathering

We analyze the formation of an export-oriented international joint venture (IJV) between a multinational corporation (MNC) and a domestic firm under demand uncertainty and in a principal-agent framework. The MNC possesses a superior production technology and is better at predicting foreign market demand. The domestic firm can reduce set-up costs of the IJV with effort levels that is endogenously determined. We examine how the MNC\u27s preference for, and the ownership structure of, a joint venture depend on the efficiency of information gathering and of cost reduction, and on the nature of credit markets. We find, inter alia, that when the credit constraint is severe the MNC does not push the domestic firm to its reservation profit level. A relaxation of the credit constraint facing the domestic firm never makes it better off and in fact makes the domestic firm worse off when the credit constraint is severe

Industry concentration and strategic trade policy in successive oligopoly

We study a policy game between exporting and importing countries in vertically linked industries. In a successive international Cournot oligopoly, we analyse incentives for using tax instruments strategically to shift rents vertically, between exporting and importing countries, and horizontally, between exporting countries. We show that the equilibrium outcome depends crucially on the relative degree of competitiveness in the upstream and downstream parts of the industry. With respect to national welfare, a more competitive upstream industry may benefit an exporting (upstream) country and harm an importing (downstream) country. On the other hand, a more competitive downstream industry may harm exporting countries.Financial support from the Norwegian Research Council, through the PETROPOL research programme, is gratefully acknowledged. The paper has been greatly improved by the suggestions of two anonymous referees. We also thank Hisashi Hokari and Frode Meland for valuable comments and suggestions

Comparative study of the efficacy and tolerability of dihydroartemisinin - piperaquine - trimethoprim versus artemether - lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in Cameroon, Ivory Coast and Senegal

<p>Abstract</p> <p>Background</p> <p>The ACT recommended by WHO is very effective and well-tolerated. However, these combinations need to be administered for three days, which may limit adherence to treatment.</p> <p>The combination of dihydroartemisinin - piperaquine phosphate - trimethoprim (Artecom^®, Odypharm Ltd), which involves treatment over two days, appears to be a good alternative, particularly in malaria-endemic areas. This study intends to compare the efficacy and tolerability of the combination dihydroartemisinin - piperaquine phosphate - trimethoprim (DPT) versus artemether - lumefantrine (AL) in the treatment of uncomplicated <it>Plasmodium falciparum </it>malaria in Cameroon, Ivory Coast and Senegal.</p> <p>Methods</p> <p>This was a randomized, controlled, open-label clinical trial with a 28-day follow-up period comparing DPT to AL as the reference drug. The study involved patients of at least two years of age, suffering from acute, uncomplicated <it>Plasmodium falciparum </it>malaria with fever. The WHO 2003 protocol was used.</p> <p>Results</p> <p>A total of 418 patients were included in the study and divided into two treatment groups: 212 in the DPT group and 206 in the AL group. The data analysis involved the 403 subjects who correctly followed the protocol (<it>per protocol </it>analysis), i.e. 206 (51.1%) in the DPT group and 197 (48.9%) in the AL group. The recovery rate at D14 was 100% in both treatment groups. The recovery rate at D28 was 99% in the DPT and AL groups before and after PCR results with one-sided 97.5% Confidence Interval of the rates difference > -1.90%. More than 96% of patients who received DPT were apyrexial 48 hours after treatment compared to 83.5% in the AL group (p < 0.001). More than 95% of the people in the DPT group had a parasite clearance time of 48 hours or less compared to approximately 90% in the AL group (p = 0.023). Both drugs were well tolerated. No serious adverse events were reported during the follow-up period. All of the adverse events observed were minor and did not result in the treatment being stopped in either treatment group. The main minor adverse events reported were vomiting, abdominal pain and pruritus.</p> <p>Conclusion</p> <p>The overall efficacy and tolerability of DPT are similar to those of AL. The ease of taking DPT and its short treatment course (two days) may help to improve adherence to treatment. Taken together, these findings make this medicinal product a treatment of choice for the effective management of malaria in Africa.</p

Presentation and Outcome of Tuberculous Meningitis in a High HIV Prevalence Setting

Mycobacterium tuberculosis is a common, devastating cause of meningitis in HIV-infected persons. Due to international rollout programs, access to antiretroviral therapy (ART) is increasing globally. Starting patients with HIV-associated tuberculous meningitis (TBM) on ART during tuberculosis (TB) treatment may increase survival in these patients. We undertook this study to describe causes of meningitis at a secondary-level hospital in a high HIV/TB co-infection setting and to determine predictors of mortality in patients with TBM.A retrospective review of cerebrospinal fluid findings and clinical records over a six-month period (March 2009-August 2009). Definite, probable and possible TBM were diagnosed according to published case definitions.TBM was diagnosed in 120/211 patients (57%) with meningitis. In 106 HIV-infected patients with TBM, six-month all-cause mortality was lower in those who received antiretroviral therapy (ART) during TB treatment; hazard ratio = 0.30 (95% CI = 0.08-0.82). Factors associated with inpatient mortality in HIV-infected patients were 1) low CD4(+) count at presentation; adjusted odds ratio (AOR) = 1.4 (95% confidence interval [CI] = 1.03-1.96) per 50 cells/µL drop in CD4(+) count and, 2) higher British Medical Research Council TBM disease grade (2 or 3 versus 1); AOR = 4.8 (95% CI = 1.45-15.87).Starting ART prior to or during TB treatment may be associated with lower mortality in patients with HIV-associated TBM. Advanced HIV and worse stage of TBM disease predict in-hospital mortality in patients presenting with TBM

Overview of systematic reviews of therapeutic ranges : methodologies and recommendations for practice

BACKGROUND: Many medicines are dosed to achieve a particular therapeutic range, and monitored using therapeutic drug monitoring (TDM). The evidence base for a therapeutic range can be evaluated using systematic reviews, to ensure it continues to reflect current indications, doses, routes and formulations, as well as updated adverse effect data. There is no consensus on the optimal methodology for systematic reviews of therapeutic ranges. METHODS: An overview of systematic reviews of therapeutic ranges was undertaken. The following databases were used: Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts and Reviews of Effects (DARE) and MEDLINE. The published methodologies used when systematically reviewing the therapeutic range of a drug were analyzed. Step by step recommendations to optimize such systematic reviews are proposed. RESULTS: Ten systematic reviews that investigated the correlation between serum concentrations and clinical outcomes encompassing a variety of medicines and indications were assessed. There were significant variations in the methodologies used (including the search terms used, data extraction methods, assessment of bias, and statistical analyses undertaken). Therapeutic ranges should be population and indication specific and based on clinically relevant outcomes. Recommendations for future systematic reviews based on these findings have been developed. CONCLUSION: Evidence based therapeutic ranges have the potential to improve TDM practice. Current systematic reviews investigating therapeutic ranges have highly variable methodologies and there is no consensus of best practice when undertaking systematic reviews in this field. These recommendations meet a need not addressed by standard protocols

SUPPORT Tools for evidence-informed health Policymaking (STP) 8: Deciding how much confidence to place in a systematic review

This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers