The Use of Aerosolized Ribavirin in Respiratory Syncytial Virus Lower Respiratory Tract Infections in Adult Immunocompromised Patients: A Systematic Review

Introduction: Respiratory syncytial virus (RSV)–associated lower respiratory tract infection (LRTI) is a concern in immunocompromised patients. Aerosolized ribavirin (RBV AER) is used for treatment of RSV LRTI; however, adverse events and rising drug costs remain a challenge for patient management. The purpose of this systematic review is to summarize the efficacy and adverse event profile of RBV AER for the treatment of hospitalized RSV LRTI in immunocompromised adult patients. Methods: A Medline/PubMed, Embase, Google Scholar, Clinicaltrials.gov, and Cochrane Library database search was conducted from 1966 to January 2019 for the use of RBV AER. Search strategy: [(ribavirin OR ICN1229) AND (“administration, oral” OR “oral” OR “administration, inhalation” OR “inhalation)] AND (“respiratory tract infection” OR “pneumonia”). Studies were reviewed if adult patients were hospitalized, immunocompromised, had RSV LRTI, received RBV AER, and included the outcome of mortality and/or adverse reactions. Methodological quality was assessed using the Cochrane Collaboration GRADE approach. Results: A total of 1787 records were identified and 15 articles met inclusion criteria: hematopoietic stem cell transplant (HSCT)/bone marrow transplant (n = 8), other malignancy/neutropenic (n = 2), solid organ transplant (n = 5). All of the trials are observational with a low quality rating; therefore, a meta-analysis was not performed. The 30-day mortality in studies that contain \u3e10 patients with HSCT, malignancy, and transplant range from 0 to 15.4%, 6.3%, and 0 to 27%, respectively. Improved mortality was cited in 4 studies when RBV AER started before mechanical ventilation or within 2 weeks of symptom onset. Only 3 studies had comparative mortality data with RBV AER and RBV PO. Adverse reactions were reported in 5 studies and included psychiatric manifestations (anxiety, depression, feeling of isolation; n = 14), wheezing/bronchospasm (n = 6), snowflakes/hail blowing in face (n = 6), and precipitation in ventilator tubing (n = 5). Conclusion: There is a lack of high quality, comparative trials on the use of RBV AER for the treatment of RSV LRTI in adult hospitalized immunocompromised patients. There may be a mortality benefit when RBV AER is initiated early after diagnosis or prior to mechanical ventilation, but requires further study. Patient isolation and psychological effects must be weighed against the benefit of therapy

Judging Genes: Implications of the Second Generation of Genetic Tests InThe Courtroom

The use of DNA tests for identification has revolutionized court proceedings in criminal and paternity cases. Now, requests by litigants to admit or compel a second generation of genetic tests – tests to confirm or predict genetic diseases and conditions – threaten to affect judicial decision-making in many more contexts. Unlike DNA tests for identification, these second generation tests may provide highly personal health and behavioral information about individuals and their relatives and will pose new challenges for trial court judges. This article reports on an original empirical study of how judges analyze these requests and uses the study results to inform the construction of a multi-factorial decision matrix to assist judges evaluate the appropriate role of this information in legal proceedings. Through this analytical framework, the article illuminates doctrinal and theoretical tensions in existing criminal, evidence, constitutional and tort law that are likely to surface when efforts are made to apply current law in these areas to cases involving the use of health-related genetic tests. In addition, the article examines the broader implications of the wide scale use of these tests in court proceedings and argues that appellate judges and policymakers, who establish procedural rules governing litigation, will need to consider the collateral consequences of such wide scale use. Changes in some existing doctrines and/or rules may be necessary to accommodate challenges to underlying legal theories presented by these genetic tests and to preserve values such as privacy and family relationships threatened by the use of these tests in the courtroom

JSRP paper: multi-layered security governance as a quick fix? The challenges of donor-supported bottom-up security provision in Ituri (DR Congo)

There is currently a lively debate among policy-makers and scholars about the role that local non-state actors can play in security provision in so-called ‘fragile situations’, or contexts characterized by high levels of insecurity and limited state capacity to deal with it. The idea that building security institutions based on Western models is the remedy to the insecurity of fragile situations, has come under increased criticism both from scholars and practitioners and has promoted the inclusion of local non-state actors in peace-building strategies

Competition, patronage and fragmentation : the limits of bottom-up approaches to security governance in Ituri

People are affected by different kinds of insecurity in the Ituri Province in the northeastern region of the Democratic Republic of Congo (DRC). This article investigates donor-driven attempts to improve security governance there. More specifically, it investigates bottom-up approaches to security governance in Ituri’s capital of Bunia and in Irumu territory. Whereas in Bunia people are faced with high levels of violent crime, Irumu is the site of a violent conflict between the Ituri Patriotic Resistance Force (FRPI), an armed group connected to the Ngiti community, and the Congolese army. Involving local non-state security actors in security governance is perceived by international and national actors as a pragmatic way to improve security conditions. However, we show that these bottom-up security governance initiatives have not succeeded in resolving the issues that generate insecurity. We argue that this is because the drivers of insecurity in northeastern Congo are translocal and too complex for localised bottom-up approaches to significantly change the status quo

Whose Duty is it Anyway?: the Kennedy Krieger Opinion and its Implications for Public Health Research

In this article, the authors discuss the Maryland Court of Appeals decision in the case of Grimes v. Kennedy Krieger Institute, Inc. and its implications for the tort duty owed by researchers, in particular public health researchers, to their subjects. The Opinion resulted from two lawsuits alleging lead poisoning of children enrolled in a study conducted by the Kennedy Krieger Institute, a world renown pediatric research and treatment facility. The opinion shocked the research establishment with its scathing characterization of researchers and its apparent holding that in Maryland a parent cannot consent to the participation of a child in nontherapeutic research or other studies in which there is any risk of injury or damage to the health of the subject. While this was the focus of much of the research community, the issue in dispute in the case was that of the scope of duty of the researchers. Hoffmann and Rothenberg describe the facts leading to the case, many of which were omitted from the Court of Appeals decision which resulted from an appeal to a motion for summary judgment, and then discuss two possible interpretations of the Court\u27s decision as it relates to the duty of researchers. One interpretation is based on a broad view of what constitutes the research endeavor and its associated risks and would arguably not result in a change in the legal duties of researchers. The other is based on a narrow view of the research project and would lead to the disclosure of risks not traditionally required by law as they fall outside of risks resulting from participation in the research protocol. The authors assert that as a result of confusion in the Opinion regarding the definition of the research study, the Court\u27s decision may result in a significantly broader duty than has been posed historically in the research setting. In addition to exploring the contrasting interpretations of the Court\u27s Opinion, the authors deconstruct the scope of the duty as articulated by the Court and pose a series of questions as to how such a duty might be discharged and how realistic the Court\u27s apparent expectations are regarding the duty or researchers. Finally, they discuss the implications of the Court\u27s apparent broad based duty requirement in the context of public health studies and raise the question whether the Opinion may ultimately have negative consequences for the future of public health research in Maryland and for the compensation of injured research subjects

Bewertung der globalen linksventrikulären Funktion: Vergleich der Mehrschicht-Spiral-CT mit der Angiokardiographie

Bewertung der globalen linksventrikulären Funktion (ESV, EDV, EF und SV)mittels EKG-gegateter ehrschicht-Spiral-Computertomographie (MSCT) unter Anwendung von vier verschiedenen Berechnungsverfahren, im Vergleich mit der Berechnung der linksventrikulären Funktion mittels Angiokardiographie