National policy development for cotrimoxazole prophylaxis in Malawi, Uganda and Zambia: the relationship between Context, Evidence and Links

BACKGROUND: Several frameworks have been constructed to analyse the factors which influence and shape the uptake of evidence into policy processes in resource poor settings, yet empirical analyses of health policy making in these settings are relatively rare. National policy making for cotrimoxazole (trimethoprim-sulfamethoxazole) preventive therapy in developing countries offers a pertinent case for the application of a policy analysis lens. The provision of cotrimoxazole as a prophylaxis is an inexpensive and highly efficacious preventative intervention in HIV infected individuals, reducing both morbidity and mortality among adults and children with HIV/AIDS, yet evidence suggests that it has not been quickly or evenly scaled-up in resource poor settings. METHODS: Comparative analysis was conducted in Malawi, Uganda and Zambia, using the case study approach. We applied the 'RAPID' framework developed by the Overseas Development Institute (ODI), and conducted a total of 47 in-depth interviews across the three countries to examine the influence of context (including the influence of donor agencies), evidence (both local and international), and the links between researcher, policy makers and those seeking to influence the policy process. RESULTS: Each area of analysis was found to have an influence on the creation of national policy on cotrimoxazole preventive therapy (CPT) in all three countries. In relation to context, the following were found to be influential: government structures and their focus, donor interest and involvement, healthcare infrastructure and other uses of cotrimoxazole and related drugs in the country. In terms of the nature of the evidence, we found that how policy makers perceived the strength of evidence behind international recommendations was crucial (if evidence was considered weak then the recommendations were rejected). Further, local operational research results seem to have been taken up more quickly, while randomised controlled trials (the gold standard of clinical research) was not necessarily translated into policy so swiftly. Finally the links between different research and policy actors were of critical importance, with overlaps between researcher and policy maker networks crucial to facilitate knowledge transfer. Within these networks, in each country the policy development process relied on a powerful policy entrepreneur who helped get cotrimoxazole preventive therapy onto the policy agenda. CONCLUSIONS: This analysis underscores the importance of considering national level variables in the explanation of the uptake of evidence into national policy settings, and recognising how local policy makers interpret international evidence. Local priorities, the ways in which evidence was interpreted, and the nature of the links between policy makers and researchers could either drive or stall the policy process. Developing the understanding of these processes enables the explanation of the use (or non-use) of evidence in policy making, and potentially may help to shape future strategies to bridge the research-policy gaps and ultimately improve the uptake of evidence in decision making

Spatial characteristics of visual field progression determined by Monte Carlo simulation: Diagnostic innovations in glaucoma study

PURPOSE. To determine the spatial characteristics of glaucomatons visual field progression in persons with glaucomatous-appearing optic neuropathy (GON) from the Diagnostic Innovations in Glaucoma Study (DIGS).METHODS. Changes in pattern deviation (PD) plot values from the average of two baseline examinations to two follow-up examinations were evaluated in test locations. All were eligible, full threshold, pattern 24-2, standard automated perimetry (SAP) examinations (Humphrey Field Analyzer II; Carl Zeiss Meditec, Inc., Dublin, CA) in visual field series from 200 patients with GON confirmed on two occasions by stereophoto review. the proportion of patients exhibiting PD plot progression was determined at each of 52 locations for patients with a baseline abnormal result (P < 5% or worse) in one or more of 52 PD, locations in either the first or second baseline test for a total of 2704 location pairings for each possible level of negative PD change from -1 to -50 dB. Progression was defined as any worsening of PD plot value in the follow-up test relative to the average PD plot value in the baseline tests. Monte Carlo simulation was used to determine the significance of the observed patterns of PD plot progression.RESULTS. Changes in PDs were dependent on their location relative to abnormal PD locations in the first test. of those patients with an abnormality at a location at baseline (mean, 0.23 +/- 0.07), the proportion of patients changing by -2 dB or more ranged between 0.09 and 0.55 (mean, 0.29 +/- 0.06) across locations. for changes of -6 dB or more, the proportions ranged between 0.00 and 0.26 (mean, 0.08 +/- 0.04) of patients. These proportions and the proportional probabilities for each of 2704 location pairings are reported for selected levels of change. the proportional probabilities are consistent with a map of the retinal nerve fiber layer bundles.CONCLUSIONS. Visual field progression occurs in retinotopically constrained patterns consistent with changes along the nerve fiber bundle

New perspectives on assessment and understanding of the patient with cranial bone defect: a morphometric and cerebral radiodensity assessment.

Peer reviewed: TrueBACKGROUND: Skull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis. METHODS: This is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis. RESULTS: There was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = -0.4) and Barthel index (p = 0.035; r = -0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = -0.37). CONCLUSION: Morphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC