Best practices in use of research evidence to inform health decisions

The WHO Advisory Committee on Health Research (ACHR) is committed to the notion that WHO should exemplify best practice in use of research evidence to inform decisions about health. A major ongoing initiative of the ACHR is the Sub-committee on the Use of Research Evidence (SURE). This group is examining WHOs roles and responsibilities in the use of health research to inform decisions about health. WHOs leadership has expressed strong support for this initiative. The series of articles being published in Health Research Policy and Systems, which examine the methods used by WHO and other organisations to formulate recommendations about health, is part of the background documentation SURE has produced to inform ACHRs advice to WHO. It is critical that health policy makers look to research, not ignorance, as the basis for action in health, and that health professionals look to evidence, not opinion, as the basis for delivery of care

Blood Pressure and Control of Cardiovascular Risk

Two key early 20th century notions, the first the primacy of diastolic pressure in determining risk, and the second that hypertension is a discrete disorder, have proved to be incorrect. We now recognize the primacy of systolic pressure as a risk factor for cardiovascular disease and that hypertension is an arbitrary definition. In the early 21st century, we are moving away from a dichotomous approach to risk classification, and away from notions of hypertension and normotension towards an appreciation that blood pressure-related risk is continuous. In parallel, there has been a paradigm shift from a single risk factor approach to comprehensive cardiovascular disease risk prevention. Accordingly, prevention of cardiovascular disease requires a focus on lowering of blood pressure and modification of associated risk factors rather than simply treatment of hypertension. This emphasis is reflected in the World Health Organization (WHO) – International Society of Hypertension (ISH) 2003 statement on management of hypertension

Cardiovascular consequences of cortisol excess

Cushing's syndrome is a consequence of primary or, more commonly, secondary oversecretion of cortisol. Cardiovascular disease is the major cause of morbidity and mortality in Cushing's syndrome, and excess risk remains even in effectively treated patients. The cardiovascular consequences of cortisol excess are protean and include, inter alia, elevation of blood pressure, truncal obesity, hyperinsulinemia, hyperglycemia, insulin resistance, and dyslipidemia. This review analyses the relationship of cortisol excess, both locally and at tissue level, to these cardiovascular risk factors, and to putative mechanisms for hypertension. Previous studies have examined correlations between cortisol, blood pressure, and other parameters in the general population and in Cushing's syndrome. This review also details changes induced by short-term cortisol administration in normotensive healthy men

Nitric oxide donation lowers blood pressure in adrenocorticotrophic hormone-induced hypertensive rats.

Adrenocorticotrophic hormone (ACTH) elevates systolic blood pressure (SBP) and lowers plasma reactive nitrogen intermediates in rats. We assessed the ability of NO donation from isosorbide dinitrate (ISDN) to prevent or reverse the hypertension caused by ACTH. In the prevention study, male Sprague Dawley rats were treated with ACTH (0.2 mg/kg/day) or saline control for 8 days, with either concurrent ISDN (100 mg/kg/day) via the drinking water or water alone. Animals receiving ISDN via the drinking water were provided with nitrate-free water for 8 hours every day. In the reversal study ISDN (100 mg/kg) or vehicle was given as a single oral dose on day 8. SBP was measured daily by the indirect tail-cuff method in conscious, restrained rats. ACTH caused a significant increase in SBP compared with saline (P < 0.0015). In the prevention study, chronic administration of ISDN (100 mg/kg/day) did not affect the SBP in either group. In the reversal study, ISDN significantly lowered SBP in ACTH-treated rats at 1 and 2.5 hours (132 +/- 3 mmHg (1 h) and 131 +/- 2 mmHg (2.5 h) versus 143 +/- 3 mmHg (0 h), P < 0.002), but not to control levels. It had no effect in control (saline treated) rats. In conclusion, the lowering of SBP by NO donation is consistent with the notion that ACTH-induced hypertension involves an impaired bioavailability or action of NO in vivo

Immunogenicity ofEscherichia coli O antigen in upper urinary tract infection

Immunogenicity ofEscherichia coli O antigen in upper urinary tract infection. The role of immunogenicity of the infecting organism (Escherichia coli) in the antibody response to O antigen in upper urinary tract infection was investigated Heat-killed vaccines were prepared from “immunogenic” organisms which had produced upper urinary tract infection associated with high titers of hemag-glutinating antibody to O antigen and “nonimmunogenic” organisms which had produced upper urinary tract infection without a rise in antibody titer. “Immunogenic” 06 vaccine produced high titers of antibody in patients regarded as possibly “poor producers” of antibody, but “nonimmunogenic” 011 vaccine was not associated with a rise in titer in patients previously regarded as “good producers”. These vaccines were significantly different in immunogenicity (P < 0.05). Five vaccines were tested in 50 rats. The difference in hemagglutinating titers to O antigen between 06 and 011 was highly significant (P < 0.001). Immunogenicity of the infecting organism appears to be a significant factor in determining antibody response to O antigen in upper urinary tract infection.Immunogénicité de l'antigène O d'Escherichia coli dans les infections du haut appareil urinaire. Le rôle de l'immunogénicité de l'organisme infectant (Escherichia coli) dans la réponse immune à l'antigène O au cours des infections du haut appareil urinaire a été étudié. Des vaccins tués par la chaleur ont été préparés à partir d'organismes “immunogéniques” qui ont été responsables d'infection du haut appareil urinaire associées à des titres élevés d'anticorps hémagglutinants contre l'antigène O et d'organismes “non immunogéniques” qui ont produit une infection du haut appareil sans augmentation du titre d'anticorps. Le vaccin “immunogénique” 06 produit des titres élevés d'anticorps chez des malades considérés comme de faibles producteurs d'anticorps et le vaccin “non immunogénique” 011 ne détermine pas d'augmentation du titre chez des malades antérieurement considérés comme de “bons producteurs”. Ces vaccins diffèrent significativement en “immunogénicité” (P < 0, 05). Cinq vaccins ont été essayés chez 50 rats. La différence dans les titres d'hémmaglutination vis à vis de l'antigène O est très significative entre 06 et 011 (P < 0, 001). L'immunogénicité de l'organisme infectant parait être un facteur important dans la détermination de la réponse immune à l'antigène O au cours des infections du haut appareil urinaire

N-Acetylcysteine prevents but does not reverse dexamethasone-induced hypertension

1. We have shown previously that N-acetylcysteine (NAC) prevents the increase in blood pressure induced by adrenocorticotropin treatment. The present study investigated the effect of NAC on dexamethasone (Dex)-induced hypertension. 2. Male Sprague-Dawle

The Frequency of Malaria Is Similar among Women Receiving either Lopinavir/Ritonavir or Nevirapine-based Antiretroviral Treatment

HIV protease inhibitors (PIs) show antimalarial activity in vitro and in animals. Whether this translates into a clinical benefit in HIV-infected patients residing in malaria-endemic regions is unknown. We studied the incidence of malaria, as defined by blood smear positivity or a positive Plasmodium falciparum histidine-rich protein 2 antigen test, among 444 HIV-infected women initiating antiretroviral treatment (ART) in the OCTANE trial (A5208; ClinicalTrials.gov: NCT00089505). Participants were randomized to treatment with PI-containing vs. PI-sparing ART, and were followed prospectively for ≥48 weeks; 73% also received cotrimoxazole prophylaxis. PI-containing treatment was not associated with protection against malaria in this study population

Economic hardship associated with managing chronic illness: a qualitative inquiry

<p>Abstract</p> <p>Background</p> <p>Chronic illness and disability can have damaging, even catastrophic, socioeconomic effects on individuals and their households. We examined the experiences of people affected by chronic heart failure, complicated diabetes and chronic obstructive pulmonary disease to inform patient centred policy development. This paper provides a first level, qualitative understanding of the economic impact of chronic illness.</p> <p>Methods</p> <p>Interviews were conducted with patients aged between 45 and 85 years who had one or more of the index conditions and family carers from the Australian Capital Territory and Western Sydney, Australia (n = 66). Content analysis guided the interpretation of data.</p> <p>Results</p> <p>The affordability of medical treatments and care required to manage illness were identified as the key aspects of economic hardship, which compromised patients' capacity to proactively engage in self-management and risk reduction behaviours. Factors exacerbating hardship included ineligibility for government support, co-morbidity, health service flexibility, and health literacy. Participants who were on multiple medications, from culturally and linguistically diverse or Indigenous backgrounds, and/or not in paid employment, experienced economic hardship more harshly and their management of chronic illness was jeopardised as a consequence. Economic hardship was felt among not only those ineligible for government financial supports but also those receiving subsidies that were insufficient to meet the costs of managing long-term illness over and above necessary daily living expenses.</p> <p>Conclusion</p> <p>This research provides insights into the economic stressors associated with managing chronic illness, demonstrating that economic hardship requires households to make difficult decisions between care and basic living expenses. These decisions may cause less than optimal health outcomes and increased costs to the health system. The findings support the necessity of a critical analysis of health, social and welfare policies to identify cross-sectoral strategies to alleviate such hardship and improve the affordability of managing chronic conditions. In a climate of global economic instability, research into the economic impact of chronic illness on individuals' health and well-being and their disease management capacity, such as this study, provides timely evidence to inform policy development.</p

Brief intervention to reduce risky drinking in pregnancy: study protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Risky drinking in pregnancy by UK women is likely to result in many alcohol-exposed pregnancies. Studies from the USA suggest that brief intervention has promise for alcohol risk reduction in antenatal care. However, further research is needed to establish whether this evidence from the USA is applicable to the UK. This pilot study aims to investigate whether pregnant women can be recruited and retained in a randomized controlled trial of brief intervention aimed at reducing risky drinking in women receiving antenatal care.</p> <p>Methods</p> <p>The trial will rehearse the parallel-group, non-blinded design and procedures of a subsequent definitive trial. Over 8 months, women aged 18 years and over (target number 2,742) attending their booking appointment with a community midwife (n = 31) in north-east England will be screened for alcohol consumption using the consumption questions of the Alcohol Use Disorders Identification Test (AUDIT-C). Those screening positive, without a history of substance use or alcohol dependence, with no pregnancy complication, and able to give informed consent, will be invited to participate in the trial (target number 120). Midwives will be randomized in a 1:1 ratio to deliver either treatment as usual (control) or structured brief advice and referral for a 20-minute motivational interviewing session with an alcohol health worker (intervention). As well as demographic and health information, baseline measures will include two 7-day time line follow-back questionnaires and the EuroQoL EQ-5D-3 L questionnaire. Measures will be repeated in telephone follow-ups in the third trimester and at 6 months post-partum, when a questionnaire on use of National Health Service and social care resources will also be completed. Information on pregnancy outcomes and stillbirths will be accessed from central health service records before the follow-ups. Primary outcomes will be rates of eligibility, recruitment, intervention delivery, and retention in the study population, to inform power calculations for a definitive trial. The health-economics component will establish how cost-effectiveness will be assessed, and examine which data on health service resource use should be collected in a main trial. Participants’ views on instruments and procedures will be sought to confirm their acceptability.</p> <p>Discussion</p> <p>The study will produce a full trial protocol with robust sample-size calculations to extend evidence on effectiveness of screening and brief intervention.</p> <p>Trial Registration</p> <p>Current Controlled Trials ISRCTN43218782</p