Cancer patterns in Arua district, Uganda: a hospital-based retrospective study.

Introduction: Cancer is the second leading cause of mortality with over 19 million cases and 10 million deaths worldwide. Available data on cancer patterns in Uganda are through modelling of data from two population-based cancer registries (PBCRs) representing only about 10% of the cancer situation in Uganda. This study sought to determine the common types of cancer among adults and children in Arua District over a 5-year period (2017-2021). Methods: Retrospective cohort chart review and 'catchment population approach' were employed. All newly diagnosed cancer patients from Arua between 2017 and 2021 were included in this study. Data were collected using Redcap whereas management and analysis were conducted using Stata 17. Cancer patterns were computed as frequencies and percentages and the interest was in finding out the common cancers among adults (above 19 years) and children (0-19 years). Results: Over the 5-year study period, a total of 1,118 new cancer cases were registered, with slightly more females (52.1%). The top five common cancers irrespective of sex and age were: liver cancer (13.7%), cervical (11.8%), breast (10.7%), oesophagus (10.5%) and Burkitt's lymphoma (BL) (6.4%). In this study, 15.3% (n = 171) of the study participants were children. The top five common childhood cancers included BL (42%), leukemia (10.5%), other lymphomas (9.4%), osteosarcoma (4.7%) and nephroblastoma (3%). Conclusion: There is a high incidence of liver cancer in Arua district. The high levels of cervical, breast and oesophagus cancer were consistent with what is reported by the two PBCRs in Uganda. However, BL could be due to the presence of a BL treatment centre at Kuluva hospital in Arua. Cancer interventions in Arua should therefore be targeted towards liver, cervix, breast, and oesophagus cancer and furthering research on the reason for the high incidence of liver cancer.

Embedding research capacity strengthening in multi-country studies in low-and middle-income countries: learnings from sexual and reproductive health research.

Research capacity strengthening (RCS) can empower individuals, institutions, networks, or countries to define and prioritize problems systematically; develop and scientifically evaluate appropriate solutions; and reinforce or improve capacities to translate knowledge into policy and practice. However, how to embed RCS into multi-country studies focusing on sexual and reproductive health and rights (SRHR) is largely undocumented. We used findings from a qualitative study, from a review of the literature, and from a validation exercise from a panel of experts from research institutions that work on SRHR RCS. We provide a framework for embedded RCS; suggest a set of seven concrete actions that research project planners, designers, implementers, and funders can utilise to guide embedded RCS activities in low- and middle-income countries; and present a practical checklist for planning and assessing embedded RCS in research projects.

Paper ContextMain findings: Building on findings from a primary qualitative study, a literature review, and a consultation with experts on capacity strengthening in LMICs, we propose a systematic approach to embedded RCS.Added knowledge: We present a framework for embedding RCS in multi-country studies and propose seven action points and a checklist for the implementation of RCS in multi-country research projects with considerations for sexual and reproductive health and rights research.Global health impact for policy and action: An easy-to-use checklist can enable global health researchers and policymakers to ensure RCS is an integral component of multi-country research.

Factors associated with malaria vaccine uptake in Nsanje district, Malawi.

BACKGROUND: Malaria remains a significant global health burden affecting millions of people, children under 5 years and pregnant women being most vulnerable. In 2019, the World Health Organization (WHO) endorsed the introduction of RTS,S/AS01 malaria vaccine as Phase IV implementation evaluation in three countries: Malawi, Kenya and Ghana. Acceptability and factors influencing vaccination coverage in implementing areas is relatively unknown. In Malawi, only 60% of children were fully immunized with malaria vaccine in Nsanje district in 2021, which is below 80% WHO target. This study aimed at exploring factors influencing uptake of malaria vaccine and identify approaches to increase vaccination. METHODS: In a cross-sectional study conducted in April-May, 2023, 410 mothers/caregivers with children aged 24-36 months were selected by stratified random sampling and interviewed using a structured questionnaire. Vaccination data was collected from health passports, for those without health passports, data was collected using recall history. Regression analyses were used to test association between independent variables and full uptake of malaria vaccine. RESULTS: Uptake of malaria vaccine was 90.5% for dose 1, but reduced to 87.6%, 69.5% and 41.2% for dose 2, 3, and 4 respectively. Children of caregivers with secondary or upper education and those who attended antenatal clinic four times or more had increased odds of full uptake of malaria vaccine [OR: 2.43, 95%CI 1.08-6.51 and OR: 1.89, 95%CI 1.18-3.02], respectively. Children who ever suffered side-effects following immunization and those who travelled long distances to reach the vaccination centre had reduced odds of full uptake of malaria vaccine [OR: 0.35, 95%CI 0.06-0.25 and OR: 0.30, 95%CI 0.03-0.39] respectively. Only 17% (n = 65) of mothers/caregivers knew the correct schedule for vaccination and 38.5% (n = 158) knew the correct number of doses a child was to receive. CONCLUSION: Only RTS,S dose 1 and 2 uptake met WHO coverage targets. Mothers/caregivers had low level of information regarding malaria vaccine, especially on numbers of doses to be received and dosing schedule. The primary modifiable factor influencing vaccine uptake was mother/caregiver knowledge about the vaccine. Thus, to increase the uptake Nsanje District Health Directorate should strengthen communities' education about malaria vaccine. Programmes to strengthen mother/caregiver knowledge should be included in scale-up of the vaccine in Malawi and across sub-Saharan Africa.

Effectiveness of integrated chronic care models for cardiometabolic multimorbidity in sub-Saharan Africa: a systematic review and meta-analysis.

OBJECTIVES: This review aimed at identifying the elements of integrated care models for cardiometabolic multimorbidity in sub-Saharan Africa (SSA) and their effects on clinical or mental health outcomes including systolic blood pressure (SBP), blood sugar, depression scores and other patient-reported outcomes such as quality of life and medication adherence. DESIGN: Systematic review and meta-analysis using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. DATA SOURCES: We systematically searched PubMed, Embase, Scopus, Web of Science, Global Health CINAHL, African Journals Online, Informit, PsycINFO, ClinicalTrials.gov, Pan African Clinical Trials Registry and grey literature from OpenSIGLE for studies published between 1999 and 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included randomised controlled trial studies featuring integrated care models with two or more elements of Wagner's chronic care model. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers used standardised methods to search and screen included studies. Publication bias was assessed using the Doi plot and Luis Furuya Kanamori Index. Meta-analysis was conducted using random effects models. RESULTS: In all, we included 10 randomised controlled trials from 11 publications with 4864 participants from six SSA countries (South Africa, Kenya, Nigeria, Eswatini, Ghana and Uganda). The overall quality of evidence based on GRADE criteria was moderate. A random-effects meta-analysis of six studies involving 1754 participants shows that integrated compared with standard care conferred a moderately lower mean SBP (mean difference=-4.85 mm Hg, 95% CI -7.37 to -2.34) for people with cardiometabolic multimorbidity; Hedges' g effect size (g=-0.25, (-0.39 to -0.11). However, integrated care compared with usual care showed mixed results for glycated haemoglobin, depression, medication adherence and quality of life. CONCLUSION: Integrated care improved SBP among patients living with cardiometabolic multimorbidity in SSA. More studies on integrated care are required to improve the evidence pool on chronic care models for multimorbidity in SSA. These include implementation studies and cost-effectiveness studies. PROSPERO REGISTRATION NUMBER: CRD42020187756.

Factors associated with viral load suppression among orphans and vulnerable children and adolescents living with HIV in Kenya.

While tremendous progress has been made on attaining HIV treatment goals (95-95-95), children's viral load suppression remains a challenge particularly among the orphans and vulnerable groups. In Sub Saharan Africa, there is limited evidence of specific interventions in orphans and vulnerable children (OVC) programs to support children and adolescents living with HIV (CALHIV) to attain durable viral load suppression. Through a large OVC cohort, the study sought to identify correlates of optimal viral load suppression among CALHIV in the Kenya OVC program. This cross-sectional study utilized data on CALHIV below the age of 18 years who were enrolled in the OVC program and actively receiving HIV care and treatment services from ART clinics across Kenya and with documented VL results between October 2019 and September 2020. To obtain a nationally representative sample, data was retrieved from USAID implementing partners' databases across the country. Association between selected variables and VL suppression (outcome of interest) were assessed using a multivariate mixed effect logistic regression model, using glmer function in the LME4 package in R. Factors associated with VL suppression included child's education status (aOR = 1.33; 95% CI: 1.07, 1.65), membership of a psychosocial support group (aOR = 1.258; 95% CI: 1.15, 1.38), and membership of a voluntary savings and lending association (VSLA) (aOR = 1.226; 95% CI: 1.129, 1.33). In addition, child's sex (aOR = 0.88; 95% CI: 0.83, 0.94), caregiver sex (aOR = 0.909; 95% CI: 0.839, 0.997) and "high" status for caregiver household vulnerability (aOR = 0.81; 95% CI: 0.71, 0.924), had an inverse relationship with VL suppression. CALHIV characteristics including child's sex, child's education status (whether currently active in school or inactive) and child's membership in a psychosocial support group were key determinants of VL suppression. Similarly, caregiver sex and membership in a voluntary savings and lending association also influence VL suppression.

Availability, accessibility and activation of mental health services among university students in Africa: a protocol of a mixed-methods systematic review with meta-analysis and meta-synthesis.

INTRODUCTION: In Africa, the prevalence of mental health problems is higher among university students than in the general population. A number of systematic reviews and recent prevalence studies have focused on prevalence of mental health issues among college. This mixed-methods systematic review, including meta-analysis and meta-synthesis, will explore: what mental health services are available to university students; the extent to which students access available services and factors associated with service access; and the degree to which students activate (use) accessible services and factors associated with service activation. METHODS AND ANALYSIS: We will conduct electronic literature search of the following databases: PubMed, Cochrane Library, Semantic Scholar, ERIC, Trip Database, Medline and PsycINFO. Disagreement, if any, will be resolved by a third reviewer. Two reviewers will independently assess the methodological quality of included studies using relevant tools. For cross-sectional studies, we will use the Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies whereas qualitative or mixed-methods studies will be assessed using the Critical Appraisal Skills Programme. OR, risk ratio or mean difference with 95% CI will be considered as the effect size. We will assess heterogeneity between studies by appropriate subgroup analyses. Publication bias will be detected using funnel plots. ETHICS AND DISSEMINATION: Ethical clearance is not required as we are not collecting primary data. Findings will be disseminated via relevant scientific conferences and peer-reviewed publications. PROSPERO REGISTRATION NUMBER: CRD42022296870.

Sexual and gender minority undergraduates' relationships and strategies for managing fit in STEM.

Undergraduates with sexual and/or gender minority (SGM) identities, including lesbian, gay, bisexual, transgender, queer/questioning, pansexual, intersexual, asexual, or additional positionalities, often face an unwelcoming STEM microclimate. The STEM microclimate includes the places students experience, such as classrooms or labs, and the people, such as peers or professors, with whom they discuss their STEM program. While previous work offers a framework of microaggressions faced by SGM people, and the behavioral, cognitive, and emotional strategies they use to react to them, little is known about the strategies SGM students use to persist in the STEM microclimate. We analyze interviews with 29 SGM STEM undergraduates to uncover how they fit in STEM, their experiences that affect fit, how social capital in the form of influential others affects fit, and the strategies used to deal with microaggressions and cultivate a supportive network. Using thematic analysis, we find that students vary in their feelings of fit, with students with gender minority identities experiencing more frequent and more severe microaggressions than students with sexual minority identities (which are often less visible). We likewise find that students with racial minority identities report compounding issues related to identity. SGM students with social capital, or a network of people to whom they can turn in order to access advice and resources, believe they fit in better than those without such capital. To support their feelings of fit, students use defenses against discrimination, including micro-defenses, wherein they change how they present their self to avoid microaggressions and/or surround themselves with accepting people. This research highlights the role of microaggressions and social capital in affecting fit as well as the micro-defenses students use to defend against discrimination. Our introduction of the concept of micro-defenses provides a way to theorize about micro-interactional dynamics and the site at which students defend against microaggressions so they feel more welcome in STEM. Implications provide insight into how SGM students can be supported in STEM as well as the institutional changes STEM departments and campuses can make in order to better support and include SGM students.

Determinants of contraceptive use among women 0-23 months postpartum in Kitui County, Kenya: A cross-sectional study.

The risk of unintended pregnancy is high in the postpartum period, especially during the first year of delivery. Yet, short birth intervals are associated with increased risk of adverse maternal and infant outcomes. In Kenya, despite women having multiple contacts with healthcare providers during their pregnancy and postpartum journeys, uptake of contraceptives during the postpartum period remains low. We examine factors that determine contraceptive use among postpartum women in Kitui County, Kenya.A cross-sectional study was conducted in six sub-counties of Kitui County covering a random sample of 768 postpartum women in April 2019. Logistic regression was used to study the association between uptake of contraceptives among women 0-23 months postpartum and several explanatory variables that included socio-demographic characteristics and facility-level factors. Overall, 68% of women in Kitui County reported using contraceptives. The likelihood of contraceptive use increased with the increase in the number of known family planning methods. Women who discussed family planning with a health worker within the last 12 months were 2.58 (95%CI: 1.73, 3.89) times more likely to use contraceptives during the postpartum period compared to those who did not. There was an increased odds of contraceptive uptake among women who received family planning information or service during postnatal care than those who did not (aOR = 2.04, 95%CI: 1.30, 3.24). A positive association was also found between contraceptive use and receipt of family planning information or service during immunization visits or during child well visits. It is evident that facility-level factors such as discussing family planning with women; educating women about different family planning methods; providing family planning information or services during postnatal care, immunization, or well child visits are associated with increased likelihood of contraceptive uptake by women during postpartum period. Programs targeting enhancing women's attendance of postnatal care clinics should be encouraged.

Factors associated with North-South research collaboration focusing on HIV/AIDS: lessons from ClinicalTrials.gov.

BACKGROUND: A North-South (N-S) research collaboration is one way through which research capacity of developing countries can be strengthened. Whereas N-S collaboration in HIV/AIDS area may result in research capacity strengthening of Southern partners, it is not clear what factors are associated with this type of collaboration. The study aims to characterize N-S research collaboration focusing on HIV/AIDS and to determine factors associated with such N-S research collaborations. METHODS: Clinical trial data on HIV/AIDS-related studies conducted between 2000 and 2019 were obtained from ClinicalTrials.gov. Using these data, we characterized N-S collaborative studies focusing on HIV/AIDS and summarized them using frequencies and percentages. To determine factors associated with these studies, we used logistic regression and reported results as adjusted odds ratios with Wald 95% confidence intervals. RESULTS AND DISCUSSION: Of the 4,832 HIV/AIDS-related studies retrieved from the registry, less than one-quarter (n = 1133, 23%) involved a Southern institution, with 77% of these studies classified as N-S collaborations. Majority of these studies have single PI (50%), are conducted at single location (39%); have large sample sizes (41%); are federally-funded (32%) or receive funding from other sources (32%); are intervention studies (64%); and involve a mixture of male and female participants (58%) and adult participants (54%). Single PIs (as opposed to multiple PIs) were more likely to be from the North than South institution (odds ratio = 5.59, 95%CI: 4.16 - 11.57). Trend analyses showed that N-S research collaborations produced HIV/AIDS-related studies at a faster rate than S-S research collaborations. N-S collaborations involving female or children produced HIV/AIDS-related studies between 2000 and 2019 at a significantly faster rate than S-S collaborations involving females and children during the same period. Holding other factors constant, N-S collaborative research focusing on HIV/AIDS are associated with: multiple PIs as opposed to single PI, multiple institutions as opposed to a single institution, multiple locations as opposed to a single location, large number of participants as opposed to small sample sizes, and public funding as opposed to industry funding. Almost half of these studies had a Northern PI only, about one-third had a Southern PI only, and much fewer had PIs from both North and South. However, these studies were less likely to receive funding from other sources than industry funding. CONCLUSIONS: HIV/AIDS-related research is increasingly becoming a more collaborative global research involving more N-S collaborations than S-S collaborations. Factors associated with N-S collaborative studies focusing on HIV/AIDS include multiple PIs, institutions, and locations; large sample sizes; publicly funded; and involve vulnerable populations such as women and children. Whereas almost half of these studies have a Northern PI only, about one-third have a Southern PI only, and much fewer have PIs from both North and South. Our results inform future design and implementation of N-S research collaborations in this area. Suggestions for improvement of ClinicalTrials.gov registry are provided.

Social Capital From Professional Engineering Organizations and the Persistence of Women and Underrepresented Minority Undergraduates.

Professional engineering organizations (PEOs) have the potential to provide women and underrepresented and minoritized (URM) students with social capital (i.e., resources gained from relationships) that aids their persistence in their engineering undergraduate programs and into the workforce. We hypothesize that women and URM students engineering students who participate in PEOs are more likely to persist in their engineering major and that PEOs contribute to their persistence by providing them access to insider information that supports their persistence. Each year for five years we administered surveys with closed- and open-ended items to examine the association between participating in PEOs and the persistence of a cohort of engineering majors from 11 diverse universities. We used logistic regression and thematic analysis to analyze the data. URM students who participated in PEOs and other engineering related activities were more likely to persist to the second year than URM students who did not (adjusted odds ratio = 2.18, CI: 1.09, 4.37). Students reported that PEOs contributed to their persistence by enabling them to network, reduce gender and race/ethnic isolation, and access professional resources. URM students should be encouraged to participate in PEOs beginning in their first year to increase their integration in their major, which we have found to increase their persistence.

Effectiveness of school-based interventions in delaying sexual debut among adolescents in sub-Saharan Africa: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Early sexual debut is associated with poor sexual and reproductive health outcomes across the life course. A majority of interventions aimed at delaying sexual debut among adolescents in sub-Saharan Africa (SSA) have been implemented in schools with mixed findings on the effectiveness of such interventions. This systematic review will summarise and synthesise existing evidence on the effectiveness of school-based interventions in delaying sexual debut among adolescents aged 10-19 years. METHODS AND ANALYSIS: We will conduct a comprehensive database search of peer-reviewed studies published in PubMed, Scopus, Science Direct, Web of Science, HINARI and EBSCO (PsycINFO, Global Health, CINAHL) and in Cochrane library, National Institute of Health and Turning Research into Practice databases for ongoing studies yet to be published. All studies conducted in SSA between January 2009 and December 2020, regardless of the study design, will be included. Two authors will independently screen all retrieved records and relevant data on sexual debut extracted.Data will be pooled using the random effects model. Dichotomous outcomes will be reported as risk ratios and continuous data as mean difference at 95% CI. Heterogeneity will be assessed using the I² statistic. Findings will be presented in tables and charts, while providing a description of all included studies, themes and concepts drawn from literature. ETHICS AND DISSEMINATION: Ethical approval is not required. The findings will be disseminated through peer-reviewed publications, presentations at relevant conferences and other convening focusing on adolescent sexual and reproductive health.

Factors associated with research productivity in higher education institutions in Africa: a systematic review.

Background: There are low levels of research productivity among Higher Education Institutions (HEIs) in Africa, a situation that is likely to compromise the development agenda of the continent if not addressed. We conducted a systematic literature review to synthesize evidence of the factors associated with research productivity in HEIs in Africa and the researchers' motives for research. Methods: We identified 838 publications related to research productivity in HEIs in Africa from various databases, from which we included 28 papers for review. The inclusion criteria were that (i) the paper's primary focus was on factors associated with research productivity, and motivations of doing research among faculty members in Africa; (ii) the setting was the HEIs in Africa; (iii) the type of publication was peer-reviewed papers and book chapters based on primary or secondary data analysis; and (iv) the language was English or French. Essays, opinions, blogs, editorials, reviews, and commentaries were excluded. Results: Most of the studies operationalized research productivity as either journal publications or conference proceedings. Both institutional and individual factors are associated with the level of research productivity in HEIs in Africa. Institutional factors include the availability of research funding, level of institutional networking, and the degree of research collaborations, while individual factors include personal motivation, academic qualifications, and research self-efficacy. Conclusions: Deliberate efforts in HEIs in Africa that addressed both individual and institutional barriers to research productivity are promising. This study recommends that the leadership of HEIs in Africa prioritizes the funding of research to enable researchers to contribute to the development agenda of the continent. Moreover, HEIs should build institutional support to research through the provision of research enabling environment, policies and incentives; strengthening of researchers' capabilities through relevant training courses, mentorship and coaching; and embracing networking and collaboration opportunities.

CARTA fellows' scientific contribution to the African public and population Health Research agenda (2011 to 2018).

BACKGROUND: Since its inception in 2009, the Consortium for Advanced Research Training in Africa (CARTA) program has focused on strengthening the capacity of nine African universities and four research centres to produce skilled researchers and scholars able to improve public and population health on the continent. This study describes the alignment between CARTA-supported doctoral topics and publications with the priorities articulated by the African public and population health research agenda. METHODS: We reviewed the output from CARTA PhD fellows between 2011 and 2018 to establish the volume and scope of the publications, and the degree to which the research focus coincided with the SDGs, World Bank, and African Development Bank research priority areas. We identified nine key priority areas into which the topics were classified. RESULTS: In total, 140 CARTA fellows published 806 articles in peer-reviewed journals over the 8 years up to 2018. All the publications considered in this paper had authors affiliated with African universities, 90% of the publications had an African university first author and 41% of the papers have CARTA fellows as the first author. The publications are available in over 6300 online versions and have been cited in over 5500 other publications. About 69% of the published papers addressed the nine African public and population health research agenda and SDG priority areas. Infectious diseases topped the list of publications (26.8%), followed by the health system and policy research (17.6%), maternal and child health (14.7%), sexual and reproductive health (14.3%). CONCLUSIONS: Investments by CARTA in supporting doctoral studies provides fellows with sufficient training and skills to publish their research in fields of public and population health. The number of publications is understandably uneven across Africa's public and population priority areas. Even while low in number, fellows are publishing in areas such as non-communicable disease, health financing, neglected tropical diseases and environmental health. Violence and injury is perhaps underrepresented. There is need to keep developing research capacity in partner institutions with low research output by training more PhDs in such institutions and by facilitating enabling environments for research.

Increasing collaborative research output between early-career health researchers in Africa: lessons from the CARTA fellowship program.

In 2008 nine African Universities and four African research institutions, in partnership with non-African institutions started the Consortium for Advanced Research Training in Africa (CARTA) to strengthen doctoral training and research capacity on health in Africa. This study describes particular aspects of the CARTA program that promotes collaboration between the PhD fellows in the program, and determines the patterns of collaborative publications that resulted from the intervention. We reviewed program monitoring and evaluation documents and conducted a bibliometric analysis of 806 peer-reviewed publications by CARTA fellows published between 2011 and 2018. Results indicate that recruiting multidisciplinary fellows from various institutions, encouraging registration of doctoral-level fellows outside home institutions, and organizing joint research seminars stimulated collaborative research on health-related topics. Fellows collaborated among themselves and with non-CARTA researchers. Fellows co-authored 75 papers (10%) between themselves, of which 53 (71%) and 42 (56%) included fellows of different cohorts and different disciplines respectively, and 19 (25%) involved fellows of different institutions. CARTA graduates continued to publish with each other after graduating - 11% of the collaborative publications occurred post-graduation - indicating that the collaborative approach was maintained after exiting from the program. However, not all fellows contributed to publishing collaborative papers. The study recommends concerted effort towards enhancing collaborative publications among the CARTA fellows, both doctoral and post-doctoral, which can include holding research exchange forums and collaborative grant-writing workshops.

The role of iron in the management of chemotherapy-induced anemia in cancer patients receiving erythropoiesis-stimulating agents.

BACKGROUND: Erythropoiesis-stimulating agents (ESAs) are commonly used to treat chemotherapy-induced anemia (CIA). However, about half of patients do not benefit. OBJECTIVES: To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA. SEARCH METHODS: We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits. SELECTION CRITERIA: All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high-quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response.The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate-quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient.We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low-quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response.Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low-quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI -0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI -0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI -0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI -0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02).We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI -0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high-quality evidence).We found no evidence for a difference in risk of grade III-IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate-quality evidence). The incidence of treatment-related mortality (TRM) was 0% (997 participants; four comparisons; high-quality evidence).Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms.Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow-up duration (up to 20 weeks), the long-term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results. AUTHORS' CONCLUSIONS: Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation.

Identifying subgroups of care providers participating in a telehealth educational intervention: hierarchical cluster analysis of evaluation data.

UNLABELLED: Health care providers (HCPs) serving HIV-infected patients, especially in rural and underserved areas, have limited access to continuing medical education. OBJECTIVES: To identify subgroups of HCPs who might benefit from a telehealth training program focusing on HIV/AIDS care based on HCPs' objective for attending the training. METHODS: Hierarchical cluster analysis combined with thematic analysis identified the subgroups. RESULTS: A total of 56 HCPs attended between 1 and 9 of the 12 sessions conducted (mean ≈ 2, standard deviated = 1.6). Subgroups identified included knowledge (HCPs interested in gaining, increasing, or updating their knowledge in HIV care), learn-expert (HCPs interested in learning, obtaining, or providing expert opinion), and observe-apply-network (HCPs interested in observing the training, applying knowledge gained to practice, and networking). No group difference were found in the participants' reaction to the session, change in knowledge following the training, and other important characteristics. CONCLUSION: Methodological contributions of the study are discussed.

Uncertainty about effects is a key factor influencing institutional review boards' approval of clinical studies.

PURPOSE: To investigate factors, which influence institutional review boards' (IRBs') decision to approve or not approve clinical studies, a nationwide vignette-based online survey of IRB members was conducted. METHODS: A factorial design was used, whereby seven aspects of each hypothetical study were randomly varied in 15 phrases in each vignette to produce unique vignettes. Participants indicated the degree of study approval and described factors influencing approval decision. Qualitative responses were thematically content analyzed. RESULTS: Sixteen themes were obtained from 208 participants from 42 institutions. Uncertainty, adherence, study design, and harms were frequently and intensely cited to influence study approval. Analysis of two extreme subgroups (approvers vs. nonapprovers) showed that uncertainty influenced approval decisions, odds ratios (OR) = 3.5 (95% confidence interval [CI], 1.3-9.8) and OR = 3.2 (95% CI, 1.1-8.9), respectively, based on theme frequency and theme intensity, ignoring multiple observations per person. Taking into consideration multiple observations per person, similar results were obtained for uncertainty: OR = 8.9 (95% CI, 0.93-85.4). CONCLUSIONS: Perceived uncertainty about benefits and harms of a proposed intervention is a key driver in IRB members' approval of clinical trials. This, in turn, calls for improved standardization in the communications of information on benefits and harms in the research protocols considered by the IRBs.

Concordance between decision analysis and matching systematic review of randomized controlled trials in assessment of treatment comparisons: a systematic review.

BACKGROUND: Systematic review (SR) of randomized controlled trials (RCT) is the gold standard for informing treatment choice. Decision analyses (DA) also play an important role in informing health care decisions. It is unknown how often the results of DA and matching SR of RCTs are in concordance. We assessed whether the results of DA are in concordance with SR of RCTs matched on patient population, intervention, control, and outcomes. METHODS: We searched PubMed up to 2008 for DAs comparing at least two interventions followed by matching SRs of RCTs. Data were extracted on patient population, intervention, control, and outcomes from DAs and matching SRs of RCTs. Data extraction from DAs was done by one reviewer and from SR of RCTs by two independent reviewers. RESULTS: We identified 28 DAs representing 37 comparisons for which we found matching SR of RCTs. Results of the DAs and SRs of RCTs were in concordance in 73% (27/37) of cases. The sensitivity analyses conducted in either DA or SR of RCTs did not impact the concordance. Use of single (4/37) versus multiple data source (33/37) in design of DA model was statistically significantly associated with concordance between DA and SR of RCTs. CONCLUSIONS: Our findings illustrate the high concordance of current DA models compared with SR of RCTs. It is shown previously that there is 50% concordance between DA and matching single RCT. Our study showing the concordance of 73% between DA and matching SR of RCTs underlines the importance of totality of evidence (i.e. SR of RCTs) in the design of DA models and in general medical decision-making.

Survival of patients with non-small cell lung cancer without treatment: a systematic review and meta-analysis.

BACKGROUND: Lung cancer is considered a terminal illness with a five-year survival rate of about 16%. Informed decision-making related to the management of a disease requires accurate prognosis of the disease with or without treatment. Despite the significance of disease prognosis in clinical decision-making, systematic assessment of prognosis in patients with lung cancer without treatment has not been performed. We conducted a systematic review and meta-analysis of the natural history of patients with confirmed diagnosis of lung cancer without active treatment, to provide evidence-based recommendations for practitioners on management decisions related to the disease. Specifically, we estimated overall survival when no anticancer therapy is provided. METHODS: Relevant studies were identified by search of electronic databases and abstract proceedings, review of bibliographies of included articles, and contacting experts in the field. All prospective or retrospective studies assessing prognosis of lung cancer patients without treatment were eligible for inclusion. Data on mortality was extracted from all included studies. Pooled proportion of mortality was calculated as a back-transform of the weighted mean of the transformed proportions using the random-effects model. To perform meta-analysis of median survival, published methods were used to pool the estimates as mean and standard error under the random-effects model. Methodological quality of the studies was examined. RESULTS: Seven cohort studies (4,418 patients) and 15 randomized controlled trials (1,031 patients) were included in the meta-analysis. All studies assessed mortality without treatment in patients with non-small cell lung cancer (NSCLC). The pooled proportion of mortality without treatment in cohort studies was 0.97 (95% CI: 0.96 to 0.99) and 0.96 in randomized controlled trials (95% CI: 0.94 to 0.98) over median study periods of eight and three years, respectively. When data from cohort and randomized controlled trials were combined, the pooled proportion of mortality was 0.97 (95% CI: 0.96 to 0.98). Test of interaction showed a statistically non-significant difference between subgroups of cohort and randomized controlled trials. The pooled mean survival for patients without anticancer treatment in cohort studies was 11.94 months (95% CI: 10.07 to 13.8) and 5.03 months (95% CI: 4.17 to 5.89) in RCTs. For the combined data (cohort studies and RCTs), the pooled mean survival was 7.15 months (95% CI: 5.87 to 8.42), with a statistically significant difference between the two designs. Overall, the studies were of moderate methodological quality. CONCLUSION: Systematic evaluation of evidence on prognosis of NSCLC without treatment shows that mortality is very high. Untreated lung cancer patients live on average for 7.15 months. Although limited by study design, these findings provide the basis for future trials to determine optimal expected improvement in mortality with innovative treatments.