Meta-analysis and public policy: Reconciling the evidence on deworming.

The WHO recommends mass drug administration (MDA) for intestinal worm infections in areas with over 20% infection prevalence. Recent Cochrane meta-analyses endorse treatment of infected individuals but recommend against MDA. We conducted a theory-agnostic random-effects meta-analysis of the effect of multiple-dose MDA and a cost-effectiveness analysis. We estimate significant effects of MDA on child weight (0.15 kg, 95% CI: 0.07, 0.24; P < 0.001), mid-upper arm circumference (0.20 cm, 95% CI: 0.03, 0.37; P = 0.02), and height (0.09 cm, 95% CI: 0.01, 0.16; P = 0.02) when prevalence is over 20% but not on Hb (0.06 g/dL, 95% CI: -0.01, 0.14; P = 0.1). These results suggest that MDA is a cost-effective intervention, particularly in the settings where it is recommended by the WHO.

Testing fractional doses of COVID-19 vaccines.

Due to the enormous economic, health, and social costs of the COVID-19 pandemic, there are high expected social returns to investing in parallel in multiple approaches to accelerating vaccination. We argue there are high expected social returns to investigating the scope for lowering the dosage of some COVID-19 vaccines. While existing evidence is not dispositive, available clinical data on the immunogenicity of lower doses combined with evidence of a high correlation between neutralizing antibody response and vaccine efficacy suggests that half or even quarter doses of some vaccines could generate high levels of protection, particularly against severe disease and death, while potentially expanding supply by 450 million to 1.55 billion doses per month, based on supply projections for 2021. An epidemiological model suggests that, even if fractional doses are less effective than standard doses, vaccinating more people faster could substantially reduce total infections and deaths. The costs of further testing alternative doses are much lower than the expected public health and economic benefits. However, commercial incentives to generate evidence on fractional dosing are weak, suggesting that testing may not occur without public investment. Governments could support either experimental or observational evaluations of fractional dosing, for either primary or booster shots. Discussions with researchers and government officials in multiple countries where vaccines are scarce suggests strong interest in these approaches.

Twenty-year economic impacts of deworming.

Estimating the impact of child health investments on adult living standards entails multiple methodological challenges, including the lack of experimental variation in health status, an inability to track individuals over time, and accurately measuring living standards and productivity in low-income settings. This study exploits a randomized school health intervention that provided deworming treatment to Kenyan children, and uses longitudinal data to estimate impacts on economic outcomes up to 20 y later. The effective respondent tracking rate was 84%. Individuals who received two to three additional years of childhood deworming experienced a 14% gain in consumption expenditures and 13% increase in hourly earnings. There are also shifts in sectors of residence and employment: treatment group individuals are 9% more likely to live in urban areas, and experience a 9% increase in nonagricultural work hours. Most effects are concentrated among males and older individuals. The observed consumption and earnings benefits, together with deworming's low cost when distributed at scale, imply that a conservative estimate of its annualized social internal rate of return is 37%, a high return by any standard.

Optimal vaccine subsidies for endemic diseases.

In Goodkin-Gold et al. (2021), we analyzed optimal subsidies for a vaccine against an epidemic outbreak like Covid-19. This companion paper alters the underlying epidemiological model to suit endemic diseases requiring continuous vaccination of new cohorts-also suiting an epidemic like Covid-19 if, following Gans (2020), one assumes peaks are leveled by social distancing. We obtain qualitatively similar results: across market structures ranging from perfect competition to monopoly, the subsidy needed to induce first-best vaccination coverage on the private market is highest for moderately infectious diseases, which invite the most free riding; extremely infectious diseases drive more consumers to become vaccinated, attenuating externalities. Stylized calibrations to HIV, among other diseases, suggest that first-best subsidies can be exorbitantly high when suppliers have market power, rationalizing alternative policies observed in practice such as bulk purchases negotiated by the government on behalf of the consumers.

Predictors of getting a residency interview: Differences by medical specialty.

OBJECTIVES: Gaining medical residency interviews has become more competitive and costly for medical students. Although limited evidence from residency programme directors indicates predictors for successfully matching into a programme, past research has not sufficiently explored the application components necessary to receive an interview offer. The present study will identify which application components are most helpful in obtaining interview offers for different medical specialties. METHODS: Data were sourced from the Texas Seeking Transparency in Application to Residency (STAR), a survey of recently matched fourth-year American medical students who self-reported information on their residency application components and interview offers. Multi-level logistic regression analyses were employed to predict the odds of interview offer according to applicants' academic, research and extracurricular characteristics. Sub-analyses were conducted for each medical specialty. RESULTS: Nearly 10 000 students reported information on over 419 010 applications submitted, which resulted in 164 696 interview offers. Across the sample, applicants had greater odds of receiving an interview offer if they had a geographic connection to the programme (odds ratio [OR] = 4.10, 95% confidence interval [CI] 4.00-4.20), had completed an away rotation at the programme (OR = 16.00, 95% CI 14.92-17.15), were Alpha Omega Alpha Honor Medical Society members (OR = 1.49, 95% CI 1.36-1.64), or had been inducted into the Gold Humanism Honor Society (OR = 1.50, 95% CI 1.39-1.62). Applicants had reduced odds of getting an interview if they had been required to remediate a course in medical school (OR = 0.73, 95% CI 0.64-0.83) or had failed the US Medical Licensing Examination Step 1 or Step 2 examination on their first attempt (OR = 0.40, 95% CI 0.33-0.47). Predictors of obtaining an interview varied by specialty. CONCLUSIONS: The present findings can assist senior medical students as they prepare residency applications and identify programmes to which they will apply. Knowledge of the significant factors can help applicants more efficiently use resources to maximise their number of interview offers. Completing away rotations and selecting programmes with which applicants have geographic connections may increase their odds of receiving interview offers.

Relationship Between Emotional Intelligence and Clinical Performance in Student Registered Nurse Anesthetists.

ABSTRACT: Emotional intelligence (EI) includes skills such as recognizing, understanding, and managing emotions. This pilot study investigated the utility of the Mayer-Salovey-Caruso Emotional Intelligence Test Version 2.0 as a screening instrument in student registered nurse anesthetists by determining if EI predicted clinical performance. Scores from 11 participants enrolled in a single nurse anesthesia program were correlated with formative clinical evaluations. Relationships between EI and clinical performance were examined. Participants consistently met clinical performance objectives but were unable to use emotion to solve problems or to recognize others' emotions, suggesting that EI abilities could impact future student registered nurse anesthetist clinical performance.

[Current surgical treatment options for liver metastasis]. / Lebermetastasen: aktueller Stand der chirurgischen Behandlungsmöglichkeiten.

Current surgical treatment options for liver metastasis Abstract. Metastasis are the most frequent hepatic tumors. Although current treatment regimens focus highly on interdisciplinarity and are individualized, surgical resection remains the only curative treatment and represents the current gold standard approach. Advances in surgical, systemic and interventional treatment within the last years have resulted in a multidisciplinary therapy, individualized for each patient depending on their disease stage and condition. With these advancements, initially non-resectable liver metastasis can now be candidates for a surgical approach. Neoadjuvant chemotherapy, minimal invasive ablation, two- or multi-staged resections of the liver with or without portal vein embolization have contributed to this development. Advances in surgical and perioperative treatment also account for significantly increased overall survival.

School health class associated with reduced odds of eating disorder symptoms in American adolescents.

OBJECTIVE: Eating disorder symptoms, including eating disorder diagnosis, binge eating, and unhealthy weight loss, are associated with health risks, and adolescence may be an optimal time to provide education on healthy alternatives. This research explored whether in-school health information during adolescence is associated with eating disorder symptoms in young adulthood. METHOD: Data were used from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative study of American youth, including information from Wave I, when participants were in Grades 7-12, and from Wave III, when participants were aged 18-26. Logistic regression analyses predicted eating disorder symptoms from in-school health information, adjusting for demographic and educational covariates. In-school health information and eating disorder symptoms were based on participant self-report. RESULTS: In-school health information about both diet (the foods you should and should not eat) and the importance of exercise compared to no health information reduced the odds of youth-reported eating disorder history odds ratio ((OR) = 0.23, 95% CI = 0.11-0.48). Individuals who received information on exercise alone compared to no health information were also less likely to use weight pills to control weight (OR = 0.26, 95% CI = 0.11-0.61). There was no difference in binge-eating symptoms based on school health class. DISCUSSION: Findings from this exploratory research study indicate that in-school receipt of information on diet and exercise has modest associations with eating disorder symptoms, including lower odds of a self-reported eating disorder and lower odds of using weight loss pills. Further research is needed to definitely test the role of school health class on eating disorder symptoms.

Resection or radiofrequency ablation for hepatocellular carcinoma? Assessment of validity of current studies, meta-analyses and their influence on guidelines.

BACKGROUND: Two Cochrane reviews compared overall survival following liver resection (LR) or radiofrequency ablation (RFA) for patients with hepatocellular carcinoma. The first from 2013, found moderate evidence for a survival advantage for LR over RFA when limiting the analysis to trials at low risk of bias. The second (2017), found no evidence for a difference in all-cause mortality for LR versus RFA. Aim was to assess the validity of the randomized controlled trials included in both Cochrane reviews and to investigate their impact on current guidelines. METHODS: The validity of the studies was analyzed using the CONSORT checklist. Two meta-analyses were then performed with all eligible studies from both meta-analyses. Finally, the impact of the result of the original meta-analyses on eight international guidelines was assessed. RESULTS: The four randomized controlled trials showed several inconsistencies (unclear or inadequate randomization, absence of sample-size calculation, missing blinded setup and/or conflicts of interest). All guidelines used recommendations based on the results of the meta-analyses or on studies included in the meta-analyses. CONCLUSION: The analyzed studies showed a substantial lack of overall validity. However the results of these studies and subsequent meta-analyses are used as the evidence base for the majority of current guidelines.

Ensuring accurate BP measurements.

Accurate BP measurements are vital for determining appropriate medication and treatment regimens. This article describes a quality improvement project to increase compliance with the American Heart Association's guidelines for BP measurement.

Presence of arthralgia exacerbates decreased quality of life in hidradenitis suppurativa patients.

Hidradenitis suppurativa is characterized by chronic follicular occlusion that presents with recurrent nodules, inflamed abscesses, and scarring. Research has shown that these patients have a decreased quality of life. In addition to its psychosocial effects, hidradenitis suppurativa has recently been associated with joint pathology. In this study, we distributed a survey consisting of the Short Form 12 Health Survey, used for assessing health outcomes, along with additional questions about joint pain to an online hidradenitis suppurativa support group in order to understand the effect of comorbid arthralgia on quality of life in this disease. The respondents in this study had significantly reduced physical health composite scores-12 (PCS-12), (35.8 versus 50, P<0.001) and mental health composite scores-12 (MCS-12), (33.7 versus 50, P<0.001) scores compared to the general population. Additionally, patients reporting severe arthralgia had significantly lower PCS-12 (32.3 versus 36.5; P<0.05) and MCS-12 (33.3 versus 40.5; P<0.001) scores compared to those with mild arthralgia. Despite the effect of comorbid arthralgia on quality of life, only 11% reported having been asked about joint pain by their dermatologist. Routine screening questions concerning associated arthralgia and diminished quality of life may be helpful during clinician assessment and treatment of hidradenitis suppurativa patients.

Impaired T cell-mediated hepatitis in peroxisome proliferator activated receptor alpha (PPARα)-deficient mice.

BACKGROUND: Peroxisome proliferator activated receptor alpha (PPARα), a regulator of enzymes involved in ß oxidation, has been reported to influence lymphocyte activation. The purpose of this study was to determine whether PPARα plays a role in T cell-mediated hepatitis induced by Concanavalin A (ConA). METHODS: Wild type (wt) or PPARα-deficient (PPARα-/-) mice were treated with ConA (15 mg/kg) by intravenous injection 0, 10 or 24 h prior to sacrifice and serum and tissue collection for analysis of tissue injury, cytokine response, T cell activation and characterization. RESULTS: Ten and 24 h following ConA administration, wt mice had significant liver injury as demonstrated by serum transaminase levels, inflammatory cell infiltrate, hepatocyte apoptosis, and expression of several cytokines including interleukin 4 (IL4) and interferon gamma (IFNγ). In contrast, PPARα-/- mice were protected from ConA-induced liver injury with significant reductions in serum enzyme release, greatly reduced inflammatory cell infiltrate, hepatocellular apoptosis, and IFNγ expression, despite having similar levels of hepatic T cell activation and IL4 expression. This resistance to liver injury was correlated with reduced numbers of hepatic natural killer T (NKT) cells and their in vivo responsiveness to alpha-galactosylceramide. Interestingly, adoptive transfer of either wt or PPARα-/- splenocytes reconstituted ConA liver injury and cytokine production in lymphocyte-deficient, severe combined immunodeficient mice implicating PPARα within the liver, possibly through support of IL15 expression and/or suppression of IL12 production and not the lymphocyte as the key regulator of T cell activity and ConA-induced liver injury. CONCLUSION: Taken together, these data suggest that PPARα within the liver plays an important role in ConA-mediated liver injury through regulation of NKT cell recruitment and/or survival.

Graft rinse prior to reperfusion in liver transplantation: literature review and online survey within the Eurotransplant community.

Graft rinse prior reperfusion in liver transplantation (LT) is believed to reduce the incidence of postreperfusion syndrome and improve clinical outcome. A MEDLINE search was performed to obtain a comprehensive review of the published literature dealing with graft rinse in LT. Moreover, all thirty-four LT centers in the Eurotransplant (ET) region were invited to participate in an online survey to whether or not graft rinse is performed and whether further research in the field is needed. Seventeen reports have been found to investigate graft rinse protocols in 1894 LT recipients. Eighteen of the thirty centers that participated in the online survey performed graft rinse prior reperfusion in LT. The most commonly used rinse solution was albumin. Nineteen centers stated interest in participating in a multicenter RCT in the field. The published literature does not provide concluding appraisal of the benefit of graft rinse in LT. Graft rinse protocols are not standardized and are based on personal experience. Appropriately designed clinical trials addressing the topic are demanded. The online survey appears to be a helpful tool for the evaluation of clinical practice and future research topics in the transplant community.

Education, HIV, and Early Fertility: Experimental Evidence from Kenya.

A seven-year randomized evaluation suggests education subsidies reduce adolescent girls' dropout, pregnancy, and marriage but not sexually transmitted infection (STI). The government's HIV curriculum, which stresses abstinence until marriage, does not reduce pregnancy or STI. Both programs combined reduce STI more, but cut dropout and pregnancy less, than education subsidies alone. These results are inconsistent with a model of schooling and sexual behavior in which both pregnancy and STI are determined by one factor (unprotected sex), but consistent with a two-factor model in which choices between committed and casual relationships also affect these outcomes.

Smad3 signaling in the regenerating liver: implications for the regulation of IL-6 expression.

Liver regeneration is vital for graft survival and adequate organ function. Smad activation regulates hepatocyte proliferation and macrophage function. The aim of the current study was to evaluate the impact of Smad3 signaling during liver regeneration in the mouse. Male C57Bl/6 wild-type (wt) mice or mice deficient in Smad3 (Smad3(-/-) ) were subjected to a 70% partial hepatectomy (pHx) or sham surgery and sacrificed 24, 42, or 48 h later. Tissue was analyzed for TGF-ß signaling, the mitogenic cytokine response [i.e., tumor necrosis factor alpha, TNF-α; interleukin (IL)-6], and liver regeneration. Partial hepatectomy stimulated a strong regenerative response measured by proliferating cell nuclear antigen-positive hepatocytes 42 and 48 h post-pHx in conjunction with an increased expression of IL-6, TNF-α, and Smad2/3 phosphorylation 24 h post-pHx in both hepatocytes and nonparenchymal cells. Surprisingly, Smad3 deficiency led to reduced hepatocyte proliferation 42 h post-pHx which recovered by 48 h, a process that correlated with and was preceded by significant reductions in IL-6 expression and signal transducer and activator of transcription 3 phosphorylation, and cyclin D1 induction 24 h post-pHx. Loss of Smad3 signaling suppresses the expression of key mitogenic cytokines and delays hepatocellular regeneration. Therapies directed at finely regulating Smad3 activation early within the regenerating liver may prove useful in promoting liver cell proliferation and restoration of liver mass.

Being surveyed can change later behavior and related parameter estimates.

Does completing a household survey change the later behavior of those surveyed? In three field studies of health and two of microlending, we randomly assigned subjects to be surveyed about health and/or household finances and then measured subsequent use of a related product with data that does not rely on subjects' self-reports. In the three health experiments, we find that being surveyed increases use of water treatment products and take-up of medical insurance. Frequent surveys on reported diarrhea also led to biased estimates of the impact of improved source water quality. In two microlending studies, we do not find an effect of being surveyed on borrowing behavior. The results suggest that limited attention could play an important but context-dependent role in consumer choice, with the implication that researchers should reconsider whether, how, and how much to survey their subjects.

Content validity testing of questions for a patient satisfaction with general anesthesia care instrument.

INTRODUCTION: Patient satisfaction with any health care experience is the result of a complex set of interactions between the patient and the health system in which care is received. Measuring patient satisfaction allows quantification of the congruence between the expectations of care and the care that is received. It is important to quantify satisfaction with care because it involves the patient in the care experience and decreases the potential gap between expected and actual care delivered over time. Despite the benefits of measuring satisfaction with anesthesia care, this outcome has been historically understudied possibly because of a lack of reliable tools that measure the construct. PURPOSE: The purpose of this study was to test the content validity of items derived from an integrated review of studies that measured patient satisfaction with anesthesia care. METHODS: The content validity of the questions was tested using an expert panel. A total of 13 nurse anesthetists consented to participate in the study as expert panel members. Each expert panel member evaluated the items for content validity on a 4-point scale. Both an Individual Content Validity Index (I-CVI) and a Scale Content Validity Index (S-CVI) were calculated. RESULTS: All I-CVI scores were greater than 0.8. The range of I-CVI was 0.833 to 1.0. The average scale Content Validity Index (S-CVI/ave) was 0.979. CONCLUSION: High content validity of all items was supported by an expert panel of anesthesia providers. The high level of agreement among raters related to the content of the general anesthesia statements supports progressing to the next step in instrument development.

Use of the Rasch model for initial testing of fit statistics and rating scale diagnosis for a general anesthesia satisfaction questionnaire.

BACKGROUND AND PURPOSE: The level of patient satisfaction is a result of a complex set of interactions between the patient and the health care provider. It is important to quantify satisfaction with care because it involves the patient in the care experience and decreases the potential gap between expected and actual care delivered. METHODS: We tested a preliminary 23-item instrument to measure patient satisfaction with general anesthesia care. The rating scale Rasch model was chosen as the framework. RESULTS: There were 10 items found to have sufficient evidence of stable fit statistics. Items included 2 questions related to information provided, 2 questions related to concern and kindness of the provider, and 1 question each for interpersonal skills of the provider, attention by the provider, feeling safe, well-being, privacy, and overall anesthesia satisfaction. CONCLUSION: Such actions as providing enough time to understand the anesthesia plan, answering questions related to the anesthetic, showing kindness and concern for the patient, displaying good interpersonal skills, providing adequate attention to the patient, providing a safe environment that maintains privacy and provides a sense of well-being are important actions that are well within the control of individual anesthesia providers and may lead to improved care from the perception of the patient.

Aging Skin and Wound Healing.

Responsible for many essential functions of life, human skin is made up of many components, each of which undergoes significant functional changes with aging and photodamage. Wound healing was previously thought to be defective in the elderly given the higher presence of chronic wounds and the longer time required for re-epithelialization of acute wounds. However, these notions have been challenged in recent research, which has shown that wound healing in the elderly is delayed but not defective. Poor healing of chronic wounds in older populations is more often attributable to comorbid conditions rather than age alone.

Enhancing Intraoperative Cholangiography Interpretation Skills: A Perceptual Learning Approach for Surgical Residents.

OBJECTIVE: Laparoscopic cholecystectomy is a commonly performed surgery with risk of serious complications. Intraoperative cholangiography (IOC) can mitigate these risks by clarifying the anatomy of the biliary tree and detecting common bile duct injuries. However, mastering IOC interpretation is largely through experience, and studies have shown that even expert surgeons often struggle with this skill. Since no formal curriculum exists for surgical residents to learn IOC interpretation, we developed a perceptual learning (PL)-based training module aimed at improving surgical residents' IOC interpretation skills. DESIGN: Surgical residents were assessed on their ability to identify IOC characteristics and provide clinical recommendations using an online training module based on PL principles. This research had 2 phases. The first phase involved pre/post assessments of residents trained via the online IOC interpretation module, measuring their IOC image recognition and clinical management accuracy (percentage of correct responses), response time and confidence. During the second phase, we explored the impact of combining simulator-based IOC training with the online interpretation module on same measures as used in the first phase (accuracy, response time, and confidence). SETTING: The study was conducted at Rush University Medical College in Chicago. The participants consisted of surgical residents from each postgraduate year (PGY). Residents participated in this study during their scheduled monthly rotation through Rush's surgical simulation center. RESULTS: Total 23 surgical residents participated in the first phase. A majority (95.7%) found the module helpful. Residents significantly increased confidence levels in various aspects of IOC interpretation, such as identifying complete IOCs and detecting abnormal findings. Their accuracy in making clinical management decisions significantly improved from pretraining (mean accuracy 68.1 +/- 17.3%) to post-training (mean accuracy 82.3 +/- 10.4%, p < 0.001). Furthermore, their response time per question decreased significantly from 25 +/- 12 seconds to 17 +/- 12 seconds (p < 0.001). In the second phase, we combined procedural simulator training with the online interpretation module. The 20, first year residents participated and 88% found the training helpful. The training group exhibited significant confidence improvements compared to the control group in various aspects of IOC interpretation with observed nonsignificant accuracy improvements related to clinical management questions. Both groups demonstrated reduced response times, with the training group showing a more substantial, though nonsignificant, reduction. CONCLUSION: This study demonstrated the effectiveness of a PL-based training module for improving aspects of surgical residents' IOC interpretation skills. The module, found helpful by a majority of participants, led to significant enhancements in clinical management accuracy, confidence levels, and decreased response time. Incorporating simulator-based training further reinforced these improvements, highlighting the potential of our approach to address the lack of formal curriculum for IOC interpretation in surgical education.