Sharing hard labour: developing a standard template for data summaries in guideline development.

BACKGROUND: A key objective of the Guidelines International Network (GIN) is to reduce duplication of effort. To address this objective, a working group was established to define a minimum dataset for inclusion in all evidence tables. METHODS: A literature review was conducted to identify existing evidence tables, and GIN member organisations were asked to provide the tables they use. The results were used to develop a minimum dataset (template) for studies addressing intervention questions. The template was pilot-tested by a group of guideline developers and reviewed at GIN conferences. RESULTS The literature search yielded 65 articles. These dealt with reporting standards and trial quality (eg, CONSORT statement) rather than which data should be extracted from studies. However, the checklist items given were considered useful. Nineteen GIN members provided evidence tables; 17 tables were used for analysis. The number of items included in the tables ranged from 8 to 19, with several items common to all tables. Within individual items, the level of detail varied widely. The draught template included a majority of items relating to objective data. Pilot testing revealed that the median time to read a paper and complete the template was 2 h for a randomised controlled trial and 2½ h for a non-randomised, controlled intervention study. The median rating for both relevance and clarity of items was high. CONCLUSION The template listing the items needed to summarise an interventional study is now available for large-scale testing by all organisations.

Clinical practice guidelines for the surgical management of rotator cuff tears in adults.

CONTEXT: Rotator cuff tears are very common. In 2005, about 45 000 patients in France underwent surgery. Surgical techniques and indications have evolved over recent years with the development of arthroscopic procedures. The lack of visibility on current practice and a request by the French Ministry of Health to assess the fixation devices used in arthroscopic surgery prompted the drafting of these guidelines. OBJECTIVES: To produce guidelines on the indications and limitations of open surgery and arthroscopic surgery. METHODS: A systematic review of the literature (2000-2007) was performed. It was submitted to a multidisciplinary working group of experts in the field (n = 12) who drafted an evidence report and clinical practice guidelines, which were amended in the light of comments from 36 peer reviewers. MAIN RECOMMENDATIONS: (i) Medical treatment (oral medication, injections, physiotherapy) is always the first option in the management of degenerative tears of rotator cuff tendons. Surgery is a later option that depends on clinical and morphological factors, and patient characteristics.(ii) Surgery can be considered for the purpose of functional recovery in cases of a painful, weak or disabling shoulder refractory to medical treatment. (iii) Arthroscopy is indicated for nonreconstructive surgery or debridement, and for partial tear debridement or repair. (iv) Open surgery, mini-open surgery or arthroscopy can be used for a full-thickness tear accessible to direct repair by suture. (v) A humeral prosthesis or total reversed prosthesis is indicated for cuff tear arthropathy. (vi) The fixation devices used for bone reinsertion (anchors, screws, staples,and buttons) are indispensable for fully arthroscopic repair. No studies have determined the number of fixation devices to be used according to tear size.

Hepatitis A among health workers in Paris hospitals. Occupational Health Physicians of Paris Hospital (AP-HP)

To design a vaccination strategy against hepatitis A among hospital employees, we carried out a serological survey against hepatitis A virus (HAV) infection in 10 university hospitals in the Paris area. Subjects under 60 years of age were consecutively enrolled by occupational health services and tested for IgG to HAV by ELISA. Of the 1,516 subjects recruited, 926 were health workers (HW), 322 clerks, and 268 cooks or kitchen employees. Among HW and clerks the HAV seroprevalence was 53.8 percent (95 percent CI: 44.0-65.6), increasing with age and being higher among Europe (83.6 percent vs 45.6 percent, P < .001). Age correlated closely with the duration of hospital work, so only age was taken into account for further analysis. The HAV seroprevalences among HW and clerks originating from Europe were close (48.8 percent vs 42.6 percent) and remained so after adjustment for age. HAV seroprevalences in HW caring for adults and those caring for children were also similar (45.2 percent vs 40.1 percent). Seroprevalence was higher in assistant nurses than in nurses (51.3 percent vs 39.8 percent, P < .02). Among cooks and kitchen employees, 53.4 percent were HAV-seropositive. This study shows that hospital employees need not routinely be vaccinated against HAV; the decision should be taken by the occupational physician according to the type of work, but should be routine for cooks and kitchen employees. The need for prevaccinal screening for anti-HAV should be assessed in the light of employees' geographical origin and age.(Au)

Hepatitis A among health workers in Paris hospitals. Occupational Health Physicians of Paris Hospital (AP-HP).

To design a vaccination strategy against hepatitis A among hospital employees, we carried out a serological survey of hepatitis A virus (HAV) infection in 10 university hospitals in the Paris area. Subjects under 60 years of age were consecutively enrolled by occupational health services and tested for IgG to HAV by ELISA. Of the 1,516 subjects recruited, 926 were health workers (HW), 322 clerks, and 268 cooks or kitchen employees. Among HW and clerks the HAV seroprevalence was 53.8% (95% CI: 44.0-65.6), increasing with age and being higher among employees of African or Caribbean origin than those from Europe (83.6% vs 45.6%, P < .001). Age correlated closely with the duration of hospital work, so only age was taken into account for further analysis. The HAV seroprevalences among HW and clerks originating from Europe were close (46.8% vs 42.6%) and remained so after adjustment for age. HAV seroprevalences in HW caring for adults and those caring for children were also similar (45.2% vs 40.1%). Seroprevalence was higher in assistant nurses than in nurses (51.3% vs. 39.8%, P < .02). Among cooks and kitchen employees, 53.4% were HAV-seropositive. This study shows that hospital employees need not routinely be vaccinated against HAV; the decision should be taken by the occupational physician according to the type of work, but should be routine for cooks and kitchen employees. The need for prevaccinal screening for anti-HAV should be assessed in the light of employees' geographical origin and age.

AIDS related eye disease in Burundi, Africa.

AIMS: To determine the prevalence of ocular manifestations in AIDS patients hospitalised in Bujumbura, Burundi, according to their CD4+ lymphocyte count, serological status for CMV and VZV, and general health status. METHODS: Prospective study of 154 consecutive patients who underwent general and ophthalmological examinations, including dilated fundus examination. AIDS was diagnosed on the basis of Bangui criteria and HIV-1 seropositivity. CD4+ lymphocyte counts were determined by the Capcellia method. CMV and VZV antibodies were detected with ELISA methods. RESULTS: The mean age was 37 (SD 9) years and 65% of the patients were male. Active tuberculosis was the most frequent underlying disease (61%). Almost all the patients (99%) were seropositive for CMV and VZV. Among the 115 patients for whom CD4+ lymphocyte counts were available, 86 (75%) had more than 100 cells x 10(6)/l. Ocular involvement comprised 16 cases of microangiopathy, six of opalescence of the anterior chamber, five of retinal perivasculitis, two of zoster ophthalmicus, two of viral retinitis, and one of opalescence of the vitreous. CONCLUSION: In Africa, the prevalence of ocular involvement in HIV infection is far lower than in Europe and the United States, possibly because most African patients die before ocular opportunistic infections occur.

Expression of p53 protein in borderline epithelial ovarian tumors: a clinicopathologic study of 39 cases.

OBJECTIVE: To evaluate the expression of p53 protein in borderline ovarian tumors and its correlations with the clinicopathological parameters. STUDY DESIGN: p53 protein was detected by immunoperoxidase in 79 ovarian tumors (39 borderline, 20 malignant, 20 benign). p53 expression was compared to histological type, FIGO stage, age, presence of ascites, recurrence and patient survival. RESULTS: The median value of quantitative p53 immunopositivity was: 0.80+/-0.42 in ovarian cancers, 0+/-0.24 in borderline tumors and 0+/-0.16 in benign tumors (p=0.001). In borderline tumors, no correlation existed between p53 expression and the histological or clinical parameters. In malignant tumors, no correlation existed between the expression of p53 and patient survival. CONCLUSION: We found no correlation between p53 immunopositivity and clinicopathological parameters in carcinomas and borderline tumors of the ovary. p53 immunopositivity may help in distinguishing borderline tumors from ovarian cancers.

Expression of cadherins in benign, borderline, and malignant ovarian epithelial tumors: a clinicopathologic study of 60 cases.

We have analyzed the expression of E- and N-cadherins in benign, borderline, and maligant ovarian tumors, and we have correlated the pattern of cadherin expression with the standard clinicopathological parameters. An immunohistochemical technique has been applied to formalin-fixed, paraffin-embedded samples of 20 benign cystic tumors, 20 borderline tumors, and 20 cancers. Expression of E- and N-cadherins immunostaining were compared with the histological type, degree of histological differentiation, International Federation of Gynecology and Obstetrics (FIGO) stage, presence of ascites, occurrence of recurrence, and survival. E-cadherin was homogeneosuly expressed in benign tumors but was heterogeneously expressed or undetectable in most borderline and malignant tumors. In contrast, N-cadherin was detected in most benign and borderline tumors but was absent or heterogeneous in most carcinomas. The difference of expression of E-cadherin and N-cadherin between the three groups of ovarian tumors was statistically significant (respectively, P = .03 and P < .001). In ovarian carcinoma, patients with negative E-cadherin staining present a significantly shorter survival. No correlation was found between cadherin expression and clinicopathological parameters in borderline tumors. Our results suggest that alterations in E-cadherin and N-cadherin expressions are differentially involved in ovarian carcinogenesis and may have diagnostic and prognostic values.

Methods for diagnosing tuberculosis among in-patients in eastern Africa whose sputum smears are negative.

SETTING: Two University hospitals in Eastern African capital cities where large prospective studies had been carried out on hospitalized patients to determine the cause of their respiratory diseases. OBJECTIVE: To identify features that differentiated between tuberculosis (TB) and non-tuberculous respiratory disease (non-TB) in hospitalized patients from Bujumbura, Burundi (n = 111) and Dar es Salaam, Tanzania (n = 71) whose sputum smears were negative on microscopic examination for acid-fast bacilli (AFB). DESIGN: Review of clinical findings, radiologic abnormalities, and laboratory test results from 182 patients, first by univariate and then by multivariate (stepwise logistic regression) analysis to assess the contribution of each factor to the final diagnosis. RESULTS: Of the 182 patients with two or more negative AFB smears, 41 had TB and 141 had non-TB. Stepwise regression analysis revealed four easily ascertained symptoms were associated with TB: 1) cough > 21 days; 2) chest pain > 15 days; 3) absence of expectoration; and 4) absence of shortness of breath. Any two of the four diagnosed TB with 85% sensitivity and 67% specificity; any three of the four with 49% sensitivity and 86% specificity. Multivariate analysis showed that adding lymphadenopathy and hematocrit < 30% improved discrimination. CONCLUSION: This methodological approach provides a means for diagnosing TB among all AFB smear-negative hospitalized patients. In this setting, simple clinical symptoms alone are helpful. Similar studies are needed to develop a system for out-patient TB suspects.

Randomized comparison of amphotericin B deoxycholate dissolved in dextrose or Intralipid for the treatment of AIDS-associated cryptococcal meningitis.

We conducted a randomized, open-labeled clinical trial to compare the tolerability and efficacy of amphotericin B deoxycholate, prepared in 5% dextrose or Intralipid (Kabi Pharmacia, Saint-Quentin-en-Yvelines, France), in the treatment of AIDS-associated cryptococcal meningitis in Burundi. Forty-four patients were assigned to receive amphotericin B/dextrose (0.7 mg/[kg.d]) for 14 days; the dose was then reduced to 1 mg/kg every other day for 28 days (infused over 6 hours). Forty-six patients were assigned to receive Intralipid/amphotericin B at a 50% higher dosage (1 mg/[kg.d]) for 14 days; the dose was then reduced to 1.5 mg/kg every other day for 28 days (infused over 2 hours). Intralipid significantly decreased the incidence of fever (P = .02) and chills (P = .0001) related to the infusion of amphotericin B deoxycholate. Analysis of the time to the onset of increased levels of serum creatinine (creatinine level, > 150 mumol/L) showed that Intralipid/amphotericin B was more nephrotoxic (P = .03). The percentage of patients who were clinically cured or had improvement in their conditions and successful mycological outcome was similar in both therapeutic groups, but analysis of the time to the first negative cerebrospinal fluid culture showed a nearly significant difference that favored Intralipid/amphotericin B (P = .07). Intralipid reduced the infusion-related toxicity of amphotericin B deoxycholate without altering its antifungal efficacy but did not confer substantial benefit against renal toxicity that would allow the unitary dosage of amphotericin B deoxycholate to be increased safely.

Pulmonary tuberculosis: comparison of CT findings in HIV-seropositive and HIV-seronegative patients.

PURPOSE: To determine the differences in the computed tomographic (CT) appearance of pulmonary tuberculosis (TB) between patients with and patients without human immunodeficiency virus (HIV) infection. MATERIALS AND METHODS: CT scans and chest radiographs of 42 HIV-seropositive and 42 HIV-seronegative patients with pulmonary TB were reviewed. CD4 T-lymphocyte counts, measured in 40 seropositive patients, were at least 200 cells per microliter in 10 patients and were less that 200 cells per microliter in 30. RESULTS: Seropositive patients had a higher prevalence of lymphadenopathy at chest radiography (P< .05). The seropositive patients had a lower prevalence of consolidation (P< .05), cavitation (P< .01), and postprimary pattern (P< .05) at CT. HIV-seropositive patients had a higher frequency of miliary (P< .01) and extrapulmonary disease (P< .001). Similar features of pulmonary TB were observed in seropositive patients with mild and severe immunosuppression. CONCLUSION: HIV-seropositive patients had a lower prevalence of localized parenchymal disease and a higher prevalence of disseminated disease at CT.

Radiographic abnormalities in tuberculosis and risk of coexisting human immunodeficiency virus infection. Results from Dar-es-Salaam, Tanzania, and scoring system.

First, we evaluated the age profile and chest radiographic abnormalities in 146 patients from Dar-es-Salaam, Tanzania, with new-onset intrathoracic tuberculosis (pulmonary, pleural, or hilar/mediastinal adenopathy), to identify features that were associated with human immunodeficiency virus (HIV) seropositivity or seronegativity; then, we combined these data with those from a companion investigation in Burundi to develop a simple scoring system to predict HIV serologic status. Using agreed-upon criteria and simplified reporting forms, initial chest radiographs were reviewed by three readers, first independently and then at a consensus conference. Of the 146 patients, 80 (55%) were HIV seropositive and 66 were seronegative. More seropositive than seronegative subjects were 31 to 40 yr old (p = 0.03). Because the radiographic characteristics of the two serologic groups were similar in Tanzania and Burundi, we combined the data for stepwise logistic regression that revealed four highly significant variables: age, small lesions, location, and lymphadenopathy. From these, we obtained an equation to calculate the probability that a given tuberculosis patients was HIV seropositive and then we derived a scoring system that in its simplest form (threshold) predicted serologic status correctly in 68.1% of patients; a graded scale was even more accurate in the high (89.1%) and low (82.6%) ranges. This scoring system should be useful when serologic testing is unavailable or refused.

Radiographic abnormalities in tuberculosis and risk of coexisting human immunodeficiency virus infection. Methods and preliminary results from Bujumbura, Burundi.

We evaluated the age profile and chest radiographic abnormalities in 158 patients from Bujumbura, Burundi, with new-onset intrathoracic tuberculosis (pulmonary, pleural, or hilar/mediastinal adenopathy), to identify features that were associated with and would allow prediction of HIV seropositivity or seronegativity. Using agreed-upon criteria and prepared reporting forms, initial chest radiographs were reviewed by three readers, first independently and then at a consensus conference. Of the 158 patients, 105 (66%) were HIV seropositive and 53 patients were seronegative. Seropositive subjects (mean age, 35.8 yr) were older (p = 0.001) than seronegative subjects (mean age, 29.4 yr). Significant or borderline differences between HIV-seropositive and -seronegative patients included the frequency of small nodular lesions (p = 0.03), upper lobe cavitation (p = 0.05), and lymphadenopathy (p = 0.12), and the location of parenchymal abnormalities (p = 0.0006). Stepwise logistic regression revealed four important variables: age, small lesions, location, and lymphadenopathy; these were then used to derive an equation to calculate the probability that a given tuberculosis patient was HIV seropositive. Our mathematical model fit the observed data and the equation predicted serologic findings reasonably well. We conclude that it is possible to determine with useful probability a Burundian tuberculosis patient's HIV serologic status.

High level of hepatitis C endemicity in Gabon, equatorial Africa.

To assess the prevalence of hepatitis C virus (HCV) infection, a community-based study was performed in eastern Gabon on 1172 subjects over 5 years of age. The prevalence of antibodies to HCV (anti-HCV) detected using second-generation enzyme-linked immunosorbent assay (ELISA) and confirmed by an immunoblot assay (RIBA 2), was 6.5%. Anti-HCV prevalence increased with age but was related to neither sex nor ethnic group. Among 30 subjects with positive ELISA results, 14 had HCV viraemia as shown by the polymerase chain reaction (11/12 RIBA positive, 2/15 RIBA negative, 1/3 RIBA indeterminate). We conclude that HCV is highly endemic in western equatorial Africa and that a high proportion of the population may be viraemic.

Pulmonary complications of human immunodeficiency virus infection in Bujumbura, Burundi.

To determine the types of pulmonary disease associated with human immunodeficiency virus (HIV) infection, we conducted a prospective study of 302 consecutive patients admitted for acute respiratory disease to a university hospital in Bujumbura, Burundi. Diagnoses were made according to well-defined criteria. Of the total, 222 patients (73.5%) were HIV seropositive, with women younger than men. Features suggestive of underlying HIV infection were the clinical findings of oral thrush, peripheral lymphadenopathy, or herpes zoster and the radiographic abnormalities of hilar-mediastinal adenopathy or a reticulonodular infiltrate. Tuberculosis and community-acquired pneumonia occurred with approximately equal frequency in the HIV-seropositive and seronegative groups. Pneumocystis carinii pneumonia was diagnosed in 11 patients, all seropositive. Gram-negative bacteremia, especially Salmonella typhimurium, occurred in 23 seropositive patients (10.4%). A total of 24 seropositive patients died during the initial hospitalization, and 11 others required readmission; no seronegative patients died or were rehospitalized. We conclude that HIV infection is a major risk factor for the development of acute respiratory diseases in adults of sufficient severity to require hospitalization in Bujumbura. In this Central African country, where exposure to virulent bacterial pathogens is ubiquitous, tuberculosis, pneumonia, and salmonellosis occur with much greater frequency than classic AIDS-defining opportunistic infections or malignancies.