Richard Bellamy

SARS: Systematic review of treatment effects

Background The SARS outbreak of 2002–2003 presented clinicians with a new, life-threatening disease for which they had no experience in treating and no research on the effectiveness of treatment options. The World Health Organization (WHO) expert panel on SARS treatment requested a systematic review and comprehensive summary of treatments used for SARS-infected patients in order to guide future treatment and identify priorities for research. Methods and Findings In response to the WHO request we conducted a systematic review of the published literature on ribavirin, corticosteroids, lopinavir and ritonavir (LPV/r), type I interferon (IFN), intravenous immunoglobulin (IVIG), and SARS convalescent plasma from both in vitro studies and in SARS patients. We also searched for clinical trial evidence of treatment for acute respiratory distress syndrome. Sources of data were the literature databases MEDLINE, EMBASE, BIOSIS, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to February 2005. Data from publications were extracted and evidence within studies was classified using predefined criteria. In total, 54 SARS treatment studies, 15 in vitro studies, and three acute respiratory distress syndrome studies met our inclusion criteria. Within in vitro studies, ribavirin, lopinavir, and type I IFN showed inhibition of SARS-CoV in tissue culture. In SARS-infected patient reports on ribavirin, 26 studies were classified as inconclusive, and four showed possible harm. Seven studies of convalescent plasma or IVIG, three of IFN type I, and two of LPV/r were inconclusive. In 29 studies of steroid use, 25 were inconclusive and four were classified as causing possible harm. Conclusions Despite an extensive literature reporting on SARS treatments, it was not possible to determine whether treatments benefited patients during the SARS outbreak. Some may have been harmful. Clinical trials should be designed to validate a standard protocol for dosage and timing, and to accrue data in real time during future outbreaks to monitor specific adverse effects and help inform treatment.

WHO Rapid Advice Guidelines for pharmacological management of sporadic human infection with avian influenza A (H5N1) virus

Summary Recent spread of avian influenza A (H5N1) virus to poultry and wild birds has increased the threat of human infections with H5N1 virus worldwide. Despite international agreement to stockpile antivirals, evidence-based guidelines for their use do not exist. WHO assembled an international multidisciplinary panel to develop rapid advice for the pharmacological management of human H5N1 virus infection in the current pandemic alert period. A transparent methodological guideline process on the basis of the Grading Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to develop evidence-based guidelines. Our development of specific recommendations for treatment and chemoprophylaxis of sporadic H5N1 infection resulted from the benefits, harms, burden, and cost of interventions in several patient and exposure groups. Overall, the quality of the underlying evidence for all recommendations was rated as very low because it was based on small case series of H5N1 patients, on extrapolation from preclinical studies, and high quality studies of seasonal influenza. A strong recommendation to treat H5N1 patients with oseltamivir was made in part because of the severity of the disease. Similarly, strong recommendations were made to use neuraminidase inhibitors as chemoprophylaxis in high-risk exposure populations. Emergence of other novel influenza A viral subtypes with pandemic potential, or changes in the pathogenicity of H5N1 virus strains, will require an update of these guidelines and WHO will be monitoring this closely.

An introduction to patient education: theory and practice

Patient education is the process of enabling individuals to make informed decisions about their personal health-related behaviour. It aims to improve health by encouraging compliance with medical treatment regimens and promoting healthy lifestyles. Behavioural change for patients is a complex process and requires more than the simple acquisition of knowledge. Several educational models based on behavioural theories have been developed to explain individuals’ health-related behaviour. The health belief model is the one most commonly used in research. The four principal components of this model are the individuals perception of his or her personal susceptibility to disease, perception of the severity of the disease and perception of the benefits from and barriers to modifying behaviour. The health belief model can be used to design educational interventions that are most likely to be effective. Patient education is a duty for all health practitioners and it should be a core component of medical school curricula.

A systematic review of educational interventions for promoting sun protection knowledge, attitudes and behaviour following the QUESTS approach

A literature review was performed to identify studies of educational interventions to promote sun protection behaviour. Fifty-nine clinical trials were identified. These studies were assessed using the QUESTS model. The studies showed that a wide range of educational interventions in different settings with a variety of target groups can be effective in promoting sun protection knowledge, attitudes, intended and actual behaviour. Relatively few studies made direct comparisons between different educational interventions. Therefore there was little evidence to suggest that any one form of intervention was more effective than any other. This review shows that the QUESTS criteria can be used to evaluate the effectiveness of patient education in the same way they are used to assess evidence in medical education. Performing systematic reviews on patient education topics should prove useful for health professionals developing educational interventions.

Novel respiratory viruses: what should the clinician be alert for?

Since 1990, several novel respiratory viruses affecting humans have been described. In this review, we focus on three pathogens that have caused significant human mortality and raise important public health concerns: severe acute respiratory syndrome (SARS)-coronavirus, Middle East respiratory syndrome (MERS)-coronavirus and avian influenza A viruses (H5N1 and H7N9). Novel respiratory viruses have the potential to instil fear in the public and physicians alike if they are associated with a high case fatality rate. Those viruses with a significant potential for onward human-to-human transmission (including in healthcare settings) might present significant challenges for national public health services and local hospital infection control.