BACKGROUND: Staphylococcus aureus (S. aureus) is the leading nosocomial (hospital acquired) pathogen in hospitals throughout the world. Traditionally, control of S. aureus has been focused on preventing cross-infection between patients, however, it has been shown repeatedly that a large proportion of nosocomial S. aureus infections originate from the patient`s own flora. Nasal carriage of S. aureus is now considered a well defined risk factor for subsequent infection in various groups of patients. Local antibiotic treatment with mupirocin ointment is often used to eradicate nasal S. aureus. OBJECTIVES: To determine whether the use of mupirocin nasal ointment in patients with identified S. aureus nasal carriage reduced S. aureus infection rates. SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (May 2008), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2 2008), MEDLINE (1950 to May 2008), EMBASE (1980 to May 2008) and CINAHL (1982 to May 2008). To identify unpublished trials, abstract books from major scientific meetings (ICAAC, ESCMID and SHEA) were handsearched, researchers and manufacturers of mupirocin were contacted and other electronic databases were searched (SIGLE, ASLIB Index, mRCT, USA Clinical Trials). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing nasal mupirocin with no treatment or placebo or alternative nasal treatment in the prevention of S. aureus infections in nasal S. aureus carriers were included. DATA COLLECTION AND ANALYSIS: Titles, abstracts and full-text articles of studies retrieved from the search process were independently assessed by two authors for inclusion. From included studies a data extraction form was made and the quality of the trial was assessed. The primary outcome was the S. aureus infection rate (any site). Secondary outcomes were time to infection, mortality, adverse events and infection rate caused by micro-organisms other than S. aureus. MAIN RESULTS: Nine RCTs involving 3396 participants met the inclusion criteria. Patient populations varied and several types of nosocomial S. aureus infection were described including bacteraemia, exit-site infections, peritonitis, respiratory tract infections, skin infections, surgical site infections (SSI) and urinary tract infections. After pooling the eight studies that compared mupirocin with placebo or with no treatment, there was a statistically significant reduction in the rate of S. aureus infection associated with intranasal mupirocin (RR 0.55, 95% CI 0.43 to 0.70).A planned subgroup analysis of surgical trials demonstrated a significant reduction in the rate of nosocomial S. aureus infection rate associated with mupirocin use (RR 0.55, 95% CI 0.34 to 0.89) however this effect disappeared if the analysis only included surgical site infections caused by S. aureus (RR 0.63, 95% CI 0.38 to 1.04), possibly due to a lack of power. The infection rate caused by micro-organisms other than S. aureus was significantly higher in patients treated with mupirocin compared with control patients (RR 1.38 95% CI 1.118 to 1.72). AUTHORS` CONCLUSIONS: In people who are nasal carriers of S. aureus, the use of mupirocin ointment results in a statistically significant reduction in S. aureus infections.
 
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OBJECTIVE: To estimate the effect of providing women with a latex diaphragm, lubricant gel, and male condoms (intervention) compared with condoms alone (control) on human papillomavirus (HPV) incidence and clearance. METHODS: Participants were 2,040 human immunodeficiency virus (HIV)-negative Zimbabwean women enrolled in a randomized trial estimating the effect of the intervention on HIV acquisition. Clinicians collected cervical samples for HPV testing at baseline, 12 months, and exit. L1 consensus polymerase chain reaction primers were used to determine HPV presence and type. RESULTS: We found no differences in the following outcomes: HPV prevalence at the time of the first postenrollment HPV test (intention-to-treat analysis, relative risk [RR] 1.02, 95% confidence interval [CI] 0.90-1.16); HPV incidence at 12 months among women HPV-negative at baseline (RR 0.95, 95% CI 0.80-1.14); and HPV clearance at 12 months among women HPV-positive at baseline (RR 0.80, 95% CI 0.61-1.05). Clearance of HPV type 58 was lower in the intervention group at 12 months (RR 0.67, 95% CI 0.48-0.92), but not at exit (RR 0.93, 95% CI 0.75-1.16); clearance of HPV type 18 was lower in the intervention group at exit (RR 0.55, 95% CI 0.33-0.89), but not at 12 months (RR 0.55, 95% CI 0.29-1.05). Women reporting diaphragm/gel use at 100% of prior sex acts had a lower likelihood of having one or more new HPV types detected at 12 months (RR 0.75, 95% CI 0.58-0.96) and exit (RR 0.77, 95% CI 0.59-0.99). CONCLUSION: Among women receiving risk reduction counseling and condoms in an HIV prevention program, diaphragm plus lubricant gel provision did not affect HPV incidence or clearance. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00211459 LEVEL OF EVIDENCE: I.
 
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OBJECTIVE: To study the immunogenicity and reactogenicity of a combined Haemophilus influenzae type b and Neisseria meningitidis serogroup C tetanus toxoid conjugate vaccine (Hib-MenC-TT) when administered as a booster dose in combination with a measles, mumps and rubella vaccine (MMR). DESIGN: A phase 3 open randomised controlled trial. SETTING: One centre in Oxford, UK and nine centres in Poland. SUBJECTS: 12-15-month-old healthy children. INTERVENTIONS: In the primary stage of the study 500 healthy 6-12-week-old infants were randomised in a 3:1 ratio to receive Hib-MenC-TT+DTPa-IPV or MenC-CRM197 vaccine+DTPa-IPV-Hib. In the booster stage, 476 participants (190 in the UK and 286 in Poland) were vaccinated with Hib-MenC-TT and MMR. MAIN OUTCOME MEASURES: The proportion of children with protective serum antibody levels against MenC and Hib 6 weeks following a Hib-MenC-TT booster dose. RESULTS: The co-primary objectives were met: the Hib-MenC-TT booster dose induced protective antibody titres in children vaccinated with Hib-MenC-TT+DTPa-IPV or MenC-CRM197+DTPa-IPV-Hib at 2, 3 and 4 months of age. 94.8% (lower limit of (LL) 95% CI 92.4) of participants had rSBA-MenC >or=1:128 and 100% (LL 95% CI 99.2) achieved anti-PRP concentrations >or=1.0 microg/ml. The percentage of toddlers with a post boost rSBA-MenC of 1:128 was significantly higher after priming with Hib-MenC-TT (97.7%) than after MenC-CRM197 (86%) (difference: 11.7%; 95% CI 6.2 to 19.4). CONCLUSION: The waning antibody titres against Hib and MenC following primary immunisation can be boosted to protective levels by administering the Hib-MenC-TT vaccine at 12-15 months of age, supporting the recent introduction of this vaccine in the UK immunisation schedule to sustain protection of children against Hib and MenC disease. TRIAL REGISTRATION NUMBER: NCT00258700. Study ID: 103974 (http://clinicaltrials.gov).
 
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OBJECTIVE: To examine the association between gestational weight gain and perinatal outcome in women with gestational diabetes mellitus (GDM). METHODS: This is a retrospective cohort study of women with nonanomalous singleton pregnancies with GDM enrolled in the Sweet Success California Diabetes and Pregnancy Program between 2001 and 2004. Gestational weight gain, calculated from prepregnancy weight and weight at last prenatal Sweet Success visit, was subgrouped into below, within, and above the Institute of Medicine (IOM) weight-gain guidelines. Perinatal outcomes were examined using chi(2) test and multivariable regression analysis with 15-35-lb weight gain as the reference group. RESULTS: There were 31,074 women meeting study criteria. Compared with women with gestational weight gain within the IOM guidelines, women who gained above the guidelines had higher odds of having large for gestational age neonates (adjusted odds ratio [aOR] 1.72, 95% confidence interval [CI] 1.53-1.93, number needed to harm 10), preterm delivery (aOR 1.30, 95% CI 1.14-1.48, number needed to harm 32), and primary cesarean delivery (aOR 1.52, 95% CI 1.26-1.83, number needed to harm 10). Women who gained below the guidelines had higher odds of having small for gestational age neonates (aOR 1.39, 95% CI 1.01-1.90) and maintaining diet-controlled GDM (aOR 1.47, 95% CI 1.34-1.63) and lower odds of having large for gestational age neonates (aOR 0.60, 95% CI 0.52-0.67). CONCLUSION: Women diagnosed with GDM who had gestational weight gain above the IOM guidelines have higher risk of undesirable outcomes, including preterm delivery, having macrosomic neonates, and cesarean delivery. Women who gained below guidelines are more likely to remain on diet control but have small for gestational age neonates. LEVEL OF EVIDENCE: II.
 
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Studies suggest that children exposed to cigarette smoke in utero are at risk of becoming obese. Few researchers have evaluated the dose-response association between maternal smoking during pregnancy and childhood obesity or whether this association varies by maternal race/ethnicity. The authors obtained retrospective cohort data by linking records from the Pregnancy Nutrition Surveillance System and the Pediatric Nutrition Surveillance System on 155,411 low-income children born during 1995-2001 in 9 US states and 2 tribal nations. The authors examined maternal smoking status, duration of smoking, quantity of smoking, and both duration and quantity combined. Childhood obesity was based on a body mass index greater than or equal to the 95th percentile for sex and age, assessed at age 2-4 years. Maternal race/ethnicity modified the association between smoking during pregnancy and childhood obesity. Among non-Hispanic White mothers, both duration and quantity of smoking were positively associated with childhood obesity in a dose-response manner. Among non-Hispanic Black mothers, only heavy smoking was positively associated with childhood obesity. Among Hispanics, American Indians/Alaska Natives, and Asians/Pacific Islanders, smoking was not associated with childhood obesity. The inconsistent association between smoking during pregnancy and childhood obesity across race/ethnicity categories merits further investigation into potential explanations for this variation, which may include confounding, reporting bias, or unexplored biologic mechanisms.
 
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BACKGROUND: Reminder systems and late patient tracers as strategies to improve patients` adherence to tuberculosis screening, diagnosis, and treatment are used in some countries, but their effectiveness has not previously been systematically reviewed. OBJECTIVES: To assess the effects of reminder systems and late patient tracers on completion of diagnostics, commencement of treatment in people referred for curative or prophylactic treatment of tuberculosis, completion of treatment in people starting curative or prophylactic treatment for tuberculosis, and cure in people being treated for active tuberculosis. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group Specialized Register (June 2008), Cochrane Effective Practice and Organization of Care Group Specialized Register (April 2007), CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1966 to June 2008), EMBASE (1974 to June 2008), LILACS (1982 to June 2008), CINAHL (1982 to June 2008), SCI-EXPANDED (1945 to June 2008), SSCI (1956 to June 2008), mRCT (June 2008), Indian Journal of Tuberculosis (1983 to June 2008), and reference lists. We also contacted researchers working in the field. SELECTION CRITERIA: Randomized controlled trials (RCTs), including cluster RCTs and quasi-RCTs, and controlled before-and-after studies comparing any reminders or late patient tracers with no or other kinds of reminders or late patient tracers. We included people in any setting who require treatment for tuberculosis or require prophylaxis against tuberculosis and are referred to tuberculosis diagnostic or screening services. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial risk of bias and extracted data. No meta-analysis could be undertaken due to the heterogeneity of interventions across trials. MAIN RESULTS: Nine trials involving 5257 participants met the inclusion criteria. Three assessed the use of late patient tracers, and six assessed reminder systems. Late patient tracers (home visit and letter) were shown to be beneficial in increasing adherence to tuberculosis treatment compared with no late patient tracer. The results from almost all the reminder trials, except one, show benefits of different types of reminders compared to no reminder on adherence to tuberculosis clinic appointments. AUTHORS` CONCLUSIONS: The included trials show significantly better outcomes among those tuberculosis patients for which late patient tracers and reminders are used. Studies of good quality (large and with rigorous study design) are needed to decide the most effective late patient tracer actions and reminders in different settings. Future studies of reminders in chemoprophylaxis and treatment settings would be useful.
 
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The primary purpose of this study was to determine whether current and midlife obesity status provide independent information on mortality risk in elderly persons. Analyses were based on 3,238 participants from the original Framingham Heart Study (FHS) cohort who lived to at least 70 years of age and who had BMI measures from when they were in their 50s. Within this group of 70-year olds, obesity based on current BMI was associated with a 21% increased risk of mortality (P = 0.019) whereas obesity in 70-year olds based on BMI measures obtained at around 50 years of age was associated with a 55% increased risk of mortality (P < 0.0001). Compared to 70-year olds who were nonobese at both 50 and 70 years of age, mortality risk was increased by 47% (P < 0.001) in those who were obese at both 50 and 70 years of age, increased by 56% (P < 0.001) in those who were obese at 50 years of age and nonobese at 70 years of age, and not significantly different (P > 0.9) in those who were nonobese at 50 years of age and obese at 70 years of age. In summary, in this cohort of elderly adults, midlife and current BMI had independent effects on mortality risk. Specifically, although mortality risk was increased in obese older adults who were already obese at midlife, this was not the case for newly obese older adults. Conversely, nonobese older adults who were obese at midlife had an increased mortality risk. These observations imply that it is imperative to consider an elderly adult`s BMI in context of their BMI at midlife.Obesity (2008) 16 11, 2504-2509. doi:10.1038/oby.2008.400.
 
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BACKGROUND: Tuberculosis is a serious infection affecting mainly the lungs. It may contribute to nutritional deficiencies which in turn may delay recovery by depressing immune functions. Nutritional supplements might therefore promote recovery in people being treated for tuberculosis. OBJECTIVES: To assess the provision of oral nutritional supplements to promote the recovery of people being treated with antituberculous drug therapy for active tuberculosis. SEARCH STRATEGY: We searched the Cochrane Infectious Disease Group Specialized Register (June 2008), CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (June 2008), EMBASE (June 2008), LILACS (June 2008), mRCT (June 2008), the Indian Journal of Tuberculosis (1983 to June 2008), and checked the reference lists of all included studies. SELECTION CRITERIA: Randomized controlled trials comparing any oral nutritional supplement given for at least four weeks with no nutritional intervention, placebo, or dietary advice only for people being treated for active tuberculosis. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, extracted data, and assessed risk of bias. We calculated risk ratios (RR) for dichotomous variables and mean differences (MD) for continuous variables, with 95% confidence intervals (CI). We pooled data from trials with similar interventions and outcomes. MAIN RESULTS: Twelve trials (3393 participants) were included. Five trials had adequate allocation concealment. Interventions included a high energy supplement, high cholesterol diet, vitamin D, vitamin A, zinc, arginine, multiple micronutrient supplements, combined multiple micronutrient supplements and zinc, combined vitamin A and zinc, and combined vitamin A and selenium. The following supplements were associated with increased body weight at follow up: high energy supplements (MD 1.73 kg, 95% CI 0.81 to 2.65; 34 participants, 1 trial); multiple micronutrients plus additional zinc (MD 2.37 kg, 95% CI 2.21 to 2.53; 192 participants, 1 trial); and vitamin A plus zinc (MD 3.10 kg, 95% CI 0.74 to 5.46; 80 participants, 1 trial). There was no evidence that any supplement affected the number of deaths or number of participants with sputum test positive results at the end of treatment. AUTHORS` CONCLUSIONS: There is limited evidence that high energy supplements and some combinations of zinc with other micronutrients may help people with tuberculosis to gain weight. There is not enough evidence to assess the effect of other combinations of nutrients. A number of relevant trials are in progress, and, where appropriate, the results will be incorporated into future updates of this review.
 
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BACKGROUND: Cutaneous leishmaniasis is caused by a parasitic infection and is considered one of the most serious skin diseases in many developing countries. Antimonials are the most commonly prescribed treatment but other drugs have been used with varying success. OBJECTIVES: To assess the effects of treatments for Old World cutaneous leishmaniasis (OWCL). SEARCH STRATEGY: We searched the Cochrane Skin Group Specialised Register (April 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (2003-April 2008), EMBASE (2005-April 2008), CINAHL (1982-August 2007), LILACS (from inception to April 2008) and ongoing trials databases (August 2007). SELECTION CRITERIA: Randomised controlled trials assessing treatments in immuno-competent people with OWCL confirmed by smear, histology, culture or polymerase chain reaction. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. MAIN RESULTS: We included 49 trials involving 5559 participants. Reporting quality was generally poor and only two studies contained sufficiently similar data to pool.In Leishmania major infections, there was good RCT evidence of benefit of cure around 3 months after treatment when compared to placebo for 200 mg oral fluconazole (1 RCT n = 200, RR 2.78; 95% CI 1.86, 4.16), topical 15% paromomycin + 12% methylbenzethonium chloride (PR-MBCL) (1 RCT n = 60, RR 3.09; 95% CI 1.14, 8.37) and photodynamic therapy (1 RCT n = 60, RR 7.02; 95% CI 3.80, 17.55). Topical PR-MBCL was less efficacious than photodynamic therapy (1 RCT n = 65, RR 0.44; 95% CI 0.29, 0.66). Oral pentoxifylline was a good adjuvant therapy to intramuscular meglumine antimoniate (IMMA) when compared to IMMA plus placebo (1 RCT n = 64, RR 1.63; 95% CI 1.11, 2.39)In Leishmania tropica infections, there was good evidence of benefit for the use of 200 mg oral itraconazole for 6 weeks compared with placebo (1 RCT n = 20, RR 7.00; 95% CI 1.04, 46.95), for intralesional sodium stibogluconate (1 RCT n = 292, RR 2.62; 95% CI 1.78, 3.86), and for thermotherapy compared with intramuscular sodium stibogluconate (1 RCT n = 283, RR 2.99; 95% CI 2.04, 4.37). AUTHORS` CONCLUSIONS: Most trials have been designed and reported poorly, resulting in a lack of evidence for potentially beneficial treatments. There is a desperate need for large well conducted studies that evaluate long-term effects of current therapies. We suggest the creation of an international platform to improve quality and standardization of future trials in order to inform clinical practice.
 
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OBJECTIVE: To assess whether non-polluting, more effective home heating (heat pump, wood pellet burner, flued gas) has a positive effect on the health of children with asthma. DESIGN: Randomised controlled trial. SETTING: Households in five communities in New Zealand. PARTICIPANTS: 409 children aged 6-12 years with doctor diagnosed asthma. INTERVENTIONS: Installation of a non-polluting, more effective home heater before winter. The control group received a replacement heater at the end of the trial. MAIN OUTCOME MEASURES: The primary outcome was change in lung function (peak expiratory flow rate and forced expiratory volume in one second, FEV(1)). Secondary outcomes were child reported respiratory tract symptoms and daily use of preventer and reliever drugs. At the end of winter 2005 (baseline) and winter 2006 (follow-up) parents reported their child`s general health, use of health services, overall respiratory health, and housing conditions. Nitrogen dioxide levels were measured monthly for four months and temperatures in the living room and child`s bedroom were recorded hourly. RESULTS: Improvements in lung function were not significant (difference in mean FEV(1) 130.7 ml, 95% confidence interval -20.3 to 281.7). Compared with children in the control group, however, children in the intervention group had 1.80 fewer days off school (95% confidence interval 0.11 to 3.13), 0.40 fewer visits to a doctor for asthma (0.11 to 0.62), and 0.25 fewer visits to a pharmacist for asthma (0.09 to 0.32). Children in the intervention group also had fewer reports of poor health (adjusted odds ratio 0.48, 95% confidence interval 0.31 to 0.74), less sleep disturbed by wheezing (0.55, 0.35 to 0.85), less dry cough at night (0.52, 0.32 to 0.83), and reduced scores for lower respiratory tract symptoms (0.77, 0.73 to 0.81) than children in the control group. The intervention was associated with a mean temperature rise in the living room of 1.10 degrees C (95% confidence interval 0.54 degrees C to 1.64 degrees C) and in the child`s bedroom of 0.57 degrees C (0.05 degrees C to 1.08 degrees C). Lower levels of nitrogen dioxide were measured in the living rooms of the intervention households than in those of the control households (geometric mean 8.5 microg/m(3) v 15.7 microg/m(3), P<0.001). A similar effect was found in the children`s bedrooms (7.3 microg/m(3) v 10.9 microg/m(3), P<0.001). CONCLUSION: Installing non-polluting, more effective heating in the homes of children with asthma did not significantly improve lung function but did significantly reduce symptoms of asthma, days off school, healthcare utilisation, and visits to a pharmacist. TRIAL REGISTRATION: Clinical Trials NCT00489762.
 
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