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Ustianowski A. i154 Serious viral infections in the immunocompromised. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key075.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Andrew Ustianowski
- Monsall Unit, North Manchester General Hospital, Manchester, UNITED KINGDOM
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da Silva Filipe A, Sreenu V, Hughes J, Aranday-Cortes E, Irving WL, Foster GR, Agarwal K, Rosenberg W, Macdonald D, Richardson P, Aldersley MA, Wiselka M, Ustianowski A, McLauchlan J, Thomson EC. Reply to: "Reply to: 'Response to DAA therapy in the NHS England Early Access Programme for rare HCV subtypes from low and middle income countries'". J Hepatol 2018; 68:864-866. [PMID: 29339112 DOI: 10.1016/j.jhep.2017.11.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/22/2017] [Indexed: 12/04/2022]
Affiliation(s)
| | | | - Joseph Hughes
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
| | | | - William L Irving
- Gastrointestinal and Liver Disorders Theme, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and the University of Nottingham, UK
| | - Graham R Foster
- Blizard Institute, Queen Mary University of London, London, UK
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital Foundation Trust, London UK
| | - William Rosenberg
- Institute of Liver and Digestive Health, University College of London, London, United Kingdom
| | - Douglas Macdonald
- Institute of Liver and Digestive Health, University College of London, London, United Kingdom
| | | | | | - Martin Wiselka
- Infectious Diseases Unit, University Hospitals Leicester NHS Trust, Leicester, UK
| | | | - John McLauchlan
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK.
| | - Emma C Thomson
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
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Abstract
BACKGROUND Hepatitis C (HCV) infection causes substantial direct health costs, but also impacts broader societal and governmental costs, such as tax revenue and social protection benefits. This study investigated the broader fiscal costs and benefits of curative interventions for chronic Hepatitis C (CHC) that allow individuals to avoid long-term HCV attributed health conditions. METHODS A prospective cohort model, assessing the long-term fiscal consequences of policy decisions, was developed for HCV infected individuals, following the generational accounting analytic framework that combines age-specific lifetime gross taxes paid and governmental transfers received (i.e. healthcare and social support costs). The analysis assessed the burden of a theoretical cohort of untreated HCV infected patients with the alternative of treating these patients with a highly efficacious curative intervention (ledipasvir/sofosbuvir [LDV/SOF]). It also compared treating patients at all fibrosis stages (Stages F0-F4) compared to late treatment (Stage F4). RESULTS Based on projected lifetime work activity and taxes paid, the treated cohort paid an additional £5,900 per patient compared to the untreated cohort. Lifetime government disability costs of £97,555 and £125,359 per patient for treated cohort vs no treatment cohort were estimated, respectively. Lifetime direct healthcare costs in the treated cohort were £32,235, compared to non-treated cohort of £26,424, with an incremental healthcare costs increase of £5,901 per patient. The benefit cost ratio (BCR) of total government benefits and savings relative to government treatment costs (including LDV/SOF) ranged from 1.8-5.6. Treating patients early resulted in 77% less disability costs, 43% lower healthcare costs, and 33% higher tax revenue. CONCLUSION The ability to cure Hepatitis C offers considerable fiscal benefits beyond direct medical costs and savings attributed to reduced disability costs, public allowances, and improved tax revenue. Changes in parameters, such as productivity, wage growth, and tax rates, can influence the conclusions described here.
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Affiliation(s)
- Mark P Connolly
- a Global Market Access Solutions , Saint-Prex , Switzerland
- b University of Groningen , Department of Pharmacy, Unit of Pharmacoepidemiology & Pharmacoeconomics , Groningen , The Netherlands
| | | | - Andrew Ustianowski
- c Regional Infectious Diseases Unit, North Manchester General Hospital , Manchester , UK
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Leblebicioglu H, Arends JE, Ozaras R, Corti G, Santos L, Boesecke C, Ustianowski A, Duberg AS, Ruta S, Salkic NN, Husa P, Lazarevic I, Pineda JA, Pshenichnaya NY, Tsertswadze T, Matičič M, Puca E, Abuova G, Gervain J, Bayramli R, Ahmeti S, Koulentaki M, Kilani B, Vince A, Negro F, Sunbul M, Salmon D. Availability of hepatitis C diagnostics and therapeutics in European and Eurasia countries. Antiviral Res 2017; 150:9-14. [PMID: 29217468 DOI: 10.1016/j.antiviral.2017.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/31/2017] [Accepted: 12/01/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND Treatment with direct acting antiviral agents (DAAs) has provided sustained virological response rates in >95% of patients with chronic hepatitis C virus (HCV) infection. However treatment is costly and market access, reimbursement and governmental restrictions differ among countries. We aimed to analyze these differences among European and Eurasian countries. METHODS A survey including 20-item questionnaire was sent to experts in viral hepatitis. Countries were evaluated according to their income categories by the World Bank stratification. RESULTS Experts from 26 countries responded to the survey. As of May 2016, HCV prevalence was reported as low (≤1%) in Croatia, Czech Republic, Denmark, France, Germany, Hungary, the Netherlands, Portugal, Slovenia, Spain, Sweden, UK; intermediate (1-4%) in Azerbaijan, Bosnia and Herzegovina, Italy, Kosovo, Greece, Kazakhstan, Romania, Russia, Serbia and high in Georgia (6.7%). All countries had national guidelines except Albania, Kosovo, Serbia, Tunisia, and UK. Transient elastography was available in all countries, but reimbursed in 61%. HCV-RNA was reimbursed in 81%. PegIFN/RBV was reimbursed in 54% of the countries. No DAAs were available in four countries: Kazakhstan, Kosovo, Serbia, and Tunisia. In others, at least one DAA combination with either PegIFN/RBV or another DAA was available. In Germany and the Netherlands all DAAs were reimbursed without restrictions: Sofosbuvir and sofosbuvir/ledipasvir were free of charge in Georgia. CONCLUSION Prevalence of HCV is relatively higher in lower-middle and upper-middle income countries. DAAs are not available or reimbursed in many Eurasia and European countries. Effective screening and access to care are essential for reducing liver-related morbidity and mortality.
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Affiliation(s)
- Hakan Leblebicioglu
- Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University, Medical School, Samsun, Turkey.
| | - Joop E Arends
- Internal Medicine and Infectious Diseases, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Resat Ozaras
- Department of Infectious Diseases and Clinical Microbiology, Istanbul University Cerrahpasa Medical School, Istanbul, Turkey
| | - Giampaolo Corti
- Infectious Disease Unit, University of Florence School of Medicine, Florence, Italy
| | - Lurdes Santos
- Infectious Diseases Service C Hospitalar São João, Faculty of Medicine, Alameda Professor Hernani Monteiro, Porto, Portugal
| | | | - Andrew Ustianowski
- Infectious Diseases & Tropical Medicine and Research Lead, North Western Infectious Diseases Unit, Pennine Acute Hospitals NHS Trust, North Manchester General Hospital, Delaunays Road, Manchester, UK
| | - Ann-Sofi Duberg
- Department of Infectious Diseases, Örebro University Hospital, School of Medical Sciences, Örebro, Sweden
| | - Simona Ruta
- Carol Davila University of Medicine and Pharmacy, Stefan S. Nicolau Institute of Virology, Bucharest, Romania
| | - Nermin N Salkic
- Department of Gastroenterology and Hepatology, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Petr Husa
- Masaryk University, Infectious Diseases, Brno, Czech Republic; University Hospital Brno, Infectious Diseases, Brno, Czech Republic
| | - Ivana Lazarevic
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Juan A Pineda
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario de Valme, Avda. de Bellavista, Sevilla, Spain
| | | | - Tengiz Tsertswadze
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia; Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia
| | - Mojca Matičič
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Slovenia
| | - Edmond Puca
- Department of Infection Diseases, University Hospital Center, Tirane, Albania
| | - Gulzhan Abuova
- Infectious Diseases Department, South - Kazakhstan State Pharmaceutical Academy, Shymkent, Kazakhstan
| | - Judit Gervain
- Division Hepato-Pancreatology 1st Department of Gastroenterology and Molecular Diagnostic Laboratory, "Szent György" Teaching Hospital Székesfehérvár, Hungary
| | - Ramin Bayramli
- Department of Microbiology and Immunology, Azerbaijan Medical University, Educational Therapeutic Hospital, Baku, Azerbaijan
| | - Salih Ahmeti
- Infectious Disease Clinic, University Clinical Centre of Kosova, Faculty of Medicine, Prishtina University, Pristina, Kosovo
| | - Mairi Koulentaki
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Badreddine Kilani
- Service des Maladies Infectieuses, Faculté de Médecine de Tunis, Université Tunis EL Manar, Hôpital la Rabta, Tunis, Tunisia
| | - Adriana Vince
- University Hospital of Infectious Diseases, Zagreb School of Medicine, Zagreb, Croatia
| | - Francesco Negro
- Divisions of Gastroenterology and Hepatology of Clinical Pathology, University Hospital of Geneva, Geneva, Switzerland
| | - Mustafa Sunbul
- Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University, Medical School, Samsun, Turkey
| | - Dominique Salmon
- Infectious Diseases, Hôpitaux Universitaires Paris Centre, Université Paris Descartes, Paris, France
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da Silva Filipe A, Sreenu V, Hughes J, Aranday-Cortes E, Irving WL, Foster GR, Agarwal K, Rosenberg W, Macdonald D, Richardson P, Aldersley MA, Wiselka M, Ustianowski A, McLauchlan J, Thomson EC. Response to DAA therapy in the NHS England Early Access Programme for rare HCV subtypes from low and middle income countries. J Hepatol 2017; 67:1348-1350. [PMID: 28789880 DOI: 10.1016/j.jhep.2017.06.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 12/04/2022]
Affiliation(s)
| | | | - Joseph Hughes
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
| | | | - William L Irving
- Gastrointestinal and Liver Disorders Theme, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and the University of Nottingham, UK
| | - Graham R Foster
- Blizard Institute, Queen Mary University of London, London, UK
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital Foundation Trust, London, UK
| | - William Rosenberg
- Institute of Liver and Digestive Health, University College London, London, UK
| | - Douglas Macdonald
- Institute of Liver and Digestive Health, University College London, London, UK
| | | | | | - Martin Wiselka
- Infectious Diseases Unit, University Hospitals Leicester NHS Trust, Leicester, UK
| | | | - John McLauchlan
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK.
| | - Emma C Thomson
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
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Abstract
Although current therapies can be successful at suppressing hepatitis B viral load, long-term viral cure is not within reach. Subsequent strategies combining pegylated interferon alfa with nucleoside/nucleotide analogues have not resulted in any major paradigm shift. An improved understanding of the hepatitis B virus (HBV) lifec ycle and virus-induced immune dysregulation has, however, revealed many potential therapeutic targets, and there are hopes that treatment of hepatitis B could soon be revolutionized. This review summarizes the current developments in HBV therapeutics-both virus directed and host directed.
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Affiliation(s)
- Joop E Arends
- Department of Internal Medicine, Section Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands.
- Utrecht University, Utrecht, The Netherlands.
| | - Faydra I Lieveld
- Department of Internal Medicine, Section Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
- Utrecht University, Utrecht, The Netherlands
| | - Shazaad Ahmad
- Regional Infectious Diseases Unit, North Manchester General Hospital, Manchester, UK
| | - Andrew Ustianowski
- Regional Infectious Diseases Unit, North Manchester General Hospital, Manchester, UK
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57
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Cahn P, Kaplan R, Sax PE, Squires K, Molina JM, Avihingsanon A, Ratanasuwan W, Rojas E, Rassool M, Bloch M, Vandekerckhove L, Ruane P, Yazdanpanah Y, Katlama C, Xu X, Rodgers A, East L, Wenning L, Rawlins S, Homony B, Sklar P, Nguyen BY, Leavitt R, Teppler H, Cahn PE, Cassetti I, Losso M, Bloch MT, Roth N, McMahon J, Moore RJ, Smith D, Clumeck N, Vanderkerckhove L, Vandercam B, Moutschen M, Baril J, Conway B, Smaill F, Smith GHR, Rachlis A, Walmsley SL, Perez C, Wolff M, Lasso MF, Chahin CE, Velez JD, Sussmann O, Reynes J, Katlama C, Yazdanpanah Y, Ferret S, Durant J, Duvivier C, Poizot-Martin I, Ajana F, Rockstroh JK, Faetkanheuer G, Esser S, Jaeger H, Degen O, Bickel M, Bogner J, Arasteh K, Hartl H, Stoehr A, Rojas EM, Arathoon E, Gonzalez LD, Mejia CR, Shahar E, Turner D, Levy I, Sthoeger Z, Elinav H, Gori A, Monforte AD, Di Perri G, Lazzarin A, Rizzardini G, Antinori A, Celesia BM, Maggiolo F, Chow TS, Lee CKC, Azwa RISR, Mustafa M, Oyanguren M, Castillo RA, Hercilla L, Echiverri C, Maltez F, da Cunha JGS, Neves I, Teofilo E, Serrao R, Nagimova F, Khaertynova I, Orlova-Morozova E, Voronin E, Sotnikov V, Yakovlev AA, Zakharova NG, Tsybakova OA, Botes ME, Mohapi L, Kaplan R, Rassool MS, Arribas JR, Gatell JM, Negredo E, Ortega E, Troya J, Berenguer J, Aguirrebengoa K, Antela A, Calmy A, Cavassini M, Rauch A, Stoeckle M, Sheng WH, Lin HH, Tsai HC, Changpradub D, Avihingsanon A, Kiertiburanakul S, Ratanasuwan W, Nelson MR, Clarke A, Ustianowski A, Winston A, Johnson MA, Asmuth DM, Cade J, Gallant JE, Ruane PJ, Kumar PN, Luque AE, Panther L, Tashima KT, Ward D, Berger DS, Dietz CA, Fichtenbaum C, Gupta S, Mullane KM, Novak RM, Sweet DE, Crofoot GE, Hagins DP, Lewis ST, McDonald CK, DeJesus E, Sloan L, Prelutsky DJ, Rondon JC, Henn S, Scarsella AJ, Morales JO, Ramirez, Santiago L, Zorrilla CD, Saag MS, Hsiao CB. Raltegravir 1200 mg once daily versus raltegravir 400 mg twice daily, with tenofovir disoproxil fumarate and emtricitabine, for previously untreated HIV-1 infection: a randomised, double-blind, parallel-group, phase 3, non-inferiority trial. The Lancet HIV 2017; 4:e486-e494. [DOI: 10.1016/s2352-3018(17)30128-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/22/2017] [Accepted: 06/23/2017] [Indexed: 12/20/2022]
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Abstract
The care paradigm for patients with human immunodeficiency virus (HIV) has changed from managing an infectious condition with a suboptimal prognosis, to managing a long-term chronic disease. The wellness thermometer is a tool that was developed to assist with monitoring the biological, psychological, social and spiritual well-being of patients with HIV. Aim To evaluate the effectiveness of using the wellness thermometer in healthcare consultations with patients with HIV. Method This was a service evaluation that was undertaken in three UK HIV clinics in 2014. After using the wellness thermometer, patients and healthcare professionals completed a survey to indicate whether they felt the tool improved their consultations. Results A total of 231 patients completed the survey. It was found that 80% (n=185) of patients felt the wellness thermometer helped to identify their concerns, while 79% (n=182) of patients felt the wellness thermometer improved their conversation with the healthcare professional. Of the 12 healthcare professionals who completed the survey, most felt that the tool helped patients to identify their concerns (n=10) and that it was easy to use (n=11). Conclusion There are several benefits associated with using the wellness thermometer in healthcare consultations, and it may support patients with HIV to report any concerns they have in relation to their treatment and quality of life. The authors envisage that the tool will become a routine part of the care of these patients.
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Ustianowski A. I64. FEVER, INFECTION OR INFLAMMATION? Rheumatology (Oxford) 2017. [DOI: 10.1093/rheumatology/kex060.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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60
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Nightingale S, Chau TTH, Fisher M, Nelson M, Winston A, Else L, Carr DF, Taylor S, Ustianowski A, Back D, Pirmohamed M, Solomon T, Farrar J, Törok ME, Khoo S. Efavirenz and Metabolites in Cerebrospinal Fluid: Relationship with CYP2B6 c.516G→T Genotype and Perturbed Blood-Brain Barrier Due to Tuberculous Meningitis. Antimicrob Agents Chemother 2016; 60:4511-8. [PMID: 27161633 PMCID: PMC4958147 DOI: 10.1128/aac.00280-16] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 05/04/2016] [Indexed: 01/11/2023] Open
Abstract
Efavirenz (EFZ) has been associated with neuropsychiatric side effects. Recently, the 8-hydroxy-EFZ (8OH-EFZ) metabolite has been shown to be a potent neurotoxin in vitro, inducing neuronal damage at concentrations of 3.3 ng/ml. EFZ induced similar neuronal damage at concentrations of 31.6 ng/ml. We investigated the effect of genotype and blood-brain barrier integrity on EFZ metabolite concentrations in cerebrospinal fluid (CSF). We measured CSF drug concentrations in subjects from two separate study populations: 47 subjects with tuberculous meningitis (TBM) coinfection in Vietnam receiving 800 mg EFZ with standard antituberculous treatment and 25 subjects from the PARTITION study in the United Kingdom without central nervous system infection receiving 600 mg EFZ. EFZ and metabolite concentrations in CSF and plasma were measured and compared with estimates of effectiveness and neurotoxicity from available published in vitro and in vivo data. The effect of the CYP2B6 c.516G→T genotype (GG genotype, fast EFV metabolizer status; GT genotype, intermediate EFV metabolizer status; TT genotype, slow EFV metabolizer status) was examined. The mean CSF concentrations of EFZ and 8OH-EFZ in the TBM group were 60.3 and 39.3 ng/ml, respectively, and those in the no-TBM group were 15.0 and 5.9 ng/ml, respectively. Plasma EFZ and 8OH-EFZ concentrations were similar between the two groups. CSF EFZ concentrations were above the in vitro toxic concentration in 76% of samples (GG genotype, 61%; GT genotype, 90%; TT genotype, 100%) in the TBM group and 13% of samples (GG genotype, 0%; GT genotype, 18%; TT genotype, 50%) in the no-TBM group. CSF 8OH-EFZ concentrations were above the in vitro toxic concentration in 98% of the TBM group and 87% of the no-TBM group; levels were independent of genotype but correlated with the CSF/plasma albumin ratio. Potentially neurotoxic concentrations of 8OH-EFZ are frequently observed in CSF independently of the CYP2B6 genotype, particularly in those with impaired blood-brain barrier integrity.
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Affiliation(s)
- Sam Nightingale
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Tran Thi Hong Chau
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Martin Fisher
- Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Mark Nelson
- St. Stephen's AIDS Research Trust and Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Alan Winston
- St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Laura Else
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Daniel F Carr
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Steven Taylor
- Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrew Ustianowski
- North Manchester General Hospital, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom
| | - David Back
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Tom Solomon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom
| | - Jeremy Farrar
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom
| | - M Estée Törok
- University of Cambridge, Department of Medicine, Cambridge, United Kingdom Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom Public Health England, Clinical Microbiology and Public Health Laboratory, Cambridge, United Kingdom
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
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Abstract
CD8+ encephalitis (CD8+E) is an emerging and incompletely understood HIV-associated neurological syndrome, typically presenting as a steroid-responsive subacute encephalopathy with prominent white matter changes in patients with apparently well-controlled HIV infection. Some cases can be associated with the phenomenon of 'viral escape' (disproportionate replication within the cerebrospinal fluid), but the most important pathophysiology of CD8+E is thought to involve an attack on HIV-infected CD4+ lymphocytes by autoreactive CD8+ cells. We report a case of CD8+E where the initial positive response to steroid treatment was followed by several relapses on withdrawal. This led to the use of mycophenolate mofetil (MMF) as a long-term steroid-sparing agent, which is the first time this approach has been reported in the literature. The patient has now been on treatment with MMF for 10 months and it has been possible to taper the steroids down to a minimal maintenance dose without further relapse.
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Affiliation(s)
- Sharfaraz Salam
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Tatiana Mihalova
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
| | | | - David McKee
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Rehka Siripurapu
- Department of Radiology, Salford Royal NHS Foundation Trust, Salford, UK
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van Halsema C, Johnson L, Baxter J, Douthwaite S, Clowes Y, Guiver M, Ustianowski A. Short Communication: Diagnosis of Pneumocystis jirovecii Pneumonia by Detection of DNA in Blood and Oropharyngeal Wash, Compared with Sputum. AIDS Res Hum Retroviruses 2016; 32:463-6. [PMID: 26739439 DOI: 10.1089/aid.2015.0213] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Molecular diagnostic methods on lower respiratory specimens for Pneumocystis pneumonia (PCP) are recommended, but specimens can be difficult to obtain. This study examined the diagnostic use of PCP polymerase chain reaction (PCR) on oropharyngeal wash (OPW) and blood versus sputum (spontaneous and induced) to find faster, simpler, and less invasive diagnostic methods. We prospectively recruited consenting adults with symptoms consistent with PCP. Real-time PCR targeted the Pneumocystis mitochondrial large subunit ribosomal RNA gene, using the aforementioned specimens. Clinical data were collected from routine records. Forty-five participants provided 45 sputa, 31 OPW, and 41 blood samples. Median age was 39 years and 41 (91%) were male, with median CD4 count being 64 cells/μL. Sputum PCR was positive in 27/45 (60%) participants. Comparative sensitivity of OPW was 9/19 (47%, 95% confidence interval [CI] 23-71) and blood 12/24 (50%, 95% CI 29-71) participants, both with specificity 100%. Including only samples obtained ≤2 days after start of treatment, sensitivity of OPW was 80% (8/10, 95% CI 51-100), that of blood was 57% (8/14, 95% CI 29-86), and that of combined tests was 88% (14/16, 95% CI 70-100). In 14/16 individuals with PCP and specimens obtained ≤2 days after start of treatment, diagnosis was possible using nonrespiratory samples. Despite moderate sensitivity of individual tests, combined PCP PCR on early blood and OPW specimens had high sensitivity and could reduce the need for invasive procedures. There were no false-positive results on nonrespiratory samples. Sampling and laboratory methods use routine technology and so require few additional resources.
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Affiliation(s)
- Clare van Halsema
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, United Kingdom
| | - Leann Johnson
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, United Kingdom
| | - Joanne Baxter
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, United Kingdom
| | - Sam Douthwaite
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, United Kingdom
| | - Yvonne Clowes
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, United Kingdom
| | - Malcolm Guiver
- Department of Virology, Central Manchester NHS Foundation Trust, Public Health England, Manchester, United Kingdom
| | - Andrew Ustianowski
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, United Kingdom
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63
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Nightingale S, Michael BD, Fisher M, Winston A, Nelson M, Taylor S, Ustianowski A, Ainsworth J, Gilson R, Haddow L, Ong E, Leen C, Minton J, Post F, Beloukas A, Borrow R, Pirmohamed M, Geretti AM, Khoo S, Solomon T. CSF/plasma HIV-1 RNA discordance even at low levels is associated with up-regulation of host inflammatory mediators in CSF. Cytokine 2016; 83:139-146. [PMID: 27131579 PMCID: PMC4889775 DOI: 10.1016/j.cyto.2016.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/04/2016] [Accepted: 04/05/2016] [Indexed: 12/20/2022]
Abstract
Discordant HIV in CSF is associated with raised inflammatory mediators in CSF. CSF mediators are raised with discordance both at high and low levels. Discordance on ultrasensitive testing can also be also associated with raised mediators.
Introduction HIV-1 RNA can be found at higher levels in cerebrospinal fluid (CSF) than in plasma, termed CSF/plasma discordance. The clinical significance of CSF/plasma discordance is not known and the degree of discordance considered important varies. We aimed to determine whether a panel of CSF cytokines, chemokines and associated mediators were raised in patients with CSF/plasma discordance at different levels. Methods A nested case-control study of 40 CSF samples from the PARTITION study. We used a cytometric bead array to measure CSF mediator concentrations in 19 discordant and 21 non-discordant samples matched for plasma HIV-1 RNA. Discordant samples were subdivided into ‘high discordance’ (>1log10) and ‘low discordance’ (0.5–1log10, or ultrasensitive discordance). CSF mediators significant in univariate analysis went forward to two-way unsupervised hierarchical clustering based on the patterns of relative mediator concentrations. Results In univariate analysis 19 of 21 CSF mediators were significantly higher in discordant than non-discordant samples. There were no significant differences between samples with high versus low discordance. The samples grouped into two clusters which corresponded to CSF/plasma discordance (p < 0.0001). In cluster one all mediators had relatively high abundance; this included 18 discordant samples and three non-discordant samples. In cluster two all mediators had relatively low abundance; this included 18 non-discordant samples and one non-discordant sample with ultrasensitive discordance only. Conclusions CSF/plasma discordance is associated with potentially damaging neuroinflammatory process. Patients with discordance at lower levels (ie. 0.5–1log10) should also be investigated as mediator profiles were similar to those with discordance >1log10. Sensitive testing may have a role to determine whether ultrasensitive discordance is present in those with low level CSF escape.
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Affiliation(s)
- Sam Nightingale
- Institute of Infection and Global Health, University of Liverpool, UK; Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK.
| | - Benedict D Michael
- Institute of Infection and Global Health, University of Liverpool, UK; Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Martin Fisher
- Brighton and Sussex University Hospitals NHS Trust, UK
| | - Alan Winston
- St Marys' Hospital, Imperial College Heathcare NHS Trust, London, UK
| | - Mark Nelson
- St Stephen's AIDS Research Trust and Chelsea and Westminster Hospital NHS Foundation Trust, UK
| | - Steven Taylor
- Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, UK
| | - Andrew Ustianowski
- North Manchester General Hospital, Pennine Acute Hospitals NHS Trust, UK
| | | | - Richard Gilson
- Research Department of Infection and Population Health, University College London, UK
| | - Lewis Haddow
- Research Department of Infection and Population Health, University College London, UK
| | - Edmund Ong
- Victoria Royal Infirmary, Newcastle upon Tyne Hospitals NHS Trust, UK
| | | | - Jane Minton
- Leeds General Infirmary, Leeds Teaching Hosptials NHS Trust, UK
| | - Frank Post
- Kings College Hospital NHS Foundation Trust, London, UK
| | | | - Ray Borrow
- Vaccine Evaluation Unit at the Health Protection Agency (HPA) North West, Manchester, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- Institute of Infection and Global Health, University of Liverpool, UK; Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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Affiliation(s)
- Shazaad S Y Ahmad
- Northwest Regional Infectious Diseases Unit, North Manchester General Hospital, Pennine Acute Hospitals Trust, Manchester M8 5RB, UK Virology Department, Manchester Royal Infirmary, Central Manchester Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK
| | - Tejal N Amin
- Department of Obstetrics and Gynaecology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Andrew Ustianowski
- Northwest Regional Infectious Diseases Unit, North Manchester General Hospital, Pennine Acute Hospitals Trust, Manchester M8 5RB, UK
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Vandewalle B, Llibre JM, Parienti JJ, Ustianowski A, Camacho R, Smith C, Miners A, Ferreira D, Félix J. EPICE-HIV: An Epidemiologic Cost-Effectiveness Model for HIV Treatment. PLoS One 2016; 11:e0149007. [PMID: 26870960 PMCID: PMC4752501 DOI: 10.1371/journal.pone.0149007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 01/25/2016] [Indexed: 11/29/2022] Open
Abstract
The goal of this research was to establish a new and innovative framework for cost-effectiveness modeling of HIV-1 treatment, simultaneously considering both clinical and epidemiological outcomes. EPICE-HIV is a multi-paradigm model based on a within-host micro-simulation model for the disease progression of HIV-1 infected individuals and an agent-based sexual contact network (SCN) model for the transmission of HIV-1 infection. It includes HIV-1 viral dynamics, CD4+ T cell infection rates, and pharmacokinetics/pharmacodynamics modeling. Disease progression of HIV-1 infected individuals is driven by the interdependent changes in CD4+ T cell count, changes in plasma HIV-1 RNA, accumulation of resistance mutations and adherence to treatment. The two parts of the model are joined through a per-sexual-act and viral load dependent probability of disease transmission in HIV-discordant couples. Internal validity of the disease progression part of the model is assessed and external validity is demonstrated in comparison to the outcomes observed in the STaR randomized controlled clinical trial. We found that overall adherence to treatment and the resulting pattern of treatment interruptions are key drivers of HIV-1 treatment outcomes. Our model, though largely independent of efficacy data from RCT, was accurate in producing 96-week outcomes, qualitatively and quantitatively comparable to the ones observed in the STaR trial. We demonstrate that multi-paradigm micro-simulation modeling is a promising tool to generate evidence about optimal policy strategies in HIV-1 treatment, including treatment efficacy, HIV-1 transmission, and cost-effectiveness analysis.
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Affiliation(s)
| | - Josep M. Llibre
- Fundació Lluita contra la SIDA, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jean-Jacques Parienti
- Department of Clinical Research and Biostatistics, Côte de Nacre University Hospital, Caen, France
| | - Andrew Ustianowski
- Regional Infectious Disease Unit, North Manchester General Hospital, Manchester, United Kingdom
| | - Ricardo Camacho
- Rega Institute for Medical Research, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Colette Smith
- Department of Infection and Population Health, University College London, London, United Kingdom
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Jorge Félix
- Exigo Consultores, Lisbon, Portugal
- * E-mail:
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Arends JE, Lieveld FI, Boeijen LL, de Kanter CTMM, van Erpecum KJ, Salmon D, Hoepelman AIM, Asselah T, Ustianowski A. Natural history and treatment of HCV/HIV coinfection: Is it time to change paradigms? J Hepatol 2015; 63:1254-62. [PMID: 26186987 DOI: 10.1016/j.jhep.2015.06.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 06/28/2015] [Accepted: 06/30/2015] [Indexed: 12/12/2022]
Abstract
Evidence over the past decades have shown that HIV/HCV coinfected patients did not respond as well to HCV therapy as HCV mono-infected patients. However, these paradigms are being recently reassessed with the improvements of care for HIV and HCV patients. This article reviews these original paradigms and how the new data is impacting upon them. Treatment efficacy now appears comparable for HIV/HCV coinfected and HCV mono-infected patients, while liver fibrosis progression is increasingly similar in optimally managed patients. Additional importance of therapy is directed to drug-drug interactions and the impact of HCV reinfection, as well as the possibility of transmitted drug resistance.
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Affiliation(s)
- Joop E Arends
- Department of Internal Medicine and Infectious Disease, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands.
| | - Faydra I Lieveld
- Department of Internal Medicine and Infectious Disease, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Lauke L Boeijen
- Department of Internal Medicine and Infectious Disease, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Clara T M M de Kanter
- Department of Clinical Pharmacy, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Dominique Salmon
- Department of Infectious Diseases, Hôpital Cochin, Paris, France
| | - Andy I M Hoepelman
- Department of Internal Medicine and Infectious Disease, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Tarik Asselah
- Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, and INSERM, UMR1149, Labex INFLAMEX, Université Denis Diderot Paris 7, France
| | - Andrew Ustianowski
- Regional Infectious Diseases Unit, North Manchester General Hospital, Manchester, United Kingdom
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van Halsema C, Whitfield T, Lin N, Ashton K, Torkington A, Ustianowski A. Five years' real-life experience with raltegravir in a large HIV centre. Int J STD AIDS 2015; 27:387-93. [PMID: 25931236 DOI: 10.1177/0956462415584485] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 03/31/2015] [Indexed: 11/15/2022]
Abstract
Raltegravir was the first licensed integrase inhibitor. Real-life experience is informative and complements trial data. We therefore evaluated raltegravir use in adults in a large HIV treatment centre. From pharmacy and departmental HIV database records, we identified all adults taking ≥1 dose of raltegravir from first availability to the end of November 2012. Data were collected using a standardised case report form. Two hundred and fifteen individuals provided 502 patient-years (median 2.6 years/person) of raltegravir use. Of 215 individuals, 166 (77%) were male, median age 43 years; 189 (88%) were antiretroviral therapy (ART)-experienced and 26 (12%) ART-naive, with median baseline CD4 counts of 324 and 54 cells/µL, respectively. Of ten individuals using once-daily raltegravir, four, with good adherence remained virologically suppressed after a median 28 months, four stopped against medical advice, one stopped to simplify and one failed virologically. In hepatitis co-infection, 35 individuals (92 patient-years) took raltegravir without evidence of hepatotoxicity. Six women started raltegravir during pregnancy for intensification (5/6) or switch for tolerability without complications. Of ten individuals stopping raltegravir after virological failure, 2/4 with successful sequencing showed resistance. Raltegravir appears safe and effective, without evidence of toxicity above that in published trials, including in pregnancy and co-infections. Once-daily dosing seems effective where adherence is good.
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Affiliation(s)
- Clare van Halsema
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Thomas Whitfield
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Naomi Lin
- University of Manchester School of Medicine, Oxford Road, Manchester, UK
| | - Kathryn Ashton
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Adele Torkington
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Andrew Ustianowski
- Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, UK
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Martin NK, Foster GR, Vilar J, Ryder S, E Cramp M, Gordon F, Dillon JF, Craine N, Busse H, Clements A, Hutchinson SJ, Ustianowski A, Ramsay M, Goldberg DJ, Irving W, Hope V, De Angelis D, Lyons M, Vickerman P, Hickman M. HCV treatment rates and sustained viral response among people who inject drugs in seven UK sites: real world results and modelling of treatment impact. J Viral Hepat 2015; 22:399-408. [PMID: 25288193 PMCID: PMC4409099 DOI: 10.1111/jvh.12338] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Hepatitis C virus (HCV) antiviral treatment for people who inject drugs (PWID) could prevent onwards transmission and reduce chronic prevalence. We assessed current PWID treatment rates in seven UK settings and projected the potential impact of current and scaled-up treatment on HCV chronic prevalence. Data on number of PWID treated and sustained viral response rates (SVR) were collected from seven UK settings: Bristol (37-48% HCV chronic prevalence among PWID), East London (37-48%), Manchester (48-56%), Nottingham (37-44%), Plymouth (30-37%), Dundee (20-27%) and North Wales (27-33%). A model of HCV transmission among PWID projected the 10-year impact of (i) current treatment rates and SVR (ii) scale-up with interferon-free direct acting antivirals (IFN-free DAAs) with 90% SVR. Treatment rates varied from <5 to over 25 per 1000 PWID. Pooled intention-to-treat SVR for PWID were 45% genotypes 1/4 [95%CI 33-57%] and 61% genotypes 2/3 [95%CI 47-76%]. Projections of chronic HCV prevalence among PWID after 10 years of current levels of treatment overlapped substantially with current HCV prevalence estimates. Scaling-up treatment to 26/1000 PWID annually (achieved already in two sites) with IFN-free DAAs could achieve an observable absolute reduction in HCV chronic prevalence of at least 15% among PWID in all sites and greater than a halving in chronic HCV in Plymouth, Dundee and North Wales within a decade. Current treatment rates among PWID are unlikely to achieve observable reductions in HCV chronic prevalence over the next 10 years. Achievable scale-up, however, could lead to substantial reductions in HCV chronic prevalence.
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Affiliation(s)
- N K Martin
- School of Social & Community Medicine, University of BristolBristol, UK,Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical MedicineLondon, UK,
Correspondence: Natasha K. Martin, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. E-mail:
| | - G R Foster
- Blizard Institute, Queen Mary's University of LondonLondon, UK
| | - J Vilar
- Pennine Acute Hospitals NHS TrustGreater Manchester, UK
| | - S Ryder
- Nottingham University Hospitals NHS TrustNottingham, UK
| | - M E Cramp
- Plymouth Hospital NHS TrustPlymouth, UK
| | - F Gordon
- University of Bristol Health TrustBristol, UK
| | | | - N Craine
- Health Protection WalesBangor, Wales, UK
| | - H Busse
- School of Social & Community Medicine, University of BristolBristol, UK
| | | | - S J Hutchinson
- Glasgow Caledonian UniversityGlasgow, UK,Health Protection ScotlandGlasgow, UK
| | - A Ustianowski
- Pennine Acute Hospitals NHS TrustGreater Manchester, UK
| | | | | | - W Irving
- University of NottinghamNottingham, UK
| | - V Hope
- Public Health EnglandLondon, UK
| | | | - M Lyons
- Health Protection WalesBangor, Wales, UK
| | - P Vickerman
- School of Social & Community Medicine, University of BristolBristol, UK,Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical MedicineLondon, UK
| | - M Hickman
- School of Social & Community Medicine, University of BristolBristol, UK
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Foster GR, Gore C, Hudson M, Moss P, Ustianowski A, Ryder S, Bhagani S. Response from Hepatitis C Trust, BASL, BIA, BVHG, BSG, and BHIVA to article asking whether widespread screening for hepatitis C is justified. BMJ 2015; 350:h998. [PMID: 25711900 DOI: 10.1136/bmj.h998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | | | - Mark Hudson
- BASL (British Association for the Study of the Liver), Lichfield, UK
| | - Peter Moss
- British Infection Association (BIA), Knutsford, UK
| | | | - Stephen Ryder
- British Society of Gastroenterology (BSG), London, UK
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Taieb V, Pacou M, Ho S, Pettré S, Van Sanden S, Pisini M, Ustianowski A, Mehnert A. A network meta-analysis to compare simeprevir with boceprevir and telaprevir in combination with peginterferon-α and ribavirin in patients infected with genotype 1 Hepatitis C virus. J Med Econ 2015; 18:787-96. [PMID: 25934147 DOI: 10.3111/13696998.2015.1046880] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To conduct a network meta-analysis (NMA) to assess the relative efficacy and safety of simeprevir, a second generation oral protease inhibitor (PI), compared to telaprevir and boceprevir in combination with pegylated interferon-α and ribavirin (PR) in patients with chronic hepatitis C. METHODS A systematic literature review and NMA of randomized controlled trials involving anti-virals added to PR were conducted. Electronic database searches and hand searches were conducted to identify relevant publications. Outcomes of interest included sustained virologic response (SVR), incidence of adverse events (AEs), and discontinuation due to AEs. Networks were based on treatment-, dose-, and duration-specific nodes. Sub-group analyses were conducted to investigate heterogeneity, based on Metavir scores, sub-genotypes 1a/1b, and prior response. RESULTS A total of 15 publications were considered for the base case of the meta-analysis. Simeprevir was associated with higher SVR rates than PR alone. Compared to telaprevir and boceprevir, SVR rates tended to be higher for simeprevir, with odds ratios ranging from 1.27 [0.81-2.00] to 2.61 [1.44-4.74] in treatment-naïve and from 1.04 [0.78-1.38] to 1.74 [0.84-3.61] in treatment-experienced patients, respectively. In terms of safety, the risks of anemia and discontinuations due to AEs were lower for simeprevir compared to PR alone, telaprevir, and boceprevir. The risk of rash was lower for simeprevir compared to telaprevir, and similar compared to PR alone and boceprevir. CONCLUSION This NMA in genotype 1 HCV patients suggests a similar or better efficacy and tolerability profile for simeprevir compared to telaprevir and boceprevir.
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Williams I, Churchill D, Anderson J, Boffito M, Bower M, Cairns G, Cwynarski K, Edwards S, Fidler S, Fisher M, Freedman A, Geretti AM, Gilleece Y, Horne R, Johnson M, Khoo S, Leen C, Marshall N, Nelson M, Orkin C, Paton N, Phillips A, Post F, Pozniak A, Sabin C, Trevelion R, Ustianowski A, Walsh J, Waters L, Wilkins E, Winston A, Youle M. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2012 (Updated November 2013. All changed text is cast in yellow highlight.). HIV Med 2014; 15 Suppl 1:1-85. [PMID: 24330011 DOI: 10.1111/hiv.12119] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Miller MH, Agarwal K, Austin A, Brown A, Barclay ST, Dundas P, Dusheiko GM, Foster GR, Fox R, Hayes PC, Leen C, Millson C, Ryder SD, Tait J, Ustianowski A, Dillon JF. Review article: 2014 UK consensus guidelines - hepatitis C management and direct-acting anti-viral therapy. Aliment Pharmacol Ther 2014; 39:1363-75. [PMID: 24754233 DOI: 10.1111/apt.12764] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/03/2014] [Accepted: 04/01/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Therapeutic options for the management of hepatitis C virus (HCV) infection have evolved rapidly over the past two decades, with a consequent improvement in cure rates. Novel therapeutic agents are an area of great interest in the research community, with a number of these agents showing promise in the clinical setting. AIMS To assess and present the available evidence for the use of novel therapeutic agents for the treatment of HCV, updating previous guidelines. METHODS All Phase 2 and 3 studies, as well as abstract presentations from international Hepatology meetings were identified and reviewed for suitable inclusion, based on studies of new therapies in HCV. Treatment-naïve and experienced individuals, as well as cirrhotic and co-infected individuals were included. RESULTS Sofosbuvir, simeprevir and faldaprevir, along with pegylated interferon and ribavirin, have a role in the treatment of chronic HCV infection. The precise regimens are largely dependent on the patient characteristics, patient and physician preferences, and cost implication. CONCLUSIONS Therapies for chronic HCV have evolved dramatically in recent years. Interferon-free regimens are now possible without compromise in the rate of sustained viral response. The decision as to which regimen is most appropriate is multifactorial, and based on efficacy, safety and cost.
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Affiliation(s)
- M H Miller
- Gut Group, Medical Research Institute, NHS Tayside Ninewells Hospital, University of Dundee, Dundee, UK
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Babiker ZOE, Wingfield T, Galloway J, Snowden N, Ustianowski A. Extreme elevation of ferritin and creatine kinase in primary infection with HIV-1. Int J STD AIDS 2014; 26:68-71. [DOI: 10.1177/0956462414531936] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The diagnosis of primary HIV-1 infection can be challenging, especially in the absence of reported risks or when presenting features are unusual and uncommon. We report an atypical case of primary HIV-1 infection with HIV-1 subtype C in a 61-year old Caucasian man who presented with extreme hyperferritinaemia without iron overload and marked elevation of serum creatine kinase without rhabdomyolysis. In view of his symptomatic seroconversion and low baseline CD4+ T-lymphocyte count, the patient was treated promptly with combination antiretroviral therapy. Subsequently, he made good clinical improvement on treatment and no opportunistic infections were diagnosed at presentation or as part of a later immune reconstitution syndrome. This novel case highlights the importance of clinical suspicion of HIV and suggests that primary HIV-1 infection should be considered in patients presenting with severe hyperferritinaemia or markedly elevated creatine kinase levels. Further studies are required to explain the causative biological mechanisms underlying this rare presentation.
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Affiliation(s)
| | - Tom Wingfield
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
- Section of Infection and Immunity, Wellcome Centre for Tropical Medicine, Imperial College, London, UK
| | - James Galloway
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Neil Snowden
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Andrew Ustianowski
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
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Murphy CL, Bangash IH, Ustianowski A, Varma A. A case of acute neurogenic weakness mimicking the axonal variant of the Guillain-Barre syndrome. Pract Neurol 2012; 12:371-5. [PMID: 23144300 DOI: 10.1136/practneurol-2012-000227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Williams I, Churchill D, Anderson J, Boffito M, Bower M, Cairns G, Cwynarski K, Edwards S, Fidler S, Fisher M, Freedman A, Geretti AM, Gilleece Y, Horne R, Johnson M, Khoo S, Leen C, Marshall N, Nelson M, Orkin C, Paton N, Phillips A, Post F, Pozniak A, Sabin C, Trevelion R, Ustianowski A, Walsh J, Waters L, Wilkins E, Winston A, Youle M. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2012. HIV Med 2012; 13 Suppl 2:1-85. [PMID: 22830364 DOI: 10.1111/j.1468-1293.2012.01029.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of adults with HIV infection with antiretroviral therapy (ART). The scope includes: (i) guidance on the initiation of ART in those previously naïve to therapy; (ii)support of patients on treatment; (iii) management of patients experiencing virological failure; and (iv) recommendations in specific patient populations where other factors need to be taken into consideration. The guidelines are aimed at clinical professionals directly involved with and responsible for the care of adults with HIV infection and at community advocates responsible for promoting the best interests and care of HIV-positive adults. They should be read in conjunction with other published BHIVA guidelines.
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Babiker ZOE, Hogan C, Ustianowski A, Wilkins E. Does interferon-sparing tenofovir disoproxil fumarate-based therapy have a role in the management of severe acute hepatitis delta superinfection? J Med Microbiol 2012; 61:1780-1783. [PMID: 22956751 DOI: 10.1099/jmm.0.046649-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Infection with hepatitis delta virus (HDV) always occurs in association with hepatitis B virus (HBV) and is a cause of significant morbidity and mortality. We present a case of severe acute HDV infection superimposed on a previously unrecognized HBV infection, in which an interferon-sparing antiviral therapy consisting of tenofovir disoproxil fumarate (TDF) and lamivudine was initiated and subsequently maintained. Evidence of successful suppression of HDV ribonucleic acid (RNA) was obtained after 65 weeks of TDF-based treatment. This was mirrored by a significant reduction in the levels of HBV DNA and HBV surface antigen. HDV RNA subsequently rebounded after our patient stopped antiviral therapy of his own accord. Interferon-sparing TDF-based antiviral therapy was safe and effective in achieving HDV RNA suppression in acute HDV superinfection. Further research into the utility of interferon-sparing TDF-based regimes in the treatment of acute HDV infection is needed.
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Affiliation(s)
- Zahir Osman Eltahir Babiker
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Celia Hogan
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Andrew Ustianowski
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Edmund Wilkins
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
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Abstract
The term tropical diseases encompasses all diseases that occur principally in the tropics. This term covers all communicable and noncommunicable diseases, genetic disorders, and disease caused by nutritional deficiencies or environmental conditions (such as heat, humidity, and altitude) that are encountered in areas that lie between, and alongside, the Tropic of Cancer and Tropic of Capricorn belts. In tropical countries, apart from noncommunicable diseases, a severe burden of disease is caused by an array of different microorganisms, parasites, land and sea animals, and arthropods.
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Affiliation(s)
- Alimuddin Zumla
- Department of Infection, Division of Infection and Immunity, University College London Medical School, University College London Hospitals NHS Foundation Trust, London WC1E 6AJ, UK.
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Asboe D, Aitken C, Boffito M, Booth C, Cane P, Fakoya A, Geretti AM, Kelleher P, Mackie N, Muir D, Murphy G, Orkin C, Post F, Rooney G, Sabin C, Sherr L, Smit E, Tong W, Ustianowski A, Valappil M, Walsh J, Williams M, Yirrell D. British HIV Association guidelines for the routine investigation and monitoring of adult HIV-1-infected individuals 2011. HIV Med 2012; 13:1-44. [PMID: 22171742 DOI: 10.1111/j.1468-1293.2011.00971.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D Asboe
- British HIV Association (BHIVA), BHIVA Secretariat, Mediscript Ltd, London, UK.
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Price VA, Smith RAS, Douthwaite S, Thomas S, Almond DS, Miller ARO, Beeching NJ, Thompson G, Ustianowski A, Beadsworth MBJ. General physicians do not take adequate travel histories. J Travel Med 2011; 18:271-4. [PMID: 21722239 DOI: 10.1111/j.1708-8305.2011.00521.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Our aim was to document how often travel histories were taken and the quality of their content. METHODS Patients admitted over 2 months to acute medical units of two hospitals in the Northwest of England with a history of fever, rash, diarrhea, vomiting, jaundice, or presenting as "unwell post-travel" were identified. The initial medical clerking was assessed. RESULTS A total of 132 relevant admissions were identified. A travel history was documented in only 26 patients (19.7%). Of the 16 patients who had traveled, there was no documentation of pretravel advice or of sexual/other activities abroad in 15 (93.8%) and 12 (75.0%) patients, respectively. CONCLUSIONS There needs to be better awareness and education about travel-related illness and the importance of taking an adequate travel history.
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Affiliation(s)
- Victoria A Price
- Acute Medical Unit, Royal Liverpool University Hospital, Liverpool, UK
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81
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Ickinger C, Musenge E, Tikly M, Barnes J, Donnison C, Scott M, Bartholomew P, Rynne M, Hamilton J, Saravanan V, Heycock C, Kelly C, de la Torre I, Moura RA, Leandro M, Edwards J, Cambridge G, de la Torre I, Leandro M, Edwards J, Cambridge G, Daniels LE, Gullick NJ, Rees JD, Kirkham BW, Daniels LE, Gullick NJ, Kirkham BW, Rees J, Scott IC, Johnson D, Scott DL, Kingsley G, Ma MH, Cope AP, Scott DL, Kirkham BW, Brode S, Nisar MK, Ostor AJ, Gullick NJ, Oakley SP, Rees JD, Jones T, Mistlin A, Panayi GS, Kirkham BW, El Miedany Y, Palmer D, Porkodi R, Rajendran P, Waller R, Williamson L, Collins D, Price E, Juarez MJ, El Miedany Y, El Gaafary M, Youssef S, Palmer D, El Miedany Y, El Gaafary M, Palmer D, El Miedany Y, El Gaafary M, Palmer D, El Miedany Y, Palmer D, Cramp F, Hewlett S, Almeida C, Kirwan J, Choy E, Chalder T, Pollock J, Christensen R, Mirjafari H, Verstappen S, Bunn D, Edlin H, Charlton-Menys V, Pemberton P, Marshall T, Wilson P, Lunt M, Symmons D, Bruce IN, Bell C, Rowe IF, Jayakumar K, Norton SJ, Dixey J, Williams P, Young A, Kurunadalingam H, Parwaiz I, Kumar K, Howlett K, Hands B, Raza K, Pitzalis C, Buckley C, Kelly S, Filer A, Wheater G, Hogan VE, Onno Teng Y, Tekstra J, Tuck SP, Lafeber FP, Huizinga TW, Bijlsma JW, Francis RM, Datta HK, van Laar J, Pratt AG, Charles PJ, Choudhury M, Wilson G, Venables PJ, Isaacs J, Raza K, Kumar K, Stack R, Kwiatkowska B, Rantapaa-Dahlqvist S, Saxne T, Sidiropoulos P, Kteniadaki E, Misirlaki C, Mann H, Vencovsky J, Ciurea A, Tamborrini G, Kyburz D, Bastian H, Burmester GR, Detert J, Buckley CD, Sheehy C, Shipman A, Stech I, Mukhtyar C, Atzeni F, Sitia S, Tomasoni L, Gianturco L, Ricci C, Sarzi-Puttini P, De Gennaro Colonna V, Turiel M, Galloway J, Low A, Mercer LK, Dixon W, Ustianowski A, Watson K, Lunt M, Fisher B, Plant D, Lundberg K, Charles PJ, Barton A, Venables P, Pratt AG, Lorenzi AR, Wilson G, Platt PN, Isaacs J. Rheumatoid arthritis - clinical aspects: 134. Predictors of Joint Damage in South Africans with Rheumatoid Arthritis. Rheumatology (Oxford) 2011. [DOI: 10.1093/rheumatology/ker029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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82
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Babiker ZOE, Beeston C, Purcell J, Desai N, Ustianowski A. Mycobacterium avium complex suppurative parotitis in a patient with human immunodeficiency virus infection presenting with immune reconstitution inflammatory syndrome. J Med Microbiol 2010; 59:1365-1367. [PMID: 20634331 DOI: 10.1099/jmm.0.022095-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Restoration of the immune system following initiation of antiretroviral therapy can result in an adverse phenomenon known as immune reconstitution inflammatory syndrome (IRIS). Herein, we report a case of Mycobacterium avium complex (MAC) suppurative parotitis associated with IRIS in a patient with advanced human immunodeficiency virus disease. To the best of our knowledge, this is the first reported case of MAC parotitis in the setting of IRIS and clinicians should be aware of this condition.
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Affiliation(s)
- Zahir Osman Eltahir Babiker
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Christine Beeston
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Janet Purcell
- Microbiology Department, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Niranjan Desai
- Radiology Department, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
| | - Andrew Ustianowski
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK
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83
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Mercer LK, Dixon WG, Watson KD, Galloway J, Lunt M, Symmons DP, Hyrich KL, Galloway J, Hyrich K, Mercer L, Dixon W, Ustianowski A, Watson K, Lunt M, Symmons D, Mirjafari H, Lunt M, Charlton-Menys V, Bunn D, Edlin H, Marshall T, Wilson P, Symmons DP, Bruce IN, Goodson NJ, Morgan K, Marks J, Symmons DP, Gullick N, Oakley S, Jones T, Mistlin A, Rees J, Gibson T, Panayi G, Kirkham B, Ma MH, Ibrahim F, Pollard L, Fekete Z, Kingsley GH, Scott DL. Concurrent Oral 7 - Rheumatoid Arthritis: Clinical Aspects [OP48-OP53]: OP48. The Risk of Non-Melanoma Skin Cancer in Patients Receiving Anti-TNF Therapies for Rheumatoid Athritis: Results from the British Society for Rheumatology Biologics Register. Rheumatology (Oxford) 2010. [DOI: 10.1093/rheumatology/keq707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Dixon WG, Hyrich KL, Watson KD, Lunt M, Galloway J, Ustianowski A, Symmons DPM. Drug-specific risk of tuberculosis in patients with rheumatoid arthritis treated with anti-TNF therapy: results from the British Society for Rheumatology Biologics Register (BSRBR). Ann Rheum Dis 2009; 69:522-8. [PMID: 19854715 PMCID: PMC2927681 DOI: 10.1136/ard.2009.118935] [Citation(s) in RCA: 443] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background The risk of tuberculosis (TB) in patients with rheumatoid arthritis (RA) is thought to be increased following anti-tumour necrosis factor (anti-TNF) therapy, with a proposed differential risk between the anti-TNF drugs etanercept (ETA), infliximab (INF) and adalimumab (ADA). Objective To compare directly the risk between drugs, to explore time to event, site of infection and the role of ethnicity. Methods Data from the British Society for Rheumatology Biologics Register (BSRBR), a national prospective observational study, were used to compare TB rates in 10 712 anti-TNF treated patients (3913 ETA, 3295 INF, 3504 ADA) and 3232 patients with active RA treated with traditional disease-modifying antirheumatic drugs. Results To April 2008, 40 cases of TB were reported, all in the anti-TNF cohort. The rate of TB was higher for the monoclonal antibodies ADA (144 events/100 000 person-years) and INF (136/100 000 person-years) than for ETA (39/100 000 person-years). After adjustment, the incidence rate ratio compared with ETA-treated patients was 3.1 (95% CI 1.0 to 9.5) for INF and 4.2 (1.4 to 12.4) for ADA. The median time to event was lowest for INF (5.5 months) compared with ETA (13.4 months) and ADA (18.5 months). 13/40 cases occurred after stopping treatment. 25/40 (62%) cases were extrapulmonary, of which 11 were disseminated. Patients of non-white ethnicity had a sixfold increased risk of TB compared with white patients treated with anti-TNF therapy. Conclusion The rate of TB in patients with RA treated with anti-TNF therapy was three- to fourfold higher in patients receiving INF and ADA than in those receiving ETA.
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Affiliation(s)
- W G Dixon
- ARC Epidemiology Unit, University of Manchester, Manchester M13 9PT, UK
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85
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Johnston V, Stockley JM, Dockrell D, Warrell D, Bailey R, Pasvol G, Klein J, Ustianowski A, Jones M, Beeching NJ, Brown M, Chapman ALN, Sanderson F, Whitty CJM. Fever in returned travellers presenting in the United Kingdom: recommendations for investigation and initial management. J Infect 2009; 59:1-18. [PMID: 19595360 DOI: 10.1016/j.jinf.2009.05.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Accepted: 05/20/2009] [Indexed: 01/23/2023]
Abstract
International travel is increasing. Most physicians and general practitioners will encounter returned travellers with fever and the majority of travel-related infection is associated with travel to the tropics. In those returning from the tropics malaria must always be excluded, and HIV considered, from all settings. Common causes of non-malarial fever include from Africa rickettsial diseases, amoebic liver abscess and Katayama syndrome; from South and South East Asia, enteric fever and arboviral infection; from the Middle East, brucellosis and from the Horn of Africa visceral leishmaniasis. Other rare but important diseases from particular geographical areas include leptospirosis, trypanosomiasis and viral haemorrhagic fever. North and South America, Europe and Australia also have infections which are geographically concentrated. Empirical treatment may have to be started based on epidemiological probability of infection whilst waiting for results to return. The evidence base for much of the management of tropical infections is limited. These recommendations provide a pragmatic approach to the initial diagnosis and management of fever in returned travellers, based on evidence where it is available and on consensus of expert opinion where it is not. With early diagnosis and treatment the majority of patients with a potentially fatal infection related to travel will make a rapid and full recovery.
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Affiliation(s)
- Victoria Johnston
- Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK.
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86
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Nic Fhogartaigh C, Hughes H, Armstrong M, Herbert S, McGregor A, Ustianowski A, Whitty CJM. Falciparum malaria as a cause of fever in adult travellers returning to the United Kingdom: observational study of risk by geographical area. QJM 2008; 101:649-56. [PMID: 18586767 DOI: 10.1093/qjmed/hcn072] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The probability that a returned traveller with a history of fever has malaria is likely to vary by geographical area, but this has not been quantified in travellers. AIM To collect data on prevalence of malaria in outpatients returning with a fever or history of fever from malaria-endemic countries, at the point of presentation for a malaria test. DESIGN Observational retrospective study. Consecutive patients presenting to an unselected 'walk-in' clinic for returned travellers. RESULTS Of 2867 patients meeting inclusion criteria, 337 (11.8%) had malaria, 89.5% originating in sub-Saharan Africa. Of travellers returning from sub-Saharan Africa excluding South Africa with fever/history of fever, 291/1497 had malaria (19.4%, 95% CI 17-21%). A high proportion was visiting friends and relatives. In those from other areas the proportions were: 16/707 (2.3%, 95% CI 1.5-3.8) from Indian subcontinent/Southeast Asia; 2/143 (1.4%) from Southern America; 4/129 (3.1%) from South Africa; 1/44 (2.3%) from North Africa; and 8/41 (19.5%) from Oceania. Compared to other malaria-endemic regions, African travel gave an adjusted odds ratio of 7.8 (95% CI 5.4-11.2, P < 0.0001). Only 45.1% of malaria cases had a fever (> or =37.5 degrees C) at the time of presentation. Only 3% of all diagnoses of malaria had no history of fever. In 28% of cases parasite count increased in the initial 24 h of antimalarial treatment. CONCLUSION The likelihood that a patient with fever returning from Africa has malaria is high (around 1 in 5), and is significantly lower from other areas. Absence of fever at presentation does not exclude malaria.
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Affiliation(s)
- C Nic Fhogartaigh
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London WC1E 6AU, UK
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87
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Abstract
Every year people die from malaria in Britain and other industrialised countries. Most of these deaths are avoidable: they occur because a patient or doctor has underestimated the severity of the disease or has not considered the diagnosis early enough. This article provides the essential facts on treating malaria in adults in a non-endemic setting and is based on the best available evidence
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88
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89
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Ustianowski A, Shaffer R, Collin S, Wilkinson RJ, Davidson RN. Prevalence and associations of vitamin D deficiency in foreign-born persons with tuberculosis in London. J Infect 2005; 50:432-7. [PMID: 15907552 DOI: 10.1016/j.jinf.2004.07.006] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2004] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The incidence of tuberculosis (TB) is high amongst foreign-born persons resident in developed countries. Vitamin D is important in the host defence against TB in vitro and deficiency may be an acquired risk factor for this disease. We aimed to determine the incidence and associations of vitamin D deficiency in TB patients diagnosed at an infectious diseases unit in London, UK. METHODS Case-note analysis of 210 unselected patients diagnosed with TB who had plasma vitamin D (25(OH)D3) levels routinely measured. Prevalence of 25(OH)D3 deficiency and its relationship to ethnic origin, religion, site of TB, sex, age, duration in the UK, month of 25(OH)D3 estimation and TB diagnosis were determined. RESULTS Of 210 patients 76% were 25(OH)D3 deficient and 56% had undetectable levels. 70/82 Indian, 24/28 East African Asian, 29/34 Somali, 14/19 Pakistani and Afghani, 16/22 Sri Lankan and 2/6 other African patients were deficient (with 58, 17, 23, 9, 6 and 1 having undetectable levels, respectively). Only 0/6 white Europeans and 1/8 Chinese/South East Asians had low plasma 25(OH)D3 levels. Muslims, Hindus and Sikhs all had equivalent rates of deficiency though Hindus were more likely to have undetectable levels (odds ratio 1.87, 95% CI 1.27-2.76). There was no significant association between 25(OH)D3 level and site of TB or duration of residence in the UK. There was no apparent seasonal variation in either TB diagnosis or 25(OH)D3 level. CONCLUSIONS 25(OH)D3 deficiency commonly associates with TB among all ethnic groups apart from white Europeans, and Chinese/South East Asians. Our data support a lack of sunlight exposure and potentially a vegetarian diet as contributors to this deficiency.
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Affiliation(s)
- A Ustianowski
- Department of Infection and Tropical Medicine, Lister Unit, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ, UK.
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90
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Ustianowski A. Oxford Handbook of Tropical Medicine, Second Edition
Michael Eddleston, Robert Davidson, Robert Wilkinson and Stephen Pierini
Oxford University Press, Oxford, UK, 2004
ISBN 0-19-852509-5. £24.95, 712 pp. J Antimicrob Chemother 2005. [DOI: 10.1093/jac/dki154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Affiliation(s)
- David Mabey
- Clinical Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7H, UK.
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92
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Kerbiriou L, Ustianowski A, Johnson M, Gillespie SH, Miller RF, Lipman M. Reply. Clin Infect Dis 2004. [DOI: 10.1086/392519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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93
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Kerbiriou L, Ustianowski A, Johnson MA, Gillespie SH, Miller RF, Lipman MCI. Human immunodeficiency virus type 1-related pulmonary Mycobacterium xenopi infection: a need to treat? Clin Infect Dis 2003; 37:1250-4. [PMID: 14557971 DOI: 10.1086/378806] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2003] [Accepted: 06/30/2003] [Indexed: 11/03/2022] Open
Abstract
We report treatment decisions and outcomes for 20 patients who were infected with human immunodeficiency virus type 1 (HIV-1) and were receiving highly active antiretroviral therapy (HAART) who had respiratory symptoms and from whom Mycobacterium xenopi was isolated. All patients also had coexisting pulmonary pathologic conditions. The median blood T cell CD4 count was 37 cells/microL (range, 2-480 cells/microL). Fifteen of 20 patients received no antimycobacterial therapy and remain healthy after a median of approximately 4 years of follow-up, and 2 patients required treatment specifically for M. xenopi infection, both showing clinical improvement. We conclude that pulmonary M. xenopi isolation in HIV-1 patients receiving HAART does not usually require specific treatment.
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Affiliation(s)
- L Kerbiriou
- Department of Respiratory Medicine, Royal Free Hospital, London, United Kingdom
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Affiliation(s)
- S Bloch
- Department of Infection and Tropical Medicine, Faculty of Medicine, Imperial College, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ, UK
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Abstract
Hyponatraemia is a common finding in malaria, but rarely appears to be of clinical significance. We describe a case of acute, profound, hyponatraemia with confusion and convulsions developing in the context of seemingly uncomplicated Plasmodium falciparum malaria. We draw attention to this rarely reported and poorly documented life-threatening complication and review the limited literature on the subject.
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Affiliation(s)
- Andrew Ustianowski
- Department of Infection and Tropical Medicine, Faculty of Medicine, Imperial College, Lister Unit, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ, UK
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Abstract
Tuberculosis is increasing. Current treatment regimens require at least 6 months, because latent or stationary phase organisms are difficult to kill. Such regimens do not achieve full compliance, and "directly observed therapy short course" (DOTS) is having less impact than expected. This worrying situation is aggravated by coinfection with human immunodeficiency virus (HIV), and by the increase in drug-resistant strains. We need new insights that lead to more rapid therapies and immunotherapies, and more reliable vaccines. Recent insights have come from: understanding of the relationship between Mycobacterium tuberculosis and macrophages; the multiple T cell types that recognise mycobacterial peptides, lipids and glycolipids; the critical role of interferon-gamma (IFNgamma) and interleukin-12 (IL-12) in human mycobacterial infection revealed by genetically defective children; quantitation of the presence and importance of Th2 lymphocyte activation in human tuberculosis; the role of local conversion of inactive cortisone to active cortisol in the lesions; the recognition that some effective prophylactic vaccines also work as immumotherapeutics whereas others do not. In the longer term the recent sequencing of the M. tuberculosis genome will lead to further advances. In the short term, effective immunotherapy remains the most accessible breakthrough in the management of tuberculosis. The types of practical advance that will result from sequencing the genome are discussed speculatively, but cannot yet be predicted with certainty.
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Affiliation(s)
- G A Rook
- Dept of Bacteriology, Royal Free and University College London Medical School, Windeyer Institute of Medical Sciences, UK
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97
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Ahmed Y, Mwaba P, Chintu C, Grange JM, Ustianowski A, Zumla A. A study of maternal mortality at the University Teaching Hospital, Lusaka, Zambia: the emergence of tuberculosis as a major non-obstetric cause of maternal death. Int J Tuberc Lung Dis 1999; 3:675-80. [PMID: 10460099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
SETTING The Department of Obstetrics and Gynaecology, University Teaching Hospital, Lusaka, Zambia. OBJECTIVES To ascertain 1) the non-obstetric causes of maternal mortality, 2) the importance of tuberculosis as a cause of maternal deaths, and 3) the trends in the aetiology of non-obstetric causes of maternal deaths during the past decade in the light of the human immunodeficiency virus epidemic. DESIGN A 2-year retrospective study of the aetiology of all maternal deaths occurring at the University Teaching Hospital (UTH), Lusaka, Zambia between 1 January 1996 and 31 December 1997. Comparison of these data with available data published between 1974 and 1989. RESULTS There were 251 maternal deaths recorded during the study period. Of these, 106 (42%) were due to direct (obstetric) causes and 145 (58%) were due to indirect (non-obstetric) causes. Malaria (30%), tuberculosis (25%) and unspecified chronic respiratory tract infections (22%) accounted for 77% of non-obstetric causes of maternal deaths and 44% of all causes of maternal deaths. The diagnosis of AIDS was closely linked with that of tuberculosis (92% of cases), and unspecified chronic respiratory illnesses (97%), but not with malaria (37%). The maternal mortality ratio for UTH was calculated at 921 per 100,000 live births, a significant increase from the 118 noted in 1982 and 667 in 1989. CONCLUSIONS Despite improved obstetric services, the maternal mortality ratios at UTH, Lusaka, have increased eight-fold over the past two decades. This dramatic increase is mainly due to non-obstetric causes of death. Malaria and AIDS-associated tuberculosis and unspecified 'chronic respiratory illnesses' are now major causes of maternal death in Zambia. Greater emphasis is urgently required on early detection, accurate diagnosis, treatment and prevention of malaria and tuberculosis in pregnancy. Further definition of chronic 'unspecified' respiratory illnesses is also required.
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Affiliation(s)
- Y Ahmed
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka
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98
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Ustianowski A, Mwaba P, Zumla A. TUBERCULOSIS AND HIV — PERSPECTIVES FROM SUB-SAHARAN AFRICA. Tuberculosis (Edinb) 1999. [DOI: 10.1142/9781848160552_0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Andrew Ustianowski
- Centre For Infectious Diseases, University College London Medical School, Windeyer Building, 46 Cleveland Street, London W1P 6DB, United Kingdom
| | - Peter Mwaba
- Department of Medicine, University of Zambia School of Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Alimuddin Zumla
- Centre For Infectious Diseases, Royal Free and University College Medical School, Windeyer Building, 46 Cleveland Street, London W1P 6DB, United Kingdom
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99
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Baboo KS, Luo NP, Murphy JR, Cummings C, Chintu C, Ustianowski A, DuPont HL, Kelinowski M, Mathewson JJ, Zumla A. HIV-1 seroprevalence in Zambian patients with acute diarrhea: a community-based study. J Acquir Immune Defic Syndr Hum Retrovirol 1999; 20:160-3. [PMID: 10048903 DOI: 10.1097/00042560-199902010-00008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The seroprevalence of HIV-1 in sub-Saharan African patients with diarrhea in the community remains largely unknown. We present the findings of a 2-month study that we undertook to ascertain the seroprevalence of HIV-1 in Zambian patients presenting with acute diarrhea in a community-based health center. A total of 256 patients with diarrhea and 140 apparently healthy controls was seen. Of the patients with diarrhea, 161 were < 16 years old and 95 were adults. Most children with diarrhea were < 6 years old (147 of 161; 91%). Overall, 81 of 256 (32%) patients with diarrhea were HIV-1-seropositive. When results from children < 18 months old and possibly having maternal anti-HIV-1 antibodies were excluded, 64 of 172 (37%) patients with diarrhea were HIV-seropositive. Rates of HIV-1 seropositivity for patients with diarrhea were significantly higher than were rates for diarrhea-free controls (p < .001 for both the total population; odds ratio [OR], 95% confidence interval [CI], 1.42 < 2.48 < 4.35) and population > 18 months old (OR, 95% CI, 1.54 < 2.90 < 5.49). Among children between 18 months and 5 years old, 14 of 63 (22%) were HIV-1-seropositive compared with 8 of 62 (13%) without diarrhea (p > .05, not significant). Moreover, 49 of 95 (52%) adults with acute diarrhea were HIV-1-seropositive compared with 10 of 44 (23%) healthy adult controls (p < .003; OR, 95% CI, 1.51 < 3.62 < 8.87). No significant differences were found in HIV-1 seroprevalence rates between males and females in all age groups. These data show a close association between acute diarrhea and HIV seropositivity in Zambian adults in the community.
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Affiliation(s)
- K S Baboo
- Department of Community Medicine, University Teaching Hospital, Lusaka, Zambia
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Baker R, Ustianowski A. Careers in academic medicine. It's surprising that any juniors consider careers in academic medicine. BMJ 1997; 315:608. [PMID: 9302982 PMCID: PMC2127434 DOI: 10.1136/bmj.315.7108.608a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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