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Kumar A, Ausayakhun S, Ausayakhun S, Apivatthakakul A, Liu Y, Snyder BM, Margolis TP, Keenan JD. Quality of Life Outcomes Among Patients Being Screened for Cytomegalovirus Retinitis in Thailand. Ocul Immunol Inflamm 2024; 32:520-524. [PMID: 37801648 DOI: 10.1080/09273948.2023.2263091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE Cytomegalovirus (CMV) retinitis can have debilitating impacts on quality of life (QOL), but few contemporary studies have characterized these ramifications. This study assessed the impact of CMV retinitis on vision-related QOL for those living with HIV/AIDS in Thailand. METHODS QOL was assessed as part of a prospective interventional cohort study of patients referred to a tertiary hospital in Thailand for CMV retinitis screening. A validated vision-related QOL questionnaire was administered at the baseline screening visit and at the 6-month study visit. Multivariable linear regression models were performed to determine the effect of CMV retinitis diagnosis on QOL score. RESULTS A total of 152 participants completed the QOL questionnaire at their initial clinic visit. At baseline, a diagnosis of CMV retinitis diagnosis was significantly associated with decreased QOL score: unilateral retinitis was associated with a 0.11 (95% CI: -0.26-0.03) decrement in QOL, and bilateral retinitis was associated with a 0.33 (95% CI: -0.51-0.16) decrement (joint P-value = 0.0009). For the 78 participants with a 6-month visit, changes in QOL from baseline were small and not significant. A diagnosis of CMV retinitis was still associated with decreased QOL score at 6 months (joint P-value = 0.03). CONCLUSIONS This study found that vision-related QOL was lower in those with CMV retinitis, especially with bilateral involvement, and did not improve after treatment among those with follow-up. These findings reinforce the debilitating clinical manifestations of this disease, and support efforts for earlier screening to detect CMV retinitis before impacts on QOL have occurred.
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Affiliation(s)
- Anika Kumar
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Somsanguan Ausayakhun
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sakarin Ausayakhun
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Atitaya Apivatthakakul
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Yingna Liu
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Blake M Snyder
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Todd P Margolis
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jeremy D Keenan
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
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Tan Yip Ming C, Rojas-Carabali W, Cifuentes-González C, Agrawal K, Grover S, Anand A, Singh Senjam S, Singh A, Dubey P, Sharma A, Blazes M, Lee CS, Lee AY, Gupta V, Agrawal R. Beyond Pathology- Exploring Salutogenesis as a Novel Approach to Eye Inflammatory Disease Prevention and Management: A Perspective. Ocul Immunol Inflamm 2024:1-9. [PMID: 38842198 DOI: 10.1080/09273948.2024.2359621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/20/2024] [Indexed: 06/07/2024]
Abstract
The aim of this perspective is to promote the theory of salutogenesis as a novel approach to addressing ophthalmologic inflammatory conditions, illustrating several concepts in which it is based upon and how they can be applied to medical practice. This theory can better contextualize why patients with similar demographics and exposures are not uniform in their clinical presentations. Stressors in daily life can contribute to a state of ill-health and there are various factors that help alleviate their negative impact. These alleviating factors are significantly impaired in people with poor vision, one of the most common presentations of ophthalmologic conditions. Salutogenic principles can guide the treatment of eye conditions to be more respectful of patient autonomy amidst shifting expectations of the doctor-patient relationship. Being able to take ownership of their health and feeling that their cultural beliefs were considered improves compliance and subsequently gives more optimal outcomes. Population-level policy interventions could also utilize salutogenic principles to identify previously overlooked domains that can be addressed. We identified several papers about salutogenesis in an ophthalmological context and acknowledged the relatively few studies on this topic at present and offer directions in which we can explore further in subsequent studies.
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Affiliation(s)
- Collin Tan Yip Ming
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - William Rojas-Carabali
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Carlos Cifuentes-González
- PROTON Study Group, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Kajal Agrawal
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Sandeep Grover
- PROTON Study Group, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Akshay Anand
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Suraj Singh Senjam
- NeuroScience Research Lab, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amarjeet Singh
- Community Medicine and School of Public Health, PGIMER, Chandigarh, India
| | - Preeti Dubey
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Aman Sharma
- Gap Analysis, Strive High Pte Ltd, Singapore, Singapore
| | - Marian Blazes
- Department of Rheumatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Cecilia S Lee
- Department of Rheumatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aaron Y Lee
- Department of Rheumatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Advance Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Ophthalmology, University of Washington, Seattle, USA
- Singapore Eye Research Institute, Singapore, Singapore
- Duke NUS Medical School, Singapore, Singapore
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Senthil MP, Simon S, Constable PA. A review of patient-reported outcome measures used in uveitis. Surv Ophthalmol 2023; 68:225-240. [PMID: 36395825 DOI: 10.1016/j.survophthal.2022.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 09/13/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
We review patient-reported outcome measures (PROMs) used to evaluate the quality of life (QoL) in uveitis and provide a quality assessment of the psychometric properties of the PROMs, making it easier to choose the best questionnaire for uveitis. Our review included 158 articles. A total of 98 PROMs were used to measure QoL in uveitis and the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ -25) was the most frequently used PROM in these studies. There were 5 uveitis-specific PROMs, but they were meant for either birdshot choroidopathy or cytomegalovirus retinitis or paediatric uveitis. There are no PROMs developed explicitly for the more common, anterior uveitis, intermediate uveitis, panuveitis, and chronic uveitis. The uveitis-specific PROMs performed better in our quality assessment criteria compared to other PROMs. However, these PROMs were constructed using traditional classical test theory and have not been assessed using the modern family of psychometric assessment methods such as Rasch analysis. As new therapeutic modalities for uveitis such as the new biological agents and steroid implants, continue to evolve, a comprehensive PROM will be increasingly valued in clinical trial settings to compare the effects of treatments from the patient's perspective.
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Affiliation(s)
- Mallika Prem Senthil
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, South Australia, Australia.
| | - Sumu Simon
- University of Adelaide, Adelaide, South Australia, Australia
| | - Paul A Constable
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, South Australia, Australia
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Siddiqui S, Hackl S, Ghoddusi H, McIntosh MR, Gomes AC, Ho J, Reeves MB, McLean GR. IgA binds to the AD-2 epitope of glycoprotein B and neutralizes human cytomegalovirus. Immunology 2021; 162:314-327. [PMID: 33283275 PMCID: PMC7884650 DOI: 10.1111/imm.13286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/30/2020] [Accepted: 11/18/2020] [Indexed: 12/04/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a ubiquitous pathogen that is potentially pathogenic in immunosuppressed individuals and pregnant females during primary infection. The HCMV envelope glycoprotein B (gB) facilitates viral entry into all cell types and induces a potent immune response. AD-2 epitope is a highly conserved linear neutralizing epitope of gB and a critical target for antibodies; however, only 50% of sero-positive individuals make IgG antibodies to this site and IgA responses have not been fully investigated. This study aimed to compare IgG and IgA responses against gB and the AD-2 epitope in naturally exposed individuals and those receiving a recombinant gB/MF59 adjuvant vaccine. Thus, vaccination of sero-positive individuals improved pre-existing gB-specific IgA and IgG levels and induced de novo gB-specific IgA and IgG responses in sero-negative recipients. Pre-existing AD-2 IgG and IgA responses were boosted with vaccination, but de novo AD-2 responses were not detected. Naturally exposed individuals had dominant IgG responses towards gB and AD-2 compared with weaker and variable IgA responses, although a significant IgA binding response to AD-2 was observed within human breastmilk samples. All antibodies binding AD-2 contained kappa light chains, whereas balanced kappa/lambda light chain usage was found for those binding to gB. V region-matched AD-2-specific recombinant IgG and IgA bound both to gB and to AD-2 and neutralized HCMV infection in vitro. Overall, these results indicate that although human IgG responses dominate, IgA class antibodies against AD-2 are a significant component of human milk, which may function to protect neonates from HCMV.
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Affiliation(s)
- Saima Siddiqui
- Cellular and Molecular Immunology Research CentreLondon Metropolitan UniversityLondonUK
| | - Sarah Hackl
- Cellular and Molecular Immunology Research CentreLondon Metropolitan UniversityLondonUK
| | - Hamid Ghoddusi
- Microbiology Research UnitLondon Metropolitan UniversityLondonUK
| | - Megan R. McIntosh
- Institute for Immunity and TransplantationUniversity College LondonLondonUK
| | - Ariane C. Gomes
- Institute for Immunity and TransplantationUniversity College LondonLondonUK
| | - Joshua Ho
- Institute for Immunity and TransplantationUniversity College LondonLondonUK
| | - Matthew B. Reeves
- Institute for Immunity and TransplantationUniversity College LondonLondonUK
| | - Gary R. McLean
- Cellular and Molecular Immunology Research CentreLondon Metropolitan UniversityLondonUK,National Heart and Lung InstituteImperial College LondonLondonUK
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Shahryari A, Saghaeian Jazi M, Mohammadi S, Razavi Nikoo H, Nazari Z, Hosseini ES, Burtscher I, Mowla SJ, Lickert H. Development and Clinical Translation of Approved Gene Therapy Products for Genetic Disorders. Front Genet 2019; 10:868. [PMID: 31608113 PMCID: PMC6773888 DOI: 10.3389/fgene.2019.00868] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
The field of gene therapy is striving more than ever to define a path to the clinic and the market. Twenty gene therapy products have already been approved and over two thousand human gene therapy clinical trials have been reported worldwide. These advances raise great hope to treat devastating rare and inherited diseases as well as incurable illnesses. Understanding of the precise pathomechanisms of diseases as well as the development of efficient and specific gene targeting and delivery tools are revolutionizing the global market. Currently, human cancers and monogenic disorders are indications number one. The elevated prevalence of genetic disorders and cancers, clear gene manipulation guidelines and increasing financial support for gene therapy in clinical trials are major trends. Gene therapy is presently starting to become commercially profitable as a number of gene and cell-based gene therapy products have entered the market and the clinic. This article reviews the history and development of twenty approved human gene and cell-based gene therapy products that have been approved up-to-now in clinic and markets of mainly North America, Europe and Asia.
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Affiliation(s)
- Alireza Shahryari
- Institute of Diabetes and Regeneration Research, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Stem Cell Research, Helmholtz Zentrum München, Neuherberg, Germany
- Stem Cell Research Center, Golestan University of Medical Sciences, Gorgan, Iran
- Department of Molecular Genetics, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Marie Saghaeian Jazi
- Stem Cell Research Center, Golestan University of Medical Sciences, Gorgan, Iran
- Metabolic Disorders Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Saeed Mohammadi
- Stem Cell Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Hadi Razavi Nikoo
- Infectious Disease Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Zahra Nazari
- Department of Biology, School of Basic Sciences, Golestan University, Gorgan, Iran
| | - Elaheh Sadat Hosseini
- Department of Nanobiotechnology, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Ingo Burtscher
- Institute of Diabetes and Regeneration Research, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Stem Cell Research, Helmholtz Zentrum München, Neuherberg, Germany
| | - Seyed Javad Mowla
- Department of Molecular Genetics, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Heiko Lickert
- Institute of Diabetes and Regeneration Research, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Stem Cell Research, Helmholtz Zentrum München, Neuherberg, Germany
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Prem Senthil M, Khadka J, Pesudovs K. Assessment of patient-reported outcomes in retinal diseases: a systematic review. Surv Ophthalmol 2017; 62:546-582. [DOI: 10.1016/j.survophthal.2016.12.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 02/03/2023]
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Jirawison C, Yen M, Leenasirimakul P, Chen J, Guadanant S, Kunavisarut P, Patikulsila D, Watanachai N, Ausayakhun S, Heiden D, Holland GN, Margolis TP, Keenan JD. Telemedicine screening for cytomegalovirus retinitis at the point of care for human immunodeficiency virus infection. JAMA Ophthalmol 2015; 133:198-205. [PMID: 25412344 DOI: 10.1001/jamaophthalmol.2014.4766] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Cytomegalovirus (CMV) retinitis is a leading cause of blindness in many developing countries, likely the result of inadequate screening. Telemedicine screening for CMV retinitis instituted at the point of care for human immunodeficiency virus (HIV) infection may allow for earlier detection. OBJECTIVES To determine the diagnostic accuracy of retinal photography in detecting CMV retinitis at the point of HIV care and to characterize the clinical manifestations of CMV retinitis detected through the screening program. DESIGN, SETTING, AND PARTICIPANTS We enrolled 103 participants from a population of 258 patients with HIV and a CD4 level of less than 100/μL treated at an HIV clinic in Thailand from June 2010 through June 2012. We captured mosaic fundus photographs through a dilated pupil using a digital fundus camera. An experienced on-site ophthalmologist masked to the results of the fundus images subsequently examined each eye with indirect ophthalmoscopy and recorded the clinical findings on a standardized form. Three remote graders evaluated each image for CMV retinitis. INTERVENTION Fundus photography and indirect ophthalmoscopy. MAIN OUTCOMES AND MEASURES Sensitivity and specificity of telemedicine relative to indirect ophthalmoscopy for diagnosis of CMV retinitis and clinical features of CMV retinitis lesions. RESULTS Sixteen patients (15.5%) were diagnosed as having CMV retinitis, of whom 5 (31%) had bilateral disease. Of the 21 eyes (10.2%) with CMV retinitis, 7 (33%) had visual symptoms. Retinitis lesions occupied less than 10% of the total retinal surface area in 13 of 21 eyes (62%) and did not involve the posterior pole (ie, zone 1) in 15 of 21 eyes (71%). Mean logMAR visual acuity in affected eyes was 0.41 (95% CI, 0.11-0.71; Snellen equivalent, 20/50 [95% CI, 20/25-20/100]). The mean sensitivity for the 3 remote graders in detecting CMV retinitis on fundus photography was 30.2% (95% CI, 10.5%-52.4%), and mean specificity was 99.1% (95% CI, 97.8%-100.0%). The CMV retinitis lesions missed by the remote graders (false-negative findings) were more likely to be small (P = .001) and located in the peripheral retina (P = .04). CONCLUSIONS AND RELEVANCE Patients undergoing screening at a clinic for HIV treatment had less extensive retinitis than patients in recent reports from an ophthalmology clinic. Retinal photography with the camera used in this study was not highly sensitive in detecting CMV retinitis but may identify disease with an immediate threat to vision. Improved accuracy will require a camera that can more easily image the peripheral retina.
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Affiliation(s)
- Choeng Jirawison
- Department of Ophthalmology, Nakornping Hospital, Chiang Mai, Thailand
| | - Michael Yen
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco3currently a medical student, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jenny Chen
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco4Ocular Inflammatory Disease Center, Jules Stein Eye Institute, University of California, Los Angeles5Department of Ophthalmology, David Geffen School of M
| | - Siripim Guadanant
- Department of Ophthalmology, Nakornping Hospital, Chiang Mai, Thailand
| | - Paradee Kunavisarut
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Direk Patikulsila
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nawat Watanachai
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Somsanguan Ausayakhun
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - David Heiden
- Department of Ophthalmology, California Pacific Medical Center, San Francisco
| | - Gary N Holland
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, University of California, Los Angeles
| | - Todd P Margolis
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco8Department of Ophthalmology, University of California, San Francisco9currently with the Department of Ophthalmology and Visual Sciences, Washington Univer
| | - Jeremy D Keenan
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco8Department of Ophthalmology, University of California, San Francisco
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Tran BX, Nguyen LH, Ohinmaa A, Maher RM, Nong VM, Latkin CA. Longitudinal and cross sectional assessments of health utility in adults with HIV/AIDS: a systematic review and meta-analysis. BMC Health Serv Res 2015; 15:7. [PMID: 25609449 PMCID: PMC4307193 DOI: 10.1186/s12913-014-0640-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 12/08/2014] [Indexed: 11/17/2022] Open
Abstract
Background Utility estimates are important health outcomes for economic evaluation of care and treatment interventions for patients with HIV/AIDS. We conducted a systematic review and meta-analysis of utility measurements to examine the performance of preference-based instruments, estimate health utility of patients with HIV/AIDS by disease stages, and investigate changes in their health utility over the course of antiretroviral treatment. Methods We searched PubMed/Medline, Cochrane Database of Systematic Review, NHS Economic Evaluation Database and Web of Science for English-language peer-reviewed papers published during 2000–2013. We selected 49 studies that used 3 direct and 6 indirect preference based instruments to make a total of 218 utility measurements. Random effect models with robust estimation of standard errors and multivariate fractional polynomial regression were used to obtain the pooled estimates of utility and model their trends. Results Reliability of direct-preference measures tended to be lower than other types of measures. Utility elicited by two of the indirect preference measures - SF-6D (0.171) and EQ-5D (0.114), and that of Time-Trade off (TTO) (0.151) was significantly different than utility elicited by Standard Gamble (SG). Compared to asymptomatic HIV patients, symptomatic and AIDS patients reported a decrement of 0.025 (p&#×2009;=&#×2009;0.40) and 0.176 (p&#×2009;=&#×2009;0.001) in utility scores, adjusting for method of assessment. In longitudinal studies, the pooled health utility of HIV/AIDS patients significantly decreased in the first 3 months of treatment, and rapidly increased afterwards. Magnitude of change varied depending on the method of assessment and length of antiretroviral treatment. Conclusion The study provides an accumulation of evidence on measurement properties of health utility estimates that can help inform the selection of instruments for future studies. The pooled estimates of health utilities and their trends are useful in economic evaluation and policy modelling of HIV/AIDS treatment strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0640-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bach Xuan Tran
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.
| | - Long Hoang Nguyen
- School of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam.
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
| | - Rachel Marie Maher
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.
| | - Vuong Minh Nong
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.
| | - Carl A Latkin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Kempen JH, Sugar EA, Varma R, Dunn JP, Heinemann MH, Jabs DA, Lyon AT, Lewis RA. Risk of cataract among subjects with acquired immune deficiency syndrome free of ocular opportunistic infections. Ophthalmology 2014; 121:2317-24. [PMID: 25109932 PMCID: PMC4252252 DOI: 10.1016/j.ophtha.2014.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/14/2014] [Accepted: 06/11/2014] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate the risk of cataract in the setting of AIDS. DESIGN Prospective cohort study. PARTICIPANTS Subjects with AIDS free of ocular opportunistic infections throughout catamnesis. METHODS From 1998 through 2008, subjects 13 years of age or older were enrolled. Demographic characteristics and clinical characteristics were documented at enrollment and semiannually. MAIN OUTCOME MEASURES Cataract was defined as high-grade lens opacity observed by biomicroscopy judged to be the cause of a best-corrected visual acuity worse than 20/40. Eyes that underwent cataract surgery during follow-up were considered to have developed cataract before the first visit when pseudophakia or aphakia was observed. RESULTS Among 1606 participants (3212 eyes) at enrollment, 1.9% (95% confidence interval [CI]: 1.3%-2.7%) were observed to have cataract or prior cataract surgery. Among the 2812 eyes initially free of cataract and followed longitudinally (median follow-up, 4.6 years), the incidence of cataract was 0.37%/eye-year (95% CI: 0.26%-0.53%). In addition to age, significant cataract risk factors included prior cataract in the contralateral eye (adjusted hazard ratio [aHR], 21.6; 95% CI: 10.4-44.8), anterior segment inflammation (aHR, 4.40; 95% CI: 1.64-11.9), prior retinal detachment (aHR, 4.94; 95% CI: 2.21-11.0), and vitreous inflammation (aHR, 7.12; 95% CI: 2.02-25.0), each studied as a time-updated characteristic. Detectable human immunodeficiency virus RNA in peripheral blood was associated with lower risk of cataract at enrollment (adjusted odds ratio, 0.32; 95% CI: 0.12-0.80) but not of incident cataract (aHR, 1.58; 95% CI: 0.90-2.76). After adjustment for other factors, neither the then-current absolute CD4+ T-cell count nor antiretroviral therapy status showed consistent association with cataract risk, nor did an additive diagnosis of other comorbidities. Compared with the available population-based studies that used similar definitions of cataract, the age-specific prevalence of cataract in our cohort was higher than in 1 of 2 such studies, and the age-specific incidence of cataract surgery was higher. CONCLUSIONS Our results suggest cataract may occur earlier among patients with AIDS free of ocular opportunistic infections than in the general population. Cataract risk was associated most strongly with age and with other ocular morbidity in this population. With improved survival, the burden of cataract likely will increase for persons with the human immunodeficiency virus or AIDS.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Elizabeth A Sugar
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Rohit Varma
- Doheny Eye Institute, Department of Ophthalmology, University of Southern California, Los Angeles, California
| | - James P Dunn
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Murk-Hein Heinemann
- Ophthalmic Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Ophthalmology, Cornell University Medical College, New York, New York
| | - Douglas A Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alice T Lyon
- Department of Ophthalmology, Northwestern University, Chicago, Illinois
| | - Richard A Lewis
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
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Mizushima D, Nishijima T, Gatanaga H, Tsukada K, Teruya K, Kikuchi Y, Oka S. Preemptive therapy prevents cytomegalovirus end-organ disease in treatment-naïve patients with advanced HIV-1 infection in the HAART era. PLoS One 2013; 8:e65348. [PMID: 23724140 PMCID: PMC3665626 DOI: 10.1371/journal.pone.0065348] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 04/24/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The efficacy of preemptive therapy against cytomegalovirus (CMV) infection remains unknown in treatment-naïve patients with advanced HIV-1 infection in the HAART era. METHODS The subjects of this single-center observation study were 126 treatment-naïve HIV-1 infected patients with positive CMV viremia between January 1, 2000 and December 31, 2006. Inclusion criteria were age more than 17 years, CD4 count less than 100/μl, plasma CMV DNA positive, never having received antiretroviral therapy (ART) and no CMV end-organ disease (EOD) at first visit. The incidence of CMV-EOD was compared in patients with and without preemptive therapy against CMV-EOD. The effects of the CMV preemptive therapy were estimated in uni- and multivariate Cox hazards models. RESULTS CMV-EOD was diagnosed in 30 of the 96 patients of the non-preemptive therapy group (31%, 230.3 per 1000 person-years), compared with 3 of the 30 patients of the preemptive therapy group (10%, 60.9 per 1000 person-years). Univariate (HR = 0.286; 95%CI, 0.087-0.939; p = 0.039) and multivariate (adjusted HR = 0.170; 95%CI, 0.049-0.602; p = 0.005) analyses confirmed that CMV-EOD is significantly prevented by CMV preemptive therapy. Multivariate analysis showed that plasma CMV DNA level correlated significantly with CMV-EOD (per log10/ml, adjusted HR = 1.941; 95%CI, 1.266-2.975; p = 0.002). Among the 30 patients on preemptive therapy, 7 (23.3%) developed grade 3-4 leukopenia. The mortality rate was not significantly different between the two groups (p = 0.193, Log-rank test). CONCLUSIONS The results indicate that preemptive therapy lowers the incidence of CMV-EOD by almost 25%. Preemptive therapy for treatment-naïve patients with CMV viremia is effective, although monitoring of potential treatment-related side effects is required.
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Affiliation(s)
- Daisuke Mizushima
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
- Center for AIDS Research, Kumamoto University, Kumamoto, Japan
| | - Takeshi Nishijima
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
- Center for AIDS Research, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Gatanaga
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
- Center for AIDS Research, Kumamoto University, Kumamoto, Japan
- * E-mail:
| | - Kunihisa Tsukada
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsuji Teruya
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshimi Kikuchi
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shinichi Oka
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
- Center for AIDS Research, Kumamoto University, Kumamoto, Japan
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Kempen JH, Sugar EA, Lyon AT, Lewis RA, Jabs DA, Heinemann MH, Dunn JP. Risk of cataract in persons with cytomegalovirus retinitis and the acquired immune deficiency syndrome. Ophthalmology 2012; 119:2343-50. [PMID: 22853972 DOI: 10.1016/j.ophtha.2012.05.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 05/24/2012] [Accepted: 05/24/2012] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate cataract risk in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis and to identify risk factors. DESIGN Prospective cohort study. PARTICIPANTS Patients with AIDS and CMV retinitis. METHODS Patients 13 years of age and older were enrolled between 1998 and 2008. Demographic and clinical characteristics, slit-lamp biomicroscopy findings, and dilated ophthalmoscopy results were documented at quarterly visits. Cataract status was determined at the initial visit (prevalence) and at follow-up visits (incidence). MAIN OUTCOME MEASURES For cataract, a high grade of lens opacity by biomicroscopy to which best-corrected visual acuity worse than 20/40 was attributed. Eyes that had undergone cataract surgery before enrollment or between visits also were counted as having cataract. RESULTS Seven hundred twenty-nine eyes of 489 patients diagnosed with CMV retinitis were evaluated. Higher prevalence was observed for patients with bilateral versus unilateral CMV retinitis (adjusted odds ratio [aOR], 2.74; 95% confidence interval [CI], 1.76-4.26) and, among unilateral CMV retinitis cases, for eyes with retinitis versus without retinitis (15% vs. 1.4%; P<0.0001). The age-adjusted prevalence of cataract among CMV retinitis cases was higher than that in a population-based sample (P<0.0001). Cataract prevalence increased with age (aOR, 11.77; 95% CI, 2.28-60.65 for age ≥ 60 years vs. younger than 40 years) and longer duration of retinitis (aOR, 1.36; 95% CI, 1.20-1.54 per year). Among eyes with CMV retinitis initially free of cataract, the cataract incidence was 8.1%/eye-year (95% CI, 6.7%-10.0%). Prior retinal detachment was associated with higher cataract risk (if repaired with silicone oil: adjusted hazard ratio [aHR], 10.37; 95% CI, 6.51-16.52; otherwise: aHR, 2.90; 95% CI, 1.73-4.87). Large CMV retinitis lesions also were associated with higher risk of cataract (for involvement of 25-49% retinal area: aHR, 2.30; 95% CI, 1.51-3.50; for ≥ 50% involvement: aHR, 3.63; 95% CI, 2.18-6.04), each with respect to ≤ 24% involvement, as were anterior segment inflammation (aHR, 2.27; 95% CI, 1.59-3.25) and contralateral cataract (aHR, 2.52; 95% CI, 1.74-3.66). CONCLUSIONS Cytomegalovirus retinitis is associated with a high absolute and relative risk of cataract. Among several risk factors, large retinal lesion size and use of silicone oil in retinal detachment repair are potentially modifiable, albeit not in all cases. Cataract is likely to be an increasingly important cause of visual morbidity in this population.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, and the Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Tosh J, Brazier J, Evans P, Longworth L. A review of generic preference-based measures of health-related quality of life in visual disorders. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:118-27. [PMID: 22264979 PMCID: PMC3268858 DOI: 10.1016/j.jval.2011.08.002] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 07/29/2011] [Accepted: 08/02/2011] [Indexed: 05/02/2023]
Abstract
OBJECTIVE This review examines generic preference-based measures and their ability to reflect health-related quality of life in patients with visual disorders. METHODS A systematic search was undertaken to identify clinical studies of patients with visual disorders where health state utility values were measured and reported. Data were extracted to assess the validity and responsiveness of the measures. A narrative synthesis of the data was undertaken due to the heterogeneity between different studies. RESULTS There was considerable heterogeneity in the 31 studies identified in terms of patient characteristics, visual disorders, and outcomes reported. Vision loss was associated with a reduction in scores across the preference-based measure, but the evidence on validity and responsiveness was mixed. The EQ-5D health-related assessment instrument's performance differed according to condition, with poor performance in age-related macular degeneration (AMD) and diabetic retinopathy. The more limited evidence on the HUI-3 instrument found it performed best in differentiating between severity groups of patients with glaucoma, AMD, cataracts, and diabetic retinopathy. One study reported data on the SF-6D instrument and showed it was able to differentiate between patients with AMD. CONCLUSIONS The performance of the EQ-5D in visual disorders was mixed. The HUI-3 seemed to perform better in some conditions, but the evidence on this and SF-6D is limited. More head to head comparisons of these three measures are required. The new five-level version of EQ-5D may do better at the milder end of visual function.
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Affiliation(s)
- Jonathan Tosh
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, South Yorkshire, UK.
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Tan S, Liu S, Jiang S. Pathogenesis and treatment of human immunodeficiency virus-associated cytomegalovirus retinitis. Future Virol 2011. [DOI: 10.2217/fvl.11.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In the era of HAART, human cytomegalovirus (HCMV) retinitis remains the leading opportunistic ocular infection and the major cause of blindness in patients with AIDS. The virus has been subjected to selection and presented with the opportunity to occupy a niche to which it is highly adapted in order to escape from host immune recognition and establish persistent infection in the retina. The imbalance between host immune protection and viral immune evasion results in retinitis progression. Moreover, a synergistic interaction between HCMV and HIV in the pathogenesis of retinitis has been proposed. HAART has had a major beneficial impact on the prognosis for HIV-infected individuals. Both HAART and specific anti-HCMV treatment contribute to therapeutic success against HCMV retinitis in AIDS patients. The improved prognosis for AIDS patients with respect to the development of HCMV retinitis has been welcomed; however, we should bear in mind the occurrence of HIV drug resistance, relapse of retinitis and immune recovery uveitis after treatment, which mean that this complication of HIV infection remains a threat.
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Affiliation(s)
- Suiyi Tan
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
- Viral Immunology Laboratory, Lindsley F Kimball Research Institute, New York Blood Center, New York, NY 10065, USA
| | - Shuwen Liu
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Shibo Jiang
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
- Viral Immunology Laboratory, Lindsley F Kimball Research Institute, New York Blood Center, New York, NY 10065, USA
- Key Laboratory of Medical Molecular Virology of MOE/MOH & Institute of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai 200032, China
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Health-related quality of life in a randomized trial of antiretroviral therapy for advanced HIV disease. J Acquir Immune Defic Syndr 2009; 50:27-36. [PMID: 19295332 DOI: 10.1097/qai.0b013e31818ce6f3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess and compare alternative approaches of measuring preference-based health-related quality of life (HRQoL) in treatment-experienced HIV patients and evaluate their association with health status and clinical variables. DESIGN Cross-sectional study. SETTING Twenty-eight Veterans Affairs hospitals in the United States, 13 hospitals in Canada, and 8 hospitals in the United Kingdom. PATIENTS Three hundred sixty-eight treatment-experienced HIV-infected patients enrolled in the Options in Management with Antiretrovirals randomized trial. MEASUREMENTS Baseline sociodemographic and clinical indicators and baseline HRQoL using the Medical Outcome Study HIV Health Survey (MOS-HIV), the EQ-5D, the EQ-5D visual analog scale (EQ-5D VAS), the Health Utilities Index Mark 3 (HUI3), and standard gamble (SG) and time trade-off (TTO) techniques. RESULTS The mean (SD) baseline HRQoL scores were as follows: MOS-HIV physical health summary score 41.70 (11.16), MOS-HIV mental health summary score 44.76 (11.38), EQ-5D 0.77 (0.19), HUI3 0.59 (0.32), EQ-5D VAS 65.94 (21.71), SG 0.75 (0.29), and TTO 0.80 (0.31). Correlations between MOS-HIV summary scores and EQ-5D, EQ-5D VAS, and HUI3 ranged from 0.60 to 0.70; the correlation between EQ-5D and HUI3 was 0.73; and the correlation between SG and TTO was 0.43. Preference-based HRQoL scores were related to physical, mental, social, and overall health as measured by MOS-HIV. Concomitant medication use, CD4 cell count, and HIV viral load were related to some instruments' scores. CONCLUSIONS On average, preference-based HRQoL for treatment-experienced HIV patients was decreased relative to national norms but also highly variable. Health status and clinical variables were related to HRQoL.
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Holland GN. AIDS and ophthalmology: the first quarter century. Am J Ophthalmol 2008; 145:397-408. [PMID: 18282490 DOI: 10.1016/j.ajo.2007.12.001] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Revised: 11/26/2007] [Accepted: 12/01/2007] [Indexed: 12/13/2022]
Abstract
PURPOSE To describe changes in the acquired immunodeficiency syndrome (AIDS) epidemic that are important to ophthalmologists, to provide an overview of issues relevant to current evaluation and treatment of human immunodeficiency virus (HIV)-related eye disease, and to identify problems related to the eye and vision that require continued study. DESIGN Literature review and commentary. METHODS Selected articles from the medical literature and the author's clinical and research experiences over 25 years were reviewed critically. RESULTS The AIDS epidemic has had a profound impact on ophthalmology since the ophthalmic manifestations of AIDS were first described in 1982. The introduction of highly active antiretroviral therapy (HAART) has markedly reduced the incidence of cytomegalovirus (CMV) retinitis, but has not eliminated new cases altogether. Treatment strategies for CMV retinitis have evolved over the past decade. Current issues of importance include choice of initial anti-CMV drugs; time at which anti-CMV drug treatment is discontinued in patients who achieve immune recovery; strategies for monitoring patients at risk for disease reactivation; and management of complications (retinal detachment, immune recovery uveitis). Attention also is being directed to the problem of visual disturbances (reduced contrast sensitivity, altered color vision, visual field abnormalities) that can occur in HIV-infected individuals without infectious retinopathies. CONCLUSIONS Ocular disorders associated with HIV disease remain important problems in the United States, despite HAART, and increasingly are important worldwide. The approach to management of CMV retinitis has evolved from short-term treatment of a preterminal infection to the long-term management of what has become a chronic disease. Many challenges remain to be addressed.
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Martin BK, Ricks MO, Forman MS, Jabs DA. Change over time in incidence of ganciclovir resistance in patients with cytomegalovirus retinitis. Clin Infect Dis 2007; 44:1001-8. [PMID: 17342657 DOI: 10.1086/512368] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Accepted: 12/28/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In the mid-1990s, the incidence of cytomegalovirus (CMV) resistance to ganciclovir was estimated to be approximately 25% by 1 year after diagnosis of retinitis in patients with acquired immunodeficiency syndrome. METHODS Two hundred fifty-seven patients with CMV retinitis were enrolled in a prospective observational study during 1993-2003 and were treated with ganciclovir. Demographic characteristics and data on CMV disease, antiretroviral therapy, and ganciclovir resistance were recorded for all patients. Human immunodeficiency virus (HIV) load and CMV load were measured for patients enrolled in 1996 or later. Kaplan-Meier and Cox proportional hazards regression methods were used to examine incidence of resistance. RESULTS The 2-year incidence of resistance was 28% among patients enrolled before 1996 and 9% among those enrolled in or after 1996 (P=.001). All cases of resistance occurred among patients with CD4+ T cell counts <50 cells/microL, and positive CMV culture results at baseline were associated with a approximately 4-fold increase in resistance. Among patients whose CMV and HIV loads were measured, a detectable CMV load at baseline and during follow-up was associated with increased risk of resistance, but a detectable HIV load was not. CONCLUSIONS Rates of resistance have decreased from the high levels seen in the pre-HAART era. Better control of CMV replication may have contributed to this decrease.
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Affiliation(s)
- Barbara K Martin
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
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Brown DM, Thorne JE, Foster GL, Duncan JL, Brune LM, Muñana A, Meinert CL, Jabs DA. Factors affecting attrition in a longitudinal study of patients with AIDS. AIDS Care 2007; 18:821-9. [PMID: 16971294 DOI: 10.1080/09540120500466747] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Anecdotal data have suggested that retention of HIV-infected patients with immune recovery in longitudinal studies may be difficult as they resume normal activities. This study evaluated risk factors for attrition among patients with AIDS in a cohort study in the era of highly active antiretroviral therapy. Patients with AIDS enrolled in the Longitudinal Study of Ocular Complications of AIDS were evaluated every three months with demographic, clinical and laboratory data collected. Lost to follow-up was defined as any patient who missed all study visits and could not be contacted for 12 consecutive months, who had not died and who did not re-enter the study at a later date. Of the 1,052 patients studied, 77 (7.3%) were lost to follow-up (rate = 0.03/person year). In the multivariate analysis, factors associated with attrition were CD4+ T-cell count category (hazard ratio (HR) = 2.03; 95%CI: 1.01, 4.24; P = 0.05 for CD4+ count < or = 50 cells/microL and HR = 1.96; 95%CI: 1.12, 3.40; P = 0.02 for CD4+ count 51-200 cells/microL) and detectable HIV viral load (HR = 1.29; 95%CI: 1.07, 1.53; P < 0.001 for HIV viral load >400 copies/mL). These data suggest that patients with compromised immunologic status are at an increased risk for being lost to follow-up.
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Affiliation(s)
- D M Brown
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Teerawattananon K, Iewsakul S, Yenjitr C, Ausayakhun S, Yenjitr W, Mugford M, Teerawattananon Y. Economic evaluation of treatment administration strategies of ganciclovir for cytomegalovirus retinitis in HIV/AIDS patients in Thailand: a simulation study. PHARMACOECONOMICS 2007; 25:413-28. [PMID: 17488139 DOI: 10.2165/00019053-200725050-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND There are many effective interventions, via various routes (intravenous [IV], oral [OR], intravitreal injection [IVT] and intraocular implantation [IMP]), for treating cytomegalovirus retinitis (CMVR) that have become available. There are large variations in treating CMVR in clinical practice in Thailand. OBJECTIVE To evaluate the incremental cost-effectiveness ratio (ICER) of providing (i) IVT, (ii) IV/OR and (iii) IMP ganciclovir to patients with HIV/AIDS and CMVR versus providing no treatment. DESIGN A simulation study for which the input parameters were derived from a systematic review of the literature, a hospital-based survey and patient interviews. SETTING The analysis assumed a Thai healthcare system perspective. However, the model was run using both societal and healthcare provider perspectives. RESULTS Our results suggest that IVT ganciclovir was cost effective and the best option for treating patients with CMVR irrespective of whether patients received antiretroviral treatment (ART). In patients receiving ART, moving from IVT to IV/OR ganciclovir was also likely to be a cost-effective option. Offering IMP ganciclovir was not likely to be cost effective. Providing treatments for patients with bilateral CMVR was more cost effective than providing treatments for those with unilateral CMVR, and offering treatments for patients receiving ART was better value for money than treating patients without ART. CONCLUSIONS Our models suggest that IV/OR ganciclovir should be recommended for the treatment of unilateral and bilateral CMVR for patients receiving ART in the Thai healthcare system. IVT ganciclovir may also have a role in the treatment of CMVR patients not receiving ART.
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Kempen JH, Min YI, Freeman WR, Holland GN, Friedberg DN, Dieterich DT, Jabs DA. Risk of Immune Recovery Uveitis in Patients with AIDS and Cytomegalovirus Retinitis. Ophthalmology 2006; 113:684-94. [PMID: 16581429 DOI: 10.1016/j.ophtha.2005.10.067] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 10/29/2005] [Accepted: 10/31/2005] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence of and risk factors for immune recovery uveitis (IRU) in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis. DESIGN Enrollment data from a 19-clinical center cohort study. PARTICIPANTS Three hundred seventy-four patients with AIDS and CMV retinitis affecting 539 eyes. METHODS Patients with AIDS were enrolled at 19 United States AIDS ophthalmology clinics. Data were collected by interview, review of medical records, ophthalmic examination, and phlebotomy. MAIN OUTCOME MEASURE Immune recovery uveitis. RESULTS Thirty-six patients (9.6%) were diagnosed with IRU involving 50 eyes. The CD4+ T-cell count of 31 of these had risen by > or =50 cells per microliter above nadir to a level > or = 100 cells per microliter (immune recovery), making up 17.6% of the patients known to have immune recovery after diagnosis of CMV retinitis (95% confidence interval, 12.3%-24.1%). No patients with IRU were observed to have active retinitis or detectable CMV DNA in peripheral blood (P<0.001 and P<0.001 with respect to patients without IRU). Other factors associated with IRU were > or =25% retinal area (odds ratio [OR], 2.72; P = 0.014) or posterior pole involvement with CMV retinitis (odds ratio, 0.43; P = 0.039), treatment with intravitreous injection of cidofovir (OR, 10.6 with respect to eyes never exposed to intravitreous or IV cidofovir; P<0.001), and male gender (OR, 0.26; P = 0.012). More eyes with IRU had visual acuity (VA) of 20/50 or worse (38.0% vs. 26.3%, P = 0.077) relative to eyes without IRU, but the proportions with VA of 20/200 or worse were similar (14.0% vs. 13.8%, P = 0.96). Eyes with IRU more commonly had cystoid macular edema (CME) (45.5% vs. 3.7%, P<0.001) and epiretinal membrane (48.9% vs. 13.3%, P<0.001) than eyes without IRU. CONCLUSIONS Among eyes of patients with immune recovery, the prevalence of IRU is substantial. Eyes with IRU have a high risk of additional morbidity over and above that seen with CMV retinitis, with several-fold higher risk of CME and epiretinal membrane. Large CMV lesions and use of intravitreous cidofovir are risk factors for IRU.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Kosobucki BR, Freeman WR. Retinal Disease in HIV-infected Patients. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ng WT, Versace P. Ocular association of HIV infection in the era of highly active antiretroviral therapy and the global perspective. Clin Exp Ophthalmol 2005; 33:317-29. [PMID: 15932540 DOI: 10.1111/j.1442-9071.2005.01001.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Ocular involvement is a common complication of HIV infection. Since the late 1990s, widespread use of highly active antiretroviral therapy (HAART) has altered the spectrum, and reduced the incidence of ocular involvement in developed countries. The incidence of the most common ocular opportunistic infection, cytomegalovirus retinitis, has decreased tremendously. However, immune recovery uveitis secondary to HAART has emerged as a frequent visually threatening condition. Early diagnosis and treatment with periocular steroids is helpful in minimizing visual loss. Clinicians should also be aware that certain antimicrobial agents used to treat opportunistic infections in HIV-positive patients are associated with potentially serious ocular side effects. In developing countries, where most of the world's 40 million HIV-positive patients live, the spectrum and incidence of ocular involvement differ from those in developed countries. The lack of HAART availability is among the many causes of these differences, which may include nutritional factors, basic medical care availability and the levels of exposure to different infectious agents. These factors add to the already challenging task of treating ocular complications and preventing blindness in HIV-positive patients in developing countries.
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Affiliation(s)
- Weng T Ng
- Department of Ophthalmology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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