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Kambayashi A, de Meijer M, Wegman K, van Veldhuizen C, Abrahamsson B, Cristofoletti R, Langguth P, Mehta M, Parr A, Polli JE, Shah VP, Dressman J. Biowaiver Monograph for Immediate-Release Dosage Forms: Levamisole Hydrochloride. J Pharm Sci 2023; 112:634-639. [PMID: 36563854 DOI: 10.1016/j.xphs.2022.12.014] [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: 10/29/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
This work describes the potential applicability of the BCS-based Biowaiver to oral solid dosage forms containing Levamisole hydrochloride, an anthelmintic drug on the WHO List of Essential Medicines. Solubility and permeability data of levamisole hydrochloride were searched in the literature and/or measured experimentally. Levamisole hydrochloride is a highly soluble drug, but there is no clear evidence of high permeability in humans, indicating that it should provisionally be assigned to BCS class III. The biowaiver procedure would thus be applicable for solid oral dosage forms containing levamisole hydrochloride as the only active ingredient. Due to the lack of data in the literature regarding excipient effects on the bioequivalence of products containing levamisole, it is currently recommended that the products comply with the ICH and WHO guidelines: the test formulation should have the same qualitative composition as the comparator, contain very similar quantities of those excipients, and be very rapidly dissolving at pH 1.2, 4.5, and 6.8. However, for certain well-studied excipients, there appears to be opportunity for additional regulatory relief in future versions of the ICH BCS Guidance M9, such as not requiring that the quantities of these common excipients in the test and comparator be the same.
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Affiliation(s)
- Atsushi Kambayashi
- Pharmaceutical Research and Technology Labs, Astellas Pharma Inc., Yaizu, Japan; School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan.
| | - Mariska de Meijer
- Baggerman Farma Consult BV, Eindhoven, the Netherlands; ACE Pharmaceuticals BV, Zeewolde, the Netherlands
| | - Kim Wegman
- ACE Pharmaceuticals BV, Zeewolde, the Netherlands
| | | | | | - Rodrigo Cristofoletti
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida
| | - Peter Langguth
- Pharmaceutical Technology and Biopharmaceutics, Institute of Pharmacy and Biochemistry, Johannes Gutenberg-University, Mainz, Germany
| | - Mehul Mehta
- Division of Clinical Pharmacology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland
| | - Alan Parr
- BioCeutics LLC, Cary, North Carolina
| | - James E Polli
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, Maryland
| | - Vinod P Shah
- The International Pharmaceutical Federation (FIP), The Hague, the Netherlands
| | - Jennifer Dressman
- Fraunhofer Institute of Translational Medicine and Pharmacology, Frankfurt am Main, Germany
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2
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Lampro L, George EC. Outcomes reported in trials of treatments for severe malaria: The need for a core outcome set. Trop Med Int Health 2022; 27:767-775. [PMID: 35916146 PMCID: PMC9545330 DOI: 10.1111/tmi.13803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Malaria is one of the most important parasitic infectious diseases worldwide. Despite the scale-up of effective antimalarials, mortality rates from severe malaria (SM) remain significantly high; thus, numerous trials are investigating both antimalarials and adjunctive therapy. This review aimed to summarise all the outcome measures used in trials in the last 10 years to see the need for a core outcome set. METHODS A systematic review was undertaken to summarise outcomes of individually randomised trials assessing treatments for SM in adults and children. We searched key databases and trial registries between 1 January 2010 and 30 July 2020. Non-randomised trials were excluded to allow comparison of similar trials. Trial characteristics including phase, region, population, interventions, were summarised. All primary and secondary outcomes were extracted and categorised using a taxonomy table. RESULTS Twenty-seven of 282 screened trials met our inclusion criteria, including 10,342 patients from 19 countries: 19 (70%) trials from Africa and 8 (30%) from Asia. A large amount of heterogeneity was observed in the selection of outcomes and instruments, with 101 different outcomes measures recorded, 78/101 reported only in a single trial. Parasitological outcomes (17 studies), neurological status (14 studies), death (14 studies) and temperature (10 studies), were the most reported outcomes. Where an outcome was reported in >1 study it was often measured differently: temperature (4 different measures), renal function (7 measures), nervous system (13 measures) and parasitology (10 measures). CONCLUSION Outcomes used in SM trials are inconsistent and heterogeneous. Absence of consensus for outcome measures used impedes research synthesis and comparability of different interventions. This systematic review demonstrates the need to develop a standardised collection of core outcomes for clinical trials of treatments for SM and next steps to include the development of a panel of experts in the field, a Delphi process, and a consensus meeting.
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Affiliation(s)
- Lamprini Lampro
- Medical Research Council Clinical Trials Unit at University College London, London, UK.,Intensive Care National Audit and Research Centre, London, UK
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit at University College London, London, UK
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3
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Dila KAS, Reda A, Elhady MT, Linh LK, Minh-Duc NT, El-Qushayri AE, Han NL, Mehta V, Hamad WMA, Eskarous H, Samsom M, Hirayama K, Huy NT. Association of anthelmintic treatment with malaria prevalence, incidence, and parasitemia: A systematic review and meta-analysis. Acta Trop 2022; 225:106213. [PMID: 34687649 DOI: 10.1016/j.actatropica.2021.106213] [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: 09/01/2020] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 11/29/2022]
Abstract
A chronic helminth infection can alter host immune response and affect malaria infection. We conducted a systematic review and meta-analysis to find the impact of anthelmintic treatment on malaria prevalence, incidence, and parasitemia. Nine and 12 electronic databases were searched on 28th July 2015 and 26th June 2020 for relevant studies. We performed meta-analysis for malaria prevalence, incidence, parasitemia, and a qualitative synthesis for other effects of anthelmintic treatment. Seventeen relevant papers were included. There was no association between anthelmintic treatment and malaria prevalence or change of parasitemia at the end of follow up period (pooled OR 0.93, 95% CI: 0.62, 1.38, p-value=0.71 and SMD -0.08, 95%CI: -0.24, 0.07, p-value=0.30 respectively) or at any defined time points in analysis. Pooled analysis of three studies demonstrated no association between malaria incidence and anthelmintic treatment (rate ratio 0.93, 95%CI: 0.80, 1.08, p-value=0.33). Our study encourages anthelmintic treatment in countries with high burden of co-infections as anthelmintic treatment is not associated with change in malaria prevalence, incidence, or parasitemia.
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Affiliation(s)
- Kadek Agus Surya Dila
- Pratama Giri Emas Hospital, Singaraja City, 81171 Buleleng, Bali, Indonesia; Online Research Club: http://www.onlineresearchclub.org/
| | - Ahmed Reda
- Online Research Club: http://www.onlineresearchclub.org/; Faculty of Pharmacy, Tanta University, Gharbia 31511, Egypt
| | - Mohamed Tamer Elhady
- Online Research Club: http://www.onlineresearchclub.org/; Department of Pediatrics, Zagazig University Hospital, Sharkia 44511, Egypt
| | - Le Khac Linh
- Online Research Club: http://www.onlineresearchclub.org/; College of Health Sciences, Vin University, Hanoi 100000, Vietnam
| | - Nguyen Tran Minh-Duc
- Online Research Club: http://www.onlineresearchclub.org/; University of Medicine and Pharmacy, Ho Chi Minh City 700000, Vietnam
| | - Amr Ehab El-Qushayri
- Online Research Club: http://www.onlineresearchclub.org/; Faculty of Medicine, Minia University, Minia 61519, Egypt
| | - Nguyen Lac Han
- Online Research Club: http://www.onlineresearchclub.org/; University of Medicine and Pharmacy, Ho Chi Minh City 700000, Vietnam
| | - Varshil Mehta
- Online Research Club: http://www.onlineresearchclub.org/; Internal Medicine Trainee, Department of Cardiology, Lister Hospital, Stevenage, United Kingdom
| | - Walid Mohamed Attiah Hamad
- Online Research Club: http://www.onlineresearchclub.org/; Departement of Internal Medicine, Zagazig University, Zagazig 44511, Egypt
| | - Hany Eskarous
- Online Research Club: http://www.onlineresearchclub.org/; Minya University, Faculty of Medicine, Egypt, Internal Medicine Resident, Easton Hospital, Easton City 18042, Pennsylvania
| | - Maryan Samsom
- Online Research Club: http://www.onlineresearchclub.org/; Internal Medicine Department, Faculty of Medicine, Egypt, Internal Medicine Resident, Jersey Shore University Medical Center, 07753 New Jersey, United States
| | - Kenji Hirayama
- School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Nguyen Tien Huy
- School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan.
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4
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Lu Q, Xu Z, You X, Ma S, Zenobi R. Atmospheric Pressure Mass Spectrometry Imaging Using Laser Ablation, Followed by Dielectric Barrier Discharge Ionization. Anal Chem 2021; 93:6232-6238. [PMID: 33826303 DOI: 10.1021/acs.analchem.1c00549] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Mass spectrometry imaging (MSI) has become a powerful tool in diverse fields, for example, life science, biomaterials, and catalysis, for its ability of in situ and real-time visualization of the location of chemical compounds in samples. Although laser ablation (LA) achieves high spatial resolution in MSI, the ion yield can be very low. We therefore combined an LA system with an ambient ion source for post-ionization and an atmospheric pressure (AP) inlet mass spectrometer to construct a novel AP-MSI platform. A dielectric barrier discharge ionization (DBDI) source is operated in the "active sampling capillary" configuration, can be coupled to any mass spectrometer with an AP interface, and possesses high ion transmission efficiency. This study presents some application examples based on LA-DBDI, a low-cost and flexible strategy for AP-MSI, which does not require any sample pretreatment, and we show MS imaging of endogenous species in a traditional Chinese herbal medicine and of a drug molecule in zebra fish tissue, with a lateral resolution of ≈20 μm.
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Affiliation(s)
- Qiao Lu
- Department of Chemistry and the MOE Key Laboratory of Spectrochemical Analysis & Instrumentation, College of Chemistry and Chemical Engineering, Xiamen University, Xiamen 361005, China
| | - Zhouyi Xu
- Department of Chemistry and the MOE Key Laboratory of Spectrochemical Analysis & Instrumentation, College of Chemistry and Chemical Engineering, Xiamen University, Xiamen 361005, China
| | - Xue You
- Department of Chemistry and the MOE Key Laboratory of Spectrochemical Analysis & Instrumentation, College of Chemistry and Chemical Engineering, Xiamen University, Xiamen 361005, China
| | - Siyuan Ma
- Department of Chemistry and the MOE Key Laboratory of Spectrochemical Analysis & Instrumentation, College of Chemistry and Chemical Engineering, Xiamen University, Xiamen 361005, China
| | - Renato Zenobi
- Department of Chemistry and the MOE Key Laboratory of Spectrochemical Analysis & Instrumentation, College of Chemistry and Chemical Engineering, Xiamen University, Xiamen 361005, China.,Department of Chemistry and Applied Biosciences, ETH Zurich, CH-8093 Zurich , Switzerland
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5
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Affiliation(s)
- Geoffrey Guenther
- Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Daniel Muller
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Dominic Moyo
- Department of Paediatric and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Douglas Postels
- Department of Pediatric Neurology, George Washington University/ Children's National Medical Center; Washington DC, USA; Blantyre Malaria Project; Blantyre, Malawi, Street Address: Department of Neurology; 111 Michigan Avenue NW; Washington DC; 20010; USA
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6
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Bioengineered 3D Microvessels for Investigating Plasmodium falciparum Pathogenesis. Trends Parasitol 2021; 37:401-413. [PMID: 33485788 DOI: 10.1016/j.pt.2020.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/15/2020] [Accepted: 12/25/2020] [Indexed: 12/18/2022]
Abstract
Plasmodium falciparum pathogenesis is complex and intimately connected to vascular physiology. This is exemplified by cerebral malaria (CM), a neurovascular complication that accounts for most of the malaria deaths worldwide. P. falciparum sequestration in the brain microvasculature is a hallmark of CM and is not replicated in animal models. Numerous aspects of the disease are challenging to fully understand from clinical studies, such as parasite binding tropism or causal pathways in blood-brain barrier breakdown. Recent bioengineering approaches allow for the generation of 3D microvessels and organ-specific vasculature that provide precise control of vessel architecture and flow dynamics, and hold great promise for malaria research. Here, we discuss recent and future applications of bioengineered microvessels in malaria pathogenesis research.
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7
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Lelièvre B, Suply B, Schmitt F, Marcorelles P, Drevin G, Maillart CR. A fatal case after an intravenous injection of levamisole. Forensic Sci Med Pathol 2020; 17:130-135. [PMID: 33180273 DOI: 10.1007/s12024-020-00336-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/30/2022]
Abstract
Levamisole is a drug originally prescribed as an antihelmintic. Because of the occurrence of severe cases of agranulocytosis and leukoencephalitis it was removed from the French market in 1998 for human use, while it remains available for veterinary use. Nowadays in France its only use in humans is regulated by authorization for temporary use for its immunomodulatory properties in the treatment of nephritic syndrome.A 52-year-old man was found dead at his farm. Injection points were observed on his arm and a syringe containing a dark orange-brown liquid was found near the body. At his home, the discovery of a letter highlighted suicidal intent. Analysis of the aforementioned liquid, peripheral blood and urine confirmed the unique presence of levamisole. The femoral blood concentration of levamisole was of 25 mg/L whereas the femoral blood concentrations reported in cases of fatalities after cocaine use do not exceed 0.0056 mg/L. In humans, levamisole can be detected in biological samples after cocaine use as this drug is also an adulterant and one of its metabolites (aminorex) seems to have amphetamine-like properties. In this case, the man consumed levamisole from time to time for its stimulant and strengthening effects.Cases of fatal poisoning using levamisole are very rare and poorly documented, which makes the interpretation of postmortem blood levamisole concentration difficult.
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Affiliation(s)
- Bénédicte Lelièvre
- Pharmacology-Toxicology Laboratory, CHU Angers, 49933, Angers, France. .,Groupe d'Etude Des Interactions Hôte-Pathogène, UNIV Angers, UNIV Brest, Institut de Biologie en Santé-IRIS, (EA 3142) SFR ICAT 4208 , Angers, France.
| | - Benoit Suply
- Forensic Unit of CHU Brest, Antenne GHBS Lorient, Lorient, France
| | | | | | - Guillaume Drevin
- Pharmacology-Toxicology Laboratory, CHU Angers, 49933, Angers, France
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8
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Zou Y, Tuo F, Zhang Z, Guo J, Yuan Y, Zhang H, Xu Z, Pan Z, Tang Y, Deng C, Julie N, Wu W, Guo W, Li C, Huang X, Xu Q, Song J, Wang Q. Safety and Efficacy of Adjunctive Therapy With Artesunate in the Treatment of Severe Malaria: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:596697. [PMID: 33343367 PMCID: PMC7748123 DOI: 10.3389/fphar.2020.596697] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/02/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: The purpose of this meta-analysis of longitudinal studies is to determine the safety and efficacy of artesunate combined with other forms of adjunctive therapies for severe malaria. Methods: Following the PRISMA guidelines, we searched multiple databases with the search terms "artesunate" and "adjunctive therapy" and "severe malaria" in July 2020. If the search showed a randomized controlled trial, the study was included in this meta-analysis. The random-effects model was used to calculate the combined incidence rate and relative risk or risk difference. Results: This meta-analysis included nine longitudinal studies with 724 participants. We found that the mortality rates in the artesunate monotherapy group and the artesunate + adjuvant therapy group are similar (RD = -0.02, 95% confidence interval: -0.06-0.02). The incidence of adverse reactions in the artesunate monotherapy group and the artesunate + adjuvant therapy group was also similar. Conclusion: No significant differences in safety and efficacy were observed between the artesunate monotherapy group and the artesunate + adjuvant therapy group. Higher quality and rigorously designed randomized controlled studies are needed to validate our findings.
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Affiliation(s)
- Yuanyuan Zou
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fei Tuo
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhiqi Zhang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiawen Guo
- Institute of Science and Technology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yueming Yuan
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China.,Institute of Science and Technology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hongying Zhang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhiyong Xu
- Institute of Science and Technology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ziyi Pan
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yexiao Tang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Changsheng Deng
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Nadia Julie
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wanting Wu
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenfeng Guo
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Changqing Li
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xinan Huang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qin Xu
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jianping Song
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qi Wang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
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9
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Schiess N, Villabona-Rueda A, Cottier KE, Huether K, Chipeta J, Stins MF. Pathophysiology and neurologic sequelae of cerebral malaria. Malar J 2020; 19:266. [PMID: 32703204 PMCID: PMC7376930 DOI: 10.1186/s12936-020-03336-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 07/13/2020] [Indexed: 12/14/2022] Open
Abstract
Cerebral malaria (CM), results from Plasmodium falciparum infection, and has a high mortality rate. CM survivors can retain life-long post CM sequelae, including seizures and neurocognitive deficits profoundly affecting their quality of life. As the Plasmodium parasite does not enter the brain, but resides inside erythrocytes and are confined to the lumen of the brain's vasculature, the neuropathogenesis leading to these neurologic sequelae is unclear and under-investigated. Interestingly, postmortem CM pathology differs in brain regions, such as the appearance of haemorragic punctae in white versus gray matter. Various host and parasite factors contribute to the risk of CM, including exposure at a young age, parasite- and host-related genetics, parasite sequestration and the extent of host inflammatory responses. Thus far, several proposed adjunctive treatments have not been successful in the treatment of CM but are highly needed. The region-specific CM neuro-pathogenesis leading to neurologic sequelae is intriguing, but not sufficiently addressed in research. More attention to this may lead to the development of effective adjunctive treatments to address CM neurologic sequelae.
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Affiliation(s)
- Nicoline Schiess
- Department of Neurology, Johns Hopkins School of Medicine, 600 N. Wolfe St., Meyer 6-113, Baltimore, MD, 21287, USA
| | - Andres Villabona-Rueda
- Malaria Research Institute, Dept Molecular Microbiology Immunology, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
| | - Karissa E Cottier
- Malaria Research Institute, Dept Molecular Microbiology Immunology, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.,BioIVT, 1450 South Rolling Road, Baltimore, MD, USA
| | | | - James Chipeta
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Monique F Stins
- Malaria Research Institute, Dept Molecular Microbiology Immunology, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
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10
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Watson JA, Holmes CC. Graphing and reporting heterogeneous treatment effects through reference classes. Trials 2020; 21:386. [PMID: 32381030 PMCID: PMC7204233 DOI: 10.1186/s13063-020-04306-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 04/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exploration and modelling of heterogeneous treatment effects as a function of baseline covariates is an important aspect of precision medicine in randomised controlled trials (RCTs). Randomisation generally guarantees the internal validity of an RCT, but heterogeneity in treatment effect can reduce external validity. Estimation of heterogeneous treatment effects is usually done via a predictive model for individual outcomes, where one searches for interactions between treatment allocation and important patient baseline covariates. However, such models are prone to overfitting and multiple testing and typically demand a transformation of the outcome measurement, for example, from the absolute risk in the original RCT to log-odds of risk in the predictive model. METHODS We show how reference classes derived from baseline covariates can be used to explore heterogeneous treatment effects via a two-stage approach. We first estimate a risk score which captures on a single dimension some of the heterogeneity in outcomes of the trial population. Heterogeneity in the treatment effect can then be explored via reweighting schemes along this axis of variation. This two-stage approach bypasses the search for interactions with multiple covariates, thus protecting against multiple testing. It also allows for exploration of heterogeneous treatment effects on the original outcome scale of the RCT. This approach would typically be applied to multivariable models of baseline risk to assess the stability of average treatment effects with respect to the distribution of risk in the population studied. CASE STUDY We illustrate this approach using the single largest randomised treatment trial in severe falciparum malaria and demonstrate how the estimated treatment effect in terms of absolute mortality risk reduction increases considerably in higher risk strata. CONCLUSIONS 'Local' and 'tilting' reweighting schemes based on ranking patients by baseline risk can be used as a general approach for exploring, graphing and reporting heterogeneity of treatment effect in RCTs. TRIAL REGISTRATION ISRCTN clinical trials registry: ISRCTN50258054. Prospectively registered on 22 July 2005.
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Affiliation(s)
- James A Watson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Chris C Holmes
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Department of Statistics, University of Oxford, Oxford, UK.
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11
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Leopold SJ, Watson JA, Jeeyapant A, Simpson JA, Phu NH, Hien TT, Day NPJ, Dondorp AM, White NJ. Investigating causal pathways in severe falciparum malaria: A pooled retrospective analysis of clinical studies. PLoS Med 2019; 16:e1002858. [PMID: 31442221 PMCID: PMC6707545 DOI: 10.1371/journal.pmed.1002858] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 07/25/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Severe falciparum malaria is a medical emergency characterised by potentially lethal vital organ dysfunction. Patient fatality rates even with parenteral artesunate treatment remain high. Despite considerable research into adjuvant therapies targeting organ and tissue dysfunction, none have shown efficacy apart from renal replacement therapy. Understanding the causal contributions of clinical and laboratory abnormalities to mortality is essential for the design and evaluation of novel therapeutic interventions. METHODS AND FINDINGS We used a structural model causal inference approach to investigate causal relationships between epidemiological, laboratory, and clinical variables in patients with severe falciparum malaria enrolled in clinical trials and their in-hospital mortality. Under this causal model, we analysed records from 9,040 hospitalised children (0-12 years, n = 5,635) and adults (n = 3,405, 12-87 years) with severe falciparum malaria from 15 countries in Africa and Asia who were studied prospectively over the past 35 years. On admission, patient covariates associated with increased in-hospital mortality were severity of acidosis (odds ratio [OR] 2.10 for a 7-mEq/L increase in base deficit [95% CI 1.93-2.28]), renal impairment (OR 1.71 for a 2-fold increase in blood urea nitrogen [95% CI 1.58, 1.86]), coma (OR 3.59 [95% CI 3.07-4.21]), seizures (OR 1.40 [95% CI 1.16-1.68]), shock (OR 1.51 [95% CI 1.14-1.99]), and presumed pulmonary oedema (OR 1.58 [95% CI 1.04-2.39]). Lower in-hospital mortality was associated with moderate anaemia (OR 0.87 for a decrease of 10 percentage points in haematocrit [95% CI 0.80-0.95]). Circulating parasite density was not associated with mortality (OR 1.02 for a 6-fold increase [95% CI 0.94-1.11]), so the pathological effects of parasitaemia appear to be mediated entirely by the downstream effects of sequestration. Treatment with an artemisinin derivative decreased mortality compared with quinine (OR 0.64 [95% CI 0.56-0.74]). These estimates were consistent across children and adults (mainly representing African and Asian patients, respectively). Using inverse probability weighting, transfusion was not estimated to be beneficial in children with admission haematocrit values between 15% and 25% (OR 0.99 [95% CI 0.97-1.02]). Except for the effects of artemisinin treatment and transfusion, causal interpretations of these estimates could be biased by unmeasured confounding from severe bacterial sepsis, immunity, and duration of illness. CONCLUSION These data suggest that moderate anaemia is associated with a reduced risk of death in severe falciparum malaria. This is possibly a direct causal association. The severe anaemia threshold criteria for a definition of severe falciparum malaria should be reconsidered.
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Affiliation(s)
- Stije J. Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - James A. Watson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Atthanee Jeeyapant
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nguyen H. Phu
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Tran T. Hien
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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12
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Impact of levamisole in co-administration with benznidazole on experimental Chagas disease. Parasitology 2019; 146:1055-1062. [PMID: 31046850 DOI: 10.1017/s0031182019000374] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Levamisole (Lms) is an anthelminthic drug with immunomodulatory activity. Chagas disease (CD) is caused by Trypanosoma cruzi and there is very low access to the drugs available, benznidazole (Bz) and nifurtimox, both far from ideal. In a drug-repurposing strategy to test potential activity as antiparasitic and immunomodulatory agent for CD, Lms was assayed on acute T. cruzi murine infection, alone and in co-administration with Bz. During protocol standardization, 100 and 10 mpk of Bz given for five consecutive days resulted in parasitaemia suppression and 100% animal survival only with the highest dose. Flow cytometry showed that both optimal (100 mpk) and suboptimal (10 mpk) doses of Bz equally decreased the plasma levels of cytokines commonly elevated in this acute infection model. Lms alone (10-0.5 mpk) did not decrease parasitaemia nor mortality rates. Co-administration was investigated using the suboptimal dose of Bz and different doses of Lms. While Bz 10 mpk did not alter parasitaemia, the combo partially reduced it but only slightly promoted animal survival. This effect could be related to Th1-response modulation since interleukin-6 and interferon-γ were higher after treatment with the combo.
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A single-group trial of end-stage patients with anthroponotic cutaneous leishmaniasis: Levamisole in combination with Glucantime in field and laboratory models. Microb Pathog 2018; 128:162-170. [PMID: 30583021 DOI: 10.1016/j.micpath.2018.12.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 11/21/2022]
Abstract
Currently, there is no satisfactory treatment modality available for cutaneous leishmaniasis (CL). The major objective of the present study was to explore the effect of immunomodulator-levamisole in combination with Glucantime in end-stage unresponsive patients with anthroponotic CL (ACL). Twenty end-stage unresponsive patients with ACL were identified for participation in this single-group trial study. Simultaneously, each patient was received a combination of levamisole pills along with Glucantime during the remedy course. Several in vitro complementary experiments were performed to evaluate the mode of action of levamisole and Glucantime alone and in combination using a macrophage model, in vitro MTT assay, flow cytometry and quantitative real time PCR (qPCR). Overall, 75% of the patients showed complete clinical cure, 10% partially improved and the remaining (15%) had underlying chronic diseases demonstrated no response to the treatment regimen. In in vitro studies, there was no cytotoxic effect associated with these drugs in the range of our experiments. The findings by the flow cytometric analysis represented that the highest apoptotic values corresponded to the drugs combination (32.23%) at 200 μg/ml concentration. Finally, the gene expression level of IL-12 p40, iNOS and TNF-α promoted while the level of IL-10 and TGF-β genes reduced as anticipated. The findings clearly indicated that the combination of levamisole and Glucantime should be considered in end-stage unresponsive patients with ACL who have not responded to basic treatments. The immunomodulatory role of levamisole in mounting immune system as documented by the in vitro experiments and further substantiated by this single-group trail study was highlighted.
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Abstract
Following unsuccessful eradication attempts there was a resurgence of malaria towards the end of the 20th century. Renewed control efforts using a range of improved tools, such as long-lasting insecticide-treated bednets and artemisinin-based combination therapies, have more than halved the global burden of disease, but it remains high with 445 000 deaths and more than 200 million cases in 2016. Pitfalls in individual patient management are delayed diagnosis and overzealous fluid resuscitation in severe malaria. Even in the absence of drug resistance, parasite recurrence can occur, owing to high parasite densities, low host immunity, or suboptimal drug concentrations. Malaria elimination is firmly back as a mainstream policy but resistance to the artemisinin derivatives, their partner drugs, and insecticides present major challenges. Vaccine development continues on several fronts but none of the candidates developed to date have been shown to provide long-lasting benefits at a population level. Increased resources and unprecedented levels of regional cooperation and societal commitment will be needed if further substantial inroads into the malaria burden are to be made.
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Affiliation(s)
- Elizabeth A Ashley
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mae Sot, Thailand; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Charles J Woodrow
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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15
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Varo R, Crowley VM, Sitoe A, Madrid L, Serghides L, Kain KC, Bassat Q. Adjunctive therapy for severe malaria: a review and critical appraisal. Malar J 2018; 17:47. [PMID: 29361945 PMCID: PMC5781278 DOI: 10.1186/s12936-018-2195-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/19/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite recent efforts and successes in reducing the malaria burden globally, this infection still accounts for an estimated 212 million clinical cases, 2 million severe malaria cases, and approximately 429,000 deaths annually. Even with the routine use of effective anti-malarial drugs, the case fatality rate for severe malaria remains unacceptably high, with cerebral malaria being one of the most life-threatening complications. Up to one-third of cerebral malaria survivors are left with long-term cognitive and neurological deficits. From a population point of view, the decrease of malaria transmission may jeopardize the development of naturally acquired immunity against the infection, leading to fewer total cases, but potentially an increase in severe cases. The pathophysiology of severe and cerebral malaria is not completely understood, but both parasite and host determinants contribute to its onset and outcomes. Adjunctive therapy, based on modulating the host response to infection, could help to improve the outcomes achieved with specific anti-malarial therapy. RESULTS AND CONCLUSIONS In the last decades, several interventions targeting different pathways have been tested. However, none of these strategies have demonstrated clear beneficial effects, and some have shown deleterious outcomes. This review aims to summarize evidence from clinical trials testing different adjunctive therapy for severe and cerebral malaria in humans. It also highlights some preclinical studies which have evaluated novel strategies and other candidate therapeutics that may be evaluated in future clinical trials.
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Affiliation(s)
- Rosauro Varo
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
| | - Valerie M Crowley
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
| | - Lola Madrid
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain
| | - Lena Serghides
- Toronto General Research Institute (TGRI), University Health Network, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Kevin C Kain
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Tropical Diseases Unit, Division of Infectious Diseases, Department of Medicine, UHN-Toronto General Hospital, Toronto, ON, Canada
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.
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16
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Wahlgren M, Goel S, Akhouri RR. Variant surface antigens of Plasmodium falciparum and their roles in severe malaria. Nat Rev Microbiol 2017; 15:479-491. [DOI: 10.1038/nrmicro.2017.47] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Mokarram P, Albokashy M, Zarghooni M, Moosavi MA, Sepehri Z, Chen QM, Hudecki A, Sargazi A, Alizadeh J, Moghadam AR, Hashemi M, Movassagh H, Klonisch T, Owji AA, Łos MJ, Ghavami S. New frontiers in the treatment of colorectal cancer: Autophagy and the unfolded protein response as promising targets. Autophagy 2017; 13:781-819. [PMID: 28358273 PMCID: PMC5446063 DOI: 10.1080/15548627.2017.1290751] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Colorectal cancer (CRC), despite numerous therapeutic and screening attempts, still remains a major life-threatening malignancy. CRC etiology entails both genetic and environmental factors. Macroautophagy/autophagy and the unfolded protein response (UPR) are fundamental mechanisms involved in the regulation of cellular responses to environmental and genetic stresses. Both pathways are interconnected and regulate cellular responses to apoptotic stimuli. In this review, we address the epidemiology and risk factors of CRC, including genetic mutations leading to the occurrence of the disease. Next, we discuss mutations of genes related to autophagy and the UPR in CRC. Then, we discuss how autophagy and the UPR are involved in the regulation of CRC and how they associate with obesity and inflammatory responses in CRC. Finally, we provide perspectives for the modulation of autophagy and the UPR as new therapeutic options for CRC treatment.
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Affiliation(s)
- Pooneh Mokarram
- a Colorectal Research Center and Department of Biochemistry , School of Medicine, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Mohammed Albokashy
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Maryam Zarghooni
- c Zabol University of Medical Sciences , Zabol , Iran.,d University of Toronto Alumni , Toronto , ON , Canada
| | - Mohammad Amin Moosavi
- e Department of Molecular Medicine , Institute of Medical Biotechnology, National Institute for Genetic Engineering and Biotechnology , Tehran , Iran
| | - Zahra Sepehri
- c Zabol University of Medical Sciences , Zabol , Iran
| | - Qi Min Chen
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | | | | | - Javad Alizadeh
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Adel Rezaei Moghadam
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Mohammad Hashemi
- g Department of Clinical Biochemistry , School of Medicine, Zahedan University of Medical Sciences , Zahedan , Iran
| | - Hesam Movassagh
- h Department of Immunology , Rady Faculty of Health Sciences, College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Thomas Klonisch
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada
| | - Ali Akbar Owji
- i Department of Clinical Biochemistry , School of Medicine, Shiraz Medical University , Shiraz , Iran
| | - Marek J Łos
- j Małopolska Centre of Biotechnology , Jagiellonian University , Krakow , Poland ; LinkoCare Life Sciences AB , Sweden
| | - Saeid Ghavami
- b Department of Human Anatomy and Cell Science , Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba , Winnipeg , MB , Canada.,k Health Policy Research Center , Shiraz University of Medical Sciences , Shiraz , Iran
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18
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Jeeyapant A, Kingston HW, Plewes K, Maude RJ, Hanson J, Herdman MT, Leopold SJ, Ngernseng T, Charunwatthana P, Phu NH, Ghose A, Hasan MMU, Fanello CI, Faiz MA, Hien TT, Day NPJ, White NJ, Dondorp AM. Defining Surrogate Endpoints for Clinical Trials in Severe Falciparum Malaria. PLoS One 2017; 12:e0169307. [PMID: 28052109 PMCID: PMC5215574 DOI: 10.1371/journal.pone.0169307] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 12/14/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical trials in severe falciparum malaria require a large sample size to detect clinically meaningful differences in mortality. This means few interventions can be evaluated at any time. Using a validated surrogate endpoint for mortality would provide a useful alternative allowing a smaller sample size. Here we evaluate changes in coma score and plasma lactate as surrogate endpoints for mortality in severe falciparum malaria. METHODS Three datasets of clinical studies in severe malaria were re-evaluated: studies from Chittagong, Bangladesh (adults), the African 'AQUAMAT' trial comparing artesunate and quinine (children), and the Vietnamese 'AQ' study (adults) comparing artemether with quinine. The absolute change, relative change, slope of the normalization over time, and time to normalization were derived from sequential measurements of plasma lactate and coma score, and validated for their use as surrogate endpoint, including the proportion of treatment effect on mortality explained (PTE) by these surrogate measures. RESULTS Improvements in lactate concentration or coma scores over the first 24 hours of admission, were strongly prognostic for survival in all datasets. In hyperlactataemic patients in the AQ study (n = 173), lower mortality with artemether compared to quinine closely correlated with faster reduction in plasma lactate concentration, with a high PTE of the relative change in plasma lactate at 8 and 12 hours of 0.81 and 0.75, respectively. In paediatric patients enrolled in the 'AQUAMAT' study with cerebral malaria (n = 785), mortality was lower with artesunate compared to quinine, but this was not associated with faster coma recovery. CONCLUSIONS The relative changes in plasma lactate concentration assessed at 8 or 12 hours after admission are valid surrogate endpoints for severe malaria studies on antimalarial drugs or adjuvant treatments aiming at improving the microcirculation. Measures of coma recovery are not valid surrogate endpoints for mortality.
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Affiliation(s)
- Atthanee Jeeyapant
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Hugh W. Kingston
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Katherine Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Richard J. Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Josh Hanson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Global Health Division, Menzies School of Health Research, Darwin, Australia
| | - M. Trent Herdman
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- University College, Oxford, United Kingdom
| | - Stije J. Leopold
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thatsanun Ngernseng
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prakaykaew Charunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol Unversity,Bangkok,Thailand
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit. Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Aniruddha Ghose
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | | | - Caterina I. Fanello
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Md Abul Faiz
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Malaria Research Group, Dev Care Foundation, Dhaka, Bangladesh
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit. Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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19
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Montes de Oca M, Good MF, McCarthy JS, Engwerda CR. The Impact of Established Immunoregulatory Networks on Vaccine Efficacy and the Development of Immunity to Malaria. THE JOURNAL OF IMMUNOLOGY 2016; 197:4518-4526. [DOI: 10.4049/jimmunol.1600619] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/26/2016] [Indexed: 02/07/2023]
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20
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Cheah PY, Parker M, Dondorp AM. Development of drugs for severe malaria in children. Int Health 2016; 8:313-6. [PMID: 27620923 PMCID: PMC5039823 DOI: 10.1093/inthealth/ihw038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 07/29/2016] [Indexed: 11/22/2022] Open
Abstract
Over 90% of deaths attributable to malaria are in African children under 5 years old. Yet, new treatments are often tested primarily in adult patients and extrapolations have proven to be sometimes invalid, especially in dosing regimens. For studies in severe malaria an additional complication is that the decline in severe malaria in adult patients precludes sufficiently powered trials in adults, before the intervention can be tested in the ultimate target group, paediatric severe malaria. In this paper we propose an alternative pathway to the development of drugs for use in paediatric severe malaria. We argue that following the classical phase I and II studies, small safety and efficacy studies using well-chosen surrogate endpoints in adult severe malaria be conducted, instead of larger mortality endpoint trials. If the drug appears safe and promising small pilot studies in paediatric severe malaria using the same endpoints can follow. Finally, with carefully observed safeguards in place to ensure high ethical standards, promising candidate interventions can be taken forward into mortality endpoint, well-powered, large paediatric studies in African children with severe malaria. Given the available research capacity, limited numbers of prudently selected interventions can be studied in phase III trials, and adaptive designs should be considered.
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Affiliation(s)
- Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Rd, Bangkok, 10400, Thailand Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Michael Parker
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Rd, Bangkok, 10400, Thailand Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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21
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Lalloo DG, Shingadia D, Bell DJ, Beeching NJ, Whitty CJM, Chiodini PL. UK malaria treatment guidelines 2016. J Infect 2016; 72:635-649. [PMID: 26880088 PMCID: PMC7132403 DOI: 10.1016/j.jinf.2016.02.001] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/06/2016] [Indexed: 12/15/2022]
Abstract
1.Malaria is the tropical disease most commonly imported into the UK, with 1300-1800 cases reported each year, and 2-11 deaths. 2. Approximately three quarters of reported malaria cases in the UK are caused by Plasmodium falciparum, which is capable of invading a high proportion of red blood cells and rapidly leading to severe or life-threatening multi-organ disease. 3. Most non-falciparum malaria cases are caused by Plasmodium vivax; a few cases are caused by the other species of plasmodium: Plasmodium ovale, Plasmodium malariae or Plasmodium knowlesi. 4. Mixed infections with more than one species of parasite can occur; they commonly involve P. falciparum with the attendant risks of severe malaria. 5. There are no typical clinical features of malaria; even fever is not invariably present. Malaria in children (and sometimes in adults) may present with misleading symptoms such as gastrointestinal features, sore throat or lower respiratory complaints. 6. A diagnosis of malaria must always be sought in a feverish or sick child or adult who has visited malaria-endemic areas. Specific country information on malaria can be found at http://travelhealthpro.org.uk/. P. falciparum infection rarely presents more than six months after exposure but presentation of other species can occur more than a year after exposure. 7. Management of malaria depends on awareness of the diagnosis and on performing the correct diagnostic tests: the diagnosis cannot be excluded until more than one blood specimen has been examined. Other travel related infections, especially viral haemorrhagic fevers, should also be considered. 8. The optimum diagnostic procedure is examination of thick and thin blood films by an expert to detect and speciate the malarial parasites. P. falciparum and P. vivax (depending upon the product) malaria can be diagnosed almost as accurately using rapid diagnostic tests (RDTs) which detect plasmodial antigens. RDTs for other Plasmodium species are not as reliable. 9. Most patients treated for P. falciparum malaria should be admitted to hospital for at least 24 h as patients can deteriorate suddenly, especially early in the course of treatment. In specialised units seeing large numbers of patients, outpatient treatment may be considered if specific protocols for patient selection and follow up are in place. 10. Uncomplicated P. falciparum malaria should be treated with an artemisinin combination therapy (Grade 1A). Artemether-lumefantrine (Riamet(®)) is the drug of choice (Grade 2C) and dihydroartemisinin-piperaquine (Eurartesim(®)) is an alternative. Quinine or atovaquone-proguanil (Malarone(®)) can be used if an ACT is not available. Quinine is highly effective but poorly-tolerated in prolonged treatment and should be used in combination with an additional drug, usually oral doxycycline. 11. Severe falciparum malaria, or infections complicated by a relatively high parasite count (more than 2% of red blood cells parasitized) should be treated with intravenous therapy until the patient is well enough to continue with oral treatment. Severe malaria is a rare complication of P. vivax or P. knowlesi infection and also requires parenteral therapy. 12. The treatment of choice for severe or complicated malaria in adults and children is intravenous artesunate (Grade 1A). Intravenous artesunate is unlicensed in the EU but is available in many centres. The alternative is intravenous quinine, which should be started immediately if artesunate is not available (Grade 1A). Patients treated with intravenous quinine require careful monitoring for hypoglycemia. 13. Patients with severe or complicated malaria should be managed in a high-dependency or intensive care environment. They may require haemodynamic support and management of: acute respiratory distress syndrome, disseminated intravascular coagulation, acute kidney injury, seizures, and severe intercurrent infections including Gram-negative bacteraemia/septicaemia. 14. Children with severe malaria should also be treated with empirical broad spectrum antibiotics until bacterial infection can be excluded (Grade 1B). 15. Haemolysis occurs in approximately 10-15% patients following intravenous artesunate treatment. Haemoglobin concentrations should be checked approximately 14 days following treatment in those treated with IV artemisinins (Grade 2C). 16. Falciparum malaria in pregnancy is more likely to be complicated: the placenta contains high levels of parasites, stillbirth or early delivery may occur and diagnosis can be difficult if parasites are concentrated in the placenta and scanty in the blood. 17. Uncomplicated falciparum malaria in the second and third trimester of pregnancy should be treated with artemether-lumefantrine (Grade 2B). Uncomplicated falciparum malaria in the first trimester of pregnancy should usually be treated with quinine and clindamycin but specialist advice should be sought. Severe malaria in any trimester of pregnancy should be treated as for any other patient with artesunate preferred over quinine (Grade 1C). 18. Children with uncomplicated malaria should be treated with an ACT (artemether-lumefantrine or dihydroartemisinin-piperaquine) as first line treatment (Grade 1A). Quinine with doxycycline or clindamycin, or atovaquone-proguanil at appropriate doses for weight can also be used. Doxycycline should not be given to children under 12 years. 19. Either an oral ACT or chloroquine can be used for the treatment of non-falciparum malaria. An oral ACT is preferred for a mixed infection, if there is uncertainty about the infecting species, or for P. vivax infection from areas where chloroquine resistance is common (Grade 1B). 20. Dormant parasites (hypnozoites) persist in the liver after treatment of P. vivax or P. ovale infection: the only currently effective drug for eradication of hypnozoites is primaquine (1A). Primaquine is more effective at preventing relapse if taken at the same time as chloroquine (Grade 1C). 21. Primaquine should be avoided or given with caution under expert supervision in patients with Glucose-6-phosphate dehydrogenase deficiency (G6PD), in whom it may cause severe haemolysis. 22. Primaquine (for eradication of P. vivax or P. ovale hypnozoites) is contraindicated in pregnancy and when breastfeeding (until the G6PD status of child is known); after initial treatment for these infections a pregnant woman should take weekly chloroquine prophylaxis until after delivery or cessation of breastfeeding when hypnozoite eradication can be considered. 23. An acute attack of malaria does not confer protection from future attacks: individuals who have had malaria should take effective anti-mosquito precautions and chemoprophylaxis during future visits to endemic areas.
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Affiliation(s)
- David G Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK.
| | - Delane Shingadia
- Department of Infectious Diseases, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK
| | - David J Bell
- Department of Infectious Diseases, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - Nicholas J Beeching
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Christopher J M Whitty
- Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street off Tottenham Court Road, London WC1E 6AU, UK
| | - Peter L Chiodini
- Malaria Reference Laboratory, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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22
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Brugat T. Editorial: CD36: Russian roulette of host and parasites during malaria infection. J Leukoc Biol 2016; 99:643-5. [PMID: 27130887 DOI: 10.1189/jlb.4ce1115-494r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/23/2015] [Indexed: 11/24/2022] Open
Affiliation(s)
- Thibaut Brugat
- Mill Hill Laboratory, Francis Crick Institute, London, United Kingdom http://www.twitter.com/@TheCrick
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23
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Hawkes M, Conroy AL, Opoka RO, Namasopo S, Zhong K, Liles WC, John CC, Kain KC. Slow Clearance of Plasmodium falciparum in Severe Pediatric Malaria, Uganda, 2011-2013. Emerg Infect Dis 2016; 21:1237-9. [PMID: 26079933 PMCID: PMC4480400 DOI: 10.3201/eid2107.150213] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Plasmodium falciparum resistance to artemisinin derivatives is emerging in Asia. We examined molecular markers of resistance in 78 children in Uganda who had severe malaria and were treated with intravenous artesunate. We observed in the K13-propeller domain, A578S, a low-frequency (3/78), nonsynonymous, single-nucleotide polymorphism associated with prolonged parasite clearance.
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Hawkes MT, Forgie S, Brophy J, Crockett M. Artesunate treatment of severe pediatric malaria: A review of parasite clearance kinetics and clinical implications. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2015; 26:237-40. [PMID: 26600806 PMCID: PMC4644001 DOI: 10.1155/2015/736159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
- School of Public Health, University of Alberta, Edmonton, Alberta
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Alberta
| | - Sarah Forgie
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Jason Brophy
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario
| | - Maryanne Crockett
- Departments of Pediatrics and Child Health, Medical Microbiology and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
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Becker TK, Bartels S, Hansoti B, Jacquet GA, Lunney K, Marsh R, Osei-Ampofo M, Lam C, Levine AC. Global emergency medicine: a review of the literature from 2014. Acad Emerg Med 2015. [PMID: 26223901 DOI: 10.1111/acem.12733] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a worldwide audience of academics and clinical practitioners. METHODS This year 6,376 articles written in six languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. A total of 477 articles were deemed appropriate by at least one reviewer and approved by the editor for formal scoring of overall quality and importance. RESULTS Of the 477 articles that met our predetermined inclusion criteria, 63% were categorized as emergency care in resource-limited settings, 13% as EM development, and 23% as disaster and humanitarian response. Twenty-five articles received scores of 17.5 or higher and were selected for formal summary and critique. Inter-rater reliability for two reviewers using our scoring system was good, with an intraclass correlation coefficient of 0.657 (95% confidence interval = 0.589 to 0.713). Studies and reviews focusing on infectious diseases, trauma, and the diagnosis and treatment of diseases common in resource-limited settings represented the majority of articles selected for final review. CONCLUSIONS In 2014, there were fewer total articles, but a slightly higher absolute number of articles screening in for formal scoring, when compared to the 2013 review. The number of EM development articles decreased, while the number of disaster and humanitarian response articles increased. As in prior years, the majority of articles focused on infectious diseases and trauma.
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Affiliation(s)
- Torben K. Becker
- Department of Emergency Medicine; University of Michigan; Ann Arbor MI
| | - Susan Bartels
- Department of Emergency Medicine; Queen's University; Kingston Ontario Canada
- Harvard Humanitarian Initiative; Cambridge MA
| | - Bhakti Hansoti
- Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Gabrielle A. Jacquet
- Department of Emergency Medicine; Boston University School of Medicine; Boston MA
- Boston University Center for Global Health and Development; Boston MA
| | - Kevin Lunney
- Medical Corps; US Navy, Department of Emergency Medicine; Navy Hospital Camp Lejeune; Camp Lejeune NC
| | - Regan Marsh
- Department of Emergency Medicine; Brigham and Women's Hospital; Boston MA
- Partners In Health; Boston MA
| | - Maxwell Osei-Ampofo
- Accident & Emergency Department; Komfo Anokye Teaching Hospital and Kwame Nkrumah University of Science and Technology; Kumasi Ghana
| | - Christopher Lam
- Warren Alpert Medical School of Brown University; Providence RI
| | - Adam C. Levine
- Department of Emergency Medicine; Warren Alpert Medical School of Brown University; Providence RI
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26
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Lelliott PM, McMorran BJ, Foote SJ, Burgio G. The influence of host genetics on erythrocytes and malaria infection: is there therapeutic potential? Malar J 2015. [PMID: 26215182 PMCID: PMC4517643 DOI: 10.1186/s12936-015-0809-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
As parasites, Plasmodium species depend upon their host for survival. During the blood stage of their life-cycle parasites invade and reside within erythrocytes, commandeering host proteins and resources towards their own ends, and dramatically transforming the host cell. Parasites aptly avoid immune detection by minimizing the exposure of parasite proteins and removing themselves from circulation through cytoadherence. Erythrocytic disorders brought on by host genetic mutations can interfere with one or more of these processes, thereby providing a measure of protection against malaria to the host. This review summarizes recent findings regarding the mechanistic aspects of this protection, as mediated through the parasites interaction with abnormal erythrocytes. These novel findings include the reliance of the parasite on the host enzyme ferrochelatase, and the discovery of basigin and CD55 as obligate erythrocyte receptors for parasite invasion. The elucidation of these naturally occurring malaria resistance mechanisms is increasing the understanding of the host-parasite interaction, and as discussed below, is providing new insights into the development of therapies to prevent this disease.
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Affiliation(s)
- Patrick M Lelliott
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia.
| | - Brendan J McMorran
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia.
| | - Simon J Foote
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia.
| | - Gaetan Burgio
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia.
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27
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Kreeftmeijer-Vegter AR, Dorlo TPC, Gruppen MP, de Boer A, de Vries PJ. Population pharmacokinetics of levamisole in children with steroid-sensitive nephrotic syndrome. Br J Clin Pharmacol 2015; 80:242-52. [PMID: 25677380 DOI: 10.1111/bcp.12607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/29/2015] [Accepted: 02/04/2015] [Indexed: 11/28/2022] Open
Abstract
AIM The aim was to investigate the population pharmacokinetics of levamisole in children with steroid-sensitive nephrotic syndrome. METHODS Non-linear mixed effects modelling was performed on samples collected during a randomized controlled trial. Samples were collected from children who were receiving 2.5 mg kg(-1) levamisole (or placebo) orally once every other day. One hundred and thirty-six plasma samples were collected from 38 children from India and Europe and included in the analysis. A one compartment model described the data well. RESULTS The apparent clearance rate (CL/F) and distribution volume (V/F) were 44 l h(-1) 70 kg(-1) and 236 l 70 kg(-1) , respectively; estimated interindividual variability was 32-42%. In addition to allometric scaling of CL/F and V/F to body weight, we identified a significant proportional effect of age on CL/F (-10.1% per year). The pharmacokinetics parameters were not affected by gender, tablet strength or study centre. The median (interquartile range) maximum plasma concentration of levamisole was 438.3 (316.5-621.8) ng ml(-1) , and the median area under the concentration-time curve was 2847 (2267-3761) ng ml(-1) h. Median tmax and t½ values were 1.65 (1.32-2.0) h and 2.60 (2.06-3.65) h, respectively. CONCLUSIONS Here, we present the first pharmacokinetic data regarding levamisole in children with steroid-sensitive nephrotic syndrome. The pharmacokinetic profile of levamisole in children was similar to findings reported in adults, although the elimination rate was slightly higher in children.
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Affiliation(s)
- A R Kreeftmeijer-Vegter
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, P.O. Box 80 082, 3508 TB, Utrecht, the Netherlands.,ACE Pharmaceuticals BV, Schepenveld 41, 3891, ZK, Zeewolde, the Netherlands
| | - T P C Dorlo
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, P.O. Box 80 082, 3508 TB, Utrecht, the Netherlands.,Department Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - M P Gruppen
- Department of Paediatric Nephrology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, the Netherlands
| | - A de Boer
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, P.O. Box 80 082, 3508 TB, Utrecht, the Netherlands
| | - P J de Vries
- ACE Pharmaceuticals BV, Schepenveld 41, 3891, ZK, Zeewolde, the Netherlands.,Department of Internal Medicine, Tergooi Ziekenhuis, Van Riebeeckweg 212, 1213 XZ, Hilversum, the Netherlands
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28
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Hanson J, Lee SJ, Hossain MA, Anstey NM, Charunwatthana P, Maude RJ, Kingston HWF, Mishra SK, Mohanty S, Plewes K, Piera K, Hassan MU, Ghose A, Faiz MA, White NJ, Day NPJ, Dondorp AM. Microvascular obstruction and endothelial activation are independently associated with the clinical manifestations of severe falciparum malaria in adults: an observational study. BMC Med 2015; 13:122. [PMID: 26018532 PMCID: PMC4453275 DOI: 10.1186/s12916-015-0365-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/12/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Microvascular obstruction and endothelial dysfunction have both been linked to tissue hypoperfusion in falciparum malaria, but their relative contributions to the disease's pathogenesis and outcome are unknown. METHODS Microvascular blood flow was quantified in adults with severe falciparum malaria on their admission to hospital; plasma biomarkers of endothelial function were measured simultaneously. The relationship between these indices and the patients' clinical findings and in-hospital course was examined. RESULTS Microvascular obstruction was observed in 119/142 (84 %) patients; a median (interquartile range (IQR)) of 14.9 % (6.6-34.9 %) of capillaries were obstructed in patients that died versus 8.3 % (1.7-26.6 %) in survivors (P = 0.039). The proportion of obstructed capillaries correlated with the estimated parasite biomass (rs = 0.25, P = 0.004) and with plasma lactate (rs = 0.38, P <0.0001), the strongest predictor of death in the series. Plasma angiopoietin-2 (Ang-2) concentrations were markedly elevated suggesting widespread endothelial activation; the median (IQR) Ang-2 concentration was 21.9 ng/mL (13.4-29.4 ng/mL) in patients that died versus 14.9 ng/mL (9.8-29.3 ng/mL) in survivors (P = 0.035). Ang-2 concentrations correlated with estimated parasite biomass (rs = 0.35, P <0.001) and plasma lactate (rs = 0.37, P <0.0001). Microvascular obstruction and Ang-2 concentrations were not significantly correlated with each other (rs = 0.17, P = 0.06), but were independently associated with plasma lactate (P <0.001 and P = 0.002, respectively). CONCLUSIONS Microvascular obstruction and systemic endothelial activation are independently associated with plasma lactate, the strongest predictor of death in adults with falciparum malaria. This supports the hypothesis that the two processes make an independent contribution to the pathogenesis and clinical manifestations of the disease.
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Affiliation(s)
- Josh Hanson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Global Health Division, Menzies School of Health Research, Darwin, Australia.
| | - Sue J Lee
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Md Amir Hossain
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh.
| | - Nicholas M Anstey
- Global Health Division, Menzies School of Health Research, Darwin, Australia.
| | - Prakaykaew Charunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Richard J Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Hugh W F Kingston
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Global Health Division, Menzies School of Health Research, Darwin, Australia.
| | - Saroj K Mishra
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India.
| | - Sanjib Mohanty
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India.
| | - Katherine Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Kim Piera
- Global Health Division, Menzies School of Health Research, Darwin, Australia.
| | - Mahtab U Hassan
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh.
| | - Aniruddha Ghose
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh.
| | - M Abul Faiz
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Specialized Care and Research, Chittagong, Bangladesh. .,Dev Care Foundation, Dhaka, Bangladesh.
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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29
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Hanson J, Phu NH, Hasan MU, Charunwatthana P, Plewes K, Maude RJ, Prapansilp P, Kingston HWF, Mishra SK, Mohanty S, Price RN, Faiz MA, Dondorp AM, White NJ, Hien TT, Day NPJ. The clinical implications of thrombocytopenia in adults with severe falciparum malaria: a retrospective analysis. BMC Med 2015; 13:97. [PMID: 25907925 PMCID: PMC4408603 DOI: 10.1186/s12916-015-0324-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/13/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Thrombocytopenia is a common finding in adults with severe falciparum malaria, but its clinical and prognostic utility is incompletely defined. METHODS Clinical and laboratory data from 647 adults with severe falciparum malaria were analysed retrospectively to determine the relationship between a patient's platelet count on admission to hospital and their subsequent clinical course. RESULTS On admission, 614 patients (94.9%) were thrombocytopenic (platelet count <150 × 10(9)/L) and 328 (50.7%) had a platelet count <50 × 10(9)/L. The admission platelet count was inversely correlated with parasite biomass (estimated from plasma PfHRP2 concentrations, rs = -0.28, P = 0.003), the degree of microvascular sequestration (measured with orthogonal polarizing spectral imaging, rs = -0.31, P = 0.001) and disease severity (the number of World Health Organization severity criteria satisfied by the patient, rs = -0.21, P <0.001). Platelet counts were lower on admission in the patients who died (median: 30 (interquartile range 22 to 52) × 10(9)/L versus 50 (34 to 78) × 10(9)/L in survivors; P <0.001), but did not predict outcome independently from other established laboratory and clinical prognostic indices. The 39 patients (6%) with profound thrombocytopenia (platelet count <20 × 10(9)/L) were more likely to die (odds ratio: 5.00, 95% confidence interval: 2.56 to 9.75) than patients with higher platelet counts, but these high-risk patients could be identified more rapidly with simple bedside clinical assessment. The admission platelet count did not reliably identify the 50 patients (7.7%) with major bleeding during the study. CONCLUSIONS Thrombocytopenia is a marker of disease severity in adults with falciparum malaria, but has limited utility in prognostication, triage and management.
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Affiliation(s)
- Josh Hanson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
| | | | - Prakaykaew Charunwatthana
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Panote Prapansilp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Chulalongkorn, Thailand.
| | - Hugh W F Kingston
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | | | | | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - M Abul Faiz
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Dev Care Foundation, Dhaka, Bangladesh.
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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Abstract
Over 90% of the world's severe and fatal Plasmodium falciparum malaria is estimated to affect young children in sub-Sahara Africa, where it remains a common cause of hospital admission and inpatient mortality. Few children will ever be managed on high dependency or intensive care units and, therefore, rely on simple supportive treatments and parenteral anti-malarials. There has been some progress on defining best practice for antimalarial treatment with the publication of the AQUAMAT trial in 2010, involving 5,425 children at 11 centres across 9 African countries, showing that in artesunate-treated children, the relative risk of death was 22.5% (95% confidence interval (CI) 8.1 to 36.9) lower than in those receiving quinine. Human trials of supportive therapies carried out on the basis of pathophysiology studies, have so far made little progress on reducing mortality; despite appearing to reduce morbidity endpoints, more often than not they have led to an excess of adverse outcomes. This review highlights the spectrum of complications in African children with severe malaria, the therapeutic challenges of managing these in resource-poor settings and examines in-depth the results from clinical trials with a view to identifying the treatment priorities and a future research agenda.
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Abstract
INTRODUCTION Chemotherapy of malaria has become a rapidly changing field. Less than two decades ago, treatment regimens were increasingly bound to fail due to emerging drug resistance against 4-aminoquinolines and sulfa compounds. By now, artemisinin-based combination therapies (ACTs) constitute the standard of care for uncomplicated falciparum malaria and are increasingly also taken into consideration for the treatment of non-falciparum malaria. AREAS COVERED This narrative review provides an overview of the state-of-art antimalarial drug therapy, highlights the global portfolio of current Phase III/IV clinical trials and summarizes current developments. EXPERT OPINION Malaria chemotherapy remains a dynamic field, with novel drugs and drug combinations continuing to emerge in order to outpace the development of large-scale drug resistance against the currently most important drug class, the artemisinin derivatives. More randomized controlled studies are urgently needed especially for the treatment of malaria in first trimester pregnant women. ACTs should be used for the treatment of imported malaria more consequently. Gaining sufficient efficacy and safety information on ACT use for non-falciparum species including Plasmodium ovale and malariae should be a research priority. Continuous investment into malaria drug development is a vital factor to combat artemisinin resistance and successfully improve malaria control toward the ultimate goal of elimination.
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Affiliation(s)
- Benjamin J Visser
- University of Amsterdam, Academic Medical Centre, Center of Tropical Medicine and Travel Medicine, Division of Infectious Diseases , Amsterdam , The Netherlands
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Storm J, Craig AG. Pathogenesis of cerebral malaria--inflammation and cytoadherence. Front Cell Infect Microbiol 2014; 4:100. [PMID: 25120958 PMCID: PMC4114466 DOI: 10.3389/fcimb.2014.00100] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 07/07/2014] [Indexed: 01/08/2023] Open
Abstract
Despite decades of research on cerebral malaria (CM) there is still a paucity of knowledge about what actual causes CM and why certain people develop it. Although sequestration of P. falciparum infected red blood cells has been linked to pathology, it is still not clear if this is directly or solely responsible for this clinical syndrome. Recent data have suggested that a combination of parasite variant types, mainly defined by the variant surface antigen, P. falciparum erythrocyte membrane protein 1 (PfEMP1), its receptors, coagulation and host endothelial cell activation (or inflammation) are equally important. This makes CM a multi-factorial disease and a challenge to unravel its causes to decrease its detrimental impact.
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Affiliation(s)
- Janet Storm
- Department of Parasitology, Liverpool School of Tropical Medicine Liverpool, UK ; Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), University of Malawi College of Medicine Blantyre, Malawi
| | - Alister G Craig
- Department of Parasitology, Liverpool School of Tropical Medicine Liverpool, UK
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Plewes K, Royakkers AA, Hanson J, Hasan MMU, Alam S, Ghose A, Maude RJ, Stassen PM, Charunwatthana P, Lee SJ, Turner GDH, Dondorp AM, Schultz MJ. Correlation of biomarkers for parasite burden and immune activation with acute kidney injury in severe falciparum malaria. Malar J 2014; 13:91. [PMID: 24618154 PMCID: PMC3995633 DOI: 10.1186/1475-2875-13-91] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 02/26/2014] [Indexed: 11/24/2022] Open
Abstract
Background Acute kidney injury (AKI) complicating severe Plasmodium falciparum malaria occurs in up to 40% of adult patients. The case fatality rate reaches 75% in the absence of renal replacement therapy (RRT). The precise pathophysiology of AKI in falciparum malaria remains unclear. Histopathology shows acute tubular necrosis with localization of host monocytes and parasitized red blood cells in the microvasculature. This study explored the relationship of plasma soluble urokinase-type plasminogen activator receptor (suPAR), as a proxy-measure of mononuclear cell activation, and plasma P. falciparum histidine rich protein 2 (PfHRP2), as a measure of sequestered parasite burden, with AKI in severe malaria. Methods Admission plasma suPAR and PfHRP2 concentrations were assessed in Bangladeshi adults with severe falciparum malaria (n = 137). Patients were stratified according to AKI severity based on admission creatinine clearance. Results A total of 106 (77%) patients had AKI; 32 (23%), 42 (31%) and 32 (23%) were classified into ‘mild, ‘moderate’ and ‘severe’ AKI groups, respectively. Plasma suPAR and PfHRP2 concentrations increased with AKI severity (test-for-trend P <0.0001) and correlated with other markers of renal dysfunction. Admission plasma suPAR and PfHRP2 concentrations were higher in patients who later required RRT (P <0.0001 and P = 0.0004, respectively). In a multivariate analysis, both increasing suPAR and PfHRP2 were independently associated with increasing urine neutrophil gelatinase-associated lipocalin concentration, a marker of acute tubular necrosis (β = 16.54 (95% CI 6.36-26.71) and β = 0.07 (0.02-0.11), respectively). Conclusions Both sequestered parasite burden and immune activation contribute to the pathogenesis of AKI in severe falciparum malaria.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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34
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Hanson J, Lee SJ, Mohanty S, Faiz MA, Anstey NM, Price RN, Charunwatthana P, Yunus EB, Mishra SK, Tjitra E, Rahman R, Nosten F, Htut Y, Maude RJ, Thi Hong Chau T, Phu NH, Hien TT, White NJ, Day NPJ, Dondorp AM. Rapid clinical assessment to facilitate the triage of adults with falciparum malaria, a retrospective analysis. PLoS One 2014; 9:e87020. [PMID: 24489828 PMCID: PMC3906099 DOI: 10.1371/journal.pone.0087020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/15/2013] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Most adults dying from falciparum malaria will die within 48 hours of their hospitalisation. An essential component of early supportive care is the rapid identification of patients at greatest risk. In resource-poor settings, where most patients with falciparum malaria are managed, decisions regarding patient care must frequently be made using clinical evaluation alone. METHODS We retrospectively analysed 4 studies of 1801 adults with severe falciparum malaria to determine whether the presence of simple clinical findings might assist patient triage. RESULTS If present on admission, shock, oligo-anuria, hypo- or hyperglycaemia, an increased respiratory rate, a decreased Glasgow Coma Score and an absence of fever were independently predictive of death. The variables were used to construct a simple clinical algorithm. When applied to the 1801 patients, this algorithm's positive predictive value for survival to 48 hours was 99.4 (95% confidence interval (CI) 97.8-99.9) and for survival to discharge 96.9% (95% CI 94.3-98.5). In the 712 patients receiving artesunate, the algorithm's positive predictive value for survival to 48 hours was 100% (95% CI 97.3-100) and to discharge was 98.5% (95% CI 94.8-99.8). CONCLUSIONS Simple clinical findings are closely linked to the pathophysiology of severe falciparum malaria in adults. A basic algorithm employing these indices can facilitate the triage of patients in settings where intensive care services are limited. Patients classified as low-risk by this algorithm can be safely managed initially on a general ward whilst awaiting senior clinical review and laboratory data.
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Affiliation(s)
- Josh Hanson
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Global Health Division, Menzies School of Health Research, Darwin, Australia
- * E-mail:
| | - Sue J. Lee
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Sanjib Mohanty
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India
| | - M. Abul Faiz
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Dev Care Foundation, Dhaka, Bangladesh
| | - Nicholas M. Anstey
- Global Health Division, Menzies School of Health Research, Darwin, Australia
| | - Ric N. Price
- Global Health Division, Menzies School of Health Research, Darwin, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | | | | | - Saroj K. Mishra
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | | | - Francois Nosten
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mae Sot, Thailand
| | - Ye Htut
- Department of Medical Research, Lower Myanmar, Ministry of Health, Yangon, Myanmar
| | - Richard J. Maude
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Tran Thi Hong Chau
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
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